Evidence-Based Reviews

Substance abuse: 12 principles to more effective outpatient treatment

Current Psychiatry. 2002 June;1(6):16-24

References

1. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Treatment episode data set (TEDS): 1994-1999. National admissions to substance abuse treatment services. DASIS series: S-14. DHHS publication no. (SMA) 01-3550. Rockville, MD: Department of Health and Human Services, 2001.

2. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 1999 uniform facility data set. DASIS series: S-12. Rockville, MD: Department of Health and Human Services, 2001.

3. Festinger DS, Lamb RJ, Kirby KC, Marlowe DB. The accelerated intake: a method for increasing initial attendance to outpatient cocaine treatment. J Applied Behav Analysis 1996;29(3):387-9.

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5. McLellan AT, Luborsky L, et al. An improved diagnostic instrument for substance abuse patients, The Addiction Severity Index. J Nervous Mental Dis 1980;168:26-33.

6. Marlowe DB, Kirby KC, et al. Assessment of coercive and noncoercive pressures to enter drug abuse treatment. Drug & Alcohol Dependence 1996;42(2):77-84.

7. Prochaska JO, DiClemente CC. The transtheoretical approach: crossing traditional boundaries of therapy. Homewood, IL: Dow Jones, Irwin, 1984.

8. Miller WR, Rollnick S. Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press, 1991.

9. National Institute on Drug Abuse. Beyond the therapeutic alliance: keeping the drug-dependent individual in treatment. Research monograph 165, NTIS 97-181606, Rockville, MD: National Institutes of Health, 1997.

10. Connors GJ, DiClemente CC, Dermen KH, et al. Predicting the therapeutic alliance in alcoholism treatment. J Studies Alcohol 2000;61(1):139-49.

11. Barber JP, Luborsky L, Gallop R, et al. Therapeutic alliance as a predictor of outcome and retention in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. J Consult Clin Psychol 2001;69(1):119-24.

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Patients with bipolar disorder, major depression, panic anxiety, and schizophrenia who present with co-occurring addiction require coordinated and simultaneous stabilization of their addictive and psychiatric disorders.

Table 1

12 PRINCIPLES OF EFFECTIVE OUTPATIENT ADDICTION TREATMENT

Open the doors wider Do a comprehensive initial evaluation Build on existing motivation Forge a therapeutic alliance Make retention a priority Provide ongoing care Match services with treatment needs Monitor abstinence Use 12-step and other community supports Manage medications Educate about addiction and recovery Involve families in treatment

Principle 3: Build on existing motivation

That an addicted patient must “hit bottom” before successful treatment may begin is a common misconception. In truth, studies find similar outcomes in individuals who enter treatment voluntarily and those who are externally pressured or legally coerced.⁶ Regardless of patients’ motivation when they enter treatment, they are likely to alternate over time between being more and less motivated. For this reason, it is necessary to remind them why they sought treatment and to use existing external pressures.

For example, with the patient’s consent it would be valuable to maintain contact with a parole officer who mandated a patient’s substance-abuse treatment. Likewise, patients entering treatment under threat of divorce should be asked to consent to family contact and should receive family therapy. Families often provide useful clinical information and can exert powerful influence when the patient’s motivation wanes. A patient’s refusal to allow contact with family (or other important sources of collateral information) often represents resistance that should be explored clinically and addressed.

With open dialogue, resistance to treatment can be reduced with education, peer groups, and family therapy. Motivational enhancement and interviewing work described by Miller, Procaska, and DiClemente^7,8 is designed to reduce treatment resistance in a respectful and clinically effective manner while avoiding confrontation that might provoke dropout and relapse.

Principle 4: Forge a therapeutic alliance

A therapeutic alliance produces positive outcomes in substance-dependent outpatients.^9-11 A recent National Institute on Drug Abuse (NIDA) therapy manual notes that a therapeutic alliance exists when the patient perceives that:

the clinician accepts and respects him or her;
the patient’s problems can be overcome by working together with the clinician;
the clinician understands what the patient is hoping to get out of treatment.¹²

Clinicians can help forge this therapeutic alliance by being active listeners, by being empathic and nonjudgmental, and by approaching treatment as an active collaboration.¹²

Principle 5: Make retention a priority

It is simple but true: you cannot treat a patient who has dropped out.

Treatment retention is associated with better outcomes^13,14 and is a key indicator of the performance of an outpatient treatment program. High drop-out rates are demoralizing to patients who remain in treatment and to the clinicians who must document so-called “3-day treatments.” Because admission and initial evaluation of patients is labor-intensive, premature attrition is costly and time-consuming. Strategies to increase retention are listed in Table 2.

Table 2

STRATEGIES TO RETAIN PATIENTS IN TREATMENT

Preadmission telephone screening interviews Telephone and mailed reminders Telephone orientations Providing timely appointments

Clinicians can improve retention by tolerating different rates of change and levels of motivation. Individuals adopt new behaviors at different rates. You might become frustrated when patients do not immediately “buy” a particular version of recovery. Patients, however, often drop out when they feel they are being “force-fed” recommendations for sacrifice and major lifestyle changes that make no sense to them (at least not at the moment).

Principle 6: Provide ongoing care

Addiction is a complex biopsychosocial problem that requires long-term treatment. Even after extended abstinence, substance abusers experience craving and are vulnerable to relapse.

Addicts often enter outpatient treatment with psychosocial, medical, and psychiatric problems. Transformation from active addiction to full functioning in society requires sustained and conscientious effort by the patient, support system, and treatment team. Like asthma, diabetes, and other chronic diseases, addiction requires ongoing care.¹⁵

Unlike other chronic conditions, however, addiction is pleasure-reinforced, and addicted individuals are particularly at risk for relapse. Ongoing care may interrupt a relapse or at least interrupt it sooner than if no ongoing treatment were provided.

Substance dependence treatment for less than 90 days is of little or no use, and treatment lasting significantly longer often is indicated, according to the NIDA.¹⁶ When patients complete an intensive treatment phase, they should be evaluated for readiness to transfer to less-intensive care, with gradual transition from several therapeutic contacts per week, to weekly contact, to semimonthly contact, and so on. The concept of “graduation” should clearly convey not an ending but a “commencement” or beginning, as it does in college.

Unfortunately, the long-term approach to substance dependence is undermined by managed care organizations’ insistence on brief treatments. Also, regulations that view addiction as an acute episode may require that patient charts be closed at the end of intensive treatment. Such failures to appreciate the chronic nature of addiction undermine access to treatment and service delivery and contribute to recidivism and medical, social, criminal, and economic consequences associated with active addiction.