John W. Finney, PhD, Rudolf H. Moos, PhD, and Paula L. Wilbourne, PhD
CHAPTER OUTLINE
■ TREATMENT SETTINGS
■ DURATION AND AMOUNT OF TREATMENT
■ IMPLICATIONS FOR POLICYMAKERS AND SERVICE PROVIDERS
This chapter examines research evidence on the effects of substance use disorder (SUD) treatment settings, duration, and amount, drawing heavily on research syntheses. Most of the research focuses on treatment for alcohol use disorders, but research on treatment of drug use disorders, other than nicotine dependence, also is considered. We argue that, to some extent, research findings (e.g., those on the relative effects of inpatient/residential vs. outpatient treatment) have been extrapolated to populations beyond those involved in the studies (e.g., those with disorders complicated by serious psychiatric conditions, homelessness) and that key issues remain unaddressed. These issues include determining the specific types of persons who benefit more from initial treatment in inpatient/residential than in outpatient settings, whether certain types of individuals benefit from longer or more intensive treatment, and whether treatment should be spread out over longer periods for some patients.
TREATMENT SETTINGS
Although inpatient treatment is more prevalent in some other countries (e.g., Germany), only about 10% of SUD patients in the United States receive residential treatment, and only 1% receive inpatient treatment where presumably medical or psychiatric care also is readily available (1). Considerable research has focused on whether inpatient/residential or outpatient treatment is more effective overall, but the more pressing issue is whether certain types of patients benefit more from an initial phase of inpatient/residential treatment before continuing outpatient care than from outpatient treatment alone.
Rationales for Inpatient/Residential and Outpatient Treatment
At least five rationales have been put forward for the superiority of an initial phase of treatment in inpatient/ residential SUD treatment settings (2). One is that such settings provide a respite for patients, removing them from unstructured and unsupportive environments that perpetuate their addiction, thereby allowing their efforts toward abstinence to be consolidated. Second, inpatient/residential settings may allow patients to receive more treatment because treatment is more intensive and patients may be less likely to drop out of treatment (3). A third rationale is that inpatient/ residential settings provide medical/psychiatric care (inpatient settings) and other comprehensive services to patients who otherwise would not have access to such care or support, services seen as crucial to achieving optimal substance use outcomes (4). Fourth, inpatient/residential treatment prepares a patient better to engage in continuing outpatient treatment (e.g., by stressing the need for continuing care) (5). Finally, inpatient/residential treatment may suggest to patients that their problems are more severe and that resolving them is more paramount than would be the case if treatment were offered in an outpatient setting (6).
Arguments in favor of outpatient treatment also focus on the patient's usual life situation, but stress the advantages of leaving the patient in, rather than removing him or her from, that context (7,8). Proponents have suggested that outpatient treatment provides an opportunity for more accurate assessments of the antecedents of substance use and for testing coping skills in real-life situations while the patient remains in a supportive therapeutic relationship. Accordingly, greater generalization of learning should take place than would be the case in the atypical environment of an inpatient/residential treatment program (9). In addition, outpatient treatment may mobilize help in the patient's natural environment (e.g., from a family physician or self-help groups), to a greater extent than does inpatient or residential treatment. Finally, it has been argued that outpatient treatment results in a more successful transition to continuing care when, for example, a patient begins to attend self-help group meetings near his or her home while still in treatment.
Relative Effectiveness of Inpatient and Outpatient Settings
Several early research reviews examined the relative effectiveness of alcohol treatment in inpatient and outpatient settings and concluded inpatient/residential treatment was no more effective than outpatient treatment (9–11). A later review (2) found that 7 of 14 relevant studies had significant setting effects on one or more drinking-related outcome variables at one or more follow-up points. In five studies, the outcome difference favored inpatient/residential (sometimes followed by continuing outpatient treatment) over outpatient treatment; in the other two, the outcome difference favored day hospital over inpatient treatment. Patients in the “superior” setting usually received more treatment.
This “box-score” approach to synthesizing the research literature has serious limitations. Nonsignificant differences between treatment groups may simply reflect lack of statistical power; significant findings may emerge by chance when multiple tests for treatment effects are conducted and not adjusted for “experimentwise” error. Indeed, Finney et al. (2) found that the seven studies yielding significant setting effects had greater statistical power and conducted more treatment contrasts, on average, than the studies with no difference in outcome. The shortcomings of box-score reviews prompted the development of meta-analytic techniques (12) that use an “effect size” to gauge treatment efficacy. A common effect size in this context is the difference in the average posttreatment functioning of two groups divided by the pooled standard deviation of outcome scores for the two groups. A between-group, standardized effect size allows one to determine by how many standard deviation units or by what proportion of a standard deviation unit the functioning of one group is superior to that of another. When Finney and Moos (13) calculated average, cross-study effect sizes on drinking-related outcome variables, only the effect size of 0.22 at 3-month follow-ups was significant and favored inpatient/residential over outpatient treatment (the effect sizes at 6- and 12- to 14-month followups were not significant).
Although some of the more recent studies of mixed SUD treatment have found small or scattered effects that favored inpatient or residential treatment on a few of many outcome variables (5,14–20), others focusing on treatment for alcohol use disorders (21–23) and cocaine abuse (24) have not. Likewise, reviews of research on outpatient methadone maintenance by Anglin and Hser (25) and outpatient drug-free treatment by Crits-Christoph and Siqueland (26) reported few differences in outcomes in comparison with residential therapeutic community programs.
Extracting appropriate policy implications from this research literature requires consideration of the representativeness and types of patients who have been included in the studies. In some studies, relatively low percentages of patients in treatment have actually participated in the research. For example, 6 of the 14 studies reviewed by Finney et al. (2) noted the percentage of patients in treatment that participated in the research; in 4 of those studies, the percentage was 25% or lower. Most studies, especially randomized trials, have examined a restricted set of patients. Ethical concerns have prevented random assignment to outpatient treatment of highly impaired patients who on clinical grounds were candidates for inpatient/ residential treatment. Accordingly, studies often have excluded patients with major medical or psychiatric disorders or insufficient resources, such as an inability to commute to treatment, homelessness, or a lack of a telephone. Thus, the findings may not generalize well to more impaired individuals or those with fewer social resources for whom inpatient/residential treatment might provide more benefit. It perhaps is no coincidence that many of the investigations indicating superiority of inpatient/residential treatment have come from naturalistic studies of more impaired patients receiving treatment in publicly funded programs (5,19).
Who Benefits from Inpatient/Residential Treatment?
Even though some degree of patient homogeneity resulting from ethical concerns in randomized trials or from admission criteria for public and private programs operates against its emergence, considerable evidence indicates that more impaired patients benefit more from an initial episode of inpatient or residential treatment than from outpatient treatment alone. In other words, patient impairment has been found to interact with treatment setting in affecting patient outcomes.
A diagnosis of a serious psychiatric disorder often has been an exclusion criterion in studies of inpatient versus outpatient alcohol treatment (2), precluding its broad examination as a matching variable. Nevertheless, Ritson (27) found that patients who had personality disorders tended to have poor outcomes in outpatient treatment, though no relationship was found between personality disorders and outcome among inpatients. Likewise, research by Moos et al. (28) found that, for patients with psychiatric disorders, an episode of inpatient treatment before transfer to a community residential facility was associated with better outcomes than direct placement in a community residential facility. With respect to social resources, Kissin et al. (29) reported that more socially stable alcohol-dependent patients experienced better outcomes in outpatient treatment, whereas socially unstable patients had better outcomes after inpatient treatment. Among both alcohol and drug use disorder patients with middle-level psychiatric severity (defined by scores from one standard deviation above to one standard deviation below the mean Addiction Severity Index [ASI] psychiatric severity rating), McLellan et al. (30) observed that those who had more serious family, legal, or employment problems experienced poorer outcomes after receiving outpatient versus inpatient treatment.
Several studies (5,22,31–35) have found that patients with greater alcohol or drug use severity at treatment intake who receive an initial episode of inpatient or residential treatment experience better outcomes than those receiving only outpatient treatment (cf. (20,36)). For example, De Leon et al. (35) examined persons who were “undertreated” (i.e., treated in outpatient treatment even though their severity indicated long-term residential treatment) versus those who were “appropriately matched” to long-term residential care. For persons who remained in treatment for 90 days or more, those who had been in residential care were more likely than those who had been in outpatient care to report no alcohol use at a 1-year follow-up. Although a significant difference emerged on only this one of the six outcome variables assessed, it did so even though the individuals who were undertreated in outpatient care had less baseline severity than the “matched” individuals treated in residential care.
Matching Patients to Treatment Settings
The evidence summarized here provides general support for matching patients to different treatment settings. However, the strength of the interactions, which statistically indicate how strongly different treatment settings are linked to different outcomes for different types of patients, is usually difficult to determine from research reports. In one study providing this information (34), the two interaction effects found, although significant, were weak. A highly impaired sample from the Department of Veterans Affairs facilities may have constrained the strength of these interactions, because stronger interactions are more likely to emerge with greater variability among the patients studied. Likewise, we know little about the precise levels of severity at which more impaired patients do better in inpatient/residential versus outpatient treatment. In the study by Tiet et al. (34), only patients who had very extreme scores on ASI alcohol and drug composites did better when they had an initial episode of inpatient/residential treatment versus only outpatient treatment.
Overall, the general concept of the American Society of Addiction Medicine's (ASAM) Patient Placement Criteria (37) is supported by much of the research reviewed here. The criteria attempt to match patients to five levels of care: (a) early intervention, (b) outpatient treatment, (c) intensive outpatient/partial hospitalization treatment, (d) residential/inpatient treatment, and (e) medically managed intensive inpatient treatment. Placement decisions are based on a patient's standing on six dimensions: (a) acute intoxication and/or withdrawal potential, (b) biomedical conditions and complications, (c) emotional/behavioral/cognitive conditions or complications, (d) readiness to change, (e) relapse, continued use, or continued problem potential, and (f) recovery/living environment. However, research is still needed to validate the specific placement assessments and algorithms used in the ASAM system (38,39), especially because the use of the ASAM criteria is required in at least some programs in over 30 states in the United States (40). The fact that Witbrodt et al. (20) found no difference in abstinence between residential and outpatient treatment among patients who met all but the recovery/living environmental ASAM criterion for residential care gives one pause, but it is only a single study, and not all the criteria for residential treatment were met in its participants. Overall, we still do not have precise, empirically supported guidelines for allocating patients to different levels of care. This state of affairs is unfortunate in light of the concern that “[w] ithout well-validated placement criteria that justify intensive treatments on the basis of their greater effectiveness, the pressures of managed care to reduce costs will continue to threaten addiction treatment quality” (41).
A more fundamental issue not addressed in existing studies is the relative attractiveness of treatment in the two types of settings, that is, their ability to induce certain types of individuals to seek and enter treatment. In randomized trials, patients already have opted for treatment and are usually preselected for their willingness to accept either inpatient/ residential or outpatient treatment. Under normal conditions of treatment delivery, inpatient/residential programs may be more effective than outpatient programs in attracting individuals who have significant barriers to receiving treatment in other settings (e.g., homeless individuals and persons who lack transportation or who live some distance from a treatment facility) (42). The findings of Milby et al. (19) support the beneficial effects of providing homeless individuals a place to stay, especially in abstinence-oriented housing, while receiving SUD treatment. More broadly, if inpatient/residential programs are not available, administrators may inappropriately be able to point to “reduced treatment demand” as evidence to support cutbacks in SUD treatment services.
DURATION AND AMOUNT OF TREATMENT
Although the chronic, relapsing nature of many individuals' SUDs suggests the need for extended treatment, the tendency in the United States has been toward shorter episodes of treatment, given reduced insurance coverage for SUD care (43). This section reviews evidence on the effectiveness of longer versus shorter stays in inpatient/residential treatment and the effects of participation in continuing outpatient care.
Because other chapters in this text review the evidence on screening and brief interventions, we only note here the need for more research to determine who is as likely to benefit from a brief intervention as from more extensive care. At present, low to moderate alcohol severity patients with positive life contexts and without severe skill deficits appear to be the best candidates for brief interventions (44–46). Also, Ashton (47) pointed to evidence suggesting that brief motivational interventions are best directed toward persons who are ambivalent about changing their substance use behavior. Persons already committed to reducing or eliminating their substance use may be “set back” by consideration of positive aspects of substance use that is a component of some brief interventions using motivational interviewing principles.
Length of Stay in Inpatient/Residential Treatment
Mattick and Jarvis (10) and Miller and Hester (11) provided early reviews of several randomized trials comparing different lengths of inpatient or residential treatment for alcohol abuse. The consistent finding was no difference in outcome. Several more recent randomized trials also have found no or only isolated (i.e., on a few outcomes) beneficial effects for longer inpatient/residential alcohol or substance abuse treatment (15,16,48,49). These findings suggest it is not useful to assign unselected clients to longer stays in residential or inpatient treatment. In contrast, many naturalistic studies of substance abuse treatment have found longer stays in treatment to be associated with better outcomes, even a reduction in premature mortality (50). For example, longer episodes of inpatient and residential care (51–53), extended care (28), community residential care (54–57), and care in therapeutic communities (58) have been associated with better substance use outcomes and psychosocial functioning, as well as lower readmission rates for subsequent inpatient care, including among SUD patients with co-occurring psychiatric disorders (59).
However, there appear to be limits to the positive effects of increasingly greater durations of residential care, even in observational studies. Harris et al. (60) examined the relationships between length of stay (LOS) and outcome for over 1,300 persons in 28 VA residential SUD treatment programs. In a mixed-effect analysis controlling for average program LOS, patient-level LOS was unrelated to substance use outcomes, but was related to greater improvement in the ASI employment composite. However, programs whose average LOS was greater than 90 days showed the least improvement in an average of 7.5 months after admission on the ASI alcohol composite score relative to programs whose average LOS was 15 to 30 or 31 to 45 days. No significant relationships were found on the ASI drug composite, and no significant interactions were found between symptom severity or prior treatment utilization and LOS in predicting patients' outcomes. Not surprisingly, programs with average LOSs greater than 90 days had higher costs than those with shorter average LOSs. The authors concluded VA residential SUD treatment programs of longer than 90 days could not be justified and raised questions about treatment exceeding 60 days in length.
It may be that beneficial effects of longer stays in inpatient/ residential treatment apply only to more impaired patients with fewer social resources, although the research on this issue is not current. For example, Welte et al. (61) found no relationship between LOS and outcome of alcoholism treatment for higher social stability patients; in contrast, for patients with lower social stability, those with longer stays had better outcomes (62,63). The finding that clients in naturalistic studies have better outcomes with longer treatment than clients who stay in treatment for shorter periods suggests that many individuals may be able to determine whether or not they will benefit from longer treatment. Thus, within limits (60), having longer courses of treatment available can be important for clients who seek them.
Continuing Outpatient Care
Most SUD treatment providers recommend additional outpatient treatment (i.e., continuing care or “aftercare”) to maintain or enhance the therapeutic gains achieved during inpatient/residential or intensive initial outpatient (e.g., day hospital) treatment. Considerable correlational evidence (26,64–68) and the findings of some controlled trials are consistent with this recommendation. McKay (69) reviewed 11 controlled studies that compared some form of continuing care to minimal or no treatment; 7 (64%) supported the efficacy of continuing care. When McKay compared the studies with positive and negative results, he found that an active approach to engaging patients in continuing care (e.g., “taking the intervention to the patient”) and a longer duration of prescribed continuing care were more likely to characterize the studies with positive findings.
McKay's “box-score” review relied on the statistical significance of continuing care effects and qualitative perusal of findings to identify factors that seemed to be associated with positive versus negative effects. The limitations of box-score reviews were noted previously. However, a recent meta-analysis employed effect sizes (70) and examined the magnitude of continuing care intervention effects relative to no- or minimal-treatment control conditions and tested moderators of continuing care effect sizes. The effect of continuing care was positive and significant, but small, at both the end of the intervention (0.19, n = 18 studies) and at follow-up (0.27, n = 13 studies). The actual amount of continuing care received often is not reported. However, the “prescribed” months of continuing care and number of sessions per week, which one assumes would be related to the care actually received, did not significantly moderate continuing care effect sizes, perhaps reflecting reduced statistical power given the relatively small number of studies. The authors concluded that lower-cost interventions and approaches tailored to the characteristics and functioning of individual clients are needed to enhance the efficiency and effectiveness of continuing care.
Naturalistic studies have shown a “dose–response” relationship between the amount of outpatient mental health care and psychiatric patients' outcomes (71–73). Similarly, naturalistic studies have provided evidence for the effectiveness of a longer duration of care for patients with SUDs. In a nationwide sample of SUD patients in an index episode of care, VA patients who received specialty outpatient mental health care experienced better risk-adjusted substance use and psychiatric symptom outcomes than did patients who did not receive such care (74). Patients who had longer index episodes of mental health care improved more than did those who had shorter episodes. There was some evidence that the duration of care contributed more to better outcomes among patients with only SUDs (20), whereas the intensity of care (number of sessions per week) was more important for patients with both substance use and psychiatric disorders.
A long-term study by Moos and Moos (75) focused on the duration of participation in professional treatment for previously untreated individuals with alcohol use disorders. Compared with individuals who remained untreated, individuals who obtained a longer duration of treatment in the first year after seeking help were more likely to be abstinent and had fewer drinking problems at 8- and 16-year followup. These findings suggest that more emphasis should be placed on ensuring that patients enter specialty care and on keeping them in treatment.
Enhancing Engagement in Continuing Outpatient Care
Although the meta-analysis by Blodgett et al. (70) did not find that studies including active attempts to engage and retain patients in continuing care had more positive effect sizes than those that did not, the analysis had very low power to detect significant differences, given only three studies that examined the addition of such enhancements. Interventions to engage and retain patients in continuing care have considerable conceptual appeal and some empirical support in individual studies. For example, research by Schaefer et al. (76) highlights some active methods for engaging SUD patients in continuing care. They focused on the continuity of care practices of staff at the point of discharge from residential or intensive outpatient treatment. Although staff practices were not linked to engagement in continuing care among residential patients, such practices as coordinating care among providers, connecting patients to community resources, maintaining contact with patients over time, and ensuring continuity in providers were associated with a longer period of continuing care for individuals receiving initial intensive outpatient treatment. Subsequent analyses (77) suggested that engagement in continuing care mediated a relationship between continuity of care practices and abstinence for individuals receiving initial intensive outpatient treatment, but the mediating relationship was weaker for patients in a high than in a low psychiatric severity subgroup (78).
Lash et al. (79) used a “contracting, prompting, and reinforcement” intervention to foster ongoing engagement in continuing care. Patients signed a behavioral contract that expressed their commitment to attend an aftercare group weekly, Alcoholics Anonymous/Narcotics Anonymous weekly, and an individual therapy session monthly for at least 8 weeks (they also were informed they would be recontacted after 8 weeks to commit to remain in continuing care for 1 year). Prompts consisted of a letter from the therapist before the first continuing care session, mailed appointment cards for all continuing care sessions and Alcoholics Anonymous/Narcotics Anonymous meetings, automated telephone reminders of appointments, and a letter and telephone call from the therapist after missed appointments. Social reinforcement included a letter from the therapist congratulating the patient on attending the first session, an encouraging letter accompanying the appointment card following the third group session, a “90 Days of Treatment” certificate for attending at least six group sessions and two individual sessions, and a medallion for attending eight group and three individual sessions in the first 3 months. Participants were reinforced for maintaining long-term participation in continuing care with a 1-year certificate and a medallion. A randomized trial demonstrated greater effectiveness for “contracting, prompting, and reinforcement” than standard treatment on engaging patients in continuing care and patient abstinence.
Telephone Care
Telephone contacts are a cost-effective means to extend care over time. McKay et al. (80,81) studied patients dependent on alcohol and/or cocaine and found that 12 weeks of telephone monitoring and counseling, along with weekly group counseling in the first 4 weeks, was as effective at a 1-year follow-up on most outcomes compared with 12 weeks of relapse prevention or standard 12-step group counseling. For individuals with only alcohol dependence, the telephone condition had better 1-year alcohol use outcomes than the 12-step condition. At 24 months, individuals in the telephone group were more likely to be abstinent and had similar percentages of days abstinent and number of consequences of substance use as did those in the other two conditions. However, individuals who had not made much progress during their initial intensive outpatient treatment did better with twice weekly face-to-face group therapy than with telephone care (82).
Similarly, McKellar et al. (83) randomly assigned 667 patients in intensive outpatient treatment for SUDs to either telephone case monitoring or usual continuing care. To deal with cross-contamination from in-person continuing care provided to participants receiving telephone case monitoring, instrumental variable analysis was used, with random assignment to condition as the instrument. Significant effects of telephone case monitoring were found at a 3-month follow-up, but not at 12 months.
Taken together, these studies and reviews of treatment intensity, LOS, and outpatient care suggest that an effective strategy may be to provide lower intensity addiction treatment over a longer duration—that is, treatment spread out at a lower rate over a longer period (65,74). The effectiveness of spreading substance abuse treatment over a longer period is suggested by the positive findings for outpatient care after inpatient treatment (65) and for interventions that incorporate somewhat extended (e.g., 12 weeks), but relatively few (e.g., four) contacts with patients (84). More extended treatment may improve patient outcomes because it provides patients with ongoing support and the potential to discuss and resolve problems before the occurrence of a full-blown relapse. In this vein, brief interventions may be most effective for relatively healthy patients who have intact community support systems. Patients who have severe substance dependence, concomitant psychiatric disorders, or insufficient social resources appear to be appropriate candidates for longer treatment and intensive monitoring (26,85) to address their multiple co-occurring problems and the chronic, relapsing nature of their SUDs.
Internet Interventions and Telephone Applications
An important new component in the continuum of care is likely to be interventions provided via the Internet and smartphone applications (“apps”). Among the advantages of such interventions is that, by being flexible and overcoming some of the barriers to entering traditional treatment, they can attract individuals with substance use problems who do not want to engage in more traditional treatment (86). They also may appeal to women who may not enter traditional treatment programs that have a predominantly or exclusively male clientele. In addition, Web-based and mobile phone interventions can be provided at a lower cost and may be a “gateway” or initial step to more intensive, in-person interventions if needed.
Most Web-based and mobile phone app interventions have been targeted to less impaired individuals, such as at-risk, heavy, and binge drinkers. A review of Internet interventions (87) for alcohol misuse found an average effect size of 0.42 on alcohol consumption outcomes in five studies relative to receiving only psychoeducational resources or only completing an online assessment. Cunningham (88) evaluated a more extended Alcohol Health Center (AHC) versus a briefer Check Your Drinking (CYD) Internet intervention for persons with more severe alcohol problems. At a 6-month follow-up, AHC participants drank significantly less relative to those randomly assigned to CYD (88).
In addition, Internet-based interventions have been developed to target cannabis use (89) and cocaine use (90), although evidence regarding their effectiveness is lacking. Similarly, a supportive smartphone intervention was developed by McTavish et al. (91) in an attempt to prevent relapse to heavy drinking by enhancing individuals' competence, social connections, and motivation following residential treatment. They demonstrated the feasibility and usability of the intervention, but effectiveness remains to be examined.
Although these interventions are promising, challenges remain. For example, attrition rates are high with Web-based interventions (92). One approach to increasing retention is to have peers and/or coaches available who interact periodically with clients; another is to offer incentives. Overall, however, Web-based and smartphone interventions should augment the continuum of cost-effective care needed to manage the full spectrum of manifestations exhibited by substance misuse and SUDs.
IMPLICATIONS FOR POLICYMAKERS AND SERVICE PROVIDERS
Studies on SUD treatment settings, amount, and duration, along with reviews of this research, have had a positive impact on health care policy: They appropriately called into question the blanket application of expensive forms of treatment. For example, in the United States, in the early 1980s, insurance coverage for alcohol treatment was such that if a socially stable individual wanted covered treatment, inpatient treatment was the only option. The advent of managed care in the 1990s resulted in more emphasis on outpatient treatment so that in 2005, 89% of individuals in treatment for alcohol and other drug use disorders were seen in less expensive outpatient settings (1). In recent years, some findings have been used to justify denial of inpatient/residential treatment and more intensive treatment to persons who may need such treatment. Thus, the pendulum may have swung too far in the opposite direction.
An important research agenda is to validate specific placement criteria for allocating individuals to different settings of care and to determine appropriate durations and intensities of care for different types of individuals. In the meantime, we believe that the best approaches for treatment providers are those recommended in previous reviews and largely embodied in the ASAM Patient Placement Criteria: (a) provide outpatient treatment for those individuals who have sufficient social resources and no serious medical/psychiatric impairment; (b) use less costly intensive outpatient treatment options for patients who have failed with brief interventions or for whom a more intensive intervention seems warranted, but who do not need the structured environment of a residential setting; (c) retain residential options for those with few social resources or a living environment that is a serious impediment to recovery; (d) reserve inpatient treatment options for individuals with serious medical/psychiatric conditions; (e) have longer-term treatment options available for clients who desire them; and (6) use active methods of engagement at the start of treatment (e.g., motivational interventions) and when clients transition to continuing care (e.g., “contracting, prompting, and reinforcement”).
With respect to treatment duration and amount, brief interventions in medical and settings other than specialty SUD treatment can be effective, especially for individuals with moderate alcohol misuse. For individuals with more severe alcohol or drug use disorders, existing research indicates that uncomplicated patients should be provided less intensive treatment; patients with SUDs complicated by co-occurring psychiatric disorders, medical problems, or social barriers to treatment should receive more intensive treatment. For many patients with alcohol or drug dependence, outpatient treatment, in some cases following an initial episode of residential care, should be provided over an extended period. Care also can be extended by linking (not just referring) patients with self- or mutual-help groups, such as Alcoholics Anonymous (93). Individuals with co-occurring psychiatric conditions can be linked to such groups as Double Trouble in Recovery (94) or Dual Recovery Anonymous.
As suggested by Humphreys and Tucker (95), “stepped care” (86,96,97) can be an “organizing principle” for efficiently providing treatment for SUD. Individuals for whom a less intensive (and less costly) initial approach is not successful can be “stepped up” to a more intensive form of treatment. In this regard, brief motivational interventions have been shown to enhance the effectiveness of more intensive treatments that follow them (98). Individuals who function well for a period of time can be “stepped down” to a less intensive form of care (e.g., continuing outpatient care after a period of intensive outpatient treatment). Later, care intensity can be reduced even further, to consist only of monitoring the individual's functioning. As McKay (99) notes, “newer models of continuing care in the addictions are designed to improve the long-term management of SUDs by engaging patients into flexible, or ‘adaptive,’ treatment algorithms that change in focus and intensity as symptoms wax and wane over time.”
Such a model is embodied in the Recovery Management Checkup (RMC) developed by Dennis et al. (100). The RMC tracks individuals quarterly over time; assesses for early indications of relapse or problems; uses motivational techniques to maintain or reinitiate desired behavioral changes; stresses the need for early reengagement in treatment, as indicated; and assists with treatment reengagement. Compared with patients randomized to an assessment-only condition (quarterly follow-up assessments over 2 years; referral to treatment only in emergency situations), RMC patients were more likely to reenter treatment, to do so sooner, and to receive more days of treatment, but to be less likely to need further treatment at the end of the 2 years (as determined by current substance use and negative consequences). Although these results are promising, two-thirds of the patients in need of treatment in the RMC condition did not obtain it. Of those reentering treatment, only one in four remained engaged in treatment for 90 days.
To strengthen the RMC intervention, regular transportation to treatment and a protocol focused on retaining people in treatment once they reentered care were added, and a second RMC trial was conducted. Examining the results of the first and second RMC trials, Scott and Dennis (101) found that, relative to outcome monitoring only, the enhanced RMC protocol was more effective in identifying persons in need of treatment (given changes to reduce false negatives from only self-report) and inducing those in need of treatment to attend meetings to link them with care, complete intake assessments, enter treatment, and remain in treatment for a minimum of 14 days. Moreover, compared to the first RMC trial, the enhanced RMC condition led to larger effect sizes at a 2-year follow-up on reducing days to readmission with substance use, reducing symptoms of dependence or abuse in the past month, and increasing days abstinent over the two years. A 4-year follow-up found that participants in the enhanced RMC condition continued to have superior process and functioning outcomes compared to those receiving only assessment monitoring, with both interventions being provided for 4 years (102). Given evidence of therapeutic impact of reassessment of persons with SUDs (103), which was the control condition in each of the RMC trials, the effect of RMC for clients in “real-world” situations likely would be greater than that captured by the relative effect of the RMC intervention versus assessment monitoring only.
For communities and health care organizations, an ideal management system should be integrated with the provision of medical care and should encompass the full continuum of SUD care with respect to treatment settings, duration, and amount. In addition, coordinated comprehensive services, such as social, housing, legal, and medical services, should be available (4). To maximize the impact of the system's resources, there should be easy access to them, and they should be coordinated, for example, by case managers (104). Rather than merely having services available and referring individuals to them, the system should track and monitor individuals with substance misuse and disorders and actively reach out to them in periods of poor functioning to engage and reengage them in treatment. Routine and active monitoring could be accomplished by medical health care providers who are more likely to interact with individuals somewhat frequently.
ACKNOWLEDGMENTS
Preparation of this chapter was supported by the U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, and NIAAA grants AA00689 and AA15685. The views expressed are those of the authors and do not necessarily reflect the views of the Department of Veterans Affairs or any US Government entity.
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