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Center for Substance Abuse Treatment. Substance Abuse: Clinical Issues in Intensive Outpatient Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2006. (Treatment Improvement Protocol (TIP) Series, No. 47.)

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Substance Abuse: Clinical Issues in Intensive Outpatient Treatment.

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Chapter 4. Services in Intensive Outpatient Treatment Programs

A set of core services is essential to all intensive outpatient treatment (IOT) efforts and should be a standard part of the treatment package for every client. Enhanced services often are added and delivered either on site or through functional and formal linkages with community-based agencies or individual providers.

This distinction between core and enhanced services is somewhat flexible. What would be considered enhanced services for the general treatment population may be core services for a particular client group. For example, a program that serves primarily working mothers of young children may view providing child care and arranging transportation as core program elements. These same services are unlikely to be needed by most clients in an IOT program that treats mostly employed single men who do not have children living with them.

This chapter describes many of the core and enhanced elements of IOT. Each description includes the purpose and the key aspects of the service. Exhibit 4-1 lists core and enhanced services for IOT programs. Some core services are discussed in other chapters, as noted in exhibit 4-1.

Exhibit 4-1. Core and Enhanced Services for IOT Programs.


Exhibit 4-1. Core and Enhanced Services for IOT Programs.

Core Services

Group Counseling and Therapy

Groups form the crux of most IOT programs. Several recent studies confirm that, for delivering relapse prevention training, a group approach is at least as effective as a one-on-one format (McKay et al. 1997; Schmitz et al. 1997). Group counseling allows programs to balance the cost of more expensive individual counseling services. A group approach supports IOT clients by

  • Providing opportunities for clients to develop communication skills and participate in socialization experiences; this is particularly useful for individuals whose socializing has revolved around using drugs or alcohol
  • Establishing an environment in which clients help, support, and, when necessary, confront one another
  • Introducing structure and discipline into the often chaotic lives of clients
  • Providing norms that reinforce healthful ways of interacting and a safe and supportive therapeutic milieu that is crucial for recovery
  • Advancing individual recovery; group members who are further along in recovery can help other members
  • Providing a venue for group leaders to transmit new information, teach new skills, and guide clients as they practice new behaviors

Types of groups

Most IOT programs place clients in several different types of groups during the course of treatment. Broadly speaking, these include psychoeducational, skills-development, support, and interpersonal process groups. These classifications are far from rigid; each type of group borrows ideas and techniques from others. Some IOT programs also add specialized groups and clubs for job-seeking or recreational activities. TIP 41, Substance Abuse Treatment: Group Therapy (CSAT 2005f ), contains specific guidance on how to organize and conduct different types of groups in the context of a treatment program. Exhibit 4-2 highlights groups commonly conducted in IOT.

Exhibit 4-2. Groups Conducted in Intensive Outpatient Treatment

Psychoeducational groups
These groups provide a supportive environment in which clients learn about substance dependence and its consequences. These time-limited groups may be initiated at the beginning of treatment. They feature
• Low-key rather than emotionally intense environment.
• Rational problemsolving mechanisms to alter dysfunctional beliefs and thinking patterns.
• Various forms of relapse prevention and skills training. Didactic components often are supplemented by videos or slides to accommodate different learning styles.
Skills-development groups
These groups offer clients the opportunity to practice specific behaviors in the safety of the treatment setting. Common types of skills training include
Drug or alcohol refusal training. Clients act out scenarios in which they are invited to use substances and role play their responses.
Relapse prevention techniques. Using relapse prevention materials, clients analyze one another's personal triggers and high-risk situations for substance use and determine ways to manage or avoid them.
Assertiveness training. Clients learn the differences among assertive, aggressive, and passive behaviors and practice being assertive in different situations.
Stress management. Clients identify situations that cause stress and learn a variety of techniques to respond to stress.
Support groups (e.g., process-oriented recovery groups)
These groups include clients in the same recovery stage—usually a middle to late phase of treatment—who are working on similar problems. Members focus on immediate issues and on
• Pragmatic ways to change negative thinking, emotions, and behavior
• Learning and trying new ways of relating to others
• Tolerating or resolving conflict without resorting to violence or substance use
• Looking at how members' actions affect others and the function of the group
Interpersonal process groups
Single-interest groups. These groups—usually organized at a later stage of treatment—focus on an issue of particular significance to and sensitivity for group members. The issues include gender issues, sexual orientation, criminal offense, and histories of physical and sexual abuse.
Family or couples groups. These groups assist clients' relatives and other significant individuals in learning about the detrimental effects of substance use on relationships and how these effects can be ameliorated or resolved. Additional information on family services is presented in chapter 6 and TIP 39, Substance Abuse Treatment and Family Therapy (CSAT 2004c ).

Key aspects of groups

Organization of groupsIOT programs often use open-ended heterogeneous groups that provide clinicians the flexibility of assigning new clients to ongoing groups. With the client census often difficult to predict from week to week, this flexibility permits immediate responsiveness to client needs. Members of open-ended heterogeneous groups have varying degrees of recognition and acceptance of their problems, and those on the road to recovery offer hope to those just beginning.

Although it may seem desirable to keep clients in the same group as they progress through the treatment process, the experience of the consensus panel has been that this is seldom possible because individuals have different responses to treatment and progress toward recovery at different rates. Hence, the composition of the group to which a client is initially assigned at admission is unlikely to remain constant throughout the treatment episode. Some clients progress rapidly to the next stage, whereas others need to cycle back to an earlier treatment intensity if they relapse or encounter other problems.

IOT programs can organize homogeneous groups based on a therapeutically relevant issue for a subset of clients or based on demographic commonalities among clients. Therapeutically relevant issues that might call for single-issue groups include single parenting, HIV/AIDS, gender issues, drug of choice, or histories of physical violence and sexual abuse. Special groups based on demographic similarities include those for women, men, elderly persons, members of minority populations, clients with common socioeconomic or legal statuses, or clients who have particular professions or are unemployed. Clients in these homogeneous groups can use their common perspective as a basis for working together. Additional information associated with programming for diverse populations is presented in chapters 9 and 10.

Client-specific adaptations. Clients with temporary or permanent cognitive impairments, literacy deficits, or language problems need special attention or assignment to special groups. IOT programs should assess whether their treatment orientation and relapse prevention materials are appropriate for clients with cognitive impairments or learning disabilities. Chapter 10 provides additional information.

Clients not yet ready to pursue abstinence (those uninterested in change—precontemplators—or those thinking about a change in the near future—contemplators) often come to the program after being mandated to treatment by another agency. These clients could be assigned to a separate, pretreatment group in which counselors raise the clients' awareness about substance use disorders through education and motivating interviews (Washton 2000).

Clients who should not participate in certain groups. Some clients should never be assigned to the same groups. Perpetrators and victims of domestic violence must be in separate groups. Neighbors, relatives, spouses, or significant others also should not be assigned to the same group (with the exception of family therapy).

Clients who violate the principles of group therapy by failing to honor group agreements or dropping out continually and clients who cannot control their impulses might respond better to individual therapy.

Some socially anxious or very introverted clients cannot tolerate groups. These clients should be offered individual counseling until they are comfortable participating in group sessions (Hoffman et al. 2000) or lower intensity group sessions that focus on coping skills training (Avants et al. 1998). Some clients with severe psychiatric disorders, such as schizophrenia or antisocial personality disorder, may be unable to participate in groups and may be able to attend individual therapy only.

Duration and frequency of group sessionsIOT group counseling sessions often are scheduled for 90 minutes, although shorter and longer timeframes also are used. Psychoeducational group sessions often are only half that long (e.g., a 30-minute lecture followed by 15 minutes for questions) because they focus on instruction instead of interaction.

The American Society of Addiction Medicine's (ASAM's) definition of IOT requires participants to have a minimum of 9 hours of therapeutic contact per week—at least in the initial treatment stage (Mee-Lee et al. 2001). A typical IOT program schedules 3 hours of treatment on 3 days or evenings each week. This might entail 2 evenings of back-to-back 90-minute groups (one for members in the same recovery stage to share day-to-day concerns and the other to study a psychoeducational topic). A third evening might include 30 minutes of individual counseling, a 90-minute family session, and an hour-long skills training group. Some IOT programs meet 5 days or evenings per week.

IOT programs vary considerably in the anticipated length of stay or expected duration of active treatment. Many courses of treatment span 12 to 16 weeks before clients step down to a less intensive (maintenance) stage. Clients may remain in the maintenance phase for 6 months or more.

Group size and formatThe optimal size of a group in most IOT programs is between 8 and 15 members. Process-oriented groups may function more effectively if membership is limited to 6 to 8 members, whereas psychoeducational groups with considerable didactic content can be somewhat larger.

Most counseling guidelines suggest structuring group time (Mercer 2000; Owen 2000). Some groups use a “rule of thirds” wherein the first third of the session is used to solicit each member's current issues or experiences, the second third is used to discuss a particular issue or skill, and the final third is used to sum up the meeting and assign an exercise (Kadden et al. 1995). Another approach uses a standard problemsolving process in which an issue of concern to the group is identified, a variety of solutions is offered, each option is explored, a decision is made about the course to follow, an action plan is developed, and affected group members agree to pursue this path and report the outcomes (Gorski 2000).

Many recovery groups have traditional opening and closing rituals that are meant to increase members' commitments to one another and to the group as a whole.

Group leaders' roles and qualificationsIOT programs usually specify the roles, responsibilities, qualifications, and personal characteristics of counselors who lead groups. Chapter 2 of TIP 46, Substance Abuse: Administrative Issues in Outpatient Treatment (CSAT 2006f ), discusses these issues in detail.

Individual Counseling

In IOT programs, individual counseling is an important, supportive adjunct to group sessions but not the primary form of treatment. Whereas concurrent psychiatric interventions and addiction counseling are appropriate for clients with co-occurring substance use and mental disorders (CSAT 1994b , 2005e ; Daley and Thase 2002), most individual counseling in IOT programs addresses the immediate problems stemming from clients' substance use disorders and their current efforts to achieve and maintain abstinence. Counseling typically does not address the client's underlying, longstanding conscious and subconscious conflicts that may have contributed to substance use. Many of the readily available counseling manuals for substance abuse treatment have enhanced components for individuals or orient the entire approach to individual counseling (Kadden et al. 1995; Mercer and Woody 1999; Nowinski et al. 1992).

A 30- to 50-minute individual counseling session is typically a scheduled part of the IOT program and occurs at least weekly during the initial treatment stage. A client is assigned a primary counselor who strives to establish a close, collaborative therapeutic alliance.

An individual counseling session frequently follows a standard format. A counselor may ask the client about reactions to the recent group meeting, explore how the client spent time since the last session, ask how the client is feeling, inquire about drug and alcohol use, and ask whether there are any urgent issues. The counselor helps the client review reactions to recent group topics, reviews treatment plans and coping strategies, addresses fears and anxieties related to the change process, provides personalized feedback on urine toxicology and Breathalyzer™ results, and probes into sensitive issues that are difficult to discuss in the group. Counselors also help clients access services they need that are outside the treatment program's capabilities and plan the transition to another level of care or discharge. A counseling session usually ends with a summary of the client's plans and a schedule for the next few days (Carroll 1998; Gorski 2000; Mercer 2000).

Psychoeducational Programming

Psychoeducational groups are more didactic than process-oriented recovery groups and involve a straightforward transmission of facts. The counselors who deliver these services need to be knowledgeable about the subject matter. They also need to know where and how to obtain additional information to support their presentations and give members of the group other references and resources. These sessions, like recovery groups, stimulate discussion that helps participants relate the topic to personal experience and foster emotional and behavioral change (Washton 2000).

Exhibit 4-3 lists typical topics that are covered in psychoeducational groups and the treatment stage at which they are introduced.

Exhibit 4-3. Typical Sequence of Topics Addressed in Psychoeducational Groups

Treatment engagement • Understanding motivation and committing to treatment
• Counteracting ambivalence and denial
• Determining the seriousness of the drug or alcohol problem
• Conducting self-assessment, setting goals, and self-monitoring progress
• Overcoming common barriers to treatment
Early recovery • Learning about biopsychosocial disease and recovery processes
• Understanding the effect of specific drugs and alcohol on the brain and body
• Placing symptoms of substance use disorders in the context of other behavioral health problems
• Learning about early and protracted withdrawal symptoms for specific drugs and alcohol
• Knowing the stages of recovery and the client's place in the continuum of care
• Learning strategies for quitting and finding the motivation to stop
• Minimizing risks of HIV/AIDS, hepatitis C, and sexually transmitted diseases (STDs)
• Identifying high-risk situations that are cues or triggers to substance use: people, places, and things
• Identifying peer pressures and compulsive sexual behavior as triggers
• Understanding cravings and urges, learning to extinguish thoughts about substance use, and coping with cravings
• Structuring personal time
• Coping with high-risk situations
• Understanding abstinence and the use of prescription and over-the-counter medications
• Understanding the goals and practices of various 12-Step or other mutual-help groups
• Identifying and using positive support networks
Maintenance and continuing care • Understanding the relapse process and common warning signs
• Identifying tools to prevent relapse
• Developing personal relapse plans
• Counteracting euphoria and the desire to test control
• Improving coping and stress management skills
• Learning anger management and relaxation techniques
• Enhancing self-efficacy for handling risky situations
• Responding safely to slips and avoiding escalation
• Finding recovery resources
• Structuring leisure time and finding recreational activities
• Knowing the importance of personal health: diet, exercise, hygiene, and checkups
• Taking a personal inventory
• Handling shame, guilt, depression, and anxiety
• Understanding family dynamics: enabling and sabotaging behaviors
• Rebuilding personal relationships
• Understanding sexual dysfunction and healthy sexual behavior
• Developing educational and vocational skills
• Learning daily living skills: money management, housing, and legal assistance
• Embracing spirituality and recovery and finding meaning in life
• Recognizing grief and loss and the relationship to substance use
• Learning about parenting: basic needs of children and their developmental stages and developmental tasks
• Maintaining balance in life

Pharmacotherapy and Medication Management

Pharmacotherapy and medication management are critical adjuncts to effective substance abuse treatment that should not be ignored or separated from other therapies, psychosocial supports, and behavioral contingencies. Medications target only specific and limited aspects of substance use disorders. Pharmacotherapy, by itself, does not change lifestyles or restore the damaged functioning that accompanies most drug dependence.

IOT programs that require attendance 3 to 5 days per week are ideal settings for identifying clients in need of medication, initiating medication regimens, and monitoring clients' compliance. IOT programs should give serious consideration to providing pharmacotherapy and medication management services

  • To provide ambulatory detoxification and relief of withdrawal symptoms for some clients
  • To prevent relapse by reducing craving, by potentially precipitating an aversive reaction, or by blocking the reinforcing effects of drugs
  • To reduce the medical and public health risks from use or injection of illicit drugs with medical maintenance
  • To ameliorate the underlying psychopathology that may contribute to substance use disorders
  • To monitor treatment of some medical conditions associated with substance use disorders

Ambulatory detoxification

ASAM criteria (Mee-Lee et al. 2001) include provisions for ambulatory detoxification when specific program and environmental supports are in place for persons who are at low risk for severe withdrawal. IOT programs should have written medical protocols or guidelines for specific detoxification procedures, as well as formal affiliations with appropriate general medical and psychiatric treatment facilities and laboratory testing and toxicology services. (This TIP is not intended to provide detailed information about detoxification and the medical management of detoxification. For more information on detoxification see appendixes 4-A and 4-B and chapter 5 of this volume and TIP 45, Detoxification and Substance Abuse Treatment [CSAT 2006e ]).

IOT programs can institute ambulatory detoxification safely for appropriate clients if they

  • Make arrangements for immediate and continuous supervision or consultation by a qualified physician, with provisions for hospitalization or alternative detoxification, if necessary.
  • Have medically trained staff (e.g., registered nurses, nurse practitioners, licensed practical nurses, physician's assistants) on site to conduct initial physical examinations, obtain medical histories, inform clients about medication effects, adjust dosages, and monitor clients for several hours or longer each service day.

The consensus panel recommends that family members be involved in monitoring and reporting adverse events for the client undergoing detoxification.

Using the CIWA-Ar scaleThe Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) scale commonly is used to determine which clients who are alcohol dependent can receive ambulatory detoxification and which should be referred for inpatient care. The CIWA-Ar can be administered reliably in a few minutes by a staff member with a minimum of 3 hours of training (for more information about the CIWA-Ar, see chapter 5).

Some disagreement exists among physicians about the cutoff points on the CIWA-Ar for conducting ambulatory detoxification or referring a client for inpatient care. Many physicians seem to concur that clients with scores of 20 or higher should be treated in an inpatient medical facility. Other experienced addiction specialists find that clients with scores up to the low 20s can be managed safely in an outpatient setting with proper monitoring, supervision of medications, and other supports (see the case illustration and appendix 4-A). Medical staff members in IOT programs must use their best judgment or rely on the program's written procedures.

The CIWA-Ar also is used to monitor the client's response to administered medications at 30- to 60-minute intervals. Symptom-triggered doses are given only when trained staff members observe withdrawal signs of a specified intensity. Appropriate use of the CIWA-Ar has been shown to reduce both the numbers of clients receiving withdrawal medications and the amount of medication administered (Reoux and Miller 2000; Wiseman et al. 1998). The instrument has been adapted for monitoring benzodiazepine withdrawal (Busto et al. 1989) and for assessing opioid withdrawal (Bradley et al. 1987). (See chapter 5 for information about other screening instruments.)

Detailed guidelines and resources regarding ambulatory detoxification are available in TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians (CSAT 1997a ), and TIP 45, Detoxification and Substance Abuse Treatment (CSAT 2006e ). Internet resources include articles from the American Family Physician (www.aafp.org), ASAM materials such as Principles of Addiction Medicine (www.asam.org), and Detoxification Clinical Practice Guidelines developed by the New South Wales Health Department (www.druginfo.nsw.gov.au/home).

Pharmacotherapies for addiction

Research supports the effectiveness of medication-assisted treatment for alcohol and opioid addiction. Despite promising leads, extensive laboratory research, and many clinical trials, no compelling evidence exists of effective medications for treating dependence on cocaine and other stimulants, marijuana, inhalants, or hallucinogens.

Preventing relapse to alcoholDisulfiram (Antabuse®) and naltrexone (ReVia®) have been used successfully to assist clients who are alcohol dependent with avoiding relapse. An IOT program is an ideal setting to initiate disulfiram treatment because doses are effective for 3 days. Clients can receive their doses during a session, with double doses or take-home doses provided for the weekends.

Early research studies suggested that naltrexone did not reduce the frequency of alcohol use relapses but appeared to shorten the duration of relapse and to lessen the amount of alcohol drunk during a relapse episode (O'Malley et al. 1992; Volpicelli et al. 1992). However, recent data suggest that naltrexone might be ineffective in limiting drinking for men with chronic, severe alcohol dependence (Krystal et al. 2001). Clinicians who are interested in naltrexone for clients who use alcohol are referred to TIP 28, Naltrexone and Alcoholism Treatment (CSAT 1998c ).

Acamprosate (Campral®) was approved by the U.S. Food and Drug Administration in 2004 for postwithdrawal maintenance of alcohol abstinence. In nearly two decades of use in Europe, acamprosate has been found to be safe and effective for treating alcohol dependence (Mann et al. 2004; Tempesta et al. 2000). Treatment with acamprosate has been shown to decrease the amount, frequency, and duration of alcohol consumption in clients who relapse to alcohol use (Chick et al. 2003; Tempesta et al. 2000) and to reduce cravings, even in clients who resume drinking (CSAT 2005a ).

Medication maintenance for opioid dependenceClients dependent on opioids, who frequently do not respond to other forms of substance abuse treatment, can be maintained effectively on certain longer acting opioid medications that enable them to function productively. These opioid medications include methadone, buprenorphine, and levo-alpha acetyl methadol (LAAM). (Although LAAM is still approved by the U.S. Food and Drug Administration for treatment of certain clients dependent on opioids, the U.S. manufacturer of LAAM ceased producing it in 2005.)

Treatment with methadone and LAAM currently must take place in specially approved and licensed programs or, under special circumstances, in a physician's office. Because new clients must attend these programs a minimum of 5 days a week, methadone maintenance programs are ideal settings for introducing many components of IOT programming.

Buprenorphine alone and a buprenorphine-naloxone combination are alternative medications for maintenance of individuals dependent on opioids. Buprenorphine was approved by the U.S. Food and Drug Administration in 2002 for the treatment of opioid dependence and is scheduled as a Class III narcotic. Buprenorphine can be dispensed or prescribed by physicians in office-based practices or in health care facilities that are not specially licensed, provided they obtain a waiver from the Substance Abuse and Mental Health Services Administration. IOT programs with a physician on staff or readily available are eligible to dispense or prescribe buprenorphine. Buprenorphine is safer for treating opioid dependence than methadone or LAAM because it is more difficult to overdose (Jaffe and O'Keefe 2003; Johnson et al. 2003) and, in combination with naloxone, reduces the risk of diversion (Johnson and McCagh 2000; Mendelson and Jones 2003). TIP 40, Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction (CSAT 2004a ), provides more information. Information about Web-based and onsite training about buprenorphine can be obtained by clicking on Medication Assisted Treatment on the CSAT Web site (www.buprenorphine.samhsa.gov/training_main.html). TIP 43, Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs (CSAT 2005b ), offers guidance about methadone, LAAM, and opioid pharmacotherapy.

Co-occurring disordersMany clients who enter substance abuse treatment have co-occurring mental disorders. ASAM patient placement criteria recommend that individuals with moderate-severity disorders be treated in IOT programs that are designed primarily for clients who abuse substances; the placement criteria also recommend that IOT programs be capable of coordination and collaboration with mental health services. These programs can provide psychopharmacologic monitoring, psychological assessment and consultation, and treatment of substance use disorders to clients with moderate-severity mental disorders. Clients with symptomatic, high-severity psychiatric diagnoses should be treated in programs that treat co-occurring disorders by integrating mental health and substance use treatment and that have cross-trained staff (Drake et al. 1998b ; Ries et al. 2000). (Moderate-severity co-occurring mental disorders include stable mood or anxiety disorders. High-severity disorders include schizophrenia, mood disorders with psychotic features, and borderline personality [Mee-Lee et al. 2001].) Chapter 9 provides additional information on treating individuals with co-occurring disorders. TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005e ), also addresses this issue.

Clinical strategies and approachWhenever medication is used to support abstinence, clients need to be educated about the drug prescribed. It is important for clients to understand

  • Expected effects of the drug prescribed, interactions with other licit and illicit drugs, and adverse reactions that should be reported at once to the medical staff
  • Side effects and how they can be ameliorated (e.g., laxatives for the commonly experienced constipation produced by methadone)
  • Cross-tolerance and synergistic or other interactive effects when mixed with other drugs, especially drugs for such chronic conditions as high blood pressure, diabetes, high cholesterol, and asthma
  • The time usually needed for the full effect of medications, such as antidepressants, to be felt

The way in which a medication is introduced and explained can affect clients' willingness to comply with the dosing schedule and their chances of receiving its full benefits. When clients begin a medication regimen, it may be useful to hold educational groups for clients and their family members. Accurate information can be imparted, and the questions of both clients and their families can be answered. If clients are given take-home doses, the inclusion of family members in such educational groups may be helpful for encouraging compliance with the medication protocol.

Medication-assisted IOT programs must build time into the treatment schedule for administering medications, monitoring the effects, and providing appropriate education about medications. The program can schedule the administration of medications to minimize the effect of withdrawal symptoms on the client's participation in psychosocial treatment and to maximize treatment attendance and retention.

Infectious diseasesOf paramount concern is encouraging client compliance with medication regimens to treat, control, or cure infectious diseases. Several TIPs address this issue, including TIP 6, Screening for Infectious Diseases Among Substance Abusers (CSAT 1993b ); TIP 18, The Tuberculosis Epidemic: Legal and Ethical Issues for Alcohol and Other Drug Abuse Treatment Providers (CSAT 1995c ); and TIP 37, Substance Abuse Treatment for Persons With HIV/AIDS (CSAT 2000c ).

Monitoring Alcohol and Drug Use

Routine monitoring of clients' illicit drug and alcohol consumption to determine whether the selected therapy is having the desired effect is a standard part of all IOT programs. Some programs rely on clients' self-reports. However, most programs use objective tests of biological specimens—usually urine samples, but also breath, saliva, sweat, blood, or hair samples. The results of these scientifically established procedures help program staff members reliably and accurately monitor a client's treatment course, recognize clients' success in remaining abstinent, and increase the accuracy of clients' self-reporting. Monitoring drug and alcohol use helps clinicians determine the need for treatment plan modifications, helps families reestablish trust, helps clients avoid slips or lapses, and discourages them from substituting a different drug or alcohol for their primary drug of choice.

Testing in the IOT program is designed to deter clients from using substances, not to punish or induce shame and guilt. Programs might use drug-free urine test results as a contingency for receiving specified rewards, reinforcing desired behaviors rather than punishing continued drug use (see Budney and Higgins 1998).

When programs are asked to report urine test results to the criminal justice system, an employer, or a children's protection agency, it is important to consider the negative effect reporting can have on treatment. Knowing that a positive test result may lead to punishment can inhibit a client's forthrightness in self-disclosure and encourage treatment dropout. Clients need to be informed fully that their test results will be disclosed and that testing positive may trigger serious consequences (CSAT 2004b ).

Procedures for collecting and testing urine and a chart showing cutoff times for detecting various drugs are provided in appendix B. (Note: Alcohol is hard to test for because it may be eliminated from the client's system rapidly.) Appendix B lists methods and screening tests for detecting alcohol and illicit drugs, using a number of tests in addition to urinalysis.

Case Management

Individuals who abuse substances are likely to have significant and interrelated problems in addition to their use of psychoactive substances. Services to address these needs often are fragmented across many agencies. Services may be difficult to access without the assistance of a case manager who is knowledgeable about service providers and can help clients access these services (exhibit 4-4). Case managers help clients identify and prioritize needs that cannot be met by the IOT program and access and participate in additional services to meet those needs.

Exhibit 4-4. Case Management Services

• Provide a core set of social services that includes assessment, planning, linkage, monitoring, and advocacy.
• Provide the client with a single contact person who is responsible for finding and mobilizing needed resources, negotiating formal systems, and bartering informally with other service providers to gain access to appropriate services.
• Respond to client's needs, tailoring resources to the individual rather than fitting the client into existing services.
• Intervene with many systems and providers on behalf of the client.
• Operate in the community and transcend facility boundaries.
• Focus on pragmatic, immediate ways to meet needs (e.g., clothing, shelter).
• React sensitively and competently to clients' ethnic, gender, and cultural differences.
Single agency model. Case managers personally establish relationships with counterparts in other agencies to find and access services for individual clients.
Informal partnership model. Staff members from several agencies link into collaborative teams or networks that consult about individual cases and share services.
Formal consortium model. Case managers and service providers are joined through written agreements or contracts that define roles, responsibilities, shared services, and costs. This model usually is organized by a lead agency that has primary responsibility and receives most or all of the funding.

Examples of client populations that might be aided by case management services include pregnant women, people who are homeless, clients with HIV/AIDS and other serious medical conditions, people with severe mental disorders, long-term welfare enrollees, people with physical disabilities, and people involved in the criminal justice system.

IOT programs—particularly those serving publicly funded clients—need to have detailed, up-to-date resource directories or formal arrangements with the following types of local services:

  • Social service and child welfare agencies
  • Vocational rehabilitation
  • Training and employment assistance programs
  • Preventive health care; inpatient, outpatient, and community health care services (e.g., visiting nurses; home health aides; physicians; specialty programs for HIV/AIDS, hepatitis C, STDs, or tuberculosis [TB]; and prenatal and pediatric care)
  • Inpatient and outpatient psychiatric treatment and mental health services
  • Recovery support groups
  • Faith-based institutions appropriate for the client population
  • Food banks and clothing distribution centers
  • Recreational facilities and programs of many types
  • Adult education programs, including instruction in adult literacy and English as a second language
  • Child care
  • Parent training programs
  • Volunteer transportation services
  • Family therapy and couples counseling
  • Housing resources, including U.S. Department of Housing and Urban Development Section 8 housing, shelters for homeless persons and battered women, and recovery houses
  • Legal assistance

Providers of heavily used services should be visited by IOT staff members to maintain close working relations.

Qualifications and Roles of Case Managers

  • Many IOT programs hire professionally trained case managers, such as social workers or counselors whose sole function is case management. Other IOT programs may expect treatment counselors to assume case management responsibilities as well as counseling duties. In some programs, peer counselors or indigenous workers augment the work of professional staff members.
  • Case managers in IOT programs develop and maintain an accurate list of local and regional services that clients may need.
  • Case managers facilitate transfers to other treatment services as dictated by the clients' needs.
  • Case managers in IOT programs participate in developing written memorandums of understanding and interagency agreements to ensure that these documents specify services offered, staff qualifications, number of available slots, costs, lines of authority, and referral procedures.

Research outcomes and findings

Several studies suggest that case management services increase client retention, improve clients' occupational and social functioning, and ameliorate their psychiatric symptoms (Siegal et al. 1996, 2002). Case management services have been found to be a low-cost enhancement that improve client retention in some publicly funded, mixed-gender substance abuse treatment programs (Schwartz et al. 1997). A study by McLellan and colleagues (1998) provides support for adding case management services to IOT programs. This study evaluated the effectiveness of case-managed social services added to public-sector substance abuse treatment programs that served inner-city clients who were severely impaired. Case management consisted of coordinating and expediting clients' use of medical screening, employment counseling, drug-free housing, parenting classes, and recreational and educational services. Clients who received enhanced services had significantly better treatment outcomes than clients in traditional outpatient treatment. The investigators concluded that both addiction-focused services and supplemental social supports are necessary for effective, long-term rehabilitation.

In another study, case management for pregnant women enrolled in specialized women's outpatient substance abuse treatment included regular phone calls and home visits, written referrals to social service agencies, staff advocacy for clients' with social service agencies, and free transportation to and from treatment. Case management and transportation services were significant predictors of retention in drug treatment (Laken and Ager 1996). In a followup study, treatment retention was associated with decreased drug use and increased infant birth weight (Laken et al. 1997). TIP 27, Comprehensive Case Management for Substance Abuse Treatment, provides detailed information (CSAT 1998a ).

24-Hour Crisis Coverage

Many clients in IOT programs develop problems that require immediate attention outside working hours. Arrangements are needed for 24-hour, 7-day-a-week coverage by trained personnel (exhibit 4-5). The benefits of this coverage include reducing unnecessary hospitalizations and providing fail-safe options for clients and families to head off crises.

Exhibit 4-5. Examples of 24-Hour Crisis Coverage Implementation

Hotline services. In some programs, afterhours calls are forwarded to a hotline or other crisis intervention service. This service can provide advice and referrals or, if indicated, can contact an IOT program staff member.
Oncall clinicians. A few large IOT programs that serve a particularly troubled population (e.g., persons with severe co-occurring mental disorders) may have rotating, oncall clinicians who answer and screen inquiries.
Agreement with 24-hour professional service providers. In some areas, afterhours calls to the IOT program are transferred to a detoxification or inpatient rehabilitation unit that is staffed 24 hours a day.

IOT programs should ensure that clients are aware of the afterhours coverage and that the coverage is listed in published materials. Clients need clear, written instructions regarding emergencies—whether to go immediately to a hospital or to call 911.

Community-Based Support Groups

IOT programs should foster active participation in community-based 12-Step and other mutual-help groups as part of the treatment process. This effort is extremely important for clients because formal substance abuse treatment is a relatively brief step in the long journey to recovery. In addition, clients need to develop a support network of positive role models and friends who can help guide their continuing recovery. Support groups serve as an important adjunct to structured therapy. At a minimum, clients need to be introduced to the basic tenets of a 12-Step or similar mutual-help group. Most IOT programs encourage participation in group meetings and give clients options about the type of community-based group they can attend.

Key aspects of community support groups

An IOT program often can facilitate voluntary attendance in support groups by helping clients understand more about local support groups through group discussion and individual counseling. At a minimum, IOT programs should give clients a thorough introduction to mutual-help programs, help clients overcome any resistance by encouraging their attendance with other group members or program alumni, and leave the decision about joining a group to the clients. Programs also can invite support groups to hold open meetings on site; these meetings allow clients to become familiar with the format of Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous (CA), or other groups.

Counselors should be familiar with the differences between various support groups in the community and help their clients select an appropriate group meeting to attend. Counselors should match clients with groups attended by persons who have similar social, ethnic, economic, and cultural backgrounds and experiences. The substances clients abuse, as well as other factors, also may affect the match (Forman 2002).

The 12-Step fellowship

Twelve-Step fellowships are the most commonly recognized and widely attended groups for continuing recovery support. Involvement in 12-Step groups such as AA, NA, or CA is correlated positively with both retention in treatment and abstinence (Fiorentine 1999). Twelve-Step groups include a spiritual focus, espouse principles of conduct, and provide ongoing support for as long as an individual wishes to participate.

Twelve-Step groups are available throughout the country. There are different types of meetings (e.g., open speaker meetings, Step meetings, open and closed discussion meetings). Basic AA texts include Alcoholics Anonymous (the “Big Book”), Twelve Steps and Twelve Traditions, and Living Sober. Basic texts of NA include Narcotics Anonymous and It Works: How and Why. Information about AA and fellowship meetings is available from the General Services Offices of Alcoholics Anonymous (www.gso.org) and from World Services, Inc. (www.alcoholics-anonymous.org). Information on AA meetings can be obtained from the central offices in each State and the District of Columbia. A list of contacts in the central offices can be found at www.aa.org/en_find_meeting.cfm. The Narcotics Anonymous Meeting Search function at www.na.org helps people locate an NA meeting throughout the United States and its territories. The CA Web site provides contact information for meetings throughout the United States, Canada, and Europe (www.ca.org/phones.html). Nowinski and colleagues (1992) and Daley and colleagues (1999) also offer guidance on conducting 12-Step-oriented counseling.

Some clients may be more comfortable in 12-Step groups that have been adapted to meet participants' needs. Depending on the geographic location, there may be gay- and lesbian-identified groups, women's groups, groups for people who are hearing impaired, men's meetings, Spanish-language meetings, meetings for agnostics, young people's meetings, and beginners' meetings.

Special 12-Step groups have been organized by people with both substance use and psychiatric disorders (see chapter 9). These groups have been shown to reduce substance use and increase compliance in clients taking prescribed medications (Laudet et al. 2000a ).

Alternatives to community-based 12-Step groups

Community support groups exist for clients who may be uncomfortable with traditional 12-Step groups (see exhibit 4-6).

Exhibit 4-6. Alternatives to Traditional 12-Step Groups

• Self-Management and Recovery Training (www​.smartrecovery.org) groups were developed during the 1980s as alternatives to the 12-Step model. These groups address recovery within a cognitive-behavioral framework. Preliminary studies suggest this approach can be a viable alternative for individuals who are reluctant to attend 12-Step meetings, although further study is needed (Connors and Dermen 1996; Godlaski et al. 1997). Atheists and agnostics are less likely than clients who describe themselves as spiritual or religious to initiate and sustain AA attendance. However, clients who identify themselves as atheist and agnostic and who persist in AA attendance show no difference in days abstinent or drinking intensity when compared with clients who identify themselves as spiritual or religious (Tonigan et al. 2002; Winzelberg and Humphreys 1999).
• Secular Organizations for Sobriety (www​.secularhumanism.org) and Save Our Selves (www​.secularsobriety.org) promote individual empowerment, self-determination, and self-affirmation and offer groups for women and members of minority groups in addition to open groups.
• A variety of support groups can be accessed through national organizations such as Women for Sobriety, Inc. (www​.womenforsobriety.org), the Women's Action Alliance, the Institute on Black Chemical Abuse (www​.aafs.net/ibca/ibca.htm), the National Black Alcoholism and Addictions Council (www​.nbacinc.org), the Hispanic Health and Human Services Organization, the Hispanic Health Council (www​.hispanichealth.com), and the National Association of Native American Children of Alcoholics.
• Clients who are former inmates may respond positively to community-based support services that address their special needs. Programs such as the Fortune Society (www​.fortunesociety.org) and the Safer Foundation, which provide assistance to former inmates, are located in several large cities.
• Religious institutions are frequently a significant community-based support system for many recovering individuals, particularly within African-American communities (CSAT 1999b ). Many IOT programs encourage interested clients to become involved with community religious groups. For example, JACS (Jewish Alcoholics, Chemically Dependent Persons, and Significant Others) helps members reconnect with one another and explore resources within Judaism that enhance recovery.
• Some IOT programs run support groups for former clients on an indefinite basis. Generally, participation in these alumni groups does not require payment to the IOT program. The groups often are supported at minimal cost by the program as part of a continuum of care for clients who successfully complete treatment. Typical support provided by the IOT program for alumni groups includes meeting space, refreshments, and promotion of the group to clients. Some clients attend both 12-Step meetings and other support groups.

Medical Treatment

Many IOT clients enter treatment with undiagnosed or untreated medical conditions that require immediate and continuing care by a physician. All IOT programs need to have preplanned arrangements with a community health center or a local hospital that can handle any overdose or withdrawal-related emergencies. Relationships need to be in place with medical providers that will test for and treat infectious diseases, including STDs, HIV infection, TB, hepatitis B and C, and other health conditions. Programs serving women who are pregnant or of childbearing age need to have arrangements in place for obstetric and gynecological care.

Psychiatric Examinations and Psychotherapy

IOT programs need to evaluate clients' mental and psychiatric status and to refer those with signs and symptoms indicating that a thorough evaluation is warranted. Chapter 5 provides guidance on conducting psychological evaluations. Chapter 9 discusses the needs of persons in IOT with co-occurring psychiatric disorders; additional information is provided in TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005e ). Ideally, IOT programs have relationships with mental health centers and with individual psychiatrists for consultation and referral.

Vocational Training and Employment Services

Unemployment or underemployment is often a problem for individuals in early recovery. Clients entering IOT programs often have issues that impede their ability to be employed fully, such as limited formal education, poor work readiness, and skill deficits. Few IOT programs are prepared to address these barriers to employment; hence, specialized vocational and employment counseling and related services on site or through case-managed referral are an optimal part of an IOT program.

IOT programs need to stay abreast of local vocational training and employment resources and to develop relationships with these agencies and with individual counselors at these agencies. Many communities offer specific vocational resources for persons with disabilities, veterans, women, criminal justice clients, and other groups. TIP 38, Integrating Substance Abuse Treatment and Vocational Services (CSAT 2000a ), presents more information.

Enhanced IOT Services

Adult Education

Clients who have educational deficits need encouragement to enroll in local adult education classes, literacy programs, or general equivalency diploma programs. Those who do not speak English well should be encouraged to attend English-as-a-second-language courses. If a sufficient number of clients do not have high school diplomas or use a language other than English at home, an IOT program might recruit volunteers to conduct classes on site.

Transportation Services

The transportation needs of clients may be met in several ways, including providing public transportation tokens or passes. This simple accommodation should be considered by all programs that serve low-income clients as a way to encourage retention in treatment. Alternatives that are likely to involve insurance liability include using staff or volunteers to drive vans.

Housing and Food

Housing programs in many cities provide room and board for recovering persons. These recovery homes usually are not licensed treatment facilities but rather are financially self-sustaining organizations that offer housing for a limited time. The homes often are established or staffed by recovering individuals and are available for a nominal weekly or monthly rent.

The ground rules for residence are abstinence, regular rent payments, and appropriate conduct. Some recovery houses require attendance at house meetings and community-based 12-Step meetings. Some recovery houses actively encourage ongoing substance abuse treatment and employment by the end of the first 30 days of residence. Other group-living houses are available to special populations, such as persons infected with HIV or individuals with psychiatric diagnoses, and professional staff members usually are in residence or readily available.

Many temporary shelters for homeless persons offer recovery support or more formal and staged substance abuse treatment. The Salvation Army, for example, operates halfway houses or supportive living residences for recovering persons. Some shelters for homeless people also incorporate short-term recovery support. Homeless populations and other low-income clients in IOT programs may need the assistance of food banks or access to surplus food that may be supplied by local merchants or other community agencies.

Recreational Activities

Organized recreational activities can be a valuable part of treatment, helping clients find healthful, substance-free interests to replace a former focus on substance use. Scheduled exercise (including walking, sports, weight training, and aerobics) has been shown to be an important aspect of substance abuse treatment (Kremer et al. 1995). Exercise can relieve underlying depression and anxiety (Paluska and Schwenk 2000). Organized sports, games, arts and crafts, and walks can have therapeutic benefits.

Adjunctive Therapies

Groups in which clients use various nonverbal, creative media (e.g., music, dance, drama, crafts, and arts such as painting, drawing, sculpture, and collage) can be therapeutic and helpful to recovery. Other alternative therapies that might help clients include acupuncture and stress reduction by means of biofeedback therapy (Richard et al. 1995).

Various forms of meditation (mindfulness, visualization, breath meditation, and transcendental meditation) have been used to treat diseases such as cancer and AIDS (Marlatt and Kristeller 1999). As an adjunct to substance abuse treatment, meditation can be used with the goal of reducing the frequency and intensity of cravings and improving clients' emotional and psychological function (CSAT 1994a ). Meditation is consonant with the philosophy of AA and other 12-Step support groups (CSAT 1999c ).

Nicotine Cessation Treatment

Clinical experience indicates that the majority of people who are drug or alcohol dependent also smoke cigarettes. More people in this group die from tobacco-related causes than from their alcoholism or drug dependence (Hurt et al. 1996). Despite the health risks associated with smoking, substance abuse treatment staff members persistently believe that smoking cessation may be detrimental to clients' abstinence from other drugs. However, believing that the best time to quit smoking would be during treatment was the main factor in clients' accepting nicotine cessation treatment at admission to substance abuse treatment (Seidner et al. 1996). In one study, fewer than 10 percent of clients objected to a clinic's smoking ban when nicotine replacement therapy was available along with substance abuse treatment (Zullino et al. 2003).

The relapse rate for smokers in the general population who are trying to quit is high. Frank and colleagues (1991) found that fewer than 4 percent of smokers who succeed in quitting did so with the help of a physician. Smokers who are trying to quit achieve the highest success rates when they participate in behavioral therapy in combination with nicotine replacement therapy (Glover et al. 2003). These findings suggest that IOT programs are good settings for smoking cessation efforts because they offer a structured environment in which clients' efforts to quit smoking can be supported by behavioral and medication-assisted interventions and other clients. Strong associations have been shown between reductions in cigarette smoking and reductions in other substance abuse during treatment (Kohn et al. 2003; Shoptaw et al. 2002).

Nicotine replacement is available in prescription (inhaler, spray) and nonprescription (gum, patch) forms. Clients may need to try several different products of the same type (e.g., different brands or dosages of gum) or try different delivery mechanisms before they find a product that works for them. Researchers have found that inhalers, sprays, gum, and patches are more effective than placebo in helping clients quit smoking (Schmitz et al. 1998). The antidepressant medications bupropion and nortriptyline have shown promise in diminishing cravings for nicotine and improving quit rates, probably because they help alleviate depression—a major cause of relapse (da Costa et al. 2002; Richmond and Zwar 2003).

Licensed Child Care

IOT programs that serve women who have young children should have appropriate childcare facilities on site or nearby to facilitate the mothers' participation in treatment. For liability and therapeutic reasons, childcare arrangements should be provided by licensed childcare professionals, not by untrained counselors or volunteers. IOT programs should check with their county government or Single State Authority about local regulations.

Parent Skills Training

Many clients need to learn parenting skills, children's developmental stages, and appropriate disciplinary strategies for each stage. Parents also may benefit from practical information about obtaining vaccinations, diets for youngsters, listening skills, and attention-increasing activities that prepare toddlers for school. Training in parenting skills is essential for parents who have survived emotional, physical, and sexual abuse in their own childhoods. Without intervention, these clients may perpetuate this type of harmful behavior with their own children.

IOT programs can help enroll clients' young children in Head Start programs (where available) and facilitate their attendance (visit the Web site of the National Head Start Association, www.nhsa.org). Focus on Families, a training program for parents in opioid treatment programs, has involved parents successfully in treatment, decreased their use of illicit substances, and reduced the risk factors and enhanced the protective factors for future drug use among their children; however, few significant changes have been seen in children's behavior at 1-year followup (Catalano et al. 1997, 1999). Information about Strengthening American Families and other age-specific model parent and family training programs evaluated by the Office of Juvenile Justice and Delinquency Prevention can be found at www.strengtheningfamilies.org. Information about programs, such as the National Center on Substance Abuse and Child Welfare and Starting Early, Starting Smart, that focus on children and families in the context of substance abuse prevention and treatment can be found at www.samhsa.gov/Matrix/programs_children.aspx.

IOT Services: A Case Illustration

Exhibit 4-7 describes a suburban, hospital-based IOT program, and appendix 4-A presents a case study illustrating the treatment course for one of its clients. This IOT program offers comprehensive services for diverse groups of clients. The treatment philosophy integrates the disease concept of chemical dependence with cognitive-behavioral approaches, motivational counseling, and the principles of 12-Step fellowship programs and similar mutual-help community support groups.

Exhibit 4-7. Key Features of a Hospital-Based Suburban IOT Program

• Qualified medical staff members make the initial assessment of applicants' withdrawal potential; these medical staff members prescribe and dispense medications for symptomatic relief and monitor clients' reactions for up to 10 hours.
• Medications can be administered on site.
• Staff members provide continuing assessment of other potential psychiatric problems that may contribute to clients' substance use disorders; a psychiatrist in the hospital's psychiatric unit is available for medication evaluation and monitoring when needed.
• Whenever possible, family members (with the consent of the client) are involved in the initial assessment, treatment planning, and psychoeducational activities.
• Randomized, monitored urine testing is used as a clinical tool for deterring clients' use of mood-altering substances.
• Clients are expected but not required to participate in 12-Step fellowships or other mutual-help groups early in treatment.
• Clients attend groups for both therapeutic and educational purposes. Most therapy groups are co-led by two counselors. Group members examine the ways in which their thoughts, emotions, and behaviors contribute to, or detract from, a satisfying lifestyle or recovery. The clinician is responsible for ensuring a psychologically and physically safe environment that provides support and maintains therapeutic pressure for positive change. Counselors are flexible in setting limits; they maintain order while allowing spontaneity and growth. The emphasis is on giving all group members an opportunity to participate as equals.
• Three 3-hour IOT sessions are organized into sequential groups. Issues identified during the first highly structured group are explored in depth during the second, less structured group therapy session. The third, didactic group session can be tailored to particular issues identified during the therapeutic discussions or to the basic interests of the group. These sessions, which use lectures and videos as well as written materials, address an array of topics, including basic information about alcohol and drugs, the 12 Steps of AA or NA fellowships and other support groups, and a cognitive-behavioral relapse prevention approach.
• The client's transition from the rehabilitation (early recovery) to the continuing care (maintenance) phase of treatment is carefully planned so that the client continues with the rehabilitation group while “trying out” the continuing care group. The client usually knows several members of the new group and, sometimes, a co-leader of the new group. The group meets in the facility in which earlier treatment was conducted and the structure of the sessions is similar to that of the primary treatment phase. Step-up care is used flexibly so that clients who have relapsed move to a more structured schedule until they are restabilized.
• Programming is structured to respond to individual client needs, including a variable, rather than a fixed, length of stay.
• Three levels of IOT services are offered in overlapping phases to reduce attrition and facilitate long-term recovery:
• Partial hospitalization (ASAM Level II.5) for up to 10 hours per day for medically monitored ambulatory detoxification.
• Intensive outpatient (ASAM Level II.1) for 3 hours per day for rehabilitation. Clients initially are seen 5 days per week. The frequency gradually is tapered to once weekly for a total of 10 to 30 sessions, depending on clinical need. Separate individual and family sessions also are scheduled.
• Nonintensive outpatient (ASAM Level I) once weekly for 2 hours for continuing care for up to 2 years

The facility is located within a hospital but has a separate entrance. It is close to public transportation and has ample parking. The reception room feels welcoming, and rooms for group sessions are furnished with upholstered couches and chairs, soft lighting, and pleasant artwork. Several group rooms double as offices for the counselors and onsite medical staff. This IOT program serves clients who are dependent on a variety of substances. Many clients have both substance use and mental disorders. The programming and schedules are sufficiently flexible to serve the needs of professionals, blue-collar workers, students, single-parent families, stay-at-home parents, and retirees.

Appendix 4-A. A Case Study of Intensive Outpatient Treatment

Case PresentationCommentary
Initial Contact
Tom, a 45-year-old African-American accountant, has been referred to the program by his supervisor through his company's employee assistance program (EAP) because of repeated Monday-morning tardiness and complaints by co-workers that his work is increasingly “sloppy” and he often smells of alcohol.Because the referral was initiated by an EAP, it is important for staff members to stay in close contact with the EAP representative.
An EAP representative telephoned and made an appointment for Tom for 9 a.m. the next day. Tom has health insurance, has not had previous treatment, and is married with a family. Tom was asked to invite his wife to come with him.A trained intake worker screens all applicants to ascertain their eligibility and whether there is any psychiatric or medical emergency that cannot wait for a regularly scheduled appointment.
Stage 1: Treatment Engagement
During the intake interview, Tom reports that he has been drinking “about a six pack” of beer daily for the past 5 years, with “maybe 10 or 15 beers” on weekend days. He denies other drug use and any major problems, although he was charged with driving while intoxicated (DWI) 2 years ago, at which time his blood alcohol level (BAL) was .22 mg/dl. He says he was “put out” that the judge sent him to alcohol education classes and AA meetings, even though he “wasn't really drunk or unable to drive.” His doctor told him at his last checkup about a year ago that his liver function tests were slightly elevated and he should stop drinking.Family members are invited to participate in intake interviews.
Many treatment applicants initially minimize the extent or intensity of substance use and associated problems. However, Tom clearly has a substance use disorder that is affecting his functioning.
After confidentiality regulations are explained, Tom consents to the program's requesting a transcript of the records of his DWI charge and his involvement with the alcohol education classes. His claim of not really being drunk despite a .22 mg/dl BAL suggests a high tolerance.
He also agrees that his internist can be asked to forward medical records and conduct additional tests or examinations, if they are indicated.
Tom says he stopped drinking for a while but started again and hasn't been back to see the doctor since then. When asked about this period of abstinence, Tom says it probably lasted 4 months and that he felt depressed during that time. “It's hard having a teenage daughter,” he offers as an excuse for drinking again. He says it was pretty easy to stop drinking then and would be now. He claims he has no withdrawal symptoms and is “healthy as a horse.”Tom's history indicates that his drinking may be complicated possibly by underlying depression, even though he blames others for his return to alcohol and does not, apparently, yet see his drinking as a problem. He agrees, however, to participate in the program because his job is in jeopardy.
When asked about Tom's drinking, his wife, Gloria, reports that he actually consumes 1½ to 2 six-packs a day and 20 or more beers per day on weekends. She's certain of this because she “picks up after him every night” after he falls asleep in his chair. She's been complaining and worrying about Tom's drinking for years and begged him to get help. She reports that his teenage daughter complains of how “mean” he gets when drinking. There has been no violence, but he shouts at the girl a lot. Gloria observes that Tom has “terrible shakes” in the morning until he has a beer. She recalls that he was pretty blue and unhappy when he stopped drinking and “couldn't sleep, either.” She has begged him to go back to the doctor and says Tom never mentioned his “liver problems” to her before.Gloria provides a more accurate description of Tom's drinking pattern and confirms both his physiological dependence and the possibility of underlying depression. She appears to be supportive of her husband although distressed by his continued drinking and its effects on the family.
Ambulatory Detoxification
Asked to stretch out his arms, Tom has slight but visible tremors in his hands and fingers. A Breathalyzer test at 9 a.m. yields a reading of .10 mg%, indicating his BAL last night at 9 p.m. when he drank his last beer was an estimated .34 mg%.The estimated BAL for last night is consistent with the DWI report and documents a high tolerance.
Tom is asked to submit an observed urine sample.All newly admitted clients provide a urine sample.
He is assigned a counselor who performs a thorough assessment. Over the next few weeks, the counselor and Tom develop a treatment plan
The counselor administers the CIWA-Ar, and a physician's assistant conducts a brief exam and draws blood for new liver function tests. The counselor discusses the results of the assessments with Tom and Gloria and clearly explains Tom's assessed need for supported detoxification and the program's ambulatory detoxification process. The counselor also discusses the program's policy of encouraging all clients to begin taking disulfiram as soon as possible. The counselor ascertains that no contraindications exist for Tom, explains the mechanism by which disulfiram works, and provides Tom and Gloria with written information. Tom agrees to begin taking disulfiram once the medication is approved by his physician.Staff members determine that Tom can be detoxified safely on an outpatient basis. He agrees to remain on site during the day for monitoring, and he has a responsible wife who can drive him home and monitor him.
Tom is given 50 mg of chlordiazepoxide (Librium®) that will be repeated every hour until he appears mildly sedated. He takes 3 doses on the first morning.Clients with CIWA-Ar scores in the low 20s have been detoxified successfully with this protocol in this setting.
Tom attends his first group meeting in the morning. In the afternoon when there are no group meetings, Tom watches TV, reads, or sleeps in a lounge chair in a quiet room where he can be observed by the medical staff.Immediate introduction to group treatment on the day of admission circumvents resistance to treatment beyond detoxification. It also allows group members to see the client at his worst so he cannot deny the severity of his withdrawal reactions once he is sober.
At 2 p.m., when his regularly monitored BAL reaches 0, Tom is given 125 mg of disulfiram. (For this program's protocol, see appendix 4-B.)
By 4 p.m., Tom is feeling very anxious again and is given another 50 mg of chlordiazepoxide, which relieves his symptoms. He is asked to sit through another 3-hour evening group session and have his wife pick him up at 8:30 p.m. when the program closes.
As he leaves for home, Tom is given three 50 mg doses of chlordiazepoxide to be taken hourly at bedtime until he falls asleep. He and Gloria are reminded that he has disulfiram in his system and should not drink.Clients are given 50 mg doses of take-home chlordiazepoxide for up to 3 nights, but the medication is under the control of a responsible family member. The number of pills supplied should be monitored carefully. If the client has a history of dependence on sedatives, such medications are not appropriate for unmonitored administration.
The next morning, Tom reports that he needed only two doses of chlordiazepoxide to sleep, and he returns the extra dose. He is given another 125 mg of disulfiram. He is not given chlordiazepoxide during the second day but is given two more 50 mg doses for the second night. He needs only one and returns the other. On the third night, Tom takes home one dose of chlordiazepoxide but returns it the next day.
Stage 2: Early Recovery
On the third day, Tom returns to his full-time job. Because Tom works days, he is scheduled for the evening program, which he will attend on the next 5 weekdays for 3 hours each session. He will be scheduled for one individual session with his primary counselor each week. In addition to providing treatment planning and individual counseling, his counselor will provide ongoing case management. The hospital's social workers are available to assist the counselor with Tom's case management needs if necessary.Clients who work days attend evening sessions. The 3-hour psychoeducational group sessions have a standard format: the first hour consists of a structured group during which each of the 6 to 14 members is asked individually to report significant emotional or behavioral events since the last meeting (e.g., moods, sleep patterns, activities, AA attendance, stress, cravings); a second hour is devoted to a modified form of group therapy that focuses on issues of particular relevance to members and encourages their interactions; and a third hour consists of didactic instruction on such relevant topics as medical aspects of addiction and relapse prevention techniques. All nondidactic groups are co-led by trained staff.
On the third day, a staff member gives Tom a prescription for 250 mg daily of disulfiram to fill at the hospital pharmacy. He will self-administer disulfiram at the start of each evening's group session. He will receive a double dose on Fridays to last through the weekend.All clients who abuse alcohol are encouraged to take disulfiram throughout the rehabilitation phase. It has been found to be a useful adjunct for helping all clients who drink—whatever other drugs they use—to achieve and maintain abstinence.
When told that his initial urine came back positive for marijuana, Tom acknowledges that he smoked a joint with friends last weekend. To deter further use of illicit substances, he must now submit observed urine samples frequently and randomly. His counselor also informs Tom that his liver function test results are back and that his levels are elevated. The counselor schedules an appointment for Tom to meet with a physician to discuss the implications of these results.The reasons and circumstances for Tom's use of marijuana—as well as alcohol—will be explored in the group. The program has a policy of total abstinence from all mood-altering drugs, and clients are expected to report any use of prescription or other substances before they are discovered by urine toxicology studies.
After five sessions, Tom's schedule is tapered to 4 evenings a week because he seems to be responding well to the group and is participating actively. He got through 1 weekend without too much difficulty and reports sleeping well and attending two AA meetings per week with a buddy from work. At the end of the second week, Tom reports that both his wife and daughter are proud of him—everything seems rosy.
During the third week of treatment, however, Tom begins feeling depressed—with early morning wakening and loss of appetite. When a score of 25 on the Beck Depression Inventory reveals that he is moderately depressed, Tom's counselor meets with him and assures him that it is not unusual for people in early recovery to feel depressed and to have trouble sleeping. They discuss some things Tom can do to manage his depression, such as starting a moderate exercise program. The counselor gives Tom a relaxation tape that he can use at night to help him fall asleep easier and encourages him to report any new symptoms or worsening of his depression immediately.Although it is not uncommon for psychiatric symptoms to emerge within the first few weeks of abstinence, clients may experience protracted abstinence withdrawal, which can cause similar symptoms. This program's policy is to manage mild-to-moderate symptoms nonmedically at first and to monitor the client carefully. Depending on the severity of the symptoms, an immediate referral for medication management of depression or for an appointment with a psychiatrist could be appropriate.
Tom also reports having some “really good” family times at baseball games over the weekends. He's pleasantly surprised at what a nice kid his daughter can be, although he's had a few arguments with her about the TV shows she prefers and the boy she has been dating. Gloria has been coming regularly to the relatives' support group and attended an Al-Anon meeting last week.Tom's wife and daughter are encouraged to attend a weekly support group for relatives and significant others. This relatives' support group meets separately for 2 hours, and then participants join the clients for the third hour of didactic substance abuse education. No additional charges are incurred for family members' attendance at support groups. Relatives also are encouraged to attend Al-Anon or Alateen meetings.
Nevertheless, at 5 weeks into treatment Tom reveals to his counselor that he and his wife are increasingly in conflict, but he's uncomfortable discussing his marital problems in group. With Tom's permission, the counselor schedules several sessions with Tom and his wife to discuss these issues and assess the need for referral for marriage counseling.During individual sessions, the counselor continues to assess clients' personal problems, helping them sort out issues related to their clients' (and their families') early adjustment to a recovery lifestyle. The counselor may need to address a client's issues of shame, guilt, sexual functioning, or childhood trauma if these issues appear to be interfering with the client's recovery.
Tom reports increasing feelings of sadness, irritability, and lack of energy. He says he has tried to exercise more, with some success, but often is “too tired.” He has used the relaxation tape every night and says that it helps “sometimes” but that he still is having significant problems sleeping. He has missed two group sessions in the last 2 weeks and is participating less in the group sessions he does attend. Tom's counselor schedules an appointment for Tom with the program's psychiatrist for further evaluation.The counselor continues to assess and monitor other medical or psychiatric conditions that may require more a detailed evaluation, counseling, or referral to outside resources.
The psychiatrist meets with Tom and decides that Tom's current level of depression should be managed medically. He prescribes antidepressant medication and discusses with Tom possible side effects and when he can expect to begin feeling the effects of the medication. The psychiatrist schedules followup appointments with Tom.The program's consulting psychiatrist is readily available to meet with Tom and assess his need for medication. The psychiatrist meets regularly with Tom to monitor his medication and answer any questions he may have.
Tom continues to attend group sessions 4 days a week for another 4 weeks. By 3 weeks after starting the antidepressant he is participating actively, reports feeling much better, and is positive about his recovery. He attends AA three times a week and has a sponsor. He reports that he has not used marijuana, and urinalysis supports his self-report.
At this point, program staff members assess that Tom is progressing well enough to step down his group treatment to two times per week and individual counseling to every other week.
Stage 3: Maintenance
In week 11, while participating in the rehabilitation phase, Tom begins attending a 2-hour continuing care group that meets in the same facility once a week in place of one of his rehabilitation phase groups. He is assigned to a group of mostly other professional people. Tom already knows a few of the members who transitioned earlier from the rehabilitation group; his counselor is a co-leader of the new group. The meeting format is familiar, consisting of group therapy but no more didactic presentations. The break between the two parts of the meeting becomes a time for group members to talk frankly and share perspectives about the therapeutic process. After 2 weeks of overlap, Tom steps down to attending only the once-per-week maintenance group. At this point, Tom is given his disulfiram prescription to take on his own at home.A 2-week overlap between early recovery and maintenance groups eases the transition to the longer term, stepdown treatment phase at the same site. If possible, clients are placed in more homogeneous groups whose members have similar interests and values. Bonding and trust among group members become important in this phase as participants give one another constructive feedback and model techniques of daily living that prevent relapse.
At the point of transition to the maintenance phase, Tom has been abstinent for more than 10 weeks, has started a regimen of antidepressant medications, has attended AA meetings regularly, has learned a great deal about alcoholism and substance abuse, and has begun to identify and understand the emotional triggers for his drinking and the negative influence that a circle of friends at work has on him. He is trying to implement several important lifestyle changes and has taken on more responsibility for his own recovery.
Tom adjusts well to his continuing care group and attends regularly for about 2 months. When he catches a bad cold, however, he calls in sick—just before the Christmas holidays. After Tom misses another session without reporting in—and his wife also stops coming to the relatives' support group— Tom's counselor telephones him at home.
Tom acknowledges that he has “slipped” and has been drinking on a daily basis for 7 days. He stopped taking disulfiram about a month after he joined the continuing care group, thinking he could “handle it.” He has drifted away from AA meetings. Now, Tom says, he has missed the last 2 days of work and is afraid his supervisor suspects the reason. Tom promises to return to the program the next day with his wife to discuss what to do. After Tom acknowledges that he has “messed up” because of overconfidence and the stress of the holidays, he is returned to the rehabilitation phase, attending 4 evenings a week and taking disulfiram again at the start of each session. He is expected to continue attending his weekly continuing care group, resume attending AA meetings, and reconnect with his sponsor.It is not unusual for clients to relapse, at least briefly, after they are comfortable, think they no longer need treatment, and stop believing recovery is a lifelong process. This is a predictable event, especially among people who are in treatment for the first time. It can be difficult for them to accept that a substance use disorder is a chronic condition, requiring lifelong care
The intensity and duration of the response to a slip or relapse—a return or step-up to the rehabilitation phase—depend on a client's reactions. Each client must understand how and why the relapse occurred and not blame others. Clients should be acknowledged for interrupting their relapse quickly and returning to treatment voluntarily. This can mark a turning point in clients' understanding of their condition and recovery needs.
After Tom attends 11 of the 3-hour rehabilitation sessions over a period of 3 weeks, program staff members agree that Tom is “back on track” with an increased appreciation for the long road of recovery. He returns to his regular schedule of weekly continuing care group and AA meetings.The program covers the costs of this more intensive relapse intervention as part of its regular charges.
Stage 4: Discharge to Continuing Community Care
Planning for discharge begins early in the continuing care process. After 3 months in the continuing care group, Tom's primary counselor refers him to a local psychiatrist for continued medication management. Tom is asked to prepare a plan for maintaining his recovery following discharge from treatment. He reports the following plans for ongoing community care to members of his group for their approval:Although treatment may continue at the program for as long as 1½ to 2 years, only a minority of clients actually stay that long.Other clients leave earlier—on average, after about 25 weeks of continuing care. They are, however, encouraged to announce their plans in advance and receive clinician and group member endorsement. The goal is for them to leave with a realistic plan for ongoing recovery.
• Continue to attend AA meetings four to five times weekly and maintain regular contact with his sponsor.
• Encourage Gloria to continue attending Al-Anon meetings.
• Join an AA club's bowling league team as a substitute for occasional “nights out” with rowdy drinking buddies at work who also smoke pot.
• Continue to attend the church that he and Gloria have joined and continue to participate in a couples group that is part of their pastoral counseling services—with the understanding that referral to a private therapist may be indicated.
• Continue his antidepressant medication and meet regularly with his psychiatrist for medication management.
• Consider courses he might take that would qualify him for a promotion to a supervisory position at work.
• Continue to attend AA meetings four to five times weekly and maintain regular contact with his sponsor.
After 6 months of continuing care, Tom is discharged from active treatment. He will receive support calls every 6 months for 3 years.

Appendix 4-B. Induction Protocol for Disulfiram

After detoxification, some IOT clients benefit from receiving drugs that help them remain abstinent and resist relapse. Disulfiram is appropriate for clients who are alcohol dependent, including clients whose alcohol dependence is combined with cocaine use and methadone clients who have alcohol problems.

Disulfiram interferes with the normal metabolism of acetaldehyde, an intermediary product in the oxidation of alcohol, and precipitates an unpleasant physical reaction if alcohol is consumed within 12 hours to 7 days (depending on dose) after taking the drug. Within several minutes of a person's drinking alcohol, the disulfiram reaction begins, with facial flushing followed by throbbing headache, tachycardia, increased respirations, and sweating. Nausea and vomiting usually occur within 30 to 60 minutes, sometimes accompanied by hypotension, dizziness, fainting, and collapse. The whole reaction can last for 1 to 3 hours and is sufficiently unpleasant to discourage most clients from drinking while taking disulfiram.

Some physicians recommend waiting 4 to 5 days after a client is alcohol free before initiating disulfiram treatment (CSAT 1997a ). The Physicians' Desk Reference 2003 instructs physicians not to administer disulfiram until 12 hours after the last drink. The IOT consensus panel finds that careful monitoring of clients' BALs achieves the same effect—assurance that no alcohol exists in the system. Exhibit 4-8 outlines the protocol for ambulatory detoxification and disulfiram induction. Low doses (125 mg) of disulfiram can be administered as soon as a client's BAL reaches zero—usually on the day of admission. The consensus panel recommends that clients who are alcohol dependent receive disulfiram as soon as they are detoxified rather than jeopardize their abstinence by waiting for a liver function test to be conducted. If needed, testing for liver impairment can be done during the 2 to 3 weeks after starting disulfiram.

Exhibit 4-8. A Protocol for Ambulatory Detoxification and Disulfiram Induction

First day: Chlordiazepoxide 50 mg hourly until anxiety is relieved—50 mg to 300 mg
When BAL = 0: Disulfiram 125 mg*
First night: Chlordiazepoxide 50 mg at bedtime repeat hourly × 2 until asleep (3 doses provided)
Second day: No medication
Second night: Chlordiazepoxide 50 mg at bedtime; repeat in 1 hour if not asleep (2 doses provided)
Third night: Chlordiazepoxide 50 mg at bedtime; repeat in 1 hour if not asleep (2 doses provided)

*Disulfiram is dispensed only at the clinic.

All unused chlordiazepoxide doses must be returned to the clinic the following morning.

Source: G. Kolodner, M.D., personal communication, 2003.

Dosage Levels

Some experienced clinicians prefer to prescribe low doses of disulfiram (125 mg) for most clients because at this dose the reaction to drinking is not as potent or potentially dangerous as it would be at a higher dose. Other physicians use an initial dose of 250 to 500 mg of disulfiram. Lower doses are appropriate for persons who have some liver impairment, small women, and elderly persons. Although no studies exist regarding the optimal length of disulfiram treatment, some clients have taken the drug for as long as 16 years (CSAT 1997a ). Compliance beyond the active treatment phase, however, is a major problem.

Episodic use of disulfiram is an effective strategy for clients who want to guard against drinking in situations that carry a high risk for alcohol consumption. These situations might be special events or celebrations where most people are consuming alcohol or meetings with friends who are former drinking buddies.

Contraindications and Cautions

Disulfiram is contraindicated for clients with acute hepatitis, severe myocardial disease or coronary occlusion, chronic lung disease or asthma, psychoses, or sensitivity to disulfiram or its derivatives used in pesticides and rubber vulcanization. Disulfiram is not prescribed for pregnant women or clients who have had a previous allergic reaction. Women of childbearing age are warned to use contraception while taking disulfiram because the medication might endanger a fetus.

Clients who take phenytoin (Dilantin®), isoniazid, or warfarin (Coumadin®) should be warned that disulfiram might intensify the effects of those medications, requiring a reduction in the disulfiram dose. Clients taking disulfiram should not take metronidazole (Flagyl®). They should avoid inadvertent exposure to the alcohol contained in many cough medicines and mouthwashes or emitted by alcohol-based solvents in a closed area. Consumption of food that contains liquor or wine usually does not cause a problem if the alcohol has been evaporated during the cooking process. Clients should report any allergic reaction in the form of an itchy rash, which usually can be controlled by lowering the dosage or administering an antihistamine.

Monitoring Procedures

Clients taking disulfiram should be monitored a minimum of every 4 months to ascertain whether any allergic hepatitis requires immediate discontinuation of the drug. Other potentially adverse effects include optic neuritis, peripheral neuritis, polyneuritis, and peripheral neuropathy. Mild reactions to the initiation of disulfiram, such as headaches and drowsiness, usually are transient and dissipate spontaneously within a few weeks.


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