Substance use disorders (SUD) often have a chronic course, characterized by cycles of abstinence, light use, and heavy use. Wider availability of effective continuing care has been recommended to increase rates of sustained recoveries and limit the severity and duration of relapse episodes that do occur (Dennis & Scott, 2007; McKay, 2010).
Despite the perceived importance of continuing care for SUDs, evidence for the effectiveness of such interventions is actually mixed. A recent comprehensive review generated only modest support for continuing care, finding statistically significant but small positive effects at the end of continuing care and at follow-up (Blodgett, Maisel, Fuh, Wilbourne, & Finney, 2014). There is some indication that continuing care interventions with durations of at least twelve months and active efforts to deliver the intervention may show larger effects than other interventions (McKay, 2010; Scott & Dennis, 2009), although the Blodgett et al. (2014) meta-analysis did not find that longer continuing care treatments were more likely to be effective than shorter ones.
Recent work has suggested that modest positive effects for continuing care in research studies may be masking larger effects in certain subgroups of patients. For example, extended telephone-based continuing care may be particularly effective for women (McKay et al., 2011; McKay et al., 2014) and for poorer prognosis patients, as indicated by lower motivation, poorer social support, and prior treatments for SUD (McKay et al., 2011), or by active alcohol and drug use at admission to or during the first few weeks of treatment (McKay et al., 2013). Furthermore, recovery management checkups, which provide monitoring every three months over four years and linkage back to treatment, was found to be more effective for participants with earlier onset of substance use disorders and higher scores on a measure of criminal and violent behavior (Dennis & Scott, 2012).
One other possible explanation for small continuing care effects in controlled studies concerns the nature of the interventions themselves. The continuing care interventions that have been evaluated typically consist of sessions provided in clinics or over the telephone, at intervals that range from weekly up to every three months, with little use of between-session contacts or frequent monitoring via urine toxicology screens or other biological measures. This approach may not be adequate for rapid identification of relapses and quick clinical response when relapse is detected. Consequently, the model of continuing care used to treat physicians and pilots has generated considerable interest. Treatment for physicians is coordinated by state physician health programs (PHPs) and typically features intensive treatment combined with professional support and frequent random drug testing for five or more years.
Physician Health Programs
All PHPs require total abstinence from use of alcohol and all other drugs of abuse and provide records documenting abstinence and program participation to licensing boards, hospitals, and malpractice carriers who require this information as a condition of continued eligibility to practice medicine. DuPont, McLellan, White, Merlo, and Gold (2009) reported that PHPs provide long-term monitoring and documentation of contract compliance, and active management of relapse or noncompliance with program requirements, with prompt reintervention and referral for further evaluation and/or treatment. PHPs deal with these occurrences rapidly, with meaningful and sustained therapeutic intervention. Factors thought to be related to the high success rate of these programs are as follows (DuPont et al., 2009):
- Clear and significant consequences for substance use and any violations of the protocol
- Frequent random drug screening
- Tight linkage with Twelve Step recovery programs
- Active management of relapses in the monitoring phase
- A continuing-care approach
- A focus on lifelong recovery
McLellan, Skipper, Campbell, and DuPont (2008) examined long-term outcomes of PHP managed care on the substance use and medical care practices of addicted physicians. The study made use of chart and urine testing records over a five-year period, in 904 consecutively admitted physicians to sixteen state PHPs. Of the 802 physicians in the sample with known out-comes, 647 completed treatment and resumed practicing. In that group of physicians, alcohol or drug misuse was detected through urine toxicology testing in 19 percent of the participants over five years, with only about 20 percent in the group with a positive test having more than one such test result. At the five-year point, 79 percent of the physicians with known outcomes were licensed without restriction and practicing medicine or working in a nonclinical capacity. These findings indicated that most addicted physicians managed by PHPs have favorable long-term outcomes.
Given the success of PHPs, there has been interest in applying this continuing care model to other patient populations. However, there has been concern that participation in frequent random urine testing and other monitoring procedures that are central to the success of PHPs would be relatively poor, without a powerful consequence such as the fear of losing one’s medical license. Despite such concerns, Caron Treatment Centers implemented a continuing care intervention modeled after PHPs for participants in its residential program in 2012. This intervention, called My First Year in Recovery (MyFYR), was designed to help clients initiate and sustain recovery, with the goal of promoting overall improved quality of life as well as sobriety. Improved quality of life was defined as physical, psychological, and spiritual well-being. The intervention is typically provided for one year postdischarge from residential care, but can be extended for up to three years.
In this article, we report initial outcomes from the MyFYR program. The outcomes examined are retention in MyFYR and substance use while in the program. The study participants were the first 198 clients who were enrolled in the MyFYR program after receiving residential treatment at Caron. All individuals consented to participate in the evaluation study. When this article was written, sufficient time had elapsed for all of the study participants to have been in MyFYR for at least twelve months, whether they stayed engaged or dropped out.
The My First Year of Recovery (MyFYR) Program
My First Year of Recovery encompasses six core functions:
- Integrative care management
- Recovery for Life contract
- Random urine drug screening
- Online Caron Recovery Network
- Circle of Support
- Interactive recovery library of curriculum for clients and family
The program currently costs $10,000 for the first twelve months of service. At this point, Caron has a contract with one employer to cover the cost of the intervention. Caron provides needs-based scholarships to about 10 percent of the clients receiving MyFYR. Most other clients are self-pay. MyFYR is delivered from Caron Treatment Center’s Pennsylvania residential pro-gram. MyFYR is typically introduced in the third week of the four-week residential treatment program. For clients who participate in extended care treatment, MyFYR is introduced in the last month of that experience. Not all clients who were offered MyFYR agreed to enroll in the program. Typical reasons for refusal are related to concerns about the cost of the program or clients/family deciding that the service would not be of sufficient benefit to them. However, we did not collect systematic information on reasons for refusal or the refusal rate.
How it Works
Integrative care management is provided by licensed and credentialed addiction treatment professionals who act as clinical specialists. The clinical specialists provide stability and support throughout the entire first year of recovery. This supportive guidance is accomplished through frequent telephone support calls, which take place several times a month. In addition, clinical specialists engage clients and family in monthly conference calls to support healthy family interactions and relationships. The monthly conference calls can also include outpatient treatment providers who are working with clients and families directly. Clinical specialists can also provide referrals to programs within the Caron continuum, other outpatient professionals, and the Twelve Step community to support personal growth. They play a key role in the coordination of interventions, if and when relapse occurs.
Clients, family members, and clinical specialists work collaboratively on the Recovery for Life contract, which is signed as a commitment to wellness. This contract serves as a recovery action plan, highlighting goals and a plan to address struggles. Moreover, it also provides a structure that facilitates proactive efforts to address relapse risk issues before these stressors lead to the onset of an actual relapse episode. The contract also outlines an approach to handle relapses, should they occur, with clear, immediate, and meaningful interventions to quickly reengage clients back into actively working the recovery program. The Recovery for Life contract is developed and signed while people is still in treatment. It is adjusted as needed throughout the MyFYR program.
A key component of the program is personal accountability, as assessed via random urine alcohol and drug screens. When clients first enroll into the MyFYR program, they are randomly screened three times a month for alcohol and drug use. The frequency of randomized testing can be adjusted over time based on clinical progress. For example, additional screens can be added if there are any concerns about the clients’ behaviors. Clients are notified to provide a random drug screening through e-notification, text, and voice message. A GPS locator provides clients with the nearest location of the independent testing site. Clients receive comprehensive urine drug-screening panels, as well as ethyl glucuronide (ETG) for alcohol. The ETG test is able to detect alcohol in urine for up to three to four days after a drinking episode. Therefore, it is more effective for monitoring alcohol use outcomes than breath tests.
For clients in the Caron system, a relapse is indicated by any use of alcohol or other drugs of abuse, at any level. If clients or family members report a relapse, or if clients have a drug- or alcohol-positive urine screen or fail to provide a scheduled urine screen, an agreed-upon intervention or response takes place. The first step is to ensure the physical health and safety of clients, which may require a trip to the emergency department or treatment program. The next step is a conference call with all family members and professional supports to gather details about the relapse and develop a plan to move forward. This plan is developed to fit the individual needs of clients who have relapsed. The plan also considers the needs of involved family members, as their well-being is also a priority. Some relapses require a higher level of care while others require adjustments to the current recovery action plan, but do not necessitate a step up in level of care.
Contact with the family increases during and after relapse episodes. Communication with professional supports increases as well during a relapse. The MyFYR team provides guidance that supports healthy communication and boundaries. If clients return to residential treatment or stop participating in MyFYR, the clinical team continues to work closely with families. Family engagement is considered a critical success factor of the program.
The interactive recovery curriculum, which is computer-based, is a structured tool designed to help clients and their family members through the challenges of early recovery. The clinical specialist guides clients and families through the program, which consists of individualized interactions, assistance in implementing coping skills, assigned readings, and audiovisual activities. The content includes topics such as wellness, spirituality, the Twelve Steps, parenting, and relationships, and is individualized for clients and their family members. This program actively engages family members in their own recovery process. The entire program for families parallels the client experience.
Caron Recovery Network Web Platform
My First Year of Recovery is situated on a social platform called the Caron Recovery Network. This is a private online forum that allows for communication between clients and families and their clinical specialists. The features of the Caron Recovery Network include: journaling; a resource library that has articles on recovery, videos, and blogs; messaging to Caron support team and family members who are engaged; and a “chit-chat” section that allows for posts, comments, and support from others in the MyFYR program. All dialog on the site is monitored daily by the staff of the MyFYR program. The platform is only for the use of MyFYR participants, their families, and their counselors.
Study Outcome Measures
The primary outcome measures for the study were retention in MyFYR and substance use. MyFYR treatment status (i.e., retained or dropped out) was determined by information in the clinical chart. For clinical purposes, MyFYR makes use of information on alcohol and drug use from the urine toxicology and ETG tests, client self-reports, and family reports. For this initial evaluation, we report on abstinence rates as determined by the combination of all three sources. Although urine toxicology tests are considered the “gold standard” for SUD outcome research, we have found that a significant number of participants do not have any alcohol or drug positive urine samples, yet self-report substance use or acknowledge use after a family member reports it. Therefore, we have adopted a “worst case scenario” approach, in which any indication of use places the participant in the nonabstinent category. We also report urine test results separately.
Data was collected on the first 198 individuals who began the MyFYR program and had the op-portunity to have been in the program for at least twelve months, whether they stayed engaged or not. Data was obtained from numerous sources including chart review, client reports, urinal-ysis findings, and case manager feedback. All participants signed informed consents at entrance into MyFYR, to authorize use of data collected during participation for program evaluation. However, the Institutional Review Board at the University of Pennsylvania indicated that the study was exempt and did not need to be IRB approved, as it made use of deidentified data collected for clinical purposes.
Data was analyzed from 198 clients (55 percent male) who entered MyFYR between November 2012 and January 2015. The average age of participants was forty-four years old (range: twenty to seventy-six). The sample was almost entirely comprised of Caucasian clients (98 percent). A total of 57 percent of the participants (N=112) had at least one diagnosed psychiatric condition in addition to a substance use disorder. Forty-one percent of clients used more than one substance. The average length of stay in inpatient residential treatment for study participants was forty-six days (Range: 5–151 days). Clients in the study sample were similar to all adult clients treated at Caron on these variables. However, we do not have systematic data on other factors, including financial means or degree of family involvement in treatment. Slightly more than three-quarters of the clients in the study (78 percent) completed their planned stays in MyFYR.
Clients in the program were initially scheduled to provide three urine samples per month. Frequency was reduced somewhat over time, if clients were compliant and had negative urines. Otherwise, more frequent urine screening was reinstated or continued. Compliance with urine testing was excellent, with 70 percent of scheduled urine tests successfully obtained. Overall, a total of 3245 urine samples were provided (i.e., average of sixteen samples per participant), of which only 133 samples (4 percent) tested positive for alcohol or other drugs.
Fifty-one of the clients in the study had one or more positive test results. Of those, twenty-one (41 percent) tested positive only once, nineteen (37 percent) had two positive urines, and eleven (22 percent) had three or more positive urines. Alcohol (41 percent) and opiates (28o percent) were the primary drugs that individuals relapsed on based on urinalysis results. Of the 107 clients who relapsed at some point, sixty (56 percent) had no positive urine samples but self-reported one or more episodes of alcohol or drug use, or acknowledged use that was reported by a family member.
Clients who completed MyFYR were significantly more likely to be abstinent throughout their stay in the program than those who dropped out (51 percent versus 32 percent; X2 = 4.87; p< .04). The 107 clients who relapsed were examined in more detail. Of those, seventy-five (70 percent) remained engaged in the MyFYR program after relapse and completed the program. A total of thirty-nine (52 percent) clients who relapsed but remained engaged and completed MyFYR were abstinent at discharge, with an average length of abstinence of six months (Range: one to eleven months). Overall, 76 percent of all clients who completed the MyFYR program, including those who relapsed at earlier time points but remained engaged or reengaged, were abstinent at time of discharge from the program, as documented by urine toxicology tests, self-report, and collateral/family report.
Summary and Discussion
Substance use disorders are seen as chronic in nature for many of the individuals who suffer from them (McLellan, Lewis, O’Brien, & Kleber, 2000). Consequently, continuing care interventions have been developed to prevent the onset and limit the severity of relapse episodes following intensive treatment. However, recent research has indicated that overall, most continuing care interventions are only modestly effective (Blodgett et al., 2014; McKay, 2010), which indicates the need to develop new, more effective interventions to support extended recovery. Caron Treatment Centers has developed and implemented a new continuing care program, which is referred to as My First Year of Recovery (MyFYR). This intervention is modeled after programs that have proved effective with physicians and airplane pilots (DuPont et al., 2009). MyFYR incorporates in-person, telephone, and online services, and provides support via case management, a coordinated circle of recovery, family involvement whenever possible, frequent monitoring of drug and alcohol use via urine toxicology tests, and rapid intervention following episodes of alcohol or drug use or missed urine tests.
Four important conclusions can be drawn from this initial evaluation of MyFYR outcomes. First, program participants were highly compliant with the urine testing component of the in-tervention, despite the fact that they were asked to provide urine samples frequently, and—unlike physicians in PHPs—suffered no serious negative consequences if they failed to provide requested urine samples. We are not sure what produced such a high rate of compliance in the absence of significant negative consequences for missed tests, but it may have been related to the close involvement of family members and others in the circle of support, as well as frequent contacts with treatment providers. The fact that most clients paid a significant amount of money to participate in MyFYR may have also enhanced their commitment to and compliance with the program.
Second, rates of alcohol or drug positive urine tests were extremely low, which coupled with the high rate of compliance with urine tests, indicates that outcomes in this program were apparently quite good. In the absence of a randomized design and a control group that did not receive MyFYR, it is not possible to estimate the actual size of the treatment effect. However, the results are clearly extremely promising.
Third, it appears that the procedures in place in MyFYR facilitated ongoing contact with many clients and their families during and following relapse episodes, and that a significant number of these clients were able to reestablish abstinence following their relapses. About 70 percent of the clients who relapsed either remained engaged in MyFYR or were quickly reengaged after a period of no contact, and half of these clients were able to reestablish abstinence following their relapses, with a mean duration of almost six months of abstinence. Therefore, more than a third of clients who relapsed reestablished significant periods of abstinence, as documented by multiple random urine tests. Given that retaining clients after they relapse and restoring stable abstinence are major challenges for continuing care interventions (McKay, 2010), these results are very encouraging.
Finally, although monitoring substance use via frequent random urine toxicology tests may have a therapeutic effect and is clearly the “gold standard” for outcome assessments, the results in this study indicate that it is important to also obtain client self-reports and family reports in order to accurately assess program abstinence rates. Despite that fact that we obtained seven of every ten urine screens scheduled and participants provided an average of sixteen urine samples, over 50 percent of the episodes of alcohol or drug use in study participants were missed by the urine drug screens and instead identified by self or family reports.
The clients at Caron are typical of clients treated at other higher-end residential programs with a strong Minnesota model orientation, such as Betty Ford and Hazelden. However, it is important to acknowledge that the sample of clients included in this study could not be considered to be representative of individuals seeking treatment for substance use disorders in the US. The clients in the study were overwhelmingly Caucasian, and most had significant financial re-sources and supportive families who were involved in the treatment. It is not clear whether the same results would have been obtained in clients with other characteristics or less family involvement and support, or in those who had completed shorter residential programs or outpatient programs.
This study does have several additional limitations. First, and most important, the study was a naturalistic evaluation, and did not include a randomized control condition. Therefore, we are not able to determine the magnitude of the MyFYR effect above and beyond standard care, or versus another type of continuing care. Second, because the abstinence rates were determined by frequent urine testing, it is not possible to compare these outcomes to those in other studies that made use entirely of self-reports to determine outcome, or of a combination of self-reports and infrequently gathered urine toxicology tests. Finally, the reported outcomes were limited to retention in MyFYR and alcohol and drug use. We acknowledge that there is growing recognition and consensus that “recovery” involves more than abstinence (Betty Ford Institute Consensus Panel, 2007).
In conclusion, these initial results for the My First Year of Recovery continuing care program are extremely promising, as they document high rates of sustained participation in frequent random urine drug and alcohol test monitoring and positive outcome in clients not under the threat of losing a professional license or incarceration. Moreover, the results indicate that clients can be retained in the program after experiencing relapses, and that many clients are able to reestablish abstinence.
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