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Intervention Summary

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Telephone Monitoring and Adaptive Counseling (TMAC)

Telephone Monitoring and Adaptive Counseling (TMAC) is a telephone-based continuing care intervention for alcohol and cocaine dependence that is designed to follow a client's initial stabilization in a 3- to 4-week intensive outpatient treatment program. The goals of TMAC are to reinforce abstinence, lengthen the time to possible relapse, and shorten relapse episodes when they do occur. TMAC is manual-driven and combines elements of low-intensity monitoring, social support, and adaptive levels of motivational interviewing (MI) counseling and cognitive-behavioral therapy (CBT) in response to a client's risk level for relapse measured at the start of each session by a structured 10-item interview. Drawing heavily from Wagner's Chronic Care Model, TMAC focuses on supporting patient self-management, linking patients to community resources, using cognitive-behavioral strategies to increase self-confidence and skill levels, setting goals, identifying barriers to achieving goals, and developing strategies to overcome these barriers.

Initial contact between a TMAC counselor and client is face-to-face and occurs during the third or fourth week of primary substance abuse treatment. The purpose of this first meeting is to introduce the intervention and provide a bridge from in-person substance use counseling sessions to telephone-based, 15- to 30-minute counseling sessions. Subsequent TMAC sessions are initiated either by the client using a toll-free number or by the counselor, depending on which method the client and counselor feel will produce the highest contact rate. The intervention is delivered weekly for the first 8 weeks, twice monthly for up to another 10 months, and monthly thereafter. When clients are at high risk for substance use relapse, phone sessions are more frequent; if the risk level does not decrease, the sessions are followed by one-on-one, clinic-based MI counseling and CBT sessions. Designed to be at least 3 months in duration, TMAC can be used for as long as 18 months.

Descriptive Information

Areas of Interest Substance abuse treatment
Outcomes Review Date: June 2010
1: Alcohol and cocaine abstinence rates
2: Alcohol use
3: Cocaine use
Outcome Categories Alcohol
Drugs
Ages 26-55 (Adult)
Genders Male
Female
Races/Ethnicities Black or African American
White
Race/ethnicity unspecified
Settings Outpatient
Other community settings
Geographic Locations Urban
Implementation History Since 1998, TMAC has been implemented in 93 sites across 5 States: Pennsylvania, California, Rhode Island, Delaware, and Arkansas. Currently, TMAC is being implemented at sites in Wisconsin and Tennessee, and the State of Maryland is currently adding TMAC to treatment sites throughout the State. As of 2010, three research trials using TMAC have been completed with funding from the National Institutes of Health (NIH); a fourth trial is almost complete, and a fifth trial is beginning. Between 750 and 1,000 clients have already participated in TMAC. As part of the SAMHSA Access to Recovery (ATR) grant initiative centralized through the Altarum Institute, several States are currently the beneficiaries of technical assistance and the sharing of resources to implement the TMAC program.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: June 2010

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

McKay, J. R., Lynch, K. G., Shepard, D. S., & Pettinati, H. M. (2005). The effectiveness of telephone-based continuing care for alcohol and cocaine dependence: 24-month outcomes. Archives of General Psychiatry, 62(2), 199-207.  Pub Med icon

Study 2

McKay, J. R., Van Horn, D. H., Oslin, D. W., Lynch, K. G., Ivey, M., Ward, K., et al. (2010). A randomized trial of extended telephone-based continuing care for alcohol dependence: Within-treatment substance use outcomes. Journal of Consulting and Clinical Psychology, 78(6), 912-23.  Pub Med icon

Supplementary Materials

Agrawal, S., Sobell, M. B., & Sobell, L. C. (2008). The Timeline Followback: A scientifically and clinically useful tool for assessing substance use. In R. F. Belli, F. P. Stafford, & D. F. Alwin (Eds.), Calendar and time diary methods in life course research (pp. 57-68). Washington DC: SAGE.

ETDD Treatment Adherence Procedures (revised 2/1/10) and Fidelity Checklist

Lynch, K. G., Van Horn, D., Drapkin, M., Ivey, M., Coviello, D., & McKay, J. R. (2010). Moderators of response to telephone continuing care for alcoholism. American Journal of Health Behavior, 34(6), 788-800.  Pub Med icon

McKay, J. R. (2005). Is there a case for extended interventions for alcohol and drug use disorders? Addiction, 100(11), 1594-1610.  Pub Med icon

McKay, J. R., Lynch, K. G., Shepard, D. S., Morgenstern, J., Forman, R. F, & Pettinati, H. M. (2005). Do patient characteristics and initial progress in treatment moderate the effectiveness of telephone-based continuing care for substance use disorders? Addiction, 100(2), 216-226.  Pub Med icon

McKay, J. R., Lynch, K. G., Shepard, D. S., Ratichek, S., Morrison, R., Koppenhaver, J., & Pettinati, H. M. (2004). The effectiveness of telephone-based continuing care in the clinical management of alcohol and cocaine use disorders: 12-month outcomes. Journal of Consulting and Clinical Psychology, 72(6), 967-979.  Pub Med icon

Mensinger, J. L., Lynch, K. G., TenHave, T. R., & McKay, J. R. (2007). Mediators of telephone-based continuing care for alcohol and cocaine dependence. Journal of Consulting and Clinical Psychology, 75(5), 775-784.  Pub Med icon

Outcomes

Outcome 1: Alcohol and cocaine abstinence rates
Description of Measures Alcohol and cocaine abstinence rates were measured by the Timeline Followback (TLFB) method. The TLFB method uses a calendar-based interview to reconstruct prior days of drinking and drug use over a specified period. Reports of daily alcohol and cocaine use were obtained at baseline (last week of intensive outpatient treatment) for the prior 6 months , at 3 months postbaseline (end of continuing care intervention), and at 6, 9, 12 18, and 24 months postbaseline.

In addition, each client was assigned a composite risk indicator score going into continuing care. To calculate the score, seven items were dichotomously scored 1 or 0 and then summed. Items measured, for example, whether the client was dependent on both alcohol and cocaine at entry into intensive outpatient treatment, whether the client had used any cocaine or any alcohol during intensive outpatient treatment, how many self-help meetings they attended, and how they rated on social support and self-efficacy measures. Higher composite scores indicated higher risk, based on poorer progress toward treatment goals and dependence on both alcohol and cocaine versus just one substance.
Key Findings Following regular group therapy attendance in a 4-week intensive outpatient treatment program for alcohol or cocaine dependence (DSM-IV criteria) and at least 1 week of negative urinalysis, clients were randomly assigned to one of three 12-week continuing care conditions: TMAC, relapse prevention (RP), and standard 12-step-oriented group counseling. Findings from this study included the following:

  • TMAC continuing care clients reported higher alcohol and cocaine abstinence rates than clients assigned to standard 12-step-oriented group counseling at all follow-up assessment points (p < .05).
  • Clients with low composite risk indicator scores (< 3) achieved higher alcohol and cocaine abstinence rates through month 21 of follow-up if assigned to TMAC than if assigned to standard 12-step-oriented group counseling. Conversely, clients with high composite risk scores (> 4) achieved higher alcohol and cocaine abstinence rates if assigned to standard 12-step-oriented group counseling than if assigned to TMAC (p = .04).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.3 (0.0-4.0 scale)
Outcome 2: Alcohol use
Description of Measures In one study, alcohol use was measured among all clients who were diagnosed with alcohol dependence (DSM-IV criteria) at the time of admission into the intensive outpatient treatment program. Measurements were obtained using blood sample assays for gamma-glutamyltransferase (GGT) enzyme levels, an index of heavy alcohol use. Samples were taken at baseline (last week of intensive outpatient treatment) and at 12- and 24-month follow-up.

In another study, alcohol use was measured by the TLFB method, which uses a calendar-based interview to reconstruct prior days of drinking and drug use over a specified period. Four alcohol use measures were derived from the TLFB data for the 3 months prior to each assessment: (1) days of alcohol use; (2) days of heavy alcohol use, defined as 5 or more drinks per day for men and 4 or more drinks per day for women; (3) any alcohol use; and (4) any heavy alcohol use. Assessments occurred at baseline (week 3 or 4 of intensive outpatient treatment) and at 3-month intervals thereafter to 18 months postbaseline (end of continuing care intervention).
Key Findings In one study, following regular group therapy attendance in a 4-week intensive outpatient treatment program for alcohol or cocaine dependence (DSM-IV criteria) and at least 1 week of negative urinalysis, clients were randomly assigned to one of three 12-week continuing care conditions: TMAC, relapse prevention (RP), and standard 12-step-oriented group counseling. At 24-month follow-up, TMAC clients had significantly lower GGT enzyme levels than RP clients (p = .005). Although TMAC clients also had lower GGT enzyme levels at the 24-month follow-up than standard 12-step-oriented group counseling clients, the difference was not statistically significant.

In another study, at 3 to 4 weeks into a 4-month intensive outpatient treatment program, alcohol-dependent clients (DSM-IV criteria) were randomly assigned to one of three conditions: 8 months of outpatient treatment as usual (TAU) only, TAU plus 36 sessions of adjunctive TMAC over 18 months, and TAU plus 36 sessions of adjunctive telephone monitoring without counseling (TM) over 18 months. TAU consisted of 9 hours of weekly group-based treatment for the first 4 months followed by one group counseling session weekly for the second 4 months of treatment. Among the findings from this study are the following:

  • TMAC clients reported fewer days of alcohol use than TAU clients during follow-up months 10-12 (p = .018), months 13-15 (p = .0002), and months 16-18 (p < .004). These group differences were associated with small to medium effect sizes (Cohen's d = 0.42, 0.65, 0.50, respectively).
  • TMAC clients reported fewer days of alcohol use (p = .02) and fewer days of heavy alcohol use (> 5 drinks per day for men and > 4 drinks per day for women, p = .01) than TM clients at the 6-month follow-up (covering months 4-6). These group differences were associated with small effect sizes (Cohen's d = 0.39 and 0.43).
  • TMAC clients reported fewer days of heavy alcohol use (> 5 drinks per day for men and > 4 drinks per day for women) than TAU clients during follow-up months 13-15 (p = .0009) and months 16-18 (p = .006). These group differences were associated with medium and small effect sizes, respectively (Cohen's d = 0.59 and 0.46).
  • TMAC clients reported the fewest days of any alcohol use (p = .016) and the fewest days of any heavy alcohol use (p = .038) compared with TAU clients at all follow-up assessments. These group differences were associated with small effect sizes (odds ratio = 1.88 and 1.74).
Studies Measuring Outcome Study 1, Study 2
Study Designs Experimental
Quality of Research Rating 3.4 (0.0-4.0 scale)
Outcome 3: Cocaine use
Description of Measures Cocaine use was measured among all clients diagnosed with cocaine dependence (DSM-IV criteria) at the time of admission into the intensive outpatient treatment program. Measurements were obtained using urinalysis for the cocaine metabolite benzoylecgonine by fluorescence polarization immunoassay (FPIA) or enzyme multiple immunoassay test (EMIT). Urine samples were collected at baseline (last week of intensive outpatient treatment) and at 3, 6, 9, 12 18, and 24 months postbaseline.
Key Findings Following regular group therapy attendance in a 4-week intensive outpatient treatment program for alcohol or cocaine dependence (DMS-IV criteria) and at least 1 week of negative urinalysis, clients were randomly assigned to one of three 12-week continuing care conditions: TMAC, relapse prevention (RP), and standard 12-step-oriented group counseling. The rate of cocaine-positive urine samples increased more slowly in TMAC clients relative to RP clients across successive follow-up assessments (p = .03).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.3 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult) 82.6% Male
17.4% Female
77% Black or African American
21% White
2% Race/ethnicity unspecified
Study 2 26-55 (Adult) 64.3% Male
35.7% Female
88.9% Black or African American
11.1% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Alcohol and cocaine abstinence rates 3.5 3.0 3.0 3.5 3.0 3.5 3.3
2: Alcohol use 3.5 3.0 3.8 3.5 3.0 3.8 3.4
3: Cocaine use 3.5 3.0 3.0 3.5 3.0 3.5 3.3

Study Strengths

The TLFB method is considered the gold standard for self-reporting alcohol use and has strong reliability and good validity. The use of self-report, collateral report, and biological convergent measures (urine and blood samples) add to the psychometric strength of each individual measure. Urinalysis was conducted by large, well-known independent laboratories, and a standardized protocol was used for handling blood samples. Treatment was manual guided, and attention to fidelity was strong. Attrition was relatively low in both studies and handled by a sophisticated pattern mix statistical analysis in the second study. Both studies were well designed and executed, using randomization with additional analyses of potential confounds. The approach to data analysis was strong in both studies and state of the art in the second study.

Study Weaknesses

In the study that used blood sample assays to test for GGT, the blood sampling procedures were implemented late in the study and used with only 54% of the participants with alcohol dependence. TMAC treatment differed in the two studies, limiting the ability to directly compare outcomes between the studies. Both studies compared treatments of unequal intensity, raising the concern that findings might reflect differences in the duration or demand for treatment rather than differences in the content of the treatment sessions.

Readiness for Dissemination
Review Date: June 2010

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Drapkin, M. L. (n.d.). A brief introduction to dancing (a.k.a. motivational interviewing) [PowerPoint slides].

Drapkin, M. L., & McKay, J. R. (n.d.). Continuing care research [PowerPoint slides].

ETDD Treatment Adherence Procedures

McKay, J. R. (2009, March). California Access to Recovery Effort (CARE) Telephone Monitoring & Adaptive Counseling (TMAC) client workbook. Philadelphia, PA: Center on the Continuum of Care in the Addictions, University of Pennsylvania.

McKay, J. R. (2009, March). California Access to Recovery Effort (CARE) Telephone Monitoring & Adaptive Counseling (TMAC) clinician manual. Philadelphia, PA: Center on the Continuum of Care in the Addictions, University of Pennsylvania.

McKay, J. R., Drapkin, M., Long, M., Lynch, K., Van Horn, D., & Oslin, D. (2010, April 15). Telephone continuing care [PowerPoint slides].

McKay, J. R., Gotham, H., & Stilen, P. (2008, July). Client workbook: Arkansas continuing care Telephone Monitoring & Adaptive Counseling. Kansas City, MO: Mid-America ATTC, University of Missouri--Kansas City.

McKay, J. R., Gotham, H., & Stilen, P. (2008, July). Clinician manual: Arkansas continuing care Telephone Monitoring & Adaptive Counseling. Kansas City, MO: Mid-America ATTC, University of Missouri--Kansas City.

McKay, J. R., Van Horn, D. H. A., & Morrison, R. (2010). Telephone continuing care therapy for adults (with CD-ROM). Center City, MN: Hazelden.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.5 3.8 2.5 3.3

Dissemination Strengths

The clinical manual includes ample theory and rationale for the intervention along with step-by-step guidance for implementation. Forms are provided electronically for easy reproduction. The developer offers consultation with organizations prior to adoption of the program to explore fit with the agency structure and client population. New implementers receive on-site training and ongoing support throughout implementation. An array of consultation and support services contribute to fidelity to the model in new implementation settings, and some guidance for monitoring treatment outcomes is provided to support quality assurance.

Dissemination Weaknesses

The materials do not provide any information for administrators tasked with securing the infrastructure necessary for implementing this program. No guidance is provided on adapting the intervention to address the unique needs of diverse cultural groups or women. Training presentations focus on the evidence base of the intervention more than on step-by-step implementation guidance. A formalized curriculum or trainer manual is not available to support standardized training for new sites. Guidance and tools for supporting fidelity and outcome monitoring are limited.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Telephone Continuing Care Therapy for Adults (book with CD-ROM; includes electronic copies of client workbook, intervention research articles, supplementary implementation tools, and quality assurance materials) $39.95 each Yes
Training and implementation package, which includes:
  • 1.5- to 2-day on-site training
  • Site-tailored therapist and patient workbooks, handouts, and confidential client recordings for training purposes
  • Ongoing consultative support
  • Monthly coaching calls for 6 months after training and monthly thereafter
$6,000-$8,000, including travel expenses No
Treating Substance Use Disorders with Adaptive Continuing Care (book) $49.95 each No
Preimplementation consultation with developer $1,000 No

Additional Information

The approximate cost of providing a 3-month TMAC program to one client is $426, or $35 to 36 per session. Actual costs may vary considerably from site to site.

Contact Information

To learn more about implementation, contact:
Deborah Van Horn, Ph.D.
(856) 905-5261
dvh@mail.med.upenn.edu

To learn more about research, contact:
James R. McKay, Ph.D.
(215) 746-7704
mckay_j@mail.trc.upenn.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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