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

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.