Intervention Summary

Service Outreach and Recovery (SOAR)

Service Outreach and Recovery (SOAR), a multicomponent program for indigent and residentially unstable clients, aims to reduce drug and alcohol use and increase participation in formal substance abuse treatment programs and 12-step self-help groups such as Alcoholics Anonymous and Narcotics Anonymous. SOAR targets individuals at soup kitchens who acknowledge current or past substance abuse problems. The program sequentially delivers two manual-driven group counseling modules--Motivational Enhancement for Recovery (MER) followed by Education and Skills for Recovery (ESR)--to a group of 3-10 clients. The 12 1-hour sessions of MER and 36 1-hour sessions of ESR are delivered thrice weekly over a period of 4 months in a trailer at the conclusion of the soup kitchen's lunchtime meal service. During MER sessions, participants learn about addiction, recovery, and readiness for change. They are encouraged to (1) discuss the ways in which substance use affects their lives by contrasting their current situation with the way they would like things to be, (2) review the options available for effecting the desired change, and (3) decide on treatment strategies they feel ready to adopt. ESR focuses on building skills for relapse prevention that include coping strategies for stress-provoking situations and painful emotions, methods to reduce the health risks associated with injection drug use (e.g., HIV infection), and identification and avoidance of emotional and situational triggers for drinking and drug use. ESR sessions also use cognitive restructuring to identify and offer alternatives to negative practices such as blaming, malingering, emotion blunting, deceiving, and dwelling on thoughts that trigger the desire to use drugs and alcohol.

Another component of SOAR is the use of peer advocates, individuals who are either in recovery from substance abuse or were raised in drug- or HIV-affected families. Peer advocates renew friendly contact whenever SOAR clients return to the soup kitchen, assist the counselor at each group session, and maintain telephone and/or mail contact with each client between sessions. Peer advocates also help clients schedule appointments and complete required treatment forms, and they are available twice weekly to either escort clients to nearby self-help meetings or meet them at the meetings.

Modest incentives (i.e., food coupon books, public transit passes) are given to clients for attendance at each MER and ESR session, attendance at each self-help meeting, and enrollment in a formal treatment program. Clients also may win a raffle prize or small gift when they graduate from SOAR. There are minimal requirements for program enrollment and participation.

Descriptive Information

Areas of Interest	Substance use disorder treatment
Outcomes	1: Substance use 2: Participation in other substance abuse treatment programs or self-help groups
Outcome Categories	Alcohol Drugs Treatment/recovery
Ages	26-55 (Adult)
Genders	Male Female
Races/Ethnicities	Black or African American Hispanic or Latino White
Settings	Other community settings
Geographic Locations	Urban
Implementation History	SOAR was first implemented at a large urban soup kitchen. Approximately 150 clients have participated in the 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

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.

Outcomes

Outcome 1: Substance use
Description of Measures	Substance use was measured by the Timeline Followback (TLFB) method, a semistructured, calendar-based interview that asks clients to retrospectively estimate their daily alcohol or drug use over a specified time period. The TLFB measured substance use for the 30-day period prior to both the baseline assessment and the follow-up assessment, which was conducted 5 months after random assignment. The following four measures were derived from the TLFB: days consumed any alcohol, days of heavy drinking (defined as 4 ounces of liquor, four glasses of wine, or four 12-ounce bottles or cans of beer in a day), days used cocaine/crack, and days used any drugs or alcohol.
Key Findings	Soup kitchen guests with current or past substance abuse problems were randomly assigned to one of two conditions: SOAR, which included group counseling, peer advocacy, and information and referral services, or the comparison condition, which included peer advocacy and information and referral services. Findings from this study included the following: At follow-up, SOAR participants reported fewer days of any alcohol use (p = .037) and fewer days of heavy drinking (p = .014) than comparison group participants. Unescorted attendance at self-help groups was a predictor of fewer number of days of alcohol use among SOAR participants (p = .012). Among participants reporting heavy drinking on at least 16 of the 30 days prior to baseline, SOAR participants reported fewer days of heavy drinking at follow-up than comparison group participants (p = .026). Among participants reporting the highest baseline severity of alcohol use (drinking on 29 or 30 days during the 30 days prior to baseline), those in the SOAR group reported fewer days of any alcohol use at follow-up than those in the comparison group (p < .001). Similarly, among participants reporting the highest baseline severity of any drug or alcohol use (using drugs or drinking on 29 or 30 days), those in the SOAR group reported fewer days of any drug or alcohol use at follow-up than those in the comparison group (p = .019).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.5 (0.0-4.0 scale)

Outcome 2: Participation in other substance abuse treatment programs or self-help groups
Description of Measures	Participation in other drug or alcohol treatment programs was determined by asking participants when they last received detoxification or formal treatment services other than the intervention, such as methadone maintenance, therapeutic community, or inpatient or outpatient services. Participation in 12-step self-help groups was measured separately by the TLFB method, a semistructured, calendar-based interview typically used to ask clients to retrospectively estimate their daily alcohol or drug use over a specified time period. Clients were asked the number of self-help meetings (e.g., Alcoholics Anonymous, Narcotics Anonymous) attended in the 3 months prior to both the baseline assessment and the follow-up assessment, which was conducted 5 months after random assignment. Attendance at self-help meetings also was recorded in logs kept by peer advocates, who escorted clients to some meetings.
Key Findings	Soup kitchen guests with current or past substance abuse problems were randomly assigned to one of two conditions: SOAR, which included group counseling, peer advocacy, and information and referral services, or the comparison condition, which included peer advocacy and information and referral services. Findings from this study included the following: At follow-up, the percentage of individuals reporting participation in treatment or attendance (unescorted) at self-help meetings was higher in the SOAR group than the comparison group (71% vs. 50%; p = .002). After controlling for treatment and self-help participation at baseline, SOAR participants were more than 2.5 times as likely as comparison group participants to report having attended an outside treatment program or self-help meetings at follow-up (p = .002), a group difference associated with a small effect size (odds ratio = 2.72). At follow-up, the percentage of individuals attending self-help meetings (client-reported, unescorted attendance combined with log-documented, escorted attendance) was higher in the SOAR group than the comparison group (51% vs. 34%; p = .014). After controlling for self-help participation at baseline, SOAR participants were almost twice as likely as comparison group participants to have attended self-help meetings at follow-up (p = .025), a group difference associated with a small effect size (odds ratio = 1.96). Among participants who reported not attending any self-help meetings at baseline, SOAR participants reported attending more self-help meetings than comparison group participants at follow-up (p = .008). However, among participants who reported attending self-help meetings at baseline, there was no group difference in reported self-help meeting attendance at follow-up.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.3 (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% Male 18% Female	68% Black or African American 17% White 15% Hispanic or Latino

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:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
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: Substance use	2.8	2.8	1.0	3.3	2.5	2.8	2.5
2: Participation in other substance abuse treatment programs or self-help groups	2.3	1.8	1.0	3.3	2.5	2.8	2.3

Study Strengths

Timeline Followback is a widely used method with prior research supporting its psychometrics when used to gather self-reported substance use data. Urinalysis or hair analysis was used at both the baseline and 5-month follow-up assessments to assess the reliability of self-reported cocaine and opiate use. Issues of missing data were addressed with sophisticated analytic methods (e.g., modeling, imputation). The study had high follow-up rates (70%) for a sample with a large number of residentially unstable participants, and there was no significant difference in follow-up rates between conditions. There were no baseline differences between participants in the intervention and comparison conditions, and researchers used baseline values as covariates for each outcome to analyze group differences at the 5-month follow-up. In general, the data analysis strategies were appropriate and well described.

Study Weaknesses

Individuals who administered the TLFB interview to collect substance use data were not blind to treatment assignment and had ongoing contact with study participants, weakening the reliability of this instrument. No adjustments were made to drug use self-reports that were discrepant with the results of urinalysis or hair analysis, and no collateral reports or biotesting of any kind were used to assess the reliability of the alcohol use self-reports. No prior research was presented to support the use of the TLFB interview format to gather data on participation in treatment and 12-step self-help meetings. Although peer advocates kept a record of self-help meetings to which they escorted participants, self-reported (unescorted) attendance at self-help meetings and treatment appointments was not verified.

No self- or independent assessment was conducted to determine the extent to which treatment components were delivered for this very intensive, multicomponent treatment program. Differential use of peer advocates between conditions coupled with a drop-in group format and minimal incentives in the SOAR group suggest that sufficient or consistent doses of the various treatment components were not delivered. There was no adherence/competence rating process described for the MER/ESR counselor, and it is unclear if this person received intensive training/certification or was already experienced before the study. Although manuals were used for the program's counseling components, there were no manuals for the peer advocacy or contingency incentive components.

A large proportion of intervention participants (38%) did not attend any SOAR counseling sessions. The elimination of data corresponding to the first 2 months of active treatment was an unconventional and insufficiently justified method to control for the influence of pretreatment behaviors.

Readiness for Dissemination

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.

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

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

Availability of implementation materials
Availability of training and support resources
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
3.3	2.8	2.0	2.7

Dissemination Strengths

Manuals are detailed and include specific actions and exercises for each session. The MER manual is user-friendly and provides counselors and facilitators with clear directions for each session, including scripts, exercises, and questions for discussion. The developer offers on-site training, including a 3-day modular counselor training program for counselors with no previous training in cognitive-behavioral therapy and motivational enhancement strategies and 1-day training programs for staff who already have training and experience in these areas. Ongoing support is also available. The treatment manuals, Timeline Followback tool, and Treatment Record can be used as quality improvement measures.

Dissemination Weaknesses

Materials lack information on the agency and clinician support necessary for successful implementation. While the ESR manual includes many exercises and activities for clients, it provides little direction for counselors and facilitators. There is no train-the-trainer manual, and no details about counselor training are provided. The materials do not include information regarding the use of the evaluation instruments, nor do they offer specific quality assurance procedures to monitor the fidelity of SOAR implementation.

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
Manuals	Free	Yes
3-day, on-site training (includes staff logs and patient assessment forms)	$2,000 per day per site for up to 20 people, plus travel expenses	No
Consulting services	$250 per hour	No

Additional Information

The primary implementation costs are for the counselor who conducts the MER and ESR sessions; the peer advocates; and incentives for participation, which are recommended but not required. The estimated cost for a counselor to deliver the SOAR program is $226 per client. Eight clients can comfortably participate in each group, with 10 clients maximum. The estimated cost for a peer advocate, assuming 2 days devoted to each client, is $237 per client. Incentives may cost $260 per client, which includes an incentive valued at $5 for each of 48 SOAR sessions attended plus a graduation raffle prize or small gift budgeted at $20. Other costs may also be involved, depending on the existing infrastructure in which the program is implemented. The training cost includes the trainer's fee, manuals, and fidelity evaluation measures, excluding the trainer's travel, food, and lodging expenses.