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M37 Clinical Issues in Intensive Outpatient Treatment 2022

Executive Summary and Recommendations

  • Revisions to CSAT materials reflect a shift from an acute-care model to a chronic-disease model for substance use disorders, with an emphasis on continuing care, case management, families, and community supports.
  • Evidence-based principles guide Intensive Outpatient Treatment (IOT) delivery, integration with research, and emphasis on engagement, retention, and continuum of care.
  • IOT sits within a broader continuum of care that ASAM defines (Level I outpatient, Level II intensive outpatient, Level II.5 partial hospitalization/day treatment, residential/inpatient, etc.), plus continuing community care (mutual-help groups) after formal treatment.
  • Core services are essential across IOT; enhanced services link to local resources and client needs. The model supports flexible, client-centered care across diverse populations.
  • The manual integrates pharmacotherapy where indicated, family involvement, culturally competent practices, and evidence-based therapies (CBT, MET/MI, 12‑Step facilitation, Therapeutic Community elements, Matrix Model, CM/CR).
  • Ethical and practical implications include maintaining confidentiality, managing co-occurring disorders, ensuring continuity of care across systems (health, welfare, justice), and balancing program administration with high-quality clinical care.

Section 1 — Introduction

  • Context: Substance abuse is treated as a chronic, biopsychosocial illness requiring ongoing care beyond 4–12 weeks. IOT Program (Level II) forms part of a continuum including outpatient and continuing community care.
  • Forces affecting IOT and the contents of the manual:
    • Chronic disease management perspective: treat long-term needs with case management, families, communities, and mutual-help.
    • Practice–research collaboration: translation of research into practice; integration of evidence-based approaches in IOT.
    • Convergence of systems: mental health, welfare, criminal justice increasingly intersect with substance abuse treatment.
    • Terminology and definitions: clarity around IOT vs IOP; IOT hours and levels of care; continuing care vs. aftercare terminology.
  • Entry barriers and engagement: entry and engagement are critical for retention; readiness to change varies; a therapeutic relationship should begin at intake.

Section 2 — Principles of Intensive Outpatient Treatment

  • The 14 Principles (as a framework for decisions in IOT):
    1. Make treatment readily available.
    • IOT serves clients with a broad range of biopsychosocial problems; match to enhanced services as needed.
    • Inpatient vs outpatient: matching matters more than which level is inherently better; continuum access improves outcomes.
    1. Ease Entry.
    • Remove admission barriers, streamline intake, consider transport/childcare, schedule on-demand access. ext{Hours} o 6 ext{ to } 30 ext{ hours/week}.
    1. Build on Existing Motivation.
    • Motivation fluctuates; contingency management (incentives) and motivational enhancement techniques improve readiness and adherence.
    1. Enhance Therapeutic Alliance.
    • Alliance components: client’s capacity to work, emotional bond, empathic understanding, and agreed goals/tasks. Emphasize active listening, empathy, collaboration.
    1. Make Retention a Priority.
    • Early dropout harms outcomes; use reminders, pre-admission interviews, prompt orientations, and incentives to promote completion.
    1. Assess and Address Individual Treatment Needs.
    • Use biopsychosocial assessments (e.g., ASI) to tailor services; match settings and interventions to individual problems.
    1. Provide Ongoing Care.
    • Chronic care model: progress may require stepping up or down intensity; graduation is a commencement, not an end. Transition to less intensive care should be gradual.
    1. Monitor Abstinence.
    • Objective measures (urine/breath tests) complement self-reports; ongoing abstinence correlates with better long-term outcomes.
    1. Use Mutual-Help and Other Community-Based Supports.
    • Facilitate integration into 12‑Step or other mutual-help groups; assist with finding home groups and sponsors; provide orientation to group formats.
    1. Use Medications If Indicated.
      • Address co-occurring disorders; on-site medication management preferred; establish links if off-site; discuss interaction effects, side effects, and cross-tolerance.
    2. Educate About Substance Use Disorders, Recovery and Relapse.
      • Provide psychoeducation about disease model, relapse triggers, coping skills, and recovery resources.
    3. Engage Families, Employers and Significant Others.
      • Family systems approach; involve families at intake, treatment planning, and throughout; offer family education, multifamily groups, and referral to family therapy if needed.
    4. Incorporate Evidence-Based Approaches.
      • CBT, MET/MI, relapse prevention, contingency management, CM, 12‑Step facilitation, case management, and integration of pharmacotherapies.
    5. Improve Program Administration.
      • Administrative competence (finances, records, HR, regulatory compliance) supports clinical care, drawing on CSAT’s administrative guidance.
  • Core features of IOT (Level II) as per ASAM PPC-2R and CSAT consensus:
    • Hours per week: 6 ext{ to } 30.
    • Stages of care: stepdown and step-up, varying intensity and duration.
    • Duration: minimum 90 ext{ days} followed by outpatient continuing care.
    • Core services: intake, biopsychosocial assessment, individualized treatment planning, individual and group counselling, family counselling, psychoeducation, case management, 24-hour crisis coverage, medical/psychiatric evaluation, medication management, mutual-help integration, vocational/educational services, and substance use monitoring.
    • Enhanced services: adult education, transportation, housing, childcare, recreational activities, adjunctive therapies, nicotine cessation, etc.
  • Entry, engagement and retention: early dropout is common; strategies include readiness assessment, motivational strategies, and rapid therapeutic engagement.
  • Continuum of care and levels: ASAM levels I–III with IOT at Level II; continued care via mutual-help and other community supports.
  • Provision for diverse populations: culturally competent models; acculturation considerations; language access; non-Christian mutual-help options; resources in Appendix 10-A.

Section 3 — Intensive Outpatient Treatment and the Continuum of Care

  • Continuum concept (Mee-Lee & Shulman): admit clients into the continuum via the program, plan transitions across levels, and maintain continuity of care.
  • IOT functions within the continuum:
    • Entry point into treatment (assessment, planning, services started).
    • Stepdown from inpatient/residential to IOT (stabilized, needs intensive treatment and relapse prevention).
    • Step-up when IOT is insufficient (reinstate higher intensity).
  • Transitions and continuity: aim for seamless transfers; minimize disruptions; align treatment philosophies and documentation transfer; ensure local treatment options and mutual-help resources are known.
  • IOT goals (Level II): abstinence, behavior change, community involvement (12‑Step or similar), addressing psychosocial problems (housing, employment), building a positive support network, improving coping/ problem-solving.
  • Intensity and duration: IOT hours per week 6 ext{-}30; minimum duration 90 ext{ days}; stepdown to maintenance or long-term outpatient; challenges of abrupt graduation; need for smooth, extended continuing care.
  • Treatment settings and stages: IOT can be in hospitals, prisons, community centers; stages include engagement, early recovery, maintenance, and community support; stage transitions are opportunities for relapse prevention and behavior change.
  • Two core stages of IOT (within finite models):
    • Stage 1: Treatment engagement (assess problems, stabilize crises, explain rules, begin treatment planning).
    • Stage 2: Early recovery (work through relapse prevention, structured groups, transitions toward maintenance while integrating mutual-help).
  • Transition planning: ensure client involvement early, maintain community linkages, obtain consent for information transfer, and designate responsible providers for transitions.

Section 4 — Services in Intensive Outpatient Treatment Programs

  • Core Services (Group Counselling and Therapy; Individual Counselling; Psychoeducational Programming; Pharmacotherapy and Medication Management; Substance Use Monitoring; Case Management; 24-hour Crisis Coverage; Induction into mutual-help; Medical Treatment; Psychiatric Evaluation and Therapy; Vocational/Educational Services).
  • Group counselling: essential to relapse prevention; multiple group types (psychoeducational, skills development, support groups, interpersonal process groups); open-ended heterogeneous groups commonly used; group sizes typically 8–15; sessions often 90 minutes; routine formats using structure and problem-solving processes.
  • Types of groups: psychoeducational, skills-development, process-oriented recovery groups, single-issue groups (e.g., gender issues, drug of choice), family or couples groups.
  • Group leaders: roles, qualifications, and supervision described in CSAT materials.
  • Individual counselling: 30–50 minutes; weekly early in treatment; aims at current abstinence efforts and problems; structured session format with review of recent groups, coping strategies, and plan for next days.
  • Psychoeducational programming: didactic, topic-based; topics listed in Exhibit 4-3 (typical sequence of topics in psychoeducational groups).
  • Pharmacotherapy and medication management: for withdrawal relief, relapse prevention, medical/psychiatric comorbidity; ambulatory detox protocols (CIWA-Ar); on-site medication management when possible; coordination with medical providers when off-site; HIV/hepatic/infectious disease considerations; education for clients and families about medications; monitoring and administration considerations.
  • Ambulatory detoxification: CIWA-Ar-guided decisions; on-site medical staff; family involvement in monitoring adverse events; may be appropriate for Level II.5 (ambulatory detoxification).
  • Medications in addiction treatment: naltrexone, disulfiram, acamprosate; methadone, buprenorphine, buprenorphine/naloxone for opioid dependence; integrated treatment for co-occurring disorders; cross-tolerances and interactions; patient education essential.
  • Case management: addresses broad social needs (housing, employment, health care) and coordinates with multiple agencies; models include single-agency, informal-partnership, and formal-consortium; evidence shows improvements in retention and outcomes with case management.
  • 24-hour crisis coverage: after-hours lines, on-call clinicians, or linkage with 24/7 services; important for preventing crises and hospitalizations; implement clear after-hours procedures for emergencies.
  • Community-based supports: fostering involvement in 12‑Step and other mutual-help groups; matching clients to groups that fit background and preferences; emphasis