Common sense suggests that greater patient adherence to substance use disorder (SUD) treatment recommendations is associated with better outcomes. Surprisingly, however, there is limited previous research systematically investigating the adherence-outcome relationship in the context of SUD treatment.
A sizeable knowledge base, primarily from the medical treatment literature, supports a link between the extent to which patients’ behaviors (e.g., taking medication, executing lifestyle changes) coincides with favorable treatment outcomes (DiMatteo, Giordani, Lepper, & Croghan, 2002; Simpson et al., 2006). The treatment of SUDs is increasingly being contextualized within a disease management framework, much like that of other chronic medical conditions such as hypertension, diabetes, and asthma (IOM, 2006; McLellan, Lewis, O’Brien, & Kleber, 2000). Accordingly, there has been a shift in focus in recent years from the primary to secondary (or continuing care) phase of treatment. The continuing care phase involves providing some form of less-intensive, tapered care such as standard outpatient treatment or community-based self-help and/or support groups. The overarching goal of any continuing care plan is to sustain treatment gains attained in the primary phase in an effort to manage SUDs and ultimately achieve remission.
According to the US Surgeon General’s recent landmark “Report on Alcohol, Drugs, and Health” (HHS, 2016), there are a number of evidence-based interventions for the treatment of SUDs with demonstrated effectiveness. Considerable work also supports the widely held belief that the provision of lower intensity continuing care services delivered on an outpatient treatment basis after the primary treatment phase (e.g., residential/inpatient) is associated with favorable long-term clinical outcomes. As described by McKay (2009), however, individual patients differ significantly in their response to continuing care interventions, which can be influenced by a number of patient-level and program-level factors. One patient-level factor of particular interest is adherence—given that poor adherence often leads to patient dropout, which in turn has been shown to be associated with unfavorable long-term outcomes (Simpson, Joe, & Brown, 1997). Although participation in continuing care activities—like community-based self-help groups and/or formal outpatient aftercare programming—is a reliable predictor of positive long-term functioning (McKay, 2009; Proctor & Herschman, 2014), research suggests that few patients are adherent in that many participate in little to no continuing care (Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997), and even fewer receive continuing care for any meaningful length of time.
Considering that SUD is increasingly being recognized as a chronic, relapsing condition requiring protracted disease management comparable to other chronic medical conditions (e.g., hypertension, diabetes, asthma), studies investigating the impact of patient adherence to continuing care plans and its impact on recovery are of paramount importance (McLellan, McKay, Forman, Cacciola, & Kemp, 2005). Several reviews of the vast SUD treatment literature suggest that long-term care strategies have the potential to produce lasting benefits for individuals with SUDs (McKay, 2009; McLellan et al., 2000; Proctor & Herschman, 2014). However, the presence of evidence-based continuing care treatment options in the absence of patient adherence presumably renders such options of limited clinical value.
The SUD treatment adherence research has largely focused on adherence to medication-assisted treatment (MAT) regimens involving the use of methadone, buprenorphine-based formulations (Suboxone), or naltrexone (Vivitrol). For such pharmacological interventions, the measurement of adherence is relatively easy and involves simply whether or not patients took their prescribed medication as directed. Conversely, the measurement of adherence for psychosocial interventions is understandably more challenging given the variability in treatment regimens and complexity of quantifying adherence. As a result, much of the current research support for the adherence-outcome relationship in the SUD literature has failed to consider the multifaceted, psychosocial, continuing care phase of SUD treatment. The use of strict inclusionary criteria in studies demonstrating the strongest support to date linking adherence to psychosocial treatment with long-term outcomes (Mattson et al., 1998) also necessitates further work with a naturalistic (i.e., “real world”) treatment population. Thus, in light of the surprisingly limited empirical evidence to date, it remains unclear to what extent patient adherence to multicomponent continuing care plans is associated with long-term recovery.
The main objective of the study was to determine whether patient adherence to multicomponent psychosocial continuing care plans during the initial twelve-month period following discharge from residential treatment predicted a number of successful long-term clinical outcomes using data from a naturalistic treatment sample.
Study Design and Sample
The study described herein was a secondary analysis of a subset of data from a previously published study evaluating the effectiveness of a protracted, telephone-based care plan management intervention (Proctor, Wainwright, Herschman, & Kopak, 2017). Data for the current study were derived from existing patient records using the management information system of a large behavioral health care management services provider. Patients were studied through retrospective electronic record review for twelve months following discharge from primary residential addictions treatment. Residential treatment included a combination of group and individual therapy using Twelve Step, mindfulness meditation, and cognitive behavioral techniques, and the average length of stay (LOS) for the sample was about twenty-eight days (SD = 8.58). Upon admission to treatment, all patients participated in a comprehensive biopsychosocial assessment and diagnostic evaluation. Diagnostic determinations were made by trained clinical staff as per the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA, 1994), and were subsequently verified by the treatment provider’s staff psychiatrist.
The study sample consisted of 271 patients (59 percent male) with an average age of 40.43 years (SD = 13.99) who were discharged from a single residential addiction treatment program located in the southwestern United States between 2013 and 2015. All patients agreed to receive telephone-based protracted care plan management postdischarge. The racial composition of the sample was predominately white (92 percent). Slightly more than half (55 percent) of patients were unemployed, and approximately two-thirds (68 percent) paid for treatment out-of-pocket (i.e., were self-pay). Nearly half (44 percent) were single at the time of admission to treatment, while a similar proportion (44 percent) indicated that they were either married or in a romantic relationship.
In terms of the clinical characteristics of the sample, the most prevalent primary SUD diagnosis involved alcohol with two-thirds (66 percent) of patients meeting criteria for a DSM-IV alcohol use disorder (AUD). The second most prevalent SUD involved opioids (i.e., heroin or prescription pain relievers) with 18 percent receiving an opioid use disorder (OUD) diagnosis, followed by stimulants (i.e., cocaine, methamphetamine, or amphetamines) at 10 percent. The majority of patients also received a co-occurring psychiatric disorder diagnosis with 61 percent of patients meeting criteria for a non-SUD mental health condition. Among those with a co-occurring disorder, major depressive disorder (31 percent) was as the most common comorbid condition, followed by an anxiety disorder (22 percent), and posttraumatic stress disorder (15 percent).
Before being discharged from residential treatment, all patients and their multidisciplinary treatment team collaboratively created a multicomponent continuing care discharge plan, which included a detailed list of goals and expectations regarding continuing care. Although continuing care plans may have been variable—given they were personalized to the patients’ unique needs—all plans included regular attendance at community-based self-help groups (e.g., AA/NA meetings) as well as standard outpatient treatment with a local provider in their home community, beginning within seven days of discharge. All patients received protracted, telephone-based care plan management by master’s level, licensed telehealth specialists for twelve months, and patients answered an average of 23.92 (SD = 0.99) telephone calls. Telephone contacts included a standardized set of questions asking patients about their recent use of alcohol or drugs as well as their perceived quality of life and adherence to continuing care plans.
It is important to note that telephone contacts did not involve counseling per se, but rather care plan management with a focus on whether patients were adherent to their personalized discharge plan. One of three possible adherence ratings was assigned by telehealth specialists based on the extent to which patients followed their continuing care plan. During each telephone contact, patients were asked a series of “yes” or “no” questions corresponding directly to their continuing care plan. The values for each continuing care plan element response were added and divided by the total number of care plan elements. For example, telehealth specialists may have asked patients whether they attended a Twelve Step meeting, attended outpatient individual therapy with their local counselor, attended their medication management appointment, and took their prescribed medication as directed. If patients responded “yes” to all continuing care discharge plan elements, then the telehealth specialists would assign a “fully adherent” rating. If patients responded “yes” to 50 percent or more but less than all of their continuing care plan elements, telehealth specialists would assign a “partially adherent” rating. Completing less than 50 percent of continuing care plan elements resulted in a “nonadherent” rating.
Primary outcomes included:
- Past thirty-day abstinence at twelve months
- Continuous abstinence through the entire twelve-month period following residential treatment discharge
Secondary outcomes included:
- Readmission to any residential level of care through twelve months
- Perceived quality of life at twelve months
Comparisons involving level of patient adherence to continuing care discharge plans with study outcomes at twelve months revealed several notable findings (see Table 1). Fully adherent patients demonstrated significantly better results on all but one study outcome at twelve months compared to patients who were partially adherent or nonadherent. Specifically, fully adherent patients evidenced significantly higher rates of continuous abstinence, past thirty-day abstinence, and a positive quality of life at twelve months compared to nonadherent patients. Fully adherent patients also demonstrated significantly higher rates of continuous abstinence and past thirty-day abstinence at twelve months compared to partially adherent patients. Finally, partially adherent patients evidenced significantly higher rates of continuous abstinence, past thirty-day abstinence, and a positive quality of life compared to nonadherent patients.
Findings from logistic regression also revealed that patient adherence was a significant predictor of continuous abstinence through the entire twelve-month postdischarge period after controlling for the effect of relevant demographic variables (i.e., age, sex, marital status, and employment status). Patients who were fully adherent to their continuing care discharge plans through twelve months were nearly ten times more likely to be continuously abstinent through the initial twelve months postdischarge from residential treatment compared to patients who were nonadherent or partially adherent to their care plans. Patient adherence was also a significant independent predictor of a positive quality of life, such that fully adherent patients were nearly eight times more likely to report positive quality of life at twelve months relative to patients who were not fully adherent to their continuing care discharge plans.
Recommendations for Practice
As the SUD treatment field’s apparent paradigm shift from the primary phase to the secondary (or continuing care) phase moves onward, there is a clear need for studies to systematically research the role of relevant variables that may influence continuing care outcomes. One such understudied variable is patient adherence to continuing care plan recommendations. Consistent with previous research (Mattson et al., 1998), the current study found that greater adherence was associated with better long-term outcomes. However, the current study extends previous work regarding the adherence-outcome relationship through the use of a naturalistic treatment sample, less restrictive inclusionary criteria, and a more sophisticated measure of patient adherence. The current findings provide empirical evidence to support the widely-weld belief that greater patient adherence to psychosocial continuing care options is linked to favorable treatment response. Although, theoretically, the assumed positive correlation between adherence to continuing care plans and outcome among SUD patients is a reasonable notion, surprisingly, very few studies have tested the effect of adherence in SUD treatment outcome beyond MAT evaluations.
The reported findings contribute to the current knowledge base and provide insight into realistic outcomes expectations for patients who are adherent to their multicomponent continuing care discharge plans. In the context of the current study, several noteworthy findings were found with respect to abstinence, which is arguably the most important outcome for patients receiving SUD treatment. Patients who were adherent to all elements of their continuing care discharge plans through twelve months were significantly more likely to demonstrate both continuous and past thirty-day abstinence at twelve months compared to patients who were not adherent. Remarkably, patients who received a fully adherent rating through twelve months were nearly ten times more likely to be continuously abstinent through the entire twelve-month period following residential treatment discharge relative to patients in the nonadherent or partially adherent groups. Therefore, providing psychoeducation to patients before they leave residential treatment during discharge planning sessions on the findings reported here and the apparent long-term benefits of following all continuing care plan elements may address one of the most commonly cited traditional barriers to adherence (e.g., failure on the patient’s part to understand the importance of adherence) and possibly lead to increased motivation and successful long-term outcomes.
It is also important to highlight that adherence was associated with additional long-term benefits beyond abstinence. Although abstinence, or more specifically, remission, is the gold standard of SUD outcomes, it alone is insufficient to fully capture the broader construct of recovery (Betty Ford Institute Consensus Panel, 2007). As such, the use of measures of quality of life is becoming an increasingly more common practice to demonstrate evidence of therapeutic benefit in SUD treatment outcomes research (Donovan, Mattson, Cisler, Longabaugh, & Zweben, 2005). This study found that patients who were fully adherent to their continuing care discharge plans were nearly eight times more likely to report a positive quality of life at twelve months compared to patients who were not fully adherent. This suggests that adherence may impact additional indicators of postresidential treatment functioning. Although the achievement of abstinence was presumably a result of greater adherence to continuing care plans—which in turn likely contributed to patients’ perception of a positive quality of life—testing for the mediating role of abstinence on quality of life was beyond the scope of the current study.
This study included a number of limitations that suggest the need for additional work in this area. First, the context of the current study was a previous evaluation of a protracted, telephone-based care plan management intervention in which all patients received regular contact over the course of an entire year following discharge. As such, the findings reported here may not generalize to all patients discharged from residential treatment given the disparate practices and treatment philosophies that often accompany different programs. Second, the sample was predominately white, and approximately two-thirds paid for their own treatment care out-of-pocket, which warrants caution in generalizing the findings to in-network programs or those serving more racially diverse patients. The overrepresentation of white patients in the current sample is especially salient considering that recent national data indicate that over one-third of national SUD treatment admissions are a member of a racial/ethnic minority group (SAMHSA, 2016). Third, the current study sample was comprised primarily of patients who had successfully completed residential treatment, which may be indicative of higher levels of motivation and readiness to change, and may not be representative of all patients. Additional research is necessary to determine if continuing care plan adherence predicts long-term outcomes among patients who are prematurely discharged from residential care. Finally, closer examination of the role of other relevant factors/barriers likely to impact patient adherence (e.g., employment, transportation, child care) is warranted and requires further investigation.
Despite the study limitations, one can assert the following important conclusion: If patients and providers aspire to positive long-term outcomes following discharge from the primary residential treatment episode, adherence to multicomponent continuing care plans is a requisite—a notion supported by the current study’s reported findings.
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Editor’s Note: This article was adapted from an article by the same authors previously published in the Journal of Substance Abuse Treatment (JSAT). This article has been adapted as part of Counselor’s memorandum of agreement with JSAT. The following citation provides the original source of the article:
Proctor, S. L., Wainwright, J. L., & Herschman, P. L. (2017). Patient adherence to multicomponent continuing care discharge plans. Journal of Substance Abuse Treatment, 80, 52–8.