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Walker D.D., Stephens R.S., Towe S. et al.
Journal of Substance Abuse Treatment: 2015, 56, p. 11–15.
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 Walker at firstname.lastname@example.org.
Arranging aftercare check-ups to see how cannabis-dependent patients were doing and whether they needed to return to treatment helped sustain cannabis use reductions – but why did this advantage emerge even before the first check-up?
Summary After up to nine sessions of outpatient therapy over up to 12 weeks based on motivational interviewing and cognitive-behavioural principles, the featured study tested whether arranging check-ups to see how patients were doing and whether they needed to return to treatment would help sustain cannabis use reductions. Patients were dependent on the drug (but not on other substances) and before starting treatment had used cannabis on at least 50 of the past 90 days.
Tested whether arranging post-treatment check-ups to see how patients were doing and whether they needed to return to treatment would help sustain cannabis use reductions among patients dependent on the drug.
Compared to a randomly allocated no check-up group, up to six months after treatment patients offered check-ups were more often abstinent from cannabis and used the drug less frequently.
However, these advantages emerged before the first check-up so were not a result of that experience but perhaps of its anticipation.
126 adults who responded to media adverts offering cannabis use treatment in the Seattle area of the United States met the study’s criteria. The 74 who joined the study were randomly assigned to the initial treatment with or without check-ups being scheduled about a month after treatment was meant to end (four months after baseline pre-treatment assessments) and again three months later. Before the start of the study they were using cannabis on average six days in every week. To test the impacts of treatments and check-ups, research staff re-assessed the patients roughly at the end of scheduled treatment (ie, before the first check-up) and six months later (ie, after the two check-ups) chart below. At these times nearly all the check-up patients could be re-assessed but only three-quarters of comparison patients. Urine tests generally confirmed the patients’ reports of their cannabis use versus non-use. Typically participants were white single men in their late 30s.
Check-up sessions were conducted by the therapist who had treated the patient initially and who (for both sets of patients) also delivered additional sessions if the patient opted to return. Check-ups included face-to-face feedback on a brief computerised assessment of changes in cannabis use, related problems, and dependence symptoms, a review of pre-treatment goals and how cannabis use hampered their achievement, and updating goals for cannabis use. Aims were to reinforce reduced cannabis use and improvement in life functioning, and to identify ongoing concerns which warranted return for more of the same kind of therapy offered initially. Comparison patients were not offered check-ups but could also return to treatment at any time.
About 8 in 10 check-up patients attended each of the two check-ups, and 62% attended on average 4.3 additional treatment sessions compared to 46% and 2.8 sessions for comparison patients, not statistically significant differences.
Though treatment uptake did not significantly differ, cannabis use did, and differences favouring check-up patients emerged even before the first check-up. A month preceding this at the first follow-up point, 36% of check-up patients had not used cannabis in the past 30 days and on average they used on a quarter of the days compared to 13% and half the days among comparison patients. Six months later and after the both check-ups, these advantages had been more or less sustained but not significantly augmented. At this time 26% of check-up patients had not used cannabis in the past 30 days and on average they used on just over 4 in every 10 days, compared to 7% and nearly 6 in 10 days among comparison patients. Except for cannabis use days at the final follow-up, all these differences met the study’s criterion for a statistically significant difference chart right. There were however no appreciable or statistically significant differences in severity of dependence on cannabis or in related problems.
Patients were also asked how confident they felt in their ability to resist using cannabis in various high-risk situations, confidence which at the end of initial treatment had strengthened significantly more among check-up than comparison patients.
Unexpectedly, patients assigned to check-ups did not return to treatment significantly more often than comparison patients, their greater reduction in cannabis use was apparent even before the first of the check-ups, and experiencing these did not create further significant improvements. Though assignment to check-ups had led to more patients avoiding cannabis use and fewer days of use, this was not a direct effect of the initial check-up; check-ups worked, but not in the way expected.
Probably the promise of extra support in the form of check-ups bolstered expectations of success in reducing cannabis use which translated to actual behaviour, an explanation consistent with these patients’ greater confidence at the end of treatment in their abilities to avoid cannabis use.
Attendance at check-ups was excellent, suggesting that ongoing interaction with treatment providers was attractive to the patients, as did the fact that over half in each group took up the offer of further treatment. The implication is that many found the initial (on average seven) sessions insufficient.
The analysis was limited by a small sample size and a short follow-up period. More substantial benefits of check-ups might emerge later and/or as a cumulative result of multiple check-ups.
commentary The key finding is that offering check-ups helped sustain post-treatment abstinence and moderate continuing use. Somewhat clouding these findings however is that more comparison patients were lost to follow-up. It means that of the 37 in each group, about 22 check-up patients were known to have used cannabis during the month before the first follow-up versus 24 comparison patients, a minor difference. By including proportionately more zeros in the calculation, the way the study calculated the difference in abstinence rates would also have bolstered the difference in the proportion of days of cannabis use. Among those known to have used cannabis at all in the month before the first follow-up, the difference in favour of check-up patients was about 41% of days versus 59% of days. These attenuated figures perhaps help make sense of there being no appreciable differences in severity of dependence on cannabis or in related problems. Clouding the implications of the findings are the missing 4 in 10 patients who could have joined the study but refused, leaving it unclear whether across the whole caseload there would have been any advantage from the check-ups.
Despite these methodological issues, the probability is that offering check-ups really did bolster abstinence and moderate use, though perhaps not as much as the presented figures suggest. That would be in line with findings from 19 randomised (or effectively randomised) trials, across which continuing care or aftercare after initial treatment modestly helped sustain substance use reductions.
Check-ups in the featured study were adapted from those trialled with a mainly cocaine-using caseload in Chicago and found to have modestly but persistently reduced substance use, apparently consequent on greater treatment access and engagement. In those studies check-ups relied on research staff who screened patients for need to return to treatment before referring them to a ‘linkage manager’ to promote treatment re-entry. More realistically, the featured study used the patient’s initial therapist for all tasks including any resumed therapy, arrangements which ought to reap the efficiency and effectiveness gains of continuity.
The mystery in the featured study is why the advantages of the check-ups emerged even before patients experienced them. Greater expectation of success in curbing cannabis use leading to more actual success was the researchers’ speculation, in line with bolstered confidence in resisting the drug’s attractions. Similar findings have emerged in respect of initial treatment entry, when substantial improvements have been noted after a substance user has taken the decision to start treatment but before it has started, and even if it does not start at all (1 2 3), and are associated with more lasting success. Such findings are common too outside substance use treatment in the general psychotherapy literature.
Whatever the mechanism for these pre-treatment improvements (perhaps the decision to seek treatment was part of and crystallised a resolve to deal with one’s substance use problems) the situation for the patients in the featured study – who had already completed treatment – was quite different. Apart from the explanation offered by the researchers, factors might have included the prospect of being ‘checked up on’ by the therapist to whom you may have said you were going to (try to) control your cannabis use, who might be disappointed in themselves and in you if their efforts had failed, and fear of looking like a ‘no-hoper’ to someone you have developed a relationship with.
See the commentary to an Effectiveness Bank analysis of a another check-up study for a discussion of the place of aftercare in UK policy. To see all analyses relating to aftercare and continuing care run this search.
Last revised 18 September 2015. First uploaded 11 September 2015
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