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 "Treatment of cannabis use disorder" 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.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
- Blodgett JC, Maisel NC, Fuh IL, et al. How effective is continuing care for substance use disorders? A meta-analytic review. J Subst Abuse Treat 2014; 46:87.
- McKay JR, Lynch KG, Shepard DS, Pettinati HM. The effectiveness of telephone-based continuing care for alcohol and cocaine dependence: 24-month outcomes. Arch Gen Psychiatry 2005; 62:199.
- McKay JR, Alterman AI, Cacciola JS, et al. Continuing care for cocaine dependence: comprehensive 2-year outcomes. J Consult Clin Psychol 1999; 67:420.
- McKay JR, Van Horn DH, Lynch KG, et al. An adaptive approach for identifying cocaine dependent patients who benefit from extended continuing care. J Consult Clin Psychol 2013; 81:1063.
- McKay JR, Van Horn D, Oslin DW, et al. Extended telephone-based continuing care for alcohol dependence: 24-month outcomes and subgroup analyses. Addiction 2011; 106:1760.
- Dutra L, Stathopoulou G, Basden SL, et al. A meta-analytic review of psychosocial interventions for substance use disorders. Am J Psychiatry 2008; 165:179.
- Silverman K, Robles E, Mudric T, et al. A randomized trial of long-term reinforcement of cocaine abstinence in methadone-maintained patients who inject drugs. J Consult Clin Psychol 2004; 72:839.
- Carpenedo CM, Kirby KC, Dugosh KL, et al. Extended voucher-based reinforcement therapy for long-term drug abstinence. Am J Health Behav 2010; 34:776.
- Marlowe DB, Festinger DS, Arabia PL, et al. Adaptive Interventions in Drug Court: A Pilot Experiment. Crim Justice Rev 2008; 33:343.
- Brooner RK, Kidorf MS, King VL, et al. Behavioral contingencies improve counseling attendance in an adaptive treatment model. J Subst Abuse Treat 2004; 27:223.
- Timko C, Debenedetti A, Billow R. Intensive referral to 12-Step self-help groups and 6-month substance use disorder outcomes. Addiction 2006; 101:678.
- McKay JR. Treating Substance Use Disorders With Adaptive Continuing Care, American Psychological Association Press, Washington, DC 2009.
- Lash SJ, Burden JL, Fearer SA. Contracting, prompting, and reinforcing substance abuse treatment aftercare adherence. J Drug Addict Educ Erad 2007; 2:455.
- Litt MD, Kadden RM, Kabela-Cormier E, Petry N. Changing network support for drinking: initial findings from the network support project. J Consult Clin Psychol 2007; 75:542.
- Blankers M, Koeter MW, Schippers GM. Internet therapy versus internet self-help versus no treatment for problematic alcohol use: A randomized controlled trial. J Consult Clin Psychol 2011; 79:330.
- Gustafson DH, McTavish FM, Chih MY, et al. A smartphone application to support recovery from alcoholism: a randomized clinical trial. JAMA Psychiatry 2014; 71:566.
- Gustafson DH, Palesh TE, Picard RW, et al. Automating addiction treatment: Enhancing the human experience and creating a fix for the future. In: Future of Intelligent and Extelligent Health Environment, Bushko R. (Ed), IOS Press, Amsterdam 2005.
- Squires DD, Bryant, MD. Substance use disorders. In: Using Technology to Support Evidence-Based Behavioral Health Practices: A Clinician’s Guide, Cucciare MA, Weingardt KR. (Eds), Routledge, New York 2009.
- Lieber CS, Weiss DG, Groszmann R, et al. I. Veterans Affairs Cooperative Study of polyenylphosphatidylcholine in alcoholic liver disease: effects on drinking behavior by nurse/physician teams. Alcohol Clin Exp Res 2003; 27:1757.
- Willenbring ML, Olson DH. A randomized trial of integrated outpatient treatment for medically ill alcoholic men. Arch Intern Med 1999; 159:1946.
- Kristenson H, Ohlin H, Hultén-Nosslin MB, et al. Identification and intervention of heavy drinking in middle-aged men: results and follow-up of 24-60 months of long-term study with randomized controls. Alcohol Clin Exp Res 1983; 7:203.
- Kristenson H, Osterling A, Nilsson JA, Lindgärde F. Prevention of alcohol-related deaths in middle-aged heavy drinkers. Alcohol Clin Exp Res 2002; 26:478.
- Miller WR, Weisner C. Integrated care. In: Changing Substance Abuse Through Health and Social Systems, Miller WR, Weisner CM. (Eds), Kluwer Academic/Plenum, New York 2002. p.243.
- Weisner C, Mertens J, Parthasarathy S, et al. Integrating primary medical care with addiction treatment: a randomized controlled trial. JAMA 2001; 286:1715.
- Mertens JR, Flisher AJ, Satre DD, Weisner CM. The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients. Drug Alcohol Depend 2008; 98:45.
- Chi FW, Parthasarathy S, Mertens JR, Weisner CM. Continuing care and long-term substance use outcomes in managed care: early evidence for a primary care-based model. Psychiatr Serv 2011; 62:1194.
- Milby JB, Schumacher JE, Raczynski JM, et al. Sufficient conditions for effective treatment of substance abusing homeless persons. Drug Alcohol Depend 1996; 43:39.
- Milby JB, Schumacher JE, McNamara C, et al. Initiating abstinence in cocaine abusing dually diagnosed homeless persons. Drug Alcohol Depend 2000; 60:55.
- Milby JB, Schumacher JE, Wallace D, et al. Day treatment with contingency management for cocaine abuse in homeless persons: 12-month follow-up. J Consult Clin Psychol 2003; 71:619.
- 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