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

大约每15名退伍军人中就有1人符合物质使用障碍（SUD）的标准。SUD具有 对人际关系、角色和社区功能产生有害影响，并与精神和 身体健康问题。它们被认为是慢性疾病，据报道退伍军人的复发率为75%。 1-治疗后一年。 在我们之前的VA康复研究中，我们观察到参与激励疗法（IT） 与最近从强化SUD日间治疗中出院的退伍军人的非常有利的结局相关， 在IT的3个月疗程中，禁欲天数接近90%，临床和生活质量良好 在12个月的随访中，约三分之二的样本结果。这与结果数据形成鲜明对比 来自也从SUD日间治疗中出院的退伍军人的历史匹配比较样本 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局。 VHA在提供全面的综合护理系统方面是独一无二的，该系统包括基础设施， 向接受SUD门诊治疗的人提供治疗和辅助就业服务。这些 计划包括职业前计划，如IT，这是为退伍军人不感兴趣， 竞争性就业，重点是工作活动对临床结果的治疗作用， 全面运作，以及其他TSES方案，其中包括支持就业和职业 援助.虽然其他TSES计划是专门为退伍军人感兴趣的竞争力 就业，这两种类型的计划都可以通过提供有意义的角色回归来促进复苏结果 功能 目前提案背后的主要目的是获得关于潜在的严格的科学数据。 IT和其他TSES的治疗益处，因此这些信息可用于了解重要的 这两种类型的程序在SUD恢复中所发挥的作用。我们建议进行一项试验，以测试IT的影响， 其他关于改善门诊治疗中新恢复退伍军人SUD结局的TSES。符合 不同TSES计划的资格标准，我们将采用两个分支研究：一个分支将用于 退伍军人谁是不感兴趣的追求有竞争力的就业，将是一个双臂RCT， 随机化（2：1）至转诊接受IT +常规治疗（TAU;包括常规SUD门诊治疗）或 单独行动。第二个分支将为退伍军人谁表示有兴趣在竞争性就业，并将 是一项随机（2：1）转诊至TSES竞争性就业服务+ TAU的双组RCT，或 单独行动。意向治疗样本总数为140（每个分支n=70）。评估将在 基线、3个月、6个月和12个月。主要结果将是清醒和全球功能。 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 探讨紧急和高强度SUD服务在不同条件下是否存在差异，以确定IT 或其他TSES成本被这些服务成本的减少所抵消，并检查 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.