Intensive Referral Intervention to Improve Substance Use Disorder Treatment Outcomes Among Rural and Highly Rural Veterans

Rural veterans have disproportionately served in OEF and OIF and are returning to their communities with significant substance use disorder (SUD) and trauma-related symptoms. Participation in post-treatment continuing care is one of the two most significant factors in preventing relapse after intensive SUD treatment,1 but as a result of the reorganization of SUD services within the VHA, rural veterans have less access than non-rural veterans to continuing care. A primary component of continuing care, social support, is a protective factor for SUD treatment relapse2 and post-deployment traumatic stress symptoms.3 Social support provided by community self-help groups (e.g. 12-step programs such as Alcoholics Anonymous) improves outcomes1,4 and efforts to promote participation reduce continuing care costs.2 Post-treatment referral to self-help groups was recently described as "an effective, low-cost option,"3 but treatment counselors vary in their referral methods, often simply telling patients to find and attend meetings in their community.

In a study of urban veterans leaving treatment, researchers increased 1-year SUD abstinence rates by more than 24% through a three-step intensive referral intervention.5 First, counselors discussed the importance of social support and meeting attendance. Second, counselors identified accessible self-help meetings near the SUD treatment site and arranged for a meeting liaison to accompany the patient to a meeting. Third, counselors followed up on attendance and addressed obstacles. A follow-up study found patients with comorbid SUD and psychiatric problems (like Post Traumatic Stress Disorder) significantly benefitted from the intervention.6

Implementing intensive referral with rural veterans is problematic because their initial SUD treatment typically occurs in an intensive residential setting in a location which is removed from the veteran's home and family. During this intensive residential SUD treatment, rural veterans attend self-help meetings near the residential treatment program with the goals of 1) identifying meetings they enjoy, 2) developing relationships with others who attend these meetings, and 3) obtaining a sponsor who will serve as a mentor to the newly sober veteran. However, upon discharge from residential SUD treatment, rural veterans return to their rural communities without these supports in place. Additionally, rural veterans attending 12- step meetings are likely to have challenges unique to their rural settings. In rural communities veterans are more likely to be recognized by others they know and rural residents rate self-help groups as less acceptable than urban residents do.7 Additionally, the only self-help groups consistently available in small communities are AA meetings which may cause some tension and ambivalence in those with problems other than alcohol.

Family members are another source of social support preventing SUD relapse,8 but rural veterans may not receive the same family support benefits urban veterans do. In urban veterans' SUD treatment, family members are typically involved in their treatment. The family members of rural veterans, however, are less likely to attend educational, individual or group sessions given their distance from the residential SUD treatment site and typically have no support themselves as they interact with their returning veteran. Thus, rural veterans return home to live with families who may be less able to provide meaningful support to their newly sober veteran.

Further complicating this clinical picture is the presence of trauma symptoms. Among those seeking SUD treatment, nearly all report lifetime trauma exposure and one-third are diagnosed with post-traumatic stress disorder (PTSD).9 The prevalence among veterans is likely higher. Persons with dual disorders, such as PTSD and SUD, have poorer SUD treatment outcomes, and may be at higher risk for homelessness. Self-help groups improve the outcomes for those with concurrent PTSD and SUD.10 Dr. Timko's work has established that the intensive referral intervention, to be adapted in this project, resulted in an 18% reduction in the number of psychiatric symptoms and a 26% reduction in perceived need for mental health treatment.6