Treatment drop-out is unfortunately a common occurrence – studies suggest up to 30% of adults with substance use disorder (SUD) who enter outpatient treatment drop out within 1 month, and 50% before 3 months.
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Based on self-determination theory, having both requisite skill and autonomy (“having a say so”) in making a decision will contribute to greater intrinsic motivation to act in healthier ways. According to this theory, offering patients a choice of treatments could help promote re-engagement.
In the current study, McKay and colleagues tested whether a phone call from a clinician using motivational interviewing that aimed to either:
a) re-engage patients in the intensive outpatient program (IOP) or
b) re-engage patients in their choice of either intensive outpatient program (IOP) or one of three other treatment options, was more effective among patients who dropped out of outpatient substance use disorder (SUD) treatment.
It was more complex than conventional randomized trials that randomly assign patients to a treatment at intake and test whether the treatments promoted different outcomes at discharge and follow-up. Specifically, patients with alcohol and cocaine use disorders (N = 500) who sought treatment at one of two intensive outpatient programs in Philadelphia, PA were followed initially for 2 weeks after they were scheduled to begin treatment.
Patients who were not yet engaged with treatment (defined differently at each setting due to different logistics of treatment, but reflecting general lack of attendance) were randomly assigned to receive:
OR
Patients who were engaged with treatment at week 2 continued in the intensive outpatient program (IOP); if at any point between weeks 3 and 8 they dropped out (reflected by no IOP attendance for 2 consecutive weeks), they were randomly assigned to MI-IOP or MI-PC at that point. If patients who were not engaged at week 2 and were then randomly assigned to one of the MI conditions were still not engaged at week 8 (reflected by no IOP attendance during weeks 7 and 8), they were randomly assigned to MI-PC or no further outreach. Therefore, some patients may have received two MI-PC interventions.
Particularly salient sample characteristics included age (mean = 48 years), gender (81% male), ethnicity (88% African American), and marital status (85% not married). Of note, the sample was drawn from two parallel, identical studies with alcohol dependent or cocaine dependent patients but were combined due to high levels of co-occurrence between the two substance use disorders in these samples. Authors analyzed the data by presence of current/lifetime alcohol dependence (n = 428) or current/lifetime cocaine dependence (n = 409). Participants were assessed at baseline (treatment intake) as well as 4, 8, 12, and 24 weeks after baseline.
Regarding group differences on treatment participation, there were generally no differences between the motivational interviewing (MI) conditions, or between MI and no outreach among those not engaged at all (although some differences were statistically significant [i.e., not likely due to chance], they were very small and not likely clinically significant, e.g., 1.3 sessions in MI-PC vs. .8 sessions in MI-IOP over 3 weeks).
Interestingly, and contrary to the authors’ hypotheses, patients with alcohol dependence who were not engaged at week 2 that received MI-IOP had better alcohol use outcomes including lower likelihood of any drinking, of a heavy drinking day in the 30 days prior to assessment, and fewer percent days drinking and heavy drinking.
Among patients who initially engaged but dropped out during weeks 3 to 8, the motivational interviewing (MI) treatments had similar outcomes, while among those who were not engaged at either weeks 2 or 8, MI-PC and no outreach also generally had similar outcomes. The MI conditions did not differ for cocaine dependent patients on the cocaine outcomes. Analyses where only patients with both alcohol and cocaine dependence were included generally yielded parallel results (effect of MI-IOP for those who weren’t engaged at week 2 with similar outcomes in other comparisons)
Although it may seem intuitive that greater choice or autonomy would help increase patients’ treatment involvement, this was not the case in the current study. In fact, it generally led to worse outcomes among patients with alcohol use disorder. This type of result, however, is not uncommon.
For example, Walsh et al. (see here) found that among individuals referred to their employee assistance program for an alcohol-related problem, those assigned to a 12-step-based inpatient treatment program with 1-year continuing care had better abstinence rates and lower likelihood of treatment re-admission than patients allowed to choose their treatment (with many choosing either inpatient treatment or 12-step groups only).
In another study of two versions of 12-step facilitation by Walitzer et al., (see here), the directive version led to more 12-step attendance and better substance use outcomes than the version rooted in motivational interviewing (which offered greater choice and autonomy).
For patients that drop out of treatment early, an outreach phone call may help re-engage them in care; clinicians were able to re-engage about half of the patients initially not engaged in treatment at 2 weeks. The clinician making this phone call may wish to use a motivational (collaborative and empathic) approach that focuses on getting the patient to return to the original program at which they initially completed an intake.
The current study highlighted the need for interventions that attempt to re-engage patients who have dropped out of treatment. Future work may build on these motivational approaches, which appear to have promise.
McKay, J. R., Drapkin, M. L., Van Horn, D. H., Lynch, K. G., Oslin, D. W., DePhilippis, D., . . . Cacciola, J. S. (2015). Effect of Patient Choice in an Adaptive Sequential Randomization Trial of Treatment for Alcohol and Cocaine Dependence. J Consult Clin Psychol. doi:10.1037/a0039534
l
Based on self-determination theory, having both requisite skill and autonomy (“having a say so”) in making a decision will contribute to greater intrinsic motivation to act in healthier ways. According to this theory, offering patients a choice of treatments could help promote re-engagement.
In the current study, McKay and colleagues tested whether a phone call from a clinician using motivational interviewing that aimed to either:
a) re-engage patients in the intensive outpatient program (IOP) or
b) re-engage patients in their choice of either intensive outpatient program (IOP) or one of three other treatment options, was more effective among patients who dropped out of outpatient substance use disorder (SUD) treatment.
It was more complex than conventional randomized trials that randomly assign patients to a treatment at intake and test whether the treatments promoted different outcomes at discharge and follow-up. Specifically, patients with alcohol and cocaine use disorders (N = 500) who sought treatment at one of two intensive outpatient programs in Philadelphia, PA were followed initially for 2 weeks after they were scheduled to begin treatment.
Patients who were not yet engaged with treatment (defined differently at each setting due to different logistics of treatment, but reflecting general lack of attendance) were randomly assigned to receive:
OR
Patients who were engaged with treatment at week 2 continued in the intensive outpatient program (IOP); if at any point between weeks 3 and 8 they dropped out (reflected by no IOP attendance for 2 consecutive weeks), they were randomly assigned to MI-IOP or MI-PC at that point. If patients who were not engaged at week 2 and were then randomly assigned to one of the MI conditions were still not engaged at week 8 (reflected by no IOP attendance during weeks 7 and 8), they were randomly assigned to MI-PC or no further outreach. Therefore, some patients may have received two MI-PC interventions.
Particularly salient sample characteristics included age (mean = 48 years), gender (81% male), ethnicity (88% African American), and marital status (85% not married). Of note, the sample was drawn from two parallel, identical studies with alcohol dependent or cocaine dependent patients but were combined due to high levels of co-occurrence between the two substance use disorders in these samples. Authors analyzed the data by presence of current/lifetime alcohol dependence (n = 428) or current/lifetime cocaine dependence (n = 409). Participants were assessed at baseline (treatment intake) as well as 4, 8, 12, and 24 weeks after baseline.
Regarding group differences on treatment participation, there were generally no differences between the motivational interviewing (MI) conditions, or between MI and no outreach among those not engaged at all (although some differences were statistically significant [i.e., not likely due to chance], they were very small and not likely clinically significant, e.g., 1.3 sessions in MI-PC vs. .8 sessions in MI-IOP over 3 weeks).
Interestingly, and contrary to the authors’ hypotheses, patients with alcohol dependence who were not engaged at week 2 that received MI-IOP had better alcohol use outcomes including lower likelihood of any drinking, of a heavy drinking day in the 30 days prior to assessment, and fewer percent days drinking and heavy drinking.
Among patients who initially engaged but dropped out during weeks 3 to 8, the motivational interviewing (MI) treatments had similar outcomes, while among those who were not engaged at either weeks 2 or 8, MI-PC and no outreach also generally had similar outcomes. The MI conditions did not differ for cocaine dependent patients on the cocaine outcomes. Analyses where only patients with both alcohol and cocaine dependence were included generally yielded parallel results (effect of MI-IOP for those who weren’t engaged at week 2 with similar outcomes in other comparisons)
Although it may seem intuitive that greater choice or autonomy would help increase patients’ treatment involvement, this was not the case in the current study. In fact, it generally led to worse outcomes among patients with alcohol use disorder. This type of result, however, is not uncommon.
For example, Walsh et al. (see here) found that among individuals referred to their employee assistance program for an alcohol-related problem, those assigned to a 12-step-based inpatient treatment program with 1-year continuing care had better abstinence rates and lower likelihood of treatment re-admission than patients allowed to choose their treatment (with many choosing either inpatient treatment or 12-step groups only).
In another study of two versions of 12-step facilitation by Walitzer et al., (see here), the directive version led to more 12-step attendance and better substance use outcomes than the version rooted in motivational interviewing (which offered greater choice and autonomy).
For patients that drop out of treatment early, an outreach phone call may help re-engage them in care; clinicians were able to re-engage about half of the patients initially not engaged in treatment at 2 weeks. The clinician making this phone call may wish to use a motivational (collaborative and empathic) approach that focuses on getting the patient to return to the original program at which they initially completed an intake.
The current study highlighted the need for interventions that attempt to re-engage patients who have dropped out of treatment. Future work may build on these motivational approaches, which appear to have promise.
McKay, J. R., Drapkin, M. L., Van Horn, D. H., Lynch, K. G., Oslin, D. W., DePhilippis, D., . . . Cacciola, J. S. (2015). Effect of Patient Choice in an Adaptive Sequential Randomization Trial of Treatment for Alcohol and Cocaine Dependence. J Consult Clin Psychol. doi:10.1037/a0039534
l
Based on self-determination theory, having both requisite skill and autonomy (“having a say so”) in making a decision will contribute to greater intrinsic motivation to act in healthier ways. According to this theory, offering patients a choice of treatments could help promote re-engagement.
In the current study, McKay and colleagues tested whether a phone call from a clinician using motivational interviewing that aimed to either:
a) re-engage patients in the intensive outpatient program (IOP) or
b) re-engage patients in their choice of either intensive outpatient program (IOP) or one of three other treatment options, was more effective among patients who dropped out of outpatient substance use disorder (SUD) treatment.
It was more complex than conventional randomized trials that randomly assign patients to a treatment at intake and test whether the treatments promoted different outcomes at discharge and follow-up. Specifically, patients with alcohol and cocaine use disorders (N = 500) who sought treatment at one of two intensive outpatient programs in Philadelphia, PA were followed initially for 2 weeks after they were scheduled to begin treatment.
Patients who were not yet engaged with treatment (defined differently at each setting due to different logistics of treatment, but reflecting general lack of attendance) were randomly assigned to receive:
OR
Patients who were engaged with treatment at week 2 continued in the intensive outpatient program (IOP); if at any point between weeks 3 and 8 they dropped out (reflected by no IOP attendance for 2 consecutive weeks), they were randomly assigned to MI-IOP or MI-PC at that point. If patients who were not engaged at week 2 and were then randomly assigned to one of the MI conditions were still not engaged at week 8 (reflected by no IOP attendance during weeks 7 and 8), they were randomly assigned to MI-PC or no further outreach. Therefore, some patients may have received two MI-PC interventions.
Particularly salient sample characteristics included age (mean = 48 years), gender (81% male), ethnicity (88% African American), and marital status (85% not married). Of note, the sample was drawn from two parallel, identical studies with alcohol dependent or cocaine dependent patients but were combined due to high levels of co-occurrence between the two substance use disorders in these samples. Authors analyzed the data by presence of current/lifetime alcohol dependence (n = 428) or current/lifetime cocaine dependence (n = 409). Participants were assessed at baseline (treatment intake) as well as 4, 8, 12, and 24 weeks after baseline.
Regarding group differences on treatment participation, there were generally no differences between the motivational interviewing (MI) conditions, or between MI and no outreach among those not engaged at all (although some differences were statistically significant [i.e., not likely due to chance], they were very small and not likely clinically significant, e.g., 1.3 sessions in MI-PC vs. .8 sessions in MI-IOP over 3 weeks).
Interestingly, and contrary to the authors’ hypotheses, patients with alcohol dependence who were not engaged at week 2 that received MI-IOP had better alcohol use outcomes including lower likelihood of any drinking, of a heavy drinking day in the 30 days prior to assessment, and fewer percent days drinking and heavy drinking.
Among patients who initially engaged but dropped out during weeks 3 to 8, the motivational interviewing (MI) treatments had similar outcomes, while among those who were not engaged at either weeks 2 or 8, MI-PC and no outreach also generally had similar outcomes. The MI conditions did not differ for cocaine dependent patients on the cocaine outcomes. Analyses where only patients with both alcohol and cocaine dependence were included generally yielded parallel results (effect of MI-IOP for those who weren’t engaged at week 2 with similar outcomes in other comparisons)
Although it may seem intuitive that greater choice or autonomy would help increase patients’ treatment involvement, this was not the case in the current study. In fact, it generally led to worse outcomes among patients with alcohol use disorder. This type of result, however, is not uncommon.
For example, Walsh et al. (see here) found that among individuals referred to their employee assistance program for an alcohol-related problem, those assigned to a 12-step-based inpatient treatment program with 1-year continuing care had better abstinence rates and lower likelihood of treatment re-admission than patients allowed to choose their treatment (with many choosing either inpatient treatment or 12-step groups only).
In another study of two versions of 12-step facilitation by Walitzer et al., (see here), the directive version led to more 12-step attendance and better substance use outcomes than the version rooted in motivational interviewing (which offered greater choice and autonomy).
For patients that drop out of treatment early, an outreach phone call may help re-engage them in care; clinicians were able to re-engage about half of the patients initially not engaged in treatment at 2 weeks. The clinician making this phone call may wish to use a motivational (collaborative and empathic) approach that focuses on getting the patient to return to the original program at which they initially completed an intake.
The current study highlighted the need for interventions that attempt to re-engage patients who have dropped out of treatment. Future work may build on these motivational approaches, which appear to have promise.
McKay, J. R., Drapkin, M. L., Van Horn, D. H., Lynch, K. G., Oslin, D. W., DePhilippis, D., . . . Cacciola, J. S. (2015). Effect of Patient Choice in an Adaptive Sequential Randomization Trial of Treatment for Alcohol and Cocaine Dependence. J Consult Clin Psychol. doi:10.1037/a0039534
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