Augmenting early phase substance use treatment with therapeutic work activity to improve clinical outcomes: a new indication for an old intervention

目前，大约每15名退伍军人中就有一人符合物质使用障碍(SUD)的标准。肥皂水有 对人际关系、角色和社区功能的有害影响，并与精神和精神障碍高度共存 身体健康问题。它们被认为是慢性病，据报道，退伍军人中有75%的复发率 治疗后1年。 在我们之前的VA康复研究中，我们观察到参与激励疗法(IT)是 与最近从强化休息日治疗中出院的退伍军人的非常良好的结果有关， 在3个月的IT疗程中有近90%的禁欲天数，以及良好的临床和生活质量 约三分之二的样本在12个月的随访中的结果。这与结果数据形成鲜明对比。 来自历史上匹配的退伍军人对比样本，这些退伍军人也从SUD日间治疗中出院 但没有参加任何职业康复服务，只有大约四分之一的人有良好的 12个月时的临床和生活质量结果。 VHA在提供全面、集成的护理系统方面是独一无二的，该系统包括以下基础设施 为接受SUD门诊治疗的患者提供治疗和就业支持服务(TSES)。这些 课程包括IT等职前课程，这些课程是为不感兴趣的退伍军人提供的 竞争性就业，关注工作活动对临床结果的治疗效果，以及 全面运作，以及其他TSES方案，其中包括支持的就业和职业 援助。虽然其他TSES计划是专门为对竞争感兴趣的退伍军人设计的 就业，这两种类型的计划都可能通过提供有意义的回归作用来促进复苏结果 功能。 当前提议背后的主要目的是获得关于潜在的 IT和其他TSE的治疗益处，因此这些信息可以用来理解 这两种类型的计划在从SUD中恢复方面发挥了作用。我们建议进行一项试验，以测试IT和 其他关于改善门诊治疗中新康复退伍军人SUD预后的TSES。与…一致 对于不同的TSES计划的资格标准，我们将采用两个分支机构研究：一个分支机构将用于 对追求竞争性就业不感兴趣的退伍军人，他们将成为一名双臂RCT 随机(2：1)转诊，照常接受IT+治疗(TAU；包括通常的SUD门诊治疗)或 只有陶一个人。第二个分部将为对竞争性就业表示兴趣的退伍军人提供服务，并将 采用两臂随机随机对照试验(2：1)转介TSES竞争性就业服务+TAU或 只有陶一个人。处理样本的总意向为140个(每个分支机构70个)。评估将在以下时间进行 基线、3个月、6个月和12个月。主要结果将是清醒和全球运转。 次要结果将是精神症状、自尊、自我效能和生活质量。我们还将 了解不同条件下的紧急和高强度SUD服务是否不同，以确定IT 或其他TSES成本被这些服务成本的降低所抵消，并检查潜在的 治疗反应。

Approximately 1 in 15 Veterans currently meet criteria for a substance use disorder (SUD). SUDs have deleterious effects on interpersonal, role, and community function, and are highly comorbid with mental and physical health problems. They are considered chronic conditions, with reported 75% relapse rates in Veterans 1-year post treatment. In our prior VA rehabilitation research, we observed that participation in Incentive Therapy (IT) was associated with very favorable outcomes in Veterans recently discharged from intensive SUD day treatment, with close to 90% of abstinent days over the 3-month course of IT, and favorable clinical and quality of life outcomes in about two-thirds of the sample at 12-month follow-up. This contrasts starkly with outcome data from a historical matched comparison sample of Veterans who were also discharged from SUD day treatment but were not enrolled in any vocational rehabilitation services, only about a quarter of whom had favorable clinical and quality of life outcomes at 12 months. VHA is unique in providing a comprehensive, integrated system of care that includes an infrastructure to provide Therapeutic and Supported Employment Services (TSES) to those in SUD outpatient treatment. These programs include pre-vocational programs such as IT, which are intended for Veterans not interested in competitive employment and which focus on the therapeutic effects of work activity on clinical outcomes and overall functioning, as well as Other TSES programs which include supported employment and vocational assistance. While Other TSES programs are specifically intended for Veterans interested in competitive employment, both types of programs may boost recovery outcomes by providing a return to meaningful role function. The primary purpose behind the current proposal is to obtain rigorous scientific data on the potential therapeutic benefits of both IT and Other TSES, so this information may be used to understand the important role these two types of programs play in recovery from SUD. We propose a trial to test the effects of IT and Other TSES on improving SUD outcomes in newly recovering Veterans in outpatient treatment. In line with eligibility criteria for different TSES programs, we will employ a two branch study: One branch will be for Veterans who are not interested in pursuing competitive employment, and will be a two arm RCT with randomization (2:1) to referral for IT + treatment as usual (TAU; including usual SUD outpatient treatment) or TAU alone. The second branch will be for Veterans who express interest in competitive employment, and will be a two arm RCT with randomization (2:1) to referral for TSES competitive employment services + TAU or TAU alone. Total Intent to Treat sample will be 140 (n=70 per branch). Assessments will be conducted at baseline, 3 months, 6 months, and 12 months. Primary outcomes will be sobriety and global functioning. Secondary outcomes will be psychiatric symptoms, self-esteem, self-efficacy, and quality of life. We will also explore whether emergency and high intensity SUD services differ between conditions to determine whether IT or Other TSES costs are offset by reductions in these service costs, and examine potential moderators of treatment response.