Continuing care for addiction: Implementation
- James R McKay, PhD
James R McKay, PhD
- Professor of Psychology in Psychiatry
- University of Pennsylvania
- Section Editors
- Richard Saitz, MD, MPH, FACP, DFASAM
Richard Saitz, MD, MPH, FACP, DFASAM
- Section Editor — Substance Use Disorders
- Professor of Community Health Sciences and Medicine
- Boston University Schools of Public Health and Medicine, Boston Medical Center
- Andrew J Saxon, MD
Andrew J Saxon, MD
- Section Editor — Substance Use Disorders
- Professor and Director, Addiction Psychiatry Residency Program, Department of Psychiatry & Behavioral Sciences
- University of Washington
Addiction is a chronic condition for many patients. Yet the traditional treatment model for addiction has emphasized intensive treatment for medically supervised withdrawal from substances/stabilization, followed by time-limited outpatient care. In recent years, public and private health care systems and clinicians have begun recognizing that chronic or relapsing addiction, like chronic physical conditions such as diabetes or hypertension, typically requires continuing, long-term care.
Continuing care for addiction includes routine assessment and treatment customized to the needs and preferences of the individual patient. The patient’s clinical status and risk of relapse are monitored systematically. The intensiveness of treatment is adjusted as the addiction waxes and wanes over time. Patients receive training in self-management skills and linkage to other sources of professional and community support.
This topic describes the implementation of continuing care in chronic or relapsing addiction and strategies for treatment resistant patients. Other topics describe indications for continuing care in addiction, components of continuing care, and the efficacy of multimodal continuing-care interventions; treatment issues specific to individual substance use disorders (SUDs); and determining the appropriate level of care for patients with SUDs. (See "Continuing care for addiction: Indications, features, and efficacy" and "Pharmacotherapy for opioid use disorder" and "Pharmacotherapy for alcohol use disorder" and "Psychosocial treatment of alcohol use disorder" and "Cannabis use disorder: Treatment, prognosis, and long-term medical effects" and "Cocaine use disorder in adults: Epidemiology, pharmacology, clinical manifestations, medical consequences, and diagnosis" and "Psychosocial interventions for stimulant use disorder in adults" and "Determining appropriate levels of care for treatment of substance use disorders".)
FIRST LINE INTERVENTIONS
Intensity of care — The intensiveness of care for patients with chronic addiction is based on the severity of the patient’s substance use disorder, risk of relapse, and willingness to engage in treatment. Below we describe our general, initial approach to care for patients with three levels of substance use disorder (SUD) severity, consistent with DSM-5 subtypes . There is an absence of research evidence of the optimal frequency and duration of continuing care ; the suggestions below are based largely on our clinical experience. (See "Continuing care for addiction: Indications, features, and efficacy", section on 'Indications'.)
These initial continuing care plans are proposed for the patient who remains abstinent as care proceeds through successively less intensive levels of care. The frequency and duration of the latter stages of continuing care would be adjusted based on the patient’s response to earlier stages. A patient who has a poor response to initial treatment or has repeated relapses, for example, will need longer continuing care at a higher intensity than the patient who responds well to treatment.
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- FIRST LINE INTERVENTIONS
- Intensity of care
- - Low intensity
- - Moderate intensity
- - High intensity
- Treatment components
- - Addiction counseling
- - Mutual help groups
- - Pharmacotherapy
- - Psychotherapy
- Subsequent continuing care
- STRATEGIES FOR TREATMENT RESISTANT PATIENTS
- Contingency management
- Intensive referral to mutual help groups
- Stepped care
- Social reinforcement
- Network support
- Technological innovations
- Primary care settings
- Specialized populations
- SUMMARY AND RECOMMENDATIONS