- Extended Continuing Care
- Adaptive Treatment
- Treatment Enhancements
- Identifying Mechanisms of Change in Behavioral Interventions
It is now generally accepted that substance use disorders can be chronic conditions for many patients who enter the treatment system. One of the primary research areas of the Continuing Care and Assessment Division is the development and evaluation of extended continuing care treatment models that are designed to better manage substance use disorders over time. These models provide care for as long as 24 months, through a combination of face-to-face clinic visits and telephone monitoring and counseling. Research in this area is currently focused on the efficacy of different long-term interventions, methods to enhance sustained participation in treatment, and economic issues such as the cost-effectiveness and benefit-cost of the interventions.
Recent work done by researchers at Penn and other institutions suggests that adaptive treatment models may provide a solution to many of the problems that interfere with the successful implementation of a continuum of care approach to the treatment of addiction. These models are designed to increase participation in treatment by providing flexible care that is adjusted over time on the basis of patient response to treatment, according to clearly operationalized, empirically derived decision rules. Adaptive approaches also seek to maximize participation by specifying lower intensity treatment whenever possible, and factoring in issues such as patient preference. Work by Division investigators addresses the main components of adaptive treatment: identification of key tailoring variables that are assessed at regular intervals during treatment, development of a menu of treatment options and modifications, specification of algorithms that link changes on tailoring variables to modifications in treatment, and incorporation of patient preferences and choice to further improve adherence.
This Division has a long history of evaluating the impact of various enhancements to standard addiction treatment. Some of these studies have also sought to determine whether focused matching of extra services to specific co-occurring problems (e.g., psychiatric, family/social, employment) at the level of the individual patient improves treatment outcome. Recent projects have included studies of the effect of integrating employment services with standard treatment, and a study that compared the impact on outcomes of adding incentives for abstinence vs. additional counseling services to prevent relapse.
This Division has led efforts over the prior 15 years to improve the Addiction Severity Index (ASI). The ASI is the most widely used multi-dimensional assessment instrument in the addictions, and was developed at Penn by Thomas McLellan, PhD and colleagues. Recently, John Cacciola, PhD and Arthur Alterman, PhD undertook a major revision of the ASI and a related instrument, the Treatment Services Review (TSR). In both cases, the revisions retained the core elements of the instruments while expanding item coverage for areas within the instrument that have been shown to be deficient or were not up to date with more recent advances in knowledge.
Psychometrically derived summary indices and accompanying scoring for the revised ASI, the ASI-6, were derived, in collaboration with Brian Habing, PhD, using nonparametric item response theory (NIRT) methodologies. Earlier work by our group and Dr. Habing, based on data from the earlier ASI-5 version, has shown that NIRT can be usefully employed to develop reliable and valid scales (Alterman AI, Cacciola JS, Habing B, Lynch KG. Addiction severity index recent and lifetime summary indexes based on nonparametric item response theory methods. Psychological Assessment. 2007 19:119-132.) At this point in time, a number of other countries, some with their government’s funding, are using translated versions of the ASI-6 for either research and clinical purposes (e.g., Brazil, Holland, Sweden).
Dr. Alterman has also conducted research over the past three years to determine whether psychological wellness (e.g., vitality, purpose in life, optimism, positive mood, spirituality) predicts treatment response and whether the predictive validity of such measures is independent of that of measures of illness (e.g., substance abuse problems, psychiatric problems, antisociality, etc.).
The study of the active ingredients of treatment, or "mediation effects," plays a key role in advancing the knowledge and practice of treatment implementation. Efficacy or effectiveness questions address whether treatment works, while mediation questions address why it works. Investigators in this Division are pursuing several approaches to identifying mediation effects in studies of telephone-based continuing care and other interventions. A recent grant awarded to Kevin Lynch, PhD seeks to extend the set of statistical methods that are used by alcohol treatment researchers in studies of the mediation of treatment effects. This proposal will make new statistical methods that test for causal mediation effects accessible to clinical researchers, and will provide software and guidelines to enable such researchers to implement, and evaluate, the methods on their own data.