Research Paper
Intensive referral to mutual-help groups: A field trial of adaptations for rural veterans

https://doi.org/10.1016/j.pec.2017.07.012Get rights and content

Highlights

  • Intensive referral to addiction support groups standardizes practice.

  • We conducted a trial of rural-adapted intensive referral (RAIR) at three sites.

  • Only one-third of intervention patients received all three sessions.

  • At six-month follow-up, control and intervention groups differed little.

  • Three dose patients were significantly more alcohol-abstinent than zero dose ones.

Abstract

Objective

A multisite field trial testing whether improved outcomes associated with intensive referral to mutual help groups (MHGs) could be maintained after the intervention was adapted for the circumstances and needs of rural veterans in treatment for substance use disorder (SUD).

Methods

In three Veterans Affairs treatment programs in the Midwest, patients (N = 195) received standard referral (SR) or rural-adapted intensive referral (RAIR) and were measured at baseline and 6-month follow-up.

Results

Both groups reported significant improvement at 6-months, but no significant differences between SR and RAIR groups in MHG participation, substance use, addiction severity, and posttraumatic stress symptoms. Inconsistent delivery of the intervention resulted in only one-third of the RAIR group receiving the full three sessions, but this group reported significantly greater 6-month abstinence from alcohol than those receiving no sessions.

Conclusion

Further research should explore implementation problems and determine whether consistent delivery of the intervention enhances 12-step facilitation.

Practice implications

The addition of rural-specific elements to the original intensive referral intervention has not been shown to increase its effectiveness among rural veterans.

Introduction

Nearly all service members deployed to Iraq and Afghanistan report facing hostile incoming fire (97%), but most also face additional traumas and stressors, including seeing people begging for food (97%), concern about enemy attack (77%), and concern about family and friends on the homefront (54%)[1]. An estimated 40% report substantial reintegration problems, including difficulty confiding personal thoughts (56%) and controlling anger (57%) [2]. An estimated 41% may have had post-traumatic stress disorder (PTSD) and 38% an alcohol use problem [2]. Approximately one-third of community samples seeking SUD treatment have co-morbid post-traumatic stress disorder (PTSD) [3] and the prevalence among veterans is likely higher [4].

Treatment for substance use disorders requires time. Patients show better outcomes with contact over a 12-month period, including 3 to 6 months of continuing care [5]. Post-treatment continuing care involves lower-intensity engagement in an outpatient setting [5], and it is helps prevent relapse after intensive SUD treatment [6]. Social support is a primary component of continuing care, and a protective factor for SUD treatment relapse [7] and post-deployment traumatic stress symptoms [8].

A mutual-help group (MHG) is any group of individuals who meet regularly to share experiences managing a common problem. Social support provided by MHGs like Alcoholics Anonymous and other 12-step groups improves outcomes [6], [9], even for those with concurrent PTSD and SUD [10], and efforts to promote participation reduce continuing care costs [7]. Post-treatment referral to mutual-help groups has been described as “an effective, low-cost option” [8] but treatment providers vary in consistency and methods of referral [11].

Rural veterans have disproportionately served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) [12] and are returning to their communities with significant substance use disorder (SUD) and trauma-related symptoms [13], [14]. However, rural veterans have less access than non-rural veterans to continuing care in an outpatient setting [15], [16]. Additionally, rural veterans attending MHG meetings are likely to have challenges unique to their rural settings. In rural communities veterans are more likely to be recognized by others [17], [18] and rural residents rate MHGs as less acceptable than urban residents do [19]. Further, the only mutual-help groups consistently available in many small or rural communities are AA meetings which may cause some ambivalence in those with problems other than alcohol [20]. In short, MHG referral does not occur in a standardized way and rural residents facing barriers to accessing continuing care may also face barriers to engaging with MHGs.

The purpose of this study is to determine whether a structured, intensive referral to mutual-help groups can be adapted to the circumstances of rural veterans while maintaining effectiveness. In a study of urban veterans leaving treatment, Timko and DeBenedetti [21] found 1-year SUD abstinence rates improved more than 24% with a three-step intensive referral intervention which (1) educated patients on the benefits of mutual-help groups, (2) identified an upcoming local meeting and recovery buddy to accompany the patient, and (3) followed up on attendance [22]. For those with a dual-diagnosis of SUD and PTSD, this intensive referral intervention was associated with an 18% reduction in the number of psychiatric symptoms and a 26% reduction in perceived need for mental health treatment [23].

During typical intensive residential SUD treatment, veterans attend nearby mutual-help meetings, develop sober relationships, and obtain a sponsor, who serves as a mentor providing advice and assistance. Urban and suburban patients often live near their treatment center and can maintain those relationships upon transitioning to the home environment, but rural patients typically do not live within commuting distance. Upon discharge, rural veterans return to communities without these supports, and are at higher risk of relapse [24], [25]. Family members are another source of social support preventing SUD relapse [26], [27]. Family members are encouraged to support treatment by attending regular sessions which prepare them for the relational turbulence which accompanies recovery. Family members of rural veterans are less likely to attend family sessions and typically have no support themselves [28], thus rural veterans may not receive the same family support benefits that urban veterans do [28].

The current study tests a rural-adapted intensive referral (RAIR) which modifies the original intensive referral intervention by identifying an MHG meeting and recovery buddy in the home community and educating family members on the importance of MHG participation. We tested the following hypotheses in a multisite field trial: Compared to the control condition of standard referral, RAIR will be associated with more MHG affiliation, less use of alcohol and other drugs, and reduced PTSD symptomology. To our knowledge, this is the first evidence-based substance use intervention modified for rural veterans.

The RAIR intervention consisted of three sessions and resources including a flowchart for each session, handouts, a self-help journal, and a list with meeting locations and mutual-help buddies in towns throughout the region. (Materials are available from the corresponding author.) This list of meetings and buddies covered each recruitment site as well as rural communities of central and eastern Nebraska. The sessions provided a trajectory for fully integrating clients into a recovery network, but staff were given flexibility to adapt to each client’s familiarity with MHGs and need for support.

The initial face-to-face session took place either in individual or in group sessions. Staff assessed participants’ knowledge and experience of MHGs, explained the importance of meeting attendance (handout 1), scheduled a MHG meeting to attend before the next session, arranged for the client to meet a MHG buddy at that meeting, provided a journal to record experiences, and sought permission to contact a family member (family handout mailed to the family member).

The subsequent two sessions followed-up on MHG attendance and participation and could be completed in person or by phone. The second session addressed whether and why MHG attendance and buddy contacts were successful. Expectations for MHG meeting behaviors were discussed (handout 2), and if buddy or family support was still needed, contact efforts were undertaken. The third session was similar, but the focus shifted to troubleshooting participation barriers (handout 3) and planning for sponsorship, service, and other forms of MHG participation (handout 4). The original intensive referral intervention [21] relied on the same MHG buddies to provide support to the patient during and after treatment, whereas rural RAIR participants might have one buddy during treatment and a different one on returning to their home community.

Section snippets

Research design

This field trial used a pretest-posttest quasi-experimental design. Patients entering treatment were assigned to an addiction therapist (AT), half of whom had been trained in RAIR. Those not trained in RAIR provided their standard referral (SR), typically a recommendation to find and attend MHG meetings upon completing residential/intensive outpatient treatment, although referral practices vary [11]. Patents were pretested at baseline and followed-up six months later on measures of mutual-help

Primary outcomes

Of the 195 baseline enrollees, 140 (72%) were successfully followed-up at six months. Those followed-up were older (M = 48.39, SD = 12.54) than those not followed-up (M = 42.96, SD = 10.62, p = .005). Otherwise, ethnicity, marital status, MHG participation, PTSD symptomology, addiction severity, and 30-day substance use measured at baseline did not significantly differ between those who were and were not followed up (results not shown).

Initial tests were conducted to determine the effectiveness of SUD

Discussion and conclusion

This field trial of a rural-adapted intensive referral to mutual help-groups found no significant difference between the RAIR and SR groups in any of the dependent variables. Compared to the no-sessions group, those receiving the full 3-sessions of RAIR showed no additional improvement on measures including MHG participation, PTSD symptoms, addiction severity, percent days abstinent, and alcohol use per using day. A significantly higher proportion of those who received the intervention as

Conclusion

At six-month follow-up, rural-adapted intensive referral and standard referral groups did not differ on measures of substance use, mutual-help group attendance or participation, or post-traumatic stress symptoms. Additional analyses comparing those receiving no RAIR sessions to the minority who received the intervention as designed likewise found no differences, with one exception: those receiving three sessions were significantly more likely to be abstinent from alcohol than those receiving no

Practice implications

In programs using Twelve Step Facilitation, addiction professionals’ routine practices to connect rural veterans with MHG members and meetings are effective. RAIR did not have additional benefits, possibly because of implementation challenges.

Informed consent and patient details: I confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.

Acknowledgments

Funding: This work was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development (RCS 00-001), the VA Office of Rural Health Midwest Rural Health Resource Center [grant number N32-FY13Q1-S1-P00642]; The Department of Veterans Affairs Substance Use Disorders Quality Enhancement Research Initiative [grant number SUDQ-LIP1403]; and The Department of Veterans Affairs Health Services Research and

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