Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 18 November 2011

The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Contents

How to implement evidence-based treatments

Articles in this bulletin are taken from a special issue of the Psychology of Addictive Behaviors reviewing research on how to implement evidence-based treatments.

What it takes to implement alcohol screening and brief intervention ...

Most comprehensive and systematic attempt yet to map treatment processes ...

Upgrading to evidence-based therapies ...

How to make aftercare the rule rather than the exception ...


Strategies to implement alcohol screening and brief intervention in primary care settings: a structured literature review.

Williams E.C., Johnson M.L., Lapham G.T. et al.
Psychology of Addictive Behaviors: 2011, 25(2), p. 206–214.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Williams at emily.williams3@va.gov.

Applying a systematic and comprehensive framework to map the strategies trialled in attempts to implement screening and counselling for risky drinking primary care patients gives some clues to what it has taken to achieve a high screening rate, the essential first step in the process.

Summary This review's starting points were the observations that screening for risky drinking in primary care patients followed by brief counselling as needed has been shown to reduce drinking, and is in some countries considered a public health priority, yet sustained implementation in to routine clinical practice has not occurred, and what might facilitate implementation remains unclear. To inform implementation efforts, the review drew on the international literature to map evaluated efforts to implement screening and brief counselling, and attempted to relate the degree of success of these implementations to the strategies used to encourage implementation.

To map implementation strategies, the reviewers used the Consolidated Framework for Implementation Research. In respect of health care innovations in general, this model identifies five implementation domains, each divided in to several sub-domains. The five main domains with relevant examples are:
Characteristics of the intervention (in this case, alcohol screening and brief intervention in primary care) such as the strength of the evidence for its effectiveness and how far it was adapted to fit the particular circumstances in which it was being implemented.
Outer setting, which refers to the economic, political, and social environment surrounding and influencing the organisation undertaking the implementation – in this case, typically primary practices and organisations offering primary care services; included here might be national political drivers, the demand from patients and their identified need for the intervention, and the degree to which the implementing organisation is networked with others (such as accreditation bodies) in ways which might promote or hinder implementation of the intervention.
Inner setting is pertinent features of the implementing organisation including the degree to which its structures, internal communication mechanisms, resources, leadership, and culture facilitate the adoption of innovations, and the degree to which the particular innovation 'fits' the organisation's needs and circumstances.
Characteristics of the individuals conducting the intervention – in this case, doctors and other primary care staff – such as what they believe about the intervention and how enthusiastic and ready they are to implement it.
Process of implementation – the extent and quality of the implementation effort, including the degree to which relevant staff are actively engaged, the efficiency with which the implementation is carried out, the extent to which progress is appropriately monitored against specific goals and progress news fed back to the participants, and the extent to which this feedback is used to adapt and promote implementation.

Methodology

English language studies available up to March 2010 were included in the review if they evaluated the implementation of alcohol screening and brief intervention into routine primary care practice when screening and intervention were primarily conducted by usual primary care staff rather than research staff. For each implementation the analysts calculated the screening rate (the proportion of patients who should have been screened actually were) and the brief intervention rate (the proportion of patients who screened positive for risky drinking were actually counselled). These outcomes were related to the extent to which each implementation adopted the implementation strategies mapped in the Consolidated Framework for Implementation Research.

Main findings

Although the analysts found 17 relevant reports, these derived from just eight implementation programmes. These efforts spanned nine countries and involved 533,903 patients (127,304 of whom were screened), 2001 providers, and 1805 medical clinics. Across the programmes the screening rate varied hugely from 2% to 93% and so did the brief intervention rate, from 1% to 73%. The programmes adopted between 7 and 25 of the 38 detailed strategies identified in the Consolidated Framework, generally adopting at least one from each of the five major domains.

At 93%, the US health service for former military personnel screened the highest proportion of the patients intended to be screened. In this study the implementation effort was distinguished by extensive use (12 of 14 sub-domains) of Inner Setting domain strategies, of Process of Implementation strategies (7 of 8 sub-domains), and of Outer Setting strategies (3 of 4 sub-domains). Two other US programmes achieved the next highest screening rates of 65% and 60%. They too used several Inner Setting (5 of 14) and Process of Implementation (4 of 8) strategies, but not to an obviously greater degree than the remaining programmes with much lower screening rates ranging from 2% to 26%.

Of patients who screened positive for risky drinking, again it was the programme mounted by the US health service for ex-military which (at one of the implementation sites) achieved one of the highest proportions counselled. At 71%, their record was exceeded only by the 73% recorded in another US study. As noted above, the programme for former military personnel was implemented using a uniquely broad range of strategies but the same could not be said of the top-ranking programme, and no clearly successful configuration of strategies emerged from the remaining studies, whose rates ranged widely from 1% to 66%.

The authors' conclusions

The programme mounted by the US health service for ex-military personnel reported a substantially higher rate of alcohol screening than others and could be distinguished from other programmes by its focus on multiple elements of the Inner Setting, Outer Setting, and Process of Implementation domains of the framework. Strategies focused on the Inner Setting and Process of Implementation domains also characterised the two programmes next in the screening rate ranking. This suggests that focusing implementation strategies on Inner Setting, Outer Setting, and Process of Implementation domains is associated with high rates of screening. However, the picture was nether detailed nor entirely consistent: implementation programmes with the highest rates of screening did not consistently share a focus on the same sub-domains within these broad categories and, when they did, were not easily discernable from programmes which did not report high rates of screening.

It may be relevant that each of these three very successful screening implementation efforts deployed electronic medical records and some form of performance accountability via measurement and feedback. They also all took place in large, geographically diverse networks of clinical practices with centralised administrations that included a research infrastructure. Possibly their screening successes were partly due to being conducted within infrastructures aligned to the implementation and evaluation of programmes. This is, however, not to say that smaller networks or single practices cannot (perhaps with different methods) achieve good results.

Though for screening rates there was some indication of what distinguishes a successful implementation, this was not the case for the next phase of the procedure, engaging positive screen patients in counselling about their drinking. It seems likely that the strategies necessary to implement screening differ from those necessary for brief intervention. Screening involves the application of a validated screening survey or other method, which can be done either by the patient or by clinical staff at all levels. In contrast, counselling risky drinkers is more complex, typically requiring individualised assessment and judgement regarding the specific feedback and advice to be offered.

Though this review was able to offer limited guidance on what makes for a successful implementation, the framework on which it was based (or other similar frameworks) can be useful in other ways. Firstly, as a roadmap for planning an implementation programme, and secondly, as a structure for documenting the strategies tested in an implementation effort.

However, this particular framework and others too perhaps have their limitations. The framework assumes that a single intervention is being implemented, when, in fact, implementing screening and brief intervention involves multiple steps, each of which may be responsive to different implementation strategies. Also it is often unclear whether a strategy belongs in the Inner or Outer Setting domain. For example, when the clinic where the work is taking place is part of a larger organisation, is that organisation an Outer or Inner domain influence? It also seems likely that there is no single answer to what is needed to successfully implement alcohol screening and brief intervention in primary care practices. In different circumstances, different strategies will be needed and be effective. When for example the existing environment, organisation and staff are already highly conducive to implementation, domains identified by the framework may be less closely related to success than in less conducive circumstances.


Findings logo commentary In recent years Britain has certainly made progress in extending alcohol screening and brief intervention to more primary care patients, but it is unclear whether this has been to the degree needed to make noticeable public health gains, and provision remains patchy. The framework adopted by the featured study offers one way to audit which implementation levers have been activated and which have yet to be adequately activated, revealing the gaps in implementation efforts.

In both England and Scotland, the prime objective for primary care is to screen new patients and/or those thought in advance to possibly be at risk from their drinking. Screening newly registered patients was the reimbursement indicator for the enhanced alcohol service. Initially for two years from 2008 but then extended to March 2013, this requires all primary care trusts in England to offer GP practices in their areas the chance to contract to provide alcohol screening and brief intervention to their new patients. If they wish, local commissioners can go further to contract for more extended services. Also in England, directors of public health are expected to include such activity among attempts to address the population-wide determinants of ill health.

In line with Scotland's own practice recommendations, national policy in Scotland prioritises screening and brief intervention, backed by a health service target for 2008/09–2010/11 to deliver 149,449 brief interventions supported by dedicated funding. The target was exceeded; over the three-year period 174,205 alcohol brief interventions were recorded across the three priority settings – primary care, accident and emergency departments, and antenatal services. In 2008, the Welsh Assembly Government announced its intention to instigate a programme to promote alcohol brief interventions in both primary and secondary health care settings.

These policy initiatives implement guidelines from Britain's National Institute for Health and Clinical Excellence (NICE), which encourage screening for new patients and in circumstances where both patient and doctor might feel it was 'natural' and justified to ask about a patient's drinking. Touching on a key barrier to widespread implementation beyond these circumstances, the guidelines cautioned that, "Clinical consultations for non-alcohol-related medical problems can be an inappropriate time to discuss alcohol use, given that users are focused on the condition for which they are seeking advice", and recognised the greater acceptability of discussing drinking "in a context that is related to the purpose of the visit (such as lifestyle assessment or chronic condition monitoring)".

It is unclear how far things have moved on since 2008 when an national audit found that systematic screening by GPs in England was the exception and few patients were screened or offered brief advice. The requirement to offer screening and intervention contracts to GPs has generated more activity, but far from consistently, and the quality and even the reality of the services supposed to have been provided has been questioned. In London in 2010 a survey of staff responsible for local alcohol policy indicated low levels of investment in developing the role of GPs in screening and treating alcohol use disorders. Nearly two thirds of areas had yet to invest in or develop screening systems beyond those nationally required. In one large London borough not known for the rarity of its drinking problems, over half the practices which had contracted to provide screening failed to identify any risky drinkers using the stipulated screening survey, and in a year screening resulted in just ten people being referred for treatment. Whilst reluctance to address drinking 'out of the blue' is understandable, there is even reluctance to raise the topic in general health and well-being assessments.

As expressed in the featured report, brief interventions have tremendous public health potential. A remaining major challenge is how to consistently realise that potential. This hot topic search retrieves relevant documents on the Findings site, but as yet these do not include the unpublished results from a government-funded national implementation trial in England, whose findings are expected to be highly influential.

Last revised 09 November 2011

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Top 10 most closely related documents on this site. For more try a subject or free text search

REVIEW 2011 Strategies to implement alcohol screening and brief intervention in primary care settings: a structured literature review

REVIEW 2011 Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence

STUDY 2010 Routine alcohol screening and brief interventions in general hospital in-patient wards: acceptability and barriers

STUDY 2013 Screening and brief intervention for alcohol and other drug use in primary care: associations between organizational climate and practice

STUDY 2014 The effectiveness of alcohol screening and brief intervention in emergency departments: a multicentre pragmatic cluster randomized controlled trial

REVIEW 2010 Alcohol-use disorders: Preventing the development of hazardous and harmful drinking

STUDY 2013 Modelling the cost-effectiveness of alcohol screening and brief interventions in primary care in England

STUDY 2010 Use of an electronic clinical reminder for brief alcohol counseling is associated with resolution of unhealthy alcohol use at follow-up screening

STUDY 2012 Alcohol screening and brief intervention in primary health care

STUDY 2013 Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial





Integration of treatment innovation planning and implementation: strategic process models and organizational challenges.

Lehman W.E.K., Simpson D.D., Knight D. K. et al.
Psychology of Addictive Behaviors: 2011, 25(2), p. 252–261.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Lehman at w.lehman@tcu.edu. You could also try this alternative source.

This review encapsulates the range of treatment assessment and improvement tools developed over decades by the Texas Christian University, widely recognised as the most comprehensive and systematic attempt to map the processes involved in treatment and to link these to interventions to improve outcomes for the client.

Summary Sustained and effective use of evidence-based practices in substance abuse treatment services faces both clinical and contextual challenges. In this overview, implementation approaches are reviewed that rely on variations of plan-do-study-act (PDSA) cycles, but most emphasise conceptual identification of core components for system change strategies. A two-phase procedural approach is therefore presented based on the integration of Texas Christian University (TCU) models and related resources for improving treatment process and programme change.

Phase 1 focuses on the dynamics of clinical services, including stages of client recovery (cross-linked with targeted assessments and interventions), as the foundations for identifying and planning appropriate innovations to improve efficiency and effectiveness. Research under this heading has shown that clients presenting to treatment with higher motivation are more likely to participate in treatment during the early months. Better participation during early treatment is then associated with greater rapport with counsellors. Clients who report stronger therapeutic relationships with counsellors show greater improvements in psychological functioning during treatment in the areas of self-esteem, depression, anxiety, social integration, and decision-making. Improved psychological functioning is then associated with favourable behaviour changes (eg, self-report and urinalysis measures of drug use). The model also portrays how specialised interventions as well as health and social support services promote stages of recovery-oriented change. Cognitive strategies (especially those for increasing levels of treatment readiness among low-motivated clients) have proven useful for improving subsequent therapeutic relationships and retention. Assessment instruments that gauge client and programme performance provide a foundation for systematic treatment monitoring and management strategies, and for tracking the evidence for using targeted interventions to improve treatment quality.

Phase 2 shifts to the operational and organisational dynamics involved in implementing and sustaining innovations (including the stages of training, adoption, implementation, and practice). Once relevant new clinical practices are identified, the process of implementing them properly begins with consideration of programme needs and resources, structural and functional characteristics, and general readiness to embrace innovations. Preparation for change is a critical feature for successful implementation. This includes review of both facilities management/services and the clinical model for service delivery. A review of facilities management and services flow helps identify where innovative practices fit into the larger organisational structure to help assure that they are compatible with other organisational practices. A thorough review of the clinical model for care planning helps identify areas where improvements in clinical practices are needed. Surveys of staff needs and functioning provide diagnostic information regarding staff readiness and ability to accept the planned changes. Basically, programmes need to 'know themselves' well in order to successfully guide their organisation toward survival and improvement.

The featured review describes this comprehensive system of TCU assessments and interventions for client and programme-level needs and functioning, and offers examples and guidelines for applications in practical settings.


Findings logo commentary The featured review encapsulates the impressive range of treatment assessment and improvement tools developed over decades by the Texas Christian University's Institute of Behavioral Research, all made freely available from their web site. This suite is widely recognised as the most comprehensive and systematic attempt to map the processes involved in treatment and to link these to interventions to improve outcomes for the client.

The therapeutic and assessment (of patients, staff and organisational health) tools described in this review have been implemented in Britain, notably by the US centre responsible for the featured review. They worked with 44 voluntary and statutory substance use treatment services in and around Manchester, Birmingham, and Wolverhampton. Each took a 'snapshot' of their clients using the US centre's CEST (Client Evaluation of Self and Treatment) forms for the clients, which asked them to rate themselves on statements representing their motivation and readiness for treatment, psychological and social functioning, and engagement with treatment. At the same time, counsellors at the services completed ORC (Organizational Readiness for Change) forms assessing their perceptions of the service they worked for and of their own professional functioning and needs. This work, which represents the most wide-ranging investigation of the organisational health of British treatment services to date, found clients engaged best when services fostered communication, participation and trust among staff, had a clear mission, but were open to new ideas and practices.

Studies are lacking on whether it is possible to deliberately engineer organisational change along the dimensions measured by these assessments in ways which actually improve treatment engagement or outcomes. Such studies are rare probably because change along dimensions like mutual trust among staff, or willingness to listen to their suggestions, cannot simply be introduced by researchers and then studied. However, at least one study has shown that feedback of scores from the ORC organisational health scale developed by the TCU can motivate less well functioning agencies to engage in an improvement programme. Agencies which scored as less open Lower scores on cohesion, communication, and openness to change were associated with a higher likelihood of further work in making improvements in the area(s) identified in an assessment and training workshop designed to improve organisational functioning. to change and staff suggestions – the ones which would normally be least likely to engage in a change process – were the ones most likely to commit to change The study was unable to report whether they actually followed through on this commitment. when faced with the evidence of their shortcomings.

This draft entry is currently subject to consultation and correction by the study authors.

Last revised 15 November 2011

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Top 10 most closely related documents on this site. For more try a subject or free text search

STUDY 2011 Therapist effectiveness: implications for accountability and patient care

REVIEW 2011 Evidence-based therapy relationships: research conclusions and clinical practices

STUDY 2012 A preliminary study of the effects of individual patient-level feedback in outpatient substance abuse treatment programs

REVIEW 2005 The motivational hallo

REVIEW 2011 Implementing evidence-based psychosocial treatment in specialty substance use disorder care

STUDY 2009 The alliance in motivational enhancement therapy and counseling as usual for substance use problems

STUDY 2010 A randomized controlled study of a web-based performance improvement system for substance abuse treatment providers

STUDY 2012 Innovation adoption as facilitated by a change-oriented workplace

STUDY 2009 Relating counselor attributes to client engagement in England

REVIEW 1999 Barriers to implementing effective correctional drug treatment programs





Implementing evidence-based psychosocial treatment in specialty substance use disorder care.

Manuel J.K., Hagedorn H.J., Finney J.W.
Psychology of Addictive Behaviors: 2011, 25(2), p. 225–237.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Manuel at jennifer.manuel@ucsf.edu. You could also try this alternative source.

Does implementing evidence-based psychosocial therapies actually lead to the intended practice changes and do these make things better for the clients? From this review, most clearly when the whole organisation is enrolled in the effort and training is bolstered by systematic and expert continuing supervision.

Summary The main aim of this review was to analyse research on the implementation of evidence-based psychosocial or behavioural (not pharmacological) treatments in specialist substance use treatment services to identify factors associated with more and less successful implementation. Where this seems useful and important, the data given in the review has been supplemented by Findings based on the original studies.

First the review identified which treatments are generally agreed to be 'evidence-based'. Among these are behavioural couples therapy, cognitive-behavioural therapy (including relapse prevention), contingency management, motivational enhancement/motivational interviewing, and 12-step facilitation treatment. Brief alcohol interventions are also widely viewed as evidence-based. Despite their research backing, there remains concern about whether findings from trials of these therapies will be replicated in routine community care settings. Often trials have optimised the chances of the treatment working, for example, by excluding patients with co-morbid disorders or who are so socially unstable that they might be hard to re-contact. Once in treatment, efforts not typical in routine care may be made to promote attendance and therapists may be unusually well qualified, trained and supervised.

In 2007 a survey found that nearly all (96%) of US specialist substance use treatment services deployed two non-evidence based approaches – counselling and 12-step treatment. However, some evidence based approaches were widely said to be used "often", notably relapse prevention (91% of facilities), cognitive-behavioural therapy (69%), motivational interviewing (56%), and contingency management (20%).

Main findings

The review then identified 21 studies of how successfully (based on therapist and/or client outcomes) evidence-based psychosocial or behavioural approaches had been implemented in specialist substance use services. In all the studies, implementation efforts included some type of workshop or didactic training. Just four studies were able to use client outcomes to assess the success of these efforts.

The accounts of the treatment providers and therapists themselves indicated that implementation programmes had enhanced knowledge and understanding of the new intervention and willingness to adopt it or led to actual adoption. However, two studies found such accounts were unrelated to how well therapists actually conducted the new intervention (in both cases, motivational interviewing).

Twelve studies avoided relying on provider accounts by actually observing interactions (or records of interactions) between therapists and real or simulated clients. Some found training did improve therapist skills, but that these skills decayed over time. An exception was a study which found that fidelity of implementation and skill levels increased in the follow-up period after training in cognitive-behavioural therapy, but only among therapists assigned to continuing post-training support in the form of supervision based on tape recordings of sessions or, less notably, continuing access to web-based training. Based on these studies, it seems that skill gains are not uniform across providers, nor are they necessarily sustained.

Of the four studies which assessed client outcomes, three found that (relative to former or usual treatments) these improved after therapists had been trained in new interventions. One found fewer positive urine tests among US cocaine dependent patients treated by therapists newly trained and expertly supervised in a network-based therapy compared to normal treatment alone. Another US study also featured post-training supervision, in this case based on tapes of therapy sessions. It found that patients of therapists trained in and who practised a therapy based on motivational interviewing were less likely to report use of their main substance than patients counselled in the usual way at the service. Moreover, the patients of more skilled and competent motivational therapists were less likely to test positive for illegal drugs and expressed greater increases in motivation. In a US study of Multidimensional Family Therapy for adolescent substance users, abstinence rates improved following implementation of the new approach. Again the implementation strongly featured post-training expert supervision based partly on actual therapy sessions. The sole exception to the improvement in client outcomes was another US study of the implementation of cognitive-behavioural therapy compared to usual treatment.

Another four studies not only offered trainees support additional to workshops, but tested whether these enhancements led to the expected improvements. In respect of motivational interviewing, skills of US therapists improved to a clinically significant degree only when workshops were supplemented by feedback on actual performance with clients and/or expert coaching. However, it took both coaching and feedback to increase the degree to which four months after training real clients expressed the desire and intention to change their substance use and reduced the degree to which they resisted such changes. In the context of US services for adolescents offering comprehensive family and related interventions, problem cannabis users were referred to a study of the introduction of contingency management techniques in to the programme. For randomly selected therapeutic teams, a workshop was supplemented by intensive quality assurance featuring (among other elements) weekly expert case consultation and quarterly booster training. According to reports from the children and their parents, these enhancements did increase the extent to which therapists implemented cognitive-behavioural elements of the training (and according to the children these changes were sustained) but not the core contingency management procedures of ensuring urine tests for drugs were conducted and followed by sanctions or rewards.

In contrast, two further studies of enhancements to motivational interviewing training found no benefits. One replaced the usual two-day workshop with short training sessions over a more extended period featuring feedback on the therapists' performance with simulated clients. This led to no temporary or lasting improvement in skills. Similarly in respect of US military substance abuse counsellors offered feedback on their sessions with a simulated client and regular expert phone consultations additional to a workshop. In both studies what was striking was that trainees whose attitudes to treatment were not conducive to adopting a motivational approach benefited relatively little even from the extended training and supervision.

In six of the 21 studies implementation efforts extended beyond work with individual therapists to organisation or systems levels, including supervisors, programme directors, or staff representation in the training and other efforts. Overall, these six studies had successful outcomes and most agencies reported adoption of the new treatment. Therapists were more likely to adopt the new evidence-based approaches if they had been supported or mandated to do so by agency leaders or supervisors, though in one study supervision, and therefore possibly treatment fidelity, decreased over time. However, just one of the six studies assessed whether client outcomes had improved as a result of the system-wide or organisation-wide efforts. It found that youth in family therapy were more likely to be abstinent from substance use after the implementation programme had been completed.

The authors' conclusions

The review highlights the need for more conceptually driven, organisationally focused (not just individual provider-focused) approaches to implementation. It also raises the possibility that, at least in some situations, it may be more effective to implement evidence-based practices or processes rather than evidence-based treatment packages. In this scenario, training would emphasise not distinct treatment approaches, but common treatment processes, such as promoting support, goal direction, and structure in treatment and in clients' life contexts, enhancing clients' involvement in new rewarding activities, and building their self-efficacy and coping skills. Such an approach to implementation enables the new learning and skills to build on and be integrated with current approaches rather than replacing these approaches, and promises a more individualised delivery of treatment.

Across the 21 reviewed studies motivational interviewing or motivational enhancement therapy and contingency management were the most widely implemented evidence-based psychosocial treatments and workshops were universally used as the basic training vehicle. Most studies found that therapist knowledge and skills improved after these workshops but often whether these improvements were sustained was not measured and when it was, sometimes the results were negative. The implication is that training should be seen as an ongoing process, with continuous opportunity for discussion and learning, rather than a time-limited activity.

However, when such enhancements were trialled they were not always successful, though relevant studies were few. One factor which may partly account for this variability and other differences in the impact of training is therapists' pre-training general clinical skills and their skills in relation to the particular approach being implemented. It may be that a minimal level of motivation and skill is needed for the successful adoption of motivational interviewing (and other evidence-based treatments). On the other hand, very high pre-existing levels of motivation and skills related to the new approach may leave little room for training to generate further improvement.

Reviewed studies and other literature suggest that the chances of a successful implementation are raised when the entire agency is the focal point, rather than individual therapists. This process may be most successful when it begins with an assessment of the needs of the agency and its clients, and a discussion of how a new intervention may best fit into or be adapted for the agency. Training in the intervention should include ongoing supervision, coaching, feedback from taped sessions, and opportunities for discussions regarding implementation barriers. Agency administrative support and ongoing supervision may not be a panacea for provider conflicts and time demands when attempting to implement new treatments, but they can facilitate discourse between agency leaders and staff regarding providers' apprehensions or conflicts about learning a new treatment. Such support may be necessary to overcome barriers to implementation.


Findings logo commentary The four studies which actually assessed whether clients benefited from the trialled implementation efforts go the heart of why such efforts are commonly mounted so are described here in greater detail. None afford an entirely consistent and convincing demonstration that implementing evidence-based therapies improves substance use outcomes for the clients. The evidence seems strongest for motivational therapies and those based on the client's social network. The clear failure was cognitive-behavioural therapy, one of the most widely implemented and respected approaches to substance use problems.

A study of network-based therapy found fewer positive urine tests among US cocaine dependent patients treated by therapists newly trained and expertly supervised compared to normal treatment alone. However, in this study the new therapy was additional to normal treatment, and neither patients nor therapists were randomly allocated, raising questions over whether the improvements were due to extra therapist contact time or differences between patients and therapists, rather than the impact of the training.

Another US study also featured post-training supervision, in this case based on tapes of therapy sessions. It found that patients of therapists trained in and who practised a therapy based on motivational interviewing were less likely to report use of their main substance over the 12 weeks (during which they may have continued to receive usual treatment at the service) following the end of the four-week trial treatment phase. However, they were not retained in treatment any longer, nor were their urines any more likely to be test free of illegal drugs during the four weeks of treatment. In this study the motivational intervention replaced usual counselling and both patients and therapists were randomly allocated, increasing confidence that the results were due to the training and implementation of the new therapeutic approach.

In the same study, the patients of more skilled and competent motivational therapists were less likely to test positive for illegal drugs during the four-week treatment phase and expressed greater increases in motivation. These associations were very modest, and most consistent between the use of fundamental and advanced motivational interviewing skills and greater competence on the hand, and the degree to which clients expressed increased motivation to reduce or stop substance use over the course of a therapy session. However, these findings from the four-week trial treatment phase were not accompanied by greater abstinence rates from the main drug the client was using in the following 12 weeks, creating a puzzling configuration of findings: being allocated to the new therapy improved main drug abstinence outcomes after the treatment phase, but not to any greater extent the more competently and skilfully it had been implemented.

There was a somewhat mixed picture too in a US study of Multidimensional Family Therapy for adolescent substance users. The key finding was that more young people became abstinent from a range of substances over a nine month follow-up period if they had entered treatment following implementation of the new approach. However, there were no such improvements in the frequency with which they used substances and the clinical significance of the increased rate of total abstinence is unclear. This was a very long-term study. Young people who started treatment before the training did so from 20 to 50 months earlier than those who entered treatment after training and researcher-backed supervision had ended. It was between these two phases that abstinence outcomes had most clearly improved to a degree which might have survived more rigorous statistical testing taking in to account the number of comparisons made in the study. But over such a period much can happen; in particular, the nature of the adolescent caseload changed significantly. Lastly, as the authors warned, this was one effort at one clinic, the results of which may not generalise to others.

The sole exception to the improvement in client outcomes associated with training was another US study of the implementation of cognitive-behavioural therapy compared to usual treatment. Even when this therapy was additional to usual outpatient treatment it created no added value in terms of abstinence from substances in general or the client's focal substance. Intense training and post-training supervision based on videos of the therapists' therapy sessions, and the fact that therapists all achieved at least adequate competence and skill levels, make inadequacies in the training an unlikely cause of the failure of clients to gain from the implementation. Failure to actually practice cognitive-behavioural therapy after the training can also be ruled since this was monitored and there were no client outcome differences between a high fidelity and lower fidelity implementation. At least two possible reasons for the negative findings remain. One that clients in the treatment-as-usual arm of the study improved so much that there was little room for extra improvement, possibly related to the criteria for joining the study which included a willingness to quit substance use rather than just cut back and a degree of social stability and connectedness. Among other criteria, these excluded over 8 in 10 of the patients screened for the study at an outpatient treatment service. The other possibility is that cognitive-behavioural therapy is actually no more effective than therapy as usually practiced at the clinics in the study. Supporting this interpretation, a synthesis of studies comparing this therapy with other treatments for alcohol or drug problems did not find it clearly more effective than other similarly extensive and coherent approaches.

Last revised 10 May 2013. First uploaded 12 November 2011

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Top 10 most closely related documents on this site. For more try a subject or free text search

STUDY 2012 Implementation issues in an innovative rural substance misuser treatment program

REVIEW 2006 My way or yours?

STUDY 2011 An experimental demonstration of training probation officers in evidence-based community supervision

REVIEW 2005 The motivational hallo

REVIEW 2011 Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence

REVIEW 2011 Evidence-based therapy relationships: research conclusions and clinical practices

MATRIX CELL 2013 Drug Matrix cell B4: Practitioners; Psychosocial therapies

REVIEW 2005 Effectiveness of workshop training for psychosocial addiction treatments: a systematic review

MATRIX CELL 2014 Alcohol Matrix cell B4: Practitioners; Psychosocial therapies

STUDY 2009 The alliance in motivational enhancement therapy and counseling as usual for substance use problems





Implementation of evidence-based substance use disorder continuing care interventions.

Lash S.J., Timko C., Curran G.M. et al.
Psychology of Addictive Behaviors: 2011, 25(2), p. 238–251.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Lash at Steven.Lash@med.va.gov. You could also try this alternative source.

As this review comments, people treated for substance use often remain precariously balanced between recovery and relapse. Widely seen as valuable if not essential, aftercare is nevertheless more the exception than the rule. How to reverse that ratio is the issue addressed by these leading US analysts.

Summary Continuing care or aftercare is the stage of treatment following initial, more intensive, treatment. This review focused on psychosocial continuing care interventions (such as individual, telephone, couples, and group therapy; case management; home visits; and brief check-ups) and 12-step mutual aid support groups. Studies of brief continuing care interventions (up to six months) have usually involved standard programmes provided after residential treatment. In contrast, most longer interventions are adapt their frequency or nature in response to systematic assessments of how well the client is doing.

Despite a broadly supportive research record, few efforts have been made to implement and sustain these interventions, and in practice few clients who might benefit from continuing care services actually receive a sufficient dose, either because they do not complete the initial treatment, do not start continuing care, or do not remain in it for a significant time. Among other things, this review seeks to better understand this discrepancy and make recommendations for future implementation efforts.

Effectiveness of continuing care

Though this review and studies have focused on either continuing care treatment or mutual aid groups, it should be remembered that many individuals participate in both and that using both sources of support is associated with the most improved treatment outcomes.

Studies have shown that receiving continuing care services is generally but not always associated with improved long-term substance use outcomes. This small and varied corpus of studies precludes conclusions about which approaches work best. However, the findings support certain general principles. Among these are increasing the duration of care to at least a year, ongoing monitoring of clients, reaching out actively to engage and link clients to care, and using incentives to improve treatment outcomes. Relatively low-cost practices can dramatically improve rates of sustained engagement in continuing care such as low level incentives and active outreach following discharge or drop-out. In contrast, the theoretical orientation and intensity of the interventions appear less important.

As well as or instead of continuing care treatment services, mutual aid groups are important continuing care resources. The most prevalent like Alcoholics Anonymous and Narcotics Anonymous follow 12-step principles. Several studies have shown that attending these groups after initial treatment is associated with positive substance use outcomes, though they are unable to prove that attendance causes these gains. Additional to attendance as such, being more involved in the groups (such as getting a sponsor or reading 12-step literature) has also been associated with better substance use outcomes. In practice though, while most US patients start attending groups, most of these are no longer attending a year later.

Interventions to promote participation in 12-step mutual aid groups can be traced to the Twelve Step Facilitation therapy trialled in Project MATCH. This large US study of treatment for alcohol dependence found this approach achieved significantly higher rates of continuous abstinence (and equivalent outcomes on other drinking measures) than cognitive-behavioural therapy and a therapy based on motivational interviewing, and did so because it led more patients to engage in 12-step activities. Similar results have emerged from other studies.

Implementing continuing care

A search for studies not of the effectiveness of continuing care, but of how to implement it, uncovered 28 relevant articles and others known to the authors of the review or referenced in the literature. To organise the analysis of these studies, the reviewers used the Consolidated Framework for Implementation Research. In respect of health care innovations in general, this model identifies five implementation domains, each divided in to several sub-domains. The five main domains with relevant examples are:
Characteristics of the intervention (in this case, continuing care) such as the strength of the evidence for its effectiveness and how far it was adapted to fit the particular circumstances in which it was being implemented.
Outer setting, which refers to the economic, political, and social environment surrounding and influencing the organisation undertaking the implementation – in this case, typically substance use treatment services; included here might be national political drivers, availability of funding, the demand from patients, and (especially in the case of 12-step groups) the degree to which the broader society is receptive to the intervention's philosophy.
Inner setting is pertinent features of the implementing organisation including the degree to which its structures, internal communication mechanisms, resources, leadership, and culture facilitate the adoption of continuing care or the particular continuing care intervention being implemented.
Characteristics of the individuals conducting the intervention – in this case, typically addiction counsellors – such as what they believe about the intervention and how enthusiastic and ready they are to implement it.
Process of implementation – the extent and quality of the implementation effort, including the degree to which relevant staff are actively engaged, the efficiency with which the implementation is carried out, the extent to which progress is appropriately monitored against specific goals and progress news fed back to the participants, and the extent to which this feedback is used to adapt and promote implementation.

Generally not enough research has been done to be able to designate specific interventions as 'evidenced-based'. However, in the aftercare area there is growing research supporting 'Contracting, Prompting and Reinforcing' aftercare attendance. This involves a written attendance contract specifying awards for attendance consisting of medallions and certificates, plus further reinforcement in the form of handwritten letters congratulating the patient on initiating and sustaining aftercare. Letters from the therapist, appointment cards and automated telephone reminders prompt patients to attend the next session in a few days time. Non-attendance is followed by a letter and phone call from the therapist.

The mutual-aid literature has one clear example of a specific and manualised intervention – Twelve Step Facilitation therapy, an approach which has been successfully adapted to different circumstances and populations. More general evidence-based interventions for promoting continuing care typically entail active and directive efforts to engage and retain clients, including education on the benefits of the groups, orientation to involvement with these groups, and connection with group members to help motivate involvement following initial treatment.

In more detail and organised under the main headings of the Consolidated Framework for Implementation Research, research offers the following guidance.

Intervention Characteristics Clinicians generally know that the evidence for continuing care is strong yet often continue to use interventions and practices without empirical support. A significant number of studies suggest that many interventions can be adapted to the needs of specific sites. Twelve Step Facilitation therapy has for example been successfully adapted to a group format, to focus on individuals' broader social networks rather than just 12-step groups, and to accommodate individuals with mental health as well as substance use problems. Similarly, treatment-based continuing care efforts have been conducted successfully using telephone and home-based visits and with different types of providers. One difficulty is the relative complexity of such interventions. Knowledge gaps include the relative advantages and cost-effectiveness of different continuing care interventions, and what are their core or essential components as opposed to those which can safely be adapted.

Outer Setting The most frequently cited factors related to successful continuing care implementation are located in the outer setting domain, especially the importance of client characteristics such as their needs and resources to support continuing care involvement. African-Americans (compared to Caucasians), and clients with more severe substance use problems, are more likely to engage in continuing care for a longer time. Psychiatric disorders seem no barrier to engagement in continuing care. Patients who see staff members as supportive and have more recovery resources are more likely to engage in treatment-based continuing care. Clients with beliefs consistent with a disease model or spiritual approach to recovery, women, and those with less prior experience with 12-step groups, may be more easily engaged in mutual aid groups, and those mandated to attend by courts may do as well as those who are not. In addition to client characteristics, the convenience of continuing care is an important facilitating factor while lack of funding is a common and significant barrier. Additionally, inviting mutual aid group members to contact patients in the initial treatment service facilitates post-treatment linkages. The role of external incentives and policies appears to be an extremely important area for future implementation efforts to address and better understand.

Inner Setting Focusing on the treatment service, those oriented to 12-step approaches facilitate linkage to 12-step mutual aid. Low rates of staff and supervisor turnover and multi-stakeholder involvement are important to sustaining continuing care treatment interventions. Goals or benchmarks that allow programmes to monitor performance and modify interventions in response are important factors in successful continuing care implementation. Mutual aid group engagement is facilitated by strong therapeutic alliances, greater supportiveness, and spirituality during initial treatment. Use of incentives with staff to promote implementation of continuing care practices appear to be a potentially powerful, but underused facilitator. Little is known about the implementation climate, including goals and benchmarks for continuing care interventions, or about the role of programme readiness for change (eg, resources and knowledge) as they relate to continuing care implementation.

Characteristics of the individual provider Treatment and mutual aid continuing care implementation are facilitated by providers and programme leaders with beliefs and attitudes supportive of the particular intervention, while a lack of knowledge about the effectiveness of interventions can be a significant barrier. Additionally, clinicians who are in recovery themselves, who have fewer concerns about religion or spirituality as a part of treatment, without allegiance to non-12-step approaches to treatment, and those who require abstinence during treatment, are more likely to facilitate 12-step mutual aid involvement following treatment. It is clear that future implementation efforts will need to address important characteristics such as the knowledge, beliefs, motivation, and self-efficacy of both providers and clients to maximise the potential for implementation success.

Implementation Process Successful continuing care implementation efforts have tended to address the important constructs of planning, engaging, executing, and reflecting and evaluating implementation efforts. These activities will be critical in the development and testing of implementation strategies.

Implication for researchers and clinicians

Having summarised continuing care implementation research, the review ended by drawing out the implications of these findings for researchers and clinicians. Though scarce, viewed through the lens of the Consolidated Framework for Implementation Research, existing research provides a starting point for closing the gap between research and clinical practice. Formative evaluations intended to develop interventions to promote continuing care should be informed by this literature, and these evaluations should address all five domains, or deploy other comprehensive implementation models. Additionally, two primary recommendations emerge from this review.

Basic Continuing Care Implementation Research Is Needed Despite its clinical importance, continuing care implementation research has been relatively neglected. Both the treatment and mutual aid continuing care implementation literature have findings relevant to all five major domains of the Consolidated Framework for Implementation Research, but all the detailed strategies and factors within each domain have yet to be addressed. One of the most striking gaps is the lack of information on the relative advantages, disadvantages, and cost-effectiveness of continuing care interventions. Little is known too about and their core elements and the impact of incentives and/or consequences related to both the inner setting and outer setting domains.

Implementation Efforts Need to Address Multiple Domains The comprehensiveness of the Consolidated Framework for Implementation Research highlights that implementation efforts typically do not consider the importance of intervening across multiple domains. For instance, as already noted, the role of incentives and consequences in the inner setting and outer setting domains and at patient, counsellor and programme level, has been neglected. This review suggests that closing the gap between knowledge about continuing care interventions and their use will require a paradigm change in which both researchers and clinicians consider intervening across multiple domains rather than within a single domain, as has been typical thus far. Research-established interventions may have too few implementation facilitators and too many barriers for them to be adopted in particular settings without attention to all the relevant domains.

People treated for substance use often remain precariously balanced between recovery and relapse following initial treatment. As currently designed, the utility of treatment is limited by high post-treatment relapse and re-admission rates, and frequently prolonged addiction and treatment careers. Assertive linkage to continuing care helps individuals transition from brief experiments in sobriety (recovery initiation) to disease management and sustainable recovery maintenance, and an enhanced quality of life. It requires close connections between the worlds of professional treatment and community recovery support resources, and implementation of continuing care promotion procedures to enhance engagement and retention with these resources.


Findings logo commentary In the UK financial constraints and the recovery agenda have brought with them potentially conflicting expectations that treatment will end as soon as the patient seems able to manage on their own and rarely extend over years, yet will do more to reintegrate patients in society. More patients exiting briefer treatments would create an increasing potential caseload for aftercare services to ensure they remain safe and can rapidly re-enter treatment if relapse occurs or is threatened. How this configuration of forces will pan out and what it will mean for extended care in the form of aftercare or continuing care is unclear. Funders seeking to contain costs and maximise drug-free treatment exits may be reluctant to fund aftercare services, especially since UK research evidence that they make a difference is lacking, probably because studies have been few. On the other hand, low-cost, check-up style aftercare allied with free mutual aid groups may make it more acceptable to cut back on intensive and expensive initial treatment. These considerations are expanded on below.

The main recent British attempt to evaluate the contribution of aftercare was an analysis of the Scottish DORIS study. On several measures, it found that the few drug dependent patients who accessed aftercare after treatment in the early 2000s did better than the majority left to (or who chose to) fend on their own. However, it was unclear whether this could this be attributed to the aftercare, or whether these patients would have done well anyway. An attempt to statistically control for differences between patients still left recently being heroin free at the last 33-month follow-up associated with having received aftercare from the initial treatment agency. Having received aftercare following methadone maintenance or residential rehabilitation made little difference to whether patients had experienced a period of being entirely drug free. But consistently at each of the three follow-ups, aftercare following non-methadone community treatment like detoxification or psychosocial therapy was associated with about double the chance of having been drug free.

Formal aftercare from the treatment agency was not the only way patients sought to sustain their abstinence. Over the 33 months of the follow-up, nearly a quarter attended mutual aid groups like NA and AA. At each of the follow-ups, patients who had accessed aftercare and mutual aid were most likely to have been drug free for a period, generally those who accessed neither were least likely, and those who accessed one but not the other were in between.

Whatever the meaning of these findings for aftercare's effectiveness, it was clear that few patients received it, and neither was it targeted at those most at risk of relapse.

An English study of problem drinkers could more securely attribute the results to aftercare enhancements, because patients were randomly allocated to normal aftercare – up to three weekly support groups plus access to the unit's recreational and social facilities – or to an additional 15 individual sessions modelled on an influential US approach called Early Warning Signs Relapse Prevention Training. During this, patients are helped to recognise personal warning signs of relapse by analysing their most recent attempts at recovery, and then to develop ways to manage these episodes without a return to drinking. Over the following year the benefits of more intensive aftercare were reflected in significantly fewer drinking days (22% of warning sign patients drank on a fifth or more of days compared to 40% in usual aftercare), fewer heavy drinking days (corresponding figures 18% and 28%), avoidance of any return to heavy drinking (45% v 26%), and improved mental well-being. In monetary terms, warning sign patients absorbed slightly less health service and rehabilitation resources, though slightly more if the warning sign regime was itself costed in. However, neither difference approached statistical significance.

In agreement with the featured review was a review of 11 studies which allocated patients at random or in a quasi-random manner to continuing care versus minimal or no continuing care. In terms of each study's main substance use outcome measures, seven of the 11 found a clear That is, not counterbalanced by a contrary finding on another primary measure of substance use. and statistically significant advantage for continuing care. The review's conclusions were endorsed by a panel of experts convened by the US Betty Ford Institute, who argued that extended and regular monitoring of the patient's progress was the key component of continuing care and the one with the greatest evidence of effectiveness. Both review and recommendations were based largely on studies of aftercare following residential treatment.

While international and to a degree UK research is at least consistent with aftercare often being an aid to lasting remission, recommendations that it be implemented run up against a strong contrary trend in current UK policy, which emphasises not continuing care, but exit from the treatment system. Without denying the need for long-term care for some patients, the English strategy on drug misuse said services needed "to become much more ambitious for individuals to leave treatment free of their drug or alcohol dependence so they can recover fully ... We will ensure that all those on a substitute prescription engage in recovery activities and build upon the 15,000 heroin and crack cocaine users who successfully leave treatment every year free of their drug(s) of dependence". Scotland's strategy too stressed the need for more patients to "move on from their addiction towards a drug-free life as a contributing member of society", implying a corresponding shift away from extended and/or indefinite treatment.

Set against this drive to contain treatment, the recovery agenda has brought with it a greater emphasis on sustained and extensive life change, and an accompanying expectation that treatment services will do more for their patients than a brief treatment for their addiction. At the same time resources are no longer increasing and probably diminishing overall. One way to square this circle is to draw on the free resource of mutual aid groups which offer former patients 24-hour access to support, frequent support meetings, a new social circle, and a new way of life. It comes therefore as no surprise that they feature in recent commissioning guidance from England's National Treatment Agency for Substance Misuse, which sees them as providing "valuable support and positive social networks for individuals who are addressing their dependency through treatment". The advice to services is that "Details of how clients can access local recovery networks should be made available throughout their treatment journey. Services may wish to consider more active engagement with local mutual aid groups, for example making rooms within the treatment service or prisons available for meetings". The agency now sees (see annual reports for 2009–10 and 2010–11) promoting mutual aid networks as a key way to achieve its objectives. Local service commissioners are being called on to ensure that the treatment system is better integrated with wider supportive services, among which mutual aid organisations are seen as the most prominent.

To see all Findings analyses relating to aftercare and continuing care run this search.

Thanks for their comments on this entry in draft to Steven Lash of the Salem Veterans Affairs Medical Center in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 16 November 2011

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