Substance Abuse: Clinical Issues in Intensive Outpatient - Addiction

294 Pages·2006·0.83 MB·English

Substance Abuse:
Clinical Issues in Intensive
Outpatient Treatment
A Treatment
Improvement
Protocol
TIP
47
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov INTENSIVE
OUTPATIENT
TREATMENT

Substance Abuse:
Clinical Issues in Intensive
Outpatient Treatment
Robert F. Forman, Ph.D.
Consensus Panel Chair
Paul D. Nagy, M.S., LCAS, LPC, CCS
Consensus Panel Co-Chair
A Treatment
Improvement
Protocol
TIP
47
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
1 Choke Cherry Road
Rockville, MD 20857
Acknowledgments considered substitutes for individualized cli-
ent care and treatment decisions.
Numerous people contributed to the develop-
ment of this Treatment Improvement Protocol
(TIP) (see pp. xi–xiv as well as appendixes C, Public Domain Notice
D, and E). This publication was produced
All materials appearing in this volume except
by JBS International, Inc. (JBS), under the
those taken directly from copyrighted sources
Knowledge Application Program (KAP)
are in the public domain and may be repro-
contract numbers 270-99-7072 and 270-04-
duced or copied without permission from
7049 with the Substance Abuse and Mental
SAMHSA/CSAT or the authors. Do not repro-
Health Services Administration (SAMHSA),
duce or distribute this publication for a fee
U.S. Department of Health and Human
without specific, written authorization from
Services (DHHS). Christina Currier served as
SAMHSA’s Office of Communications.
the Center for Substance Abuse Treatment
(CSAT) Government Project Officer, and
Andrea Kopstein, Ph.D., M.P.H., served as Electronic Access and Copies
Deputy Government Project Officer. Lynne
of Publication
MacArthur, M.A., A.M.L.S., served as the JBS
KAP Executive Project Co-Director. Barbara Copies may be obtained free of charge from
Fink, RN, M.P.H., served as the JBS KAP SAMHSA’s National Clearinghouse for
Managing Project Co-Director. Other KAP Alcohol and Drug Information (NCADI), (800)
personnel included Dennis Burke, M.S., M.A., 729-6686 or [phone]; TDD (for hearing
and Emily Schifrin, M.S., Deputy Directors for impaired), [phone]; or electronically
Product Development; Patricia A. Kassebaum, through www.ncadi.samhsa.gov.
M.A., Senior Writer; Elliott Vanskike, Ph.D.,
Senior Writer/Publication Manager; Candace
Recommended Citation
Baker, M.S.W., Senior Writer; Wendy Caron,
Editorial Quality Assurance Manager; Frances Center for Substance Abuse Treatment.
Nebesky, M.A., Quality Assurance Editor; Substance Abuse: Clinical Issues in
Leah Bogdan, Junior Editor; and Pamela Intensive Outpatient Treatment. Treatment
Frazier, Document Production Specialist. In Improvement Protocol (TIP) Series 47. DHHS
addition, Sandra Clunies, M.S., ICADC, served Publication No. (SMA) 06-4182. Rockville,
as Content Advisor. Dixie M. Butler, M.S.W., MD: Substance Abuse and Mental Health
and Paddy Shannon Cook were writers. Services Administration, 2006.
Disclaimer Originating Office
The opinions expressed herein are the views of Practice Improvement Branch, Division of
the consensus panel members and do not nec- Services Improvement, Center for Substance
essarily reflect the official position of CSAT, Abuse Treatment, Substance Abuse and
SAMHSA, or DHHS. No official support of or Mental Health Services Administration, 1
endorsement by CSAT, SAMHSA, or DHHS Choke Cherry Road, Rockville, MD 20857.
for these opinions or for particular instru-
DHHS Publication No. (SMA) 06-4182
ments, software, or resources described in this
NCADI Publication No. BKD551
document is intended or should be inferred.
Printed 2006
The guidelines in this document should not be
Contents
What Is a TIP? ..............................................................................................................................ix
Consensus Panel ..........................................................................................................................xi
KAP Expert Panel and Federal Government Participants ........................................................xiii
Foreword ......................................................................................................................................xv
Executive Summary ..................................................................................................................xvii
Chapter 1—Introduction ...............................................................................................................1
Forces Affecting IOT and the Contents of This TIP ..................................................................................2
Terminology and Definitions .......................................................................................................................3
Summary of This TIP ....................................................................................................................................5
Chapter 2— Principles of Intensive Outpatient Treatment ...........................................................7
Principle 1: Make Treatment Readily Available ........................................................................................8
Principle 2: Ease Entry .................................................................................................................................9
Principle 3: Build on Existing Motivation .................................................................................................9
Principle 4: Enhance Therapeutic Alliance .............................................................................................10
Principle 5: Make Retention a Priority ....................................................................................................10
Principle 6: Assess and Address Individual Treatment Needs ..............................................................11
Principle 7: Provide Ongoing Care ............................................................................................................11
Principle 8: Monitor Abstinence ...............................................................................................................12
Principle 9: Use Mutual-Help and Other Community-Based Supports ................................................12
Principle 10: Use Medications if Indicated ..............................................................................................13
Principle 11: Educate About Substance Use Disorders, Recovery, and Relapse .................................14
Principle 12: Engage Families, Employers, and Significant Others ....................................................14
Principle 13: Incorporate Evidence-Based Approaches .........................................................................15
Principle 14: Improve Program Administration ...................................................................................................15
Chapter 3—Intensive Outpatient Treatment and the Continuum of Care .................................17
Overview of a Continuum of Care .............................................................................................................17
Conceiving of a Continuum of Care ...........................................................................................................18
Key Aspects of IOT (Level II) ......................................................................................................................19
iiiiii
Key Aspects of Outpatient Treatment (Level I) ........................................................................................23
Continuing Community Care .....................................................................................................................24
Chapter 4—Services in Intensive Outpatient Treatment Programs ...........................................27
Core Services ................................................................................................................................................27
Enhanced IOT Services ...............................................................................................................................44
IOT Services: A Case Illustration ...............................................................................................................46
Appendix 4-A. A Case Study of Intensive Outpatient Treatment ..........................................................48
Appendix 4-B. Induction Protocol for Disulfiram ...................................................................................56
Chapter 5—Treatment Entry and Engagement ..........................................................................59
Elements of Engaging the Client in IOT ...................................................................................................60
Collect Screening Information ...................................................................................................................62
Assessing Barriers to Treatment ................................................................................................................64
Crises and Emergencies ..............................................................................................................................67
Components of the IOT Admission Process .............................................................................................67
Sample Treatment Plans ............................................................................................................................76
Appendix 5-A. Substance Use History Form ............................................................................................84
Appendix 5-B. Instruments for Determining Substance-Related and Psychiatric Diagnoses ............85
Appendix 5-C. DSM-IV Criteria for Substance Dependence and Substance Abuse ............................87
Appendix 5-D. Supplements to the Six Assessment Domains in the ASI and Other Topics ................88
Chapter 6—Family-Based Services ..............................................................................................93
Planning for Family Involvement ..............................................................................................................94
Engaging the Family in Treatment ...........................................................................................................95
Family Services ...........................................................................................................................................98
Family Clinical Issues in IOT ...................................................................................................................102
Appendix 6-A. Format and Symbols for Family Genogram .................................................................107
Appendix 6-B. Family Social Network Map ............................................................................................109
Appendix 6-C. Resources for Family-Based Services .............................................................................112
Chapter 7— Clinical Issues, Challenges, and Strategies in Intensive Outpatient Treatment ........115
Client Retention .........................................................................................................................................115
iv Contents
Relapse and Continued Substance Use ..................................................................................................117
Substance Use by Family Members .........................................................................................................119
Group Work Issues .....................................................................................................................................120
Safety and Security ....................................................................................................................................125
Client Privacy .............................................................................................................................................128
Clients Who Work ......................................................................................................................................130
Boundary Issues .........................................................................................................................................132
Appendix 7-A. Instruments for Assessing Relapse Potential ................................................................135
Chapter 8—Intensive Outpatient Treatment Approaches ........................................................137
12-Step Facilitation Approach .................................................................................................................138
Cognitive–Behavioral Approach ..............................................................................................................140
Motivational Approaches .........................................................................................................................141
Therapeutic Community Approach .........................................................................................................142
The Matrix Model ......................................................................................................................................146
Community Reinforcement and Contingency Management Approaches ...........................................148
Chapter 9— Adapting Intensive Outpatient Treatment for Specific Populations .............................153
Justice System Population ........................................................................................................................153
Women ........................................................................................................................................................157
Populations With Co-Occurring Psychiatric Disorders .........................................................................162
Adolescents .................................................................................................................................................171
Young Adults ..............................................................................................................................................175
Chapter 10— Addressing Diverse Populations in Intensive Outpatient Treatment ..................179
What It Means To Be a Culturally Competent Clinician ......................................................................180
Principles in Delivering Culturally Competent IOT Services ...............................................................181
Issues of Special Concern .........................................................................................................................183
Clinical Implications of Culturally Competent Treatment ..................................................................188
Sketches of Diverse IOT Client Populations ...........................................................................................189
Appendix 10-A. Cultural Competence Resources ..................................................................................197
Contents v
Appendix A—Bibliography ........................................................................................................205
Appendix B—Urine Collection and Testing Procedures and
Alternative Methods for Monitoring Drug Use .........................................................................237
Appendix C—Resource Panel ....................................................................................................247
Appendix D—Cultural Competency and Diversity Network Participants ................................249
Appendix E—Field Reviewers ....................................................................................................251
Index .........................................................................................................................................255
CSAT TIPs and Publications Based on TIPs ............................................................................265
Exhibits
3-1 Goals, Duration, Activities, and Completion Criteria of Stage 1 ..................................................21
3-2 Goals, Duration, Activities, and Completion Criteria of Stage 2 ..................................................22
3-3 Goals, Duration, Activities, and Completion Criteria of Stage 3 ..................................................25
3-4 Goals, Duration, Activities, and Completion Criteria of Stage 4 ..................................................26
4-1 Core and Enhanced Services for IOT Programs .............................................................................28
4-2 Groups Conducted in Intensive Outpatient Treatment .................................................................29
4-3 Typical Sequence of Topics Addressed in Psychoeducational Group .........................................33
4-4 Case Management Services ................................................................................................................39
4-5 Examples of 24-Hour Crisis Coverage Implementation ................................................................41
4-6 Alternatives to Traditional 12-Step Groups ....................................................................................43
4-7 Key Features of a Hospital-Based Suburban IOT Program ..........................................................46
4-8 A Protocol for Ambulatory Detoxification and Disulfiram Induction .........................................56
5-1 Effective Interviewing Techniques ....................................................................................................63
5-2 ABC Model for Psychiatric Screening ..............................................................................................66
5-3 The Six Dimensions of the ASAM PPC-2R for Level II.1 IOT ......................................................69
5-4 Brief Screening Instruments That Assess Motivational Stage .......................................................70
5-5 Mild Withdrawal Symptoms for Four Drug Classes That Can Be Managed in Level II.5
Ambulatory Detoxification ................................................................................................................71
vi Contents
6-1 Suggestions for Engaging Family Members at Intake ...................................................................96
6-2 A Treatment Calendar for Family Members ...................................................................................99
6-3 Social Network Grid Used in Conjunction With Network Map ..................................................111
7-1 Examples of Immediate Safety Concerns and Counselor Responses ........................................126
8-1 Strengths and Challenges of 12-Step Approaches ........................................................................139
8-2 Strengths and Challenges of Cognitive–Behavioral Approaches ................................................141
8-3 Strengths and Challenges of Motivational Approaches ...............................................................143
8-4 Strengths and Challenges of the Therapeutic Community Approach .......................................145
8-5 Strengths and Challenges of Matrix Model Treatment ................................................................147
8-6 Strengths and Challenges of Community Reinforcement and Contingency
Management Approaches ................................................................................................................151
9-1 Core Treatment Needs and Service Elements for Women ..........................................................160
9-2 SAMHSA’s Service Coordination Framework for Co-Occurring Disorders ...............................164
9-3 The Family Intervention Program ..................................................................................................174
9-4 Characteristics and Behaviors of Adolescents and Treatment Suggestions ..............................176
B-1 Urine Toxicology Detection Periods for Different Substances ....................................................240
B-2 Effectiveness of Drug Detection Methods That Use Different Biological Products ..................243
Contents vii