Traditionally, the focus of substance use disorder (SUD) treatment has been on intensive primary treatment interventions. Increasingly, however, there is an appreciation for how the chronicity of these disorders necessitates increased emphasis on continuing care interventions that seek to preserve and enhance initial treatment gains.1 Although additional research is needed, a growing body of continuing care literature indicates that the duration of continuing care, support group, and outpatient aftercare therapy participation, following initial SUD treatment, is often important for achieving good treatment outcomes.2 – 4 One year after beginning treatment for SUD, only about 25 to 40% of clients are abstinent, dependent on how abstinence is defined.3 , 5 The combination of low continuing care participation rates and the association of continuing care participation with positive treatment outcome has supported the notion that SUD treatment outcome could be improved if continuing care participation could be increased.

Among the evidence-based interventions focused on the continuing care phase of treatment is the Contracts, Prompts, and Reinforcement (CPR) intervention. CPR has shown positive impact on SUD continuing care retention and abstinence rates in Veterans Affairs Health Services Research and Development (HSR&D) funded clinical trials (described below in detail).6 – 9 CPR is conceptually similar to contingency management (CM). However, in contrast to traditional CM interventions, which tend to use material (e.g., monetary) reinforcers, CPR uses contingent social reinforcement (e.g., certificates and medallions).10 The relatively low cost of CPR11 (estimated at $98 above standard care per year per patient) offers a promising and practical approach to translating CM into clinical settings as called for in this literature.12 , 13

CPR Clinical Trials

The CPR intervention includes behavioral contracting, prompting with behavioral feedback, and contingent social reinforcement of treatment participation and abstinence. A brief contract focused on the positive outcomes associated with aftercare and self-help attendance is completed by the therapist with the patient using a motivational enhancement style. Contracting takes place during primary rehabilitation and includes research-derived information on abstinence rates associated with varying degrees of continuing care participation. Following contracting, clients are prompted with regular mailed appointment reminders and with phone calls following any missed therapy sessions. These prompts also incorporate feedback on progress toward the goals established in the continuing care contract (i.e., group attendance and abstinence). For the reinforcement component, CM principles are used to reinforce patient attendance and ongoing abstinence using social reinforcers (e.g., recognition within the continuing care group with the presentation of certificates and medallions) rather than monetary ones.

The CPR intervention, developed in a series of five randomized clinical trials6 , 14 – 16 and one quasi-experimental study,7 , 8 and then further assessed by two VA HSR&D-funded randomized clinical trials,9 , 11 has typically demonstrated a significant impact on continuing care retention and abstinence rates. The detailed review of the entire body of data related to the development of the CPR intervention is beyond the scope of this paper. The results of the two most recent clinical trials have been included. In the first of two VA HSR&D-funded randomized clinical trials examining the impact of CPR on continuing care participation, CPR was compared to standard (STX) continuing care treatment for 150 participants in the Salem VAMC Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) over a 1-year period.9 Over the entire 1-year follow-up period, significant findings indicated CPR participants attended aftercare more regularly and for a longer duration than STX participants did and had improved treatment outcomes. Compared to those in STX, CPR participants were more likely to begin aftercare (95 vs. 82%). Examining average monthly aftercare attendance over 1 year, 40% of CPR participants attended aftercare at least twice a month compared to only 26% of STX participants. The typical participant in the CPR condition stayed in treatment for approximately 5.5 months compared to 4.4 months for those in STX. CPR produced a large, statistically significant improvement in 1-year abstinence rates (57 to 37%) compared to STX (defined as abstinence during the 90 days preceding the 1-year follow-up assessment). Moderator analyses demonstrated that CPR was particularly effective for participants with co-occurring psychiatric disorders.

Based on the promising significant findings in the above clinical trial, VA HSR&D funded a multi-site effectiveness trial (N = 183) aimed at determining the generalizability of the intervention at two VA sites. This trial included a number of modifications to CPR aimed at enhancing participation in community self-help groups and augmenting treatment outcome11 but did not promote individual aftercare therapy participation. In this trial, graduates of two intensive substance use disorder programs were randomized to either CPR or STX. In contrast to the previous trial, CPR did not produce significantly greater continuing care participation rates or abstinence rates during follow-up (trends suggested greater aftercare attendance for participants in the CPR condition). However, additional analyses revealed that these findings were specific to those participants who were required to attend continuing care as a contingency of the legal system, their housing, or employment. The 62% of participants to whom this applied was much higher than in previous CPR studies and likely limited the impact of the additional reinforcement provided by CPR. Notably, CPR did significantly improve attendance and substance use rates for those participants who did not have externally enforced requirements to attend continuing care activities.

While many evidence-based treatments (EBTs) have been developed in the SUD treatment field, treatment programs, in large part, use practices with little evidence of effectiveness and clinicians are typically not trained in the use of EBTs.17 – 19 Additionally, few direct implementation trials have been published in the SUD continuing care literature.20 Although the CPR intervention has been established as an evidence-based treatment (SAMHSA) which meaningfully improves clients’ attendance of aftercare and substance use treatment outcomes,9 it is not widely used and its implementation has not been previously studied. As with many EBT’s in SUD treatment, implementation research is needed to understand how these interventions can best be translated into routine clinical practice.

Evidence-based quality improvement (EBQI), originally developed by Rubenstein and colleagues,21 , 22 was used to guide this pre-implementation study of implementation barriers and facilitators of the CPR intervention. EBQI is an adaptation of the Plan-Do-Study-Act (PDSA) cycle of continuous quality improvement (CQI) that emphasizes empirical evidence and the co-involvement of clinical and implementation experts (i.e., researchers) and an organization’s own healthcare professionals. Organizational theory and experience suggest that adaptation to local context is critical to adoption and sustainability, and EBQI builds upon traditional CQI techniques (e.g., team-based approach and PDSA cycle) by incorporating outside clinical and implementation experts to ensure that QI efforts are evidence-based21 while also emphasizing the involvement of an organization’s own healthcare professionals and staff improving their own systems.23 More specifically, researchers contribute knowledge of the evidence base about a particular evidence-based practice, as well as materials, procedures, and tools needed for successful implementation. Local clinicians and administrators contribute local knowledge needed to tailor the evidence-based practice for their own particular needs and organizational capabilities. In addition to providing expertise, researchers in the EBQI model also facilitate problem solving and provide ongoing technical support for developing data collection/analysis tools, informatics tools, and training materials. EBQI fosters a researcher/clinician partnership and promotes buy-in.23 , 24

Taking an EBQI approach to implementing CPR, the aim for the current project was to use qualitative methods to identify the barriers and facilitators at specific implementation sites. Information was obtained from both clinicians and administrators with the aim of understanding factors that may impact the broader implementation of CPR in routine care. Knowledge of these barriers and facilitators was used to inform revision of the existing research-based treatment manual, an implementation tool kit, and therapist fidelity measures that would directly support implementation under a range of routine clinical conditions.

Methods

The protocol was approved by the respective institutional review boards and research and development committees of both parent study sites as well as the three data collection sites prior to initiation of study activities. All study participants provided informed consent.

Formative evaluations

Formative evaluations were conducted with staff from residential SUD treatment programs at three Veterans Affairs Medical Centers (VAMCs) with the goals of better understanding potential barriers and facilitators to implementation of CPR and developing tools needed to support implementation. Prior to each site visit, each program’s written treatment policies and procedures were reviewed to better understand individual program structure, content, and operating parameters. Facility mental health and SUD leadership, as well as core SUD clinical staff, were recruited for participation in the formative evaluations. Potential participants at each site received a brief (30 min) presentation about CPR that included vignettes produced by VA’s Employee Education System (EES) and a review of the intervention. Following the presentation, those staff interested in participating in the project participated in an informed consent session. Those consenting then participated in either the focus group or a key informant interview. Individual key informant interviews were completed with facility mental health and SUD program leaders (n = 6). A focus group was conducted with core clinical staff at each of the three sites (n = 14 total participants across the focus groups). A total of nine interviews were conducted (three focus groups and six individual interviews). Interviews with leadership were conducted separate from the clinical staff focus groups in order to address any concerns core clinical staff may have had in discussing possible barriers to implementation.

The focus groups and key informant interviews followed an interview guide developed by the authors with input from experts in the formative evaluation process. The Consolidated Framework for Implementation Research (CFIR)25 was used as a model when developing the interview guide. The CFIR provides a meta-theoretical framework that spans implementation models to better characterize key implementation themes. The CFIR includes five major domains: (1) intervention characteristics, (2) outer setting of the organization or clinic (e.g., client needs, resources), (3) inner setting of the organization or clinic (e.g., program culture, implementation climate), (4) characteristics of those involved with implementation, and (5) process of implementation. While there was a general interview guide, the overall content of the questions varied depending on the participants’ responses. Interviews were conducted by two authors (DW and JB). All interviews were recorded and subsequently transcribed prior to initiation of data analyses. Data were analyzed using a grounded theory approach, in which data collection, coding, analysis, and interpretation are integrated activities.26 , 27 As there are a variety of approaches to grounded theory,28 the following describes the authors’ approach. After transcription, interview transcripts were studied, reviewed, and divided into “meaning units” or segments of text that contain a single idea or theme.29 These units were “grounded” in the data in that the text of the units stayed close to the lived experience of the participants, and units were not developed a priori based on the interview guide. These initial meaning unit codes, then, were compared within and across interviews, based on similarities and differences, to develop higher order codes. This process of comparing and contrasting codes to form higher order codes continued, resulting in both major themes—capturing the overarching ideas for both facilitators and barriers to implementation and sub-themes, consisting of lower order codes that capture more specific themes. Finally, “theoretical memos” were created throughout this process, which represented analytical thinking regarding the connections of themes and which served to build the foundation for modifying the CPR intervention and fidelity measures. The initial codes and main themes were created by one author (DW) experienced in qualitative analysis. All authors then reviewed the codes and themes independently before they collaboratively refined the final coding product. The interpretations of the coder and the interviewers were prioritized as they had the most contextual familiarity with the data.

Fidelity measure development

Three fidelity measures were developed for each of the three core elements of the CPR intervention: contracts, prompts, and reinforcement. The fidelity measures assessed all core, or essential, components for each element (e.g., providing symbolic reinforcement). Components determined to be non-essential elements of CPR (e.g., use of an honor roll to publically display names of clients reaching attendance goals) were excluded from the measures. The determination of essential versus non-essential elements was based on previous research on CPR during which specific elements were removed and/or added.6 – 8 , 11 , 14 Fidelity measures were designed to be user-friendly for clinicians and their supervisors. Copies of these measures are part of the clinical toolbox (see below) that was the product of this study and are available from the corresponding author upon request. The fidelity measures were developed with the authors who have experience conducting and supervising CPR to support future implementation efforts and as tools for supervision of clinicians in the use of CPR.

Tool kit development

Information obtained from the formative evaluation process was used to inform development of an implementation toolkit that could be disseminated to programs interested in implementing the CPR intervention and to facilitate future implementation intervention research. As a first step, a concise and attractive informational brochure was created to disseminate in print and PDF format. A complete set of materials necessary for CPR implementation were developed for use as part of the implementation toolkit based on the results of this study. These additional elements will be described in detail in the “Discussion” section.

Results

The qualitative analysis focused on identifying the barriers and facilitators to implementation of the CPR intervention (Tables 1 and 2). The analysis of facilitators revealed 10 major themes and 29 sub-themes, while the analysis of barriers resulted in 7 major themes and 16 sub-themes. Due to the large number of major and sub-themes, those themes with endorsement from less than three interviews are not included or discussed. While there were 20 total participants (14 group interview participants and 6 individual interviews), the n reported below reflects the number of interviews in which the theme arose (n = 9 interviews).

Table 1 Facilitators for implementing CPR: frequency of major themes and sub-themes identified in key informant and focus group interviews
Full size table
Table 2 Barriers to implementing CPR: frequency of major themes and sub-themes identified in key informant and focus group interviews
Full size table

Facilitators of CPR implementation

Leadership factors

Participants identified two specific leadership factors they believed would facilitate implementation of CPR. First, most interview sessions (n = 6) expressed confidence that facility leaders would “buy-in” to the intervention if they were presented with the objective research data demonstrating the efficacy and effectiveness of CPR in a way that clearly demonstrated to leadership how the results of CPR can directly benefit leadership (e.g., meeting performance measures). Second, many (n = 5) were optimistic that facility leadership would be responsive to the need for an intervention such as CPR which increases continuing care treatment adherence.

Staff attitudes

The analysis suggested staff attitudes would facilitate the implementation of CPR. During interviews (n = 5), participants were generally optimistic that staff members had the clients’ best interest at heart and would be interested in implementing CPR, which they viewed as promising.

Contract characteristics

Analysis revealed six qualities of the contract that were seen as possible facilitators of implementation, including (1) the contracts represent a client’s commitment to himself or herself, rather than to an outside party (n = 7); (2) similar informal procedures were already in place locally, thus making formal CPR implementation easier (n = 5); (3) contracts give clients ownership over the direction and speed of treatment (n = 4); (4) contract graphs are measurable and demonstrate the research outcomes (n = 3); and (5) contracts are generally useful clinical tools (n = 5).

Aftercare characteristics

Four major sub-themes emerged from characteristics of aftercare that facilitate implementation of CPR. First, nearly all interviews (n = 7) indicated that CPR supports administrative benchmarks for minimum follow-up rates. Second, several reported that, in general, CPR supported the providers’ desire to have clients attend recovery-supportive continuing care groups (n = 3). Third, several interviews (n = 3) endorsed that providing aftercare helped clients transition and integrate into the recovery community beyond the treatment center. Lastly, several (n = 3) reported that aftercare helps clients buy-in to treatment and strongly supports their recovery.

Reinforcement characteristics

The most highly endorsed sub-theme related to reinforcement was that it is broadly viewed as beneficial to clients in early recovery (n = 3).

Drug-testing characteristics

One theme related to drug-testing was identified as a facilitator. Having procedures already in place for obtaining urine drug screens (n = 3) was seen as a CPR intervention facilitator.

Prompt characteristics

Six sub-themes emerged from the major theme that certain prompting characteristics facilitate the implementation of CPR. First was the general belief during a large number of the interviews (n = 6) that prompts encourage clients to participate in recovery and get needed help. Second, many (n = 5) endorsed the belief that the design and appearance of the CPR prompt materials contribute to building hope by clearly demonstrating patient progress through provision of feedback on aftercare attendance and drug screen results. Third, a number of interviews (n = 5) reported that having a system of prompting clients to remember key recovery activities already in place allowed for easier implementation. Next, several (n = 4) believed that prompts encourage clients to attend recovery activities even if they slip or relapse, and that prompts are particularly helpful for those who legitimately forget scheduled appointments (n = 3). Finally, several (n = 3) endorsed that prompts give clients personal attention which demonstrates that staff care about their success.

Training staff characteristics

The following six characteristics related to training staff to use CPR were viewed during the interviews as facilitating its use: (1) the belief that presenting objective research data to staff will help with buy-in (n = 6); (2) that a formal presentation to staff would improve implementation (n = 4); (3) the importance of providing a variety of training materials, in a variety of formats (n = 4); (4) that providing ongoing support and education to staff would improve adherence (n = 4); (5) the importance of providing reinforcement to highly performing staff (n = 3); and (6) that staff would respond better to being trained at their home facility (n = 3).

Financial factors

One theme related to financial resources was identified as a facilitator. Four interviews (n = 4) identified that having established program funds in place to apply toward CPR would greatly improve the programs’ abilities to implement CPR.

Global factors

A few findings related to beliefs tied to the overall impact of CPR as opposed to those tied to a specific CPR intervention were identified as possible facilitators of implementation. These included the belief that CPR, as a whole, would improve patient care (n = 4) and reduce recidivism (n = 4).

Barriers to CPR implementation

Staff attitudes

The analysis revealed sub-themes suggesting staff attitudes that could impede the implementation of CPR. First, most (n = 6) thought that some staff members’ individual philosophies and beliefs about addiction, treatment, and CPR could influence their willingness to try an intervention that is reinforcement-based (e.g., incompatible with approaches emphasizing confrontation or authority). Second, many (n = 5) reported that the staff may resist having to adhere to a protocol out of distaste for having their practice rigidly dictated, regardless of their underlying beliefs about CPR. Third, several (n = 4) specifically thought that the frequency of urine drug screens in CPR was an area in which staff members would find less utility.

Contract characteristics

While less frequently noted, a barrier emerged that contracts in general were not beneficial to clients and were likely to set clients up for failure or lead to negative self-evaluations if clients were unable to adhere to them (n = 3).

Reinforcement characteristics

The participants’ primary concern with reinforcement was protecting the clients’ privacy on the honor roll (n = 5) as the patients’ names are posted on a bulletin board in the group room during the group.

Drug testing characteristics

A number of perceived barriers related to drug testing were identified. A common concern (n = 5) was that drug screen results were not widely available within a short time frame as required by the CPR protocol, with some sites currently requiring 1–2 weeks to obtain results. Additional barriers included the lack of available staff to observe drug screens (n = 5), limited authorization for non-medical staff to enter drug screen orders into the patient’s medical record (n = 4), and that programs were not in the habit of conducting breathalyzer tests regularly (n = 3).

Prompt characteristics

A large number of barriers associated with prompting in CPR were identified. The two most strongly endorsed sub-themes related to prompts were that the staff lacked the time to conduct prompting (e.g., tracking activities; n = 9) and the difficulty of contacting a transient population (n = 6). Lesser endorsed sub-themes included the need for adequate strength to punch holes in aftercare attendance and abstinence feedback cards using a hole-punch (n = 3).

Financial factors

Two financially related sub-themes emerged as potential barriers to the implementation of CPR—one at a macro-level and another at the micro-level. The first was that facility or system budget problems would make administrators less willing to support CPR even with its modest financial requirements, hindering buy-in at the macro-level (n = 6). Second, at the micro-level, many participant units (n = 5) had concerns that their clinic budgets were not adequate to finance CPR.

Global barriers

Two general or global factors emerged from the analysis. First, during multiple interviews (n = 6), the participants expressed concern that the criteria for gauging success were not adequately individualized to account for differences in context across clients (e.g., an employed client may not be able to attend as many appointments as an unemployed client). Second, many interviews (n = 5) reported that while encouraging aftercare attendance was a priority for the staff, there were other pressing priorities that often trumped their allegiance to promoting aftercare (e.g., accreditation standards to meet).

Discussion

The current study helps to set the stage for an implementation trial to support uptake and sustainability of CPR across SUD treatment programs. The qualitative process examining domains of the CFIR (i.e., the characteristics of the intervention, the external setting in which the programs reside, internal characteristics of the treatment program, characteristics of the individuals involved, and the process of implementation)20 , 25 found that CPR was generally well received by administrators (i.e., key informants) and clinicians with many characteristics seen as facilitators of its implementation. However, several barriers to implementation also were identified.

Any implementation of CPR will need to take into account the barriers identified. One major concern was the need to conduct regular breathalyzer and urine drug screens. Some clinicians saw this as unnecessary or unhelpful and had concerns that its implementation would be impossible or impractical due to limitations of staff time or perceived system issues related to working with the laboratory. A related concern expressed by both program leaders and clinicians was the amount of staff time required to implement CPR, especially the prompting component which typically involves the use of a database combined with individualized mailings and telephone calls. In response to these identified barriers, the tool kit was modified to allow providers to quickly streamline the intervention based on core elements, lessening the impact on provider time. Some clinicians also believed that CPR social reinforcement might allow opportunistic clients to manipulate the reward system or that the clients’ behavior would be based on external rewards that might not lead to changes in internal motivation or lasting change. Other clinicians saw evidence-based treatments such as CPR as too structured and constraining or contrary to their approach to treatment, and that the social reinforcers in CPR would be impotent relative to the reinforcing aspects of substance use. Additionally, some interviewees were concerned that the display of the clients’ names on the honor roll may violate confidentiality and raise concerns for accreditation. Finally, clinicians in some settings expressed that the outer setting in which the program is located promotes moving clients through intensive continuing care quickly rather than promoting longer, less intensive engagement, the primary goal of CPR.

While several important barriers to implementation were identified, several facilitating factors also were identified. In general, the key informants in this study believed that clinicians could be trained to use CPR quickly and that it would be inexpensive to use. Furthermore, the administrators and clinicians reported favorable views on the general practice of promoting continuing care participation and sustaining clients in SUD treatment for longer durations, a primary goal of the CPR intervention. Additionally, their values and practices were consistent with CPR’s use of social reinforcement. Further, the structured contracting of continuing care participation and the promotion of 12-step support group participation was seen as attractive. Administrators also saw the treatment adherence and outcome data from trials of CPR in clinical settings as increasing their interest in using the CPR intervention. These data suggest that these facilitators of the CPR intervention should be key factors in marketing the use of CPR to treatment programs. Incentives at the administrative and treatment program level are too seldom considered when attempting to promote and sustain SUD continuing care interventions,20 and the above findings suggest that these aspects of the CPR intervention will be important to emphasize in implementation efforts.

As noted previously, these facilitators and barriers to implementation of CPR guided the development of the CPR fidelity measures, marketing materials, and the treatment manual discussed earlier. These materials emphasize the core components of the intervention—those elements that are essential to its effectiveness—while at the same time identifying aspects of the intervention that can be adapted to the local environment where CPR will be used (including removal from the intervention protocol). The research-focused fidelity measures were modified to assess how well the core components of the intervention are being implemented and to be user friendly for clinicians and supervisors with briefer forms that target only relevant clinical aspects of the intervention. Similarly, the research-focused treatment manual was rewritten to create a clinically focused manual with the design and content of the manual shaped by the findings of the qualitative analyses. This manual and the marketing materials were modified to emphasize facilitating components of CPR and provide targeted information related to the barriers identified during the formative evaluation process with direct guidance on how such barriers might be minimized or eliminated. Facilitators and barriers perceived by administrators or clinicians are identified in the manual. Finally, a frequently asked questions (FAQ) document was developed for the tool kit to address these barriers identified by the clinical and administrative participants in this study. The FAQ provides specific guidance on those elements of the intervention that may be modified and provides examples for flexibility in implementing the intervention.

Importantly, the treatment manual now contains a section of FAQs that provides examples of how barriers have been overcome in clinical and research settings while maintaining the core components of CPR. Furthermore, the CPR treatment materials were revised to maximize accessibility, flexibility, and utility for clinicians. This included computerized versions of the treatment manual, contracting script, and contracts that allow for rapid modification. Options to customize the intervention are embedded within electronic copies of the materials in a manner that allows programs to select which aspects of the intervention will be implemented resulting in an immediate modification of the document to match the program’s needs. For example, both the contracting script and the actual contracts have embedded macros that allow the user to indicate whether or not they will be using non-core aspects of the intervention such as the honor roll, prompting for AA and NA attendance, and prompting and reinforcement for abstinence. Additionally, tool kits were assembled to allow for ease of storage and transport of materials. The tool kits include all of the basic materials (i.e., a small supply of medallions, punch cards and prompts, and materials for printing certificates) for conducting CPR using the full protocol in order to facilitate implementation.

The implementation research plan initiated in this project is modeled after Curran, Allee, Mukherjee, and Owen’s30 method of developmental formative evaluation. In addition to having a CPR knowledge base, researchers now have adaptable materials, procedures, and tools that are designed in light of facilitators and barriers to the successful implementation of CPR and designed to promote buy-in by administrators and clinicians. Similarly, clinicians and administrators are provided with information and materials that allow CPR to be adapted to overcome many barriers posed by particular needs and organizational capabilities of specific clinical settings so that CPR can be adapted and sustained.

The current results provide knowledge of facilitators and barriers that can be addressed to disseminate CPR from an EBQI approach and demonstrated how this approach can be used to study the dissemination of other SUDs continuing care interventions. A next step will be to conduct dissemination trials of CPR in which traditional and enhanced implementation of CPR across different clinicians and/or treatment sites are examined and compared on quality of implementation and sustainability. Such implementation efforts will need to address in what situations the intervention would be appropriate based on the clinical conceptualization of the client’s treatment needs and where another approach may be clinically more appropriate. The materials developed during the current pre-implementation trial will facilitate completion of this important next step.

The strengths of the current study are that it represents the first step toward implementing CPR using specific principles of implementation science and is one of the few implementation studies in the area of SUD continuing care.20 Limitations include the context in which CPR was examined in this study. The facilitators and barriers identified here may not generalize to non-VA settings. For instance, continuity of care is a performance benchmark at VAMCs, but there may be fewer incentives for promoting continuing care in other treatment contexts. Similarly, the lack of insurance reimbursement for continuing care may be a significant external barrier to the use of CPR at some sites but was not an identified barrier in the current sample which only receives a small portion of its funding from this source. Conversely, longer term enrollment in treatment may generate increased revenue for sites that bill insurance and/or clients for care at higher rates than VAMC sites which receive their funding largely from the federal government. The current project may provide a model for pre-implementation studies for other interventions in the area of SUD continuing care. Further, it provides a foundation for continuing implementation efforts specific to the CPR intervention.

Implications for Behavioral Health

The high prevalence and high-cost nature of SUDs calls for close attention to any intervention that improves contact with effective treatment. The underappreciated importance of engagement in continuing care after intensive treatment interventions provides the rationale and incentive for implementation of CPR in SUD treatment settings. Beyond that, however, is the fact that the dependence of good treatment outcome on engagement in treatment over time is not unique to SUDs. Indeed, engagement is crucial across many categories of behavioral health and medical treatments. The CPR intervention is modular and is based on well-established behavioral principles. Thus, it can easily be modified to address issues such as medication compliance, appointment-keeping, and the like. These factors support implementation of CPR in SUD settings as well as in other behavioral health and medical settings.