The Continuum of Care for Patients with Substance Use Disorders in the New Millennium
By Jon Weeldreyer, MA, CAAC
A brief history of treatment
Treatment for mental health and substance use disorder (SUD) patients had very different beginnings. The medical community initiated most mental health treatment, while most SUD treatment was originated by recovering people who, out of gratitude for their own recovery, wanted to help others in need. For many years, persons who were chronically addicted to alcohol or other drugs were often placed in state hospitals, where they were treated for what appeared to be symptoms of psychosis. Many were placed on medications for mental health disorders once they were developed.
After the beginning of the fellowship of Alcoholics Anonymous (AA) in 1935, groups of recovering men and women set up homes to aid persons wanting to quit their drinking. Doctors were consulted, and as the treatment for SUD became more professionally led, detoxification protocols became more specialized and sophisticated. As addiction was increasingly understood to be a biological brain disorder, insurances began to support treatment for SUD.
In time, a 28-day inpatient program became the treatment of choice, where patients were detoxified and led through the initial steps of the 12-step AA program. With the inception of managed care and its desire to cut costs and improve the efficiency of treatment, the “one size fits all” 28-day program has been modified to the present day “treatment continuum” available to the SUD patient.
Today, the environment calls for treatment programs to be capable of providing treatment for patients with co-occurring substance use and mental health disorders. Therapists need skills to treat patients whose dual conditions trigger and sabotage each other. On-site medication management by psychiatrists is in high demand.
Today’s treatment has graduated steps designed to meet the differing needs of each patient and each phase of addiction or recovery. This treatment continuum allows patients to “step-up” or “step-down” to match treatment intensity with their recovery needs. At the initial evaluation, American Society of Addictions Medicine (ASAM) criteria are used for patient placement into the varied treatment options listed below. Patients can continue to see their therapist or case manager one-on-one while involved in the specific medical or group services that meet their individual needs.
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Treatment modalities available today
- Intensive Outpatient Program (IOP)
- Traditional Outpatient and Outpatient Group
- Community Support Groups
- Long Term Residential
- Opioid Maintenance
- Substance abuse vs. addiction
- A final word
Treatment modalities available today for substance use disorders
Detoxification: Initially, many patients need medical monitoring or management to complete a medical detoxification. Each category of addictive chemical has its own detoxification symptoms and dangers. A broad variety of medications are available from doctors to increase safety and comfort during the process. Most acute detoxification lasts from two to five days.
Inpatient/Residential: Often a controlled environment is necessary to establish initial abstinence. Inpatient (hospital-based) or Residential (free-standing facility) treatment length of stay varies greatly. Stays ranging from two to 14 days are typical, and are based on patient need, insurance coverage, and ability to pay. Treatment includes intensive group therapy, lectures, videos, experiential activities, and on-site community support groups such as AA or NA (Narcotics Anonymous). Inpatient care is focused on stabilization and preparation for return to the environment that supported the addiction in the past, but with increased awareness of relapse triggers and behavioral changes needed to maintain abstinence.
Intensive Outpatient Program (IOP): IOP is designed for those persons not needing residential care, but who are likely to relapse without close assistance and monitoring. Simply put, IOP is for SUD patients unable to maintain abstinence in traditional outpatient care. IOP has become the focus of most intensive treatment today. In some locations, “domiciliary IOP” is available, with an insurance carrier picking up the cost of treatment, and the patient paying a nominal room and board fee. This allows for intensive services and the safety of a controlled environment when residential treatment may otherwise be unavailable.
Traditional Outpatient and Outpatient Group: This includes individual and/or group therapy for persons who need guidance in early recovery, or to prevent or halt relapse. Traditional Outpatient therapy uses the one-on-one session as the basis for treatment, augmented by group experiences. The best programs have a seamless system where group members can “step up or down” between weekly or multiple visits per week in group sessions, without changing group peers or therapists.
Group therapy can also increase a patient’s comfort in groups, paving the way to the community support groups. Outpatient care is highly individualized and frequently addresses underlying issues that can trigger relapse.
Research has found group therapy to be the most effective form of treatment for persons with SUD. At the beginning of each group session, patients participate in setting the agenda for the day. This format allows the therapy to be delivered at “teachable moments” as the clients deal with how recovery interfaces with their real world issues. The therapist’s role is to ensure that each patient is focused on, and addresses, his/her identified problem areas. Didactic presentations and videos are provided as necessary according to each group’s needs and each patient’s individualized treatment plan. The primary goal in therapy is to build an active recovery plan that can assist the patient in maintaining long-term recovery.
Community Support Groups: Fellowships AA and NA are strongly encouraged throughout treatment. For over 75 years, recovering persons have shared their strength, hope, and experience with others in the AA and NA programs. Treatment frequently uses the principles and language of the AA and NA programs to prepare the patient for success in the recovering community. While spiritually-based, these fellowships are not religious organizations and are very accepting to persons regardless of spiritual orientation. AA and NA meetings are often available on the Pine Rest Campus.
Long Term Residential: For patients with the most progressed forms of SUD, long-term, therapeutic communities are sometimes necessary. These programs run from three to 12 months. While having less intensive therapy, long-term care provides a controlled environment with continuous access to others in recovery throughout the day. Patients are often allowed to work and have home visitation as they progress through the program. For patients with the most progressed forms of chemical dependency, long-term, therapeutic communities are sometimes necessary. These programs run from three to 12 months. While having less intensive therapy, long-term care provides a controlled environment with continuous access to others in recovery throughout the day. Patients are often allowed to work and have home visitation as they progress through the program.
Opioid Maintenance: The use of methadone has been found to aid some opiate-addicted persons to lead a more manageable life. Methadone is a long-lasting opiate that can minimize the “loss of control” behaviors in many persons previously addicted to illegal or illegally obtained opiate drugs such as heroin. Daily dosing of methadone is required, often at significant cost to the patient.
Medications: The idea of giving medications to someone with a SUD problem seems conflicting at first glance. However, as we grow in our understanding of addiction as a biological brain disorder, it makes a great deal of sense to medically address the chemical imbalances within the body.
Antabuse (Disulfiram) is a medication that has been used for many years, causing a variety of negative physical symptoms if a person drinks alcohol while taking the medication. This is often enough to prevent taking the first drink. Other drugs such as Wellbutrin, Naltrexone, and Suboxoneact on brain circuitry to reduce the desire to use tobacco, alcohol or other drugs. Other non-addictive medications are available to reduce anxiety or depression that are often triggers for relapse.
Many people who use substances access care before developing the disease of addiction. These persons also need specialized treatment, often focusing on the decision-making processes leading them to abuse alcohol or other drugs. Many times legal, occupational, relational, or medical complications arise, and other persons in their life recommend therapy to the patient. This “external motivation” for treatment can cause resentment and resistance. The therapist must be able to balance the needs of the patient and the needs of the referrer.
Today, therapy for the person with a substance use disorder is multifaceted and patient specific. Specialized training is required for both therapy and medical staff. Research continues to yield new information on biological predisposition, brain chemistry, and behaviors. Treatment will need to continue to change and improve. Treatment providers must create trusting, open and caring relationships with the person struggling with substance use disorder.