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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 1. Introduction

The current volume addresses clinical issues and a companion volume, TIP 46, Substance Abuse: Administrative Issues in Outpatient Treatment (CSAT 2006f ), discusses administration. Together, these TIPs break new ground as the first two-volume TIP issued by the Center for Substance Abuse Treatment (CSAT). This volume represents the most extensive discussion in a TIP of clinical issues for intensive outpatient treatment (IOT) programs.

Several developments in health care and the treatment of substance use disorders have prompted this full revision of TIP 8, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse (CSAT 1994c ). Since the original TIP was published, substantial changes have occurred in almost every aspect of how treatment services are conceptualized and delivered. By the late 1990s, IOT had moved from being a peripheral and relatively circumscribed clinical service, serving a small range of clients, to a robust, multidimensional treatment modality that plays a central role in the care of many individuals with substance use disorders. TIP 46, Substance Abuse: Administrative Issues in Outpatient Treatment (CSAT 2006f ), provides a full history of IOT.

As with all TIPs sponsored by CSAT, this volume represents the thinking, experience, and work of a consensus panel. The rapidity of recent changes in the IOT field and the variety of challenges and opportunities that accompany them compelled this TIP's consensus panel to draw on its clinical experience and current research to create a TIP that is both practical and evidence based. Substance Abuse: Clinical Issues in Intensive Outpatient Treatment examines significant and sometimes perplexing issues facing IOT providers and offers analytical discussions and incisive opinions. In writing the TIP, the consensus panel attempted to reflect the changes of the past decade and anticipate directions that IOT may take.

Forces Affecting IOT and the Contents of This TIP

Chronic Disease Management

Recognizing that substance abuse is a chronic disorder similar to diabetes, hypertension, and asthma led the panel to question the acute care model of service delivery that has characterized substance abuse treatment for the past 50 years (McLellan et al. 2000). Panel members felt strongly that IOT providers—like providers in the rest of the health care system—should rethink the acute care approach to treating substance use disorders. Increasingly, IOT programs are involved in substance abuse treatment beyond the initial 4 to 12 weeks. Much of the discussion in this volume is devoted to continuing care and to finding ways to include case management service providers, families, communities, and mutual-help groups in the ongoing care of individuals with substance use disorders.

Practice-Research Collaboration

In the past decade, emphasis on the blending of evidence-based interventions with community-based service delivery has increased. The longstanding divide between practitioners and researchers needed to be bridged. This disparity, described in the Institute of Medicine 1998 report, Bridging the Gap Between Practice and Research, was a major impetus behind the creation of the National Institute on Drug Abuse's (NIDA's) Clinical Trials Network and CSAT's Addiction Technology Transfer Centers and Practice Improvement Centers. Research has resulted in new knowledge about how biochemical processes, learning, spirituality, and environment affect people who abuse substances. These advances may make it easier for clinicians, clients, family members, and the public to understand that substance use disorders are complex illnesses with important biological—as well as social, psychological, and spiritual—dimensions. IOT programs play a central role in translating scientific findings into clinically meaningful information and treatments.

The discussions of treatment and the clinical recommendations in this TIP are informed by the links between practice and research that are becoming the norm in the IOT field.

New Treatment Approaches

A growing interest in evidence-supported interventions has led practitioners to examine long-held assumptions about treatment and the recovery process. Several therapeutic approaches, previously applied primarily in university-based research centers, have begun to emerge as viable and effective interventions that can be implemented successfully in community-based treatment settings. Discussions on cognitive-behavioral interventions, relapse prevention training, motivational enhancement therapy, the use of incentives, and case management approaches have been incorporated into this TIP. Similarly, the TIP describes the benefits of integrating pharmacotherapies into IOT to help manage withdrawal and stabilize people with co-occurring disorders.

Convergence of Systems

Approximately 10 years ago, substance abuse treatment services were viewed widely as specialty services that interacted with a variety of other important stakeholders, such as the mental health, welfare, and criminal justice systems. A profound and important change affecting the delivery of IOT services is the convergence of these previously distinct systems and the substance abuse treatment system. The divisions among services have long been based on administrative convenience and funding streams, not the clinical needs of clients. Programs must be prepared to treat clients who simultaneously may be receiving public welfare, have children in protective services, and be under criminal justice supervision. Each system may place substance abuse treatment requirements on the client, and, as a consequence, these systems can play an important role in supporting the goals of treatment. This TIP addresses the importance of simultaneously working with multiple systems.

Client and Program Diversity

IOT programs serve a greater variety of clients than they did when TIP 8 was published in 1994. The current volume makes a broader and deeper study of how individual differences affect treatment needs. Ten years ago IOT was offered primarily to privately insured clients with mild-to-moderate levels of dysfunction. Since then, IOT programs have adjusted their models to treat adolescents, clients who are homeless or economically disadvantaged, clients with mental disorders, clients involved with the criminal justice system, clients who are disabled, and those with other special needs once considered beyond the scope of IOT programs. Most programs also are responding to the needs of increasingly diverse racial and ethnic client populations. Many IOT programs now incorporate onsite ambulatory detoxification services, medication management, and infectious disease interventions.

Terminology and Definitions

IOT vs. IOP

Just as the treatment field has yet to settle on a commonly accepted name for itself (e.g., “substance abuse” versus “addiction” versus “substance use disorder” versus “chemical dependence”), there is also no agreed-on term to describe this intensive level of care. Because use of the terms “intensive outpatient treatment” and “intensive outpatient program” (IOP) varies by region, for the sake of consistency, the consensus panel agreed to use the term “intensive outpatient treatment” (“IOT”) to refer to this level of care instead of the equally acceptable term “intensive outpatient program.” Because of the variety of definitions applied by clinicians and researchers to “intensive outpatient treatment,” IOT studies cited in this volume also include day treatment, day hospital treatment, and partial hospitalization programs, in addition to IOT programs.

Outpatient Care vs. Aftercare vs. Continuing Care

The term “aftercare” is avoided throughout this TIP in favor of “continuing care.” Research literature occasionally uses the term “aftercare” when discussing traditional outpatient treatment that follows residential or intensive outpatient treatment. Others use the term “aftercare” when discussing clients' participation in mutual-help groups after formal treatment is completed. In this volume, the term “continuing care” designates the mutual-help groups (including 12-Step and other support groups) available in the community after formal treatment ends. Even during the continuing community care phase or treatment, many clients return to the IOT clinic for occasional followup visits, similar to regular medical checkups for other chronic diseases.

Substance Abuse Treatment vs. Mutual-Help Groups

The distinction between substance abuse treatment programs and mutual-help groups, such as 12-Step support groups, often is misunderstood by managed care organizations and the public. The American Medical Association (1998) has adopted a policy stating that clients with substance use disorders should be treated by qualified professionals and that mutual-help groups should serve as adjuncts to a treatment plan devised within the practice guidelines of the substance abuse treatment field. Likewise, the American Psychiatric Association, American Academy of Addiction Psychiatry, and American Society of Addiction Medicine (ASAM) have issued a joint policy statement that asserts that treatment involves at least the following (American Society of Addiction Medicine 1997):

  • A qualified professional is in charge of treatment.
  • A thorough evaluation is performed to determine the stage and severity of illness and to screen for medical and mental disorders.
  • A treatment plan is developed.
  • The treatment professional or program is accountable for the treatment and for referring the client to additional services, if necessary.
  • The treatment professional or program maintains contact with the client until recovery is completed.

According to the policy statement adopted by these treatment professionals' associations, mutual-help groups are an important component of treatment, but they cannot substitute for substance abuse treatment as outlined above.

What Constitutes IOT?

Although IOT traditionally has consisted of at least 9 hours of treatment per week, usually delivered in three 3-hour sessions, some programs have substantially longer hours and others provide only 6 contact hours per week. The consensus panel agrees that a program that schedules treatment daily, for 6 hours per day, should be considered a partial hospitalization program. But does such a program differ by kind or just by degree from an IOT program? At what point does an IOT service become a partial hospitalization program? Programs in which clients attend sessions 9 hours per week are clearly more intensive than once-a-week outpatient programs. But where does outpatient end and IOT begin? According to ASAM's Patient Placement Criteria, IOT programs provide 9 or more hours of structured programming per week; ASAM does not specify a minimum duration of treatment (Mee-Lee et al. 2001).

This TIP is intended to be equally useful to all IOT programs, regardless of the number of contact hours per week. But for the discussions and guidelines in this TIP to be meaningful, IOT must be delimited. The consensus panel agreed that IOT has the following features:

  • Contact hours per week: 6 to 30
  • Stages: Stepdown and step-up stages of care that vary in intensity and duration
  • Duration: Minimum of 90 days followed by outpatient continuing care
  • Core features and services:
    • Program orientation and intake
    • Comprehensive biopsychosocial assessment
    • Individual treatment planning
    • Group counseling
    • Individual counseling
    • Family counseling
    • Psychoeducational programming
    • Case management
    • Integration of clients into mutual-help and community-based support groups
    • 24-hour crisis coverage
    • Medical treatment
    • Substance use screening and monitoring (urine or breath tests)
    • Vocational and educational services
    • Psychiatric evaluation and psychotherapy
    • Medication management
    • Transition management and discharge planning
  • Enhanced services:
    • Adult education
    • Transportation
    • Housing and food
    • Recreational activities
    • Adjunctive therapies
    • Nicotine cessation treatment
    • Child care
    • Parent skills training

Summary of This TIP

The following topics are covered in this volume:

Chapter 2—Principles of Intensive Outpatient Treatment presents 14 guiding principles of IOT and the research that supports them. The principles combine the findings of substance abuse research with the experiences of practiced clinicians. The principles are drawn from NIDA's Principles of Drug Addiction Treatment (National Institute on Drug Abuse 1999), but the chapter focuses on issues that are critical to effective delivery of IOT services.

Chapter 3—Intensive Outpatient Treatment and the Continuum of Care places IOT within a broad substance abuse treatment continuum that includes outpatient treatment and continuing community care. This chapter situates IOT within the framework of ASAM's levels of care and discusses goals, intensity and duration of treatment, treatment setting, and stages for Level I and Level II care. The chapter discusses IOT as both an entry point for substance abuse treatment and a stepdown or step-up level of care for clients and addresses the importance of transitioning clients to continuing community care.

Chapter 4—Services in Intensive Outpatient Treatment Programs describes the core services a program should provide and enhanced services that often are delivered on site or through established links with community-based providers. Core services include group counseling and therapy, individual counseling, psychoeducational programming, pharmacotherapy and medication management, monitoring substance use, case management, 24-hour crisis coverage, induction into community-based support groups, medical treatment, psychiatric screening and therapy, and vocational training and employment services. Enhanced services include adult education, transportation, adjunctive therapies, and parenting classes.

Chapter 5—Treatment Entry and Engagement addresses the complex and critical processes of screening and diagnosis, placement, assessment, and treatment planning. The desired result of these processes is the client's engagement in treatment at the appropriate level of care and the implementation of treatment that addresses his or her needs. This chapter discusses specific steps in the IOT admission process, including engaging and screening the client, assessing barriers to treatment, and attending to crises; it also illustrates them in two case studies.

Chapter 6—Family-Based Services discusses a family systems approach to IOT that acknowledges and supports the important role and influence of family members on treatment outcomes. The chapter includes goals and outcomes of family-based services and strategies for engaging families in treatment. The chapter also describes various types of family services (family education, multifamily groups, family therapy, retreats, support groups) and clinical issues that often arise when including families in treatment, such as unrealistic expectations and sabotage of the client's recovery.

Chapter 7—Clinical Issues, Challenges, and Strategies in Intensive Outpatient Treatment looks at issues and problems that arise in clinical practice and offers solutions grounded in research and clinical experience. The chapter covers client retention, relapse and continued substance use, family members who abuse substances, group work issues, safety and security, client privacy, conflicting mandates, clients who work, and boundary issues.

Chapter 8—Intensive Outpatient Treatment Approaches provides detailed descriptions of established IOT program models and approaches. The chapter describes 12-Step facilitation, cognitive-behavioral, motivational, therapeutic community, Matrix model, and community reinforcement and contingency management approaches. The descriptions address the key aspects, research outcomes, and strengths and challenges of each approach.

Chapter 9—Adapting Intensive Outpatient Treatment for Specific Populations highlights the flexibility and adaptability of the IOT model to meet the diverse needs of specific populations: those involved with the criminal justice system, women, individuals with co-occurring disorders, and adolescents and young adults. The chapter provides a demographic overview of each group and discusses implications for IOT programming as well as clinical issues and strategies to use with each population.

Chapter 10—Addressing Diverse Populations in Intensive Outpatient Treatment examines the importance of cultural competence to substance abuse treatment. Reviewing research that supports the need for individualized treatment, the chapter describes principles for the delivery of culturally competent services and explores topics of special concern: foreign-born clients, women from other cultures, and religious considerations. Sketches of diverse populations include Hispanics/Latinos; African-Americans; Native Americans; Asian Americans and Pacific Islanders; persons with HIV/AIDS; lesbian, gay, and bisexual individuals; persons with physical or cognitive disabilities; rural populations; individuals who are homeless; and older adults. The sketches describe each group's demographic characteristics, statistics on substance use, clinical considerations, and implications for IOT. A chapter appendix contains an extensive list of resources on culturally competent treatment and on treating members of each population.

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