Continuing Care For Addiction - Context, Components, and Efficacy - UpToDate

11/07/2021 Continuing care for addiction: Context, components, and efficacy - UpToDate
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Continuing care for addiction: Context, components,

and efficacy
Author: James R McKay, PhD
Section Editors: Richard Saitz, MD, MPH, FACP, DFASAM, Andrew J Saxon, MD
Deputy Editor: Michael Friedman, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2021. | This topic last updated: Apr 03, 2020.
INTRODUCTION
Addiction is a chronic or relapsing condition for many patients. Yet the traditional treatment
model for addiction has emphasized episodic intensive treatment for medically supervised
substance withdrawal and/or stabilization, followed by time-limited outpatient care. In
recent years, public and private health care systems and clinicians are coming to recognize
that chronic or relapsing addiction, like chronic physical conditions such as diabetes or
hypertension, typically requires continuing, long-term care.
Continuing care for addiction includes routine assessment and treatment customized to the
needs and preferences of the individual patient [1]. The patient’s clinical status and risk of
relapse are monitored systematically and longitudinally. The intensiveness of treatment is
adjusted as the addiction waxes and wanes over time. Patients receive training in self-
management skills and linkage to other sources of professional and community support.
Continuing care for chronic or relapsing addiction along with its clinical and theoretical
context, components, and efficacy are reviewed here. The treatment of specific substance
use disorders and determining the appropriate level of care for patients with substance use
disorders are reviewed separately. (See "Approach to treating opioid use disorder" and
"Approach to treating alcohol use disorder" and "Cannabis use disorder in adults" and
"Approach to treatment of stimulant use disorder in adults" and "Determining appropriate
levels of care for treatment of substance use disorders" and "Continuing care for addiction:
Implementation".)
CONTEXT
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Chronicity of addiction — Treatment of addiction has traditionally been short-term and

focused on acute episodes of care. After initial medically-supervised substance withdrawal
and/or stabilization at a higher level of care (eg, inpatient or residential), patients would
typically receive a time-limited course of outpatient treatment. A national survey of
outpatient substance use disorder treatment programs found that the planned duration of
outpatient care was most often 90 days, while the actual duration was less than 30 days [2].
Treatment has largely taken place in specialty addiction programs that employ a single
modality of treatment, often without access to medication.
For many patients, however, addiction is a chronic or relapsing condition that lasts many
years subsequent to diagnosis [3]. Studies have found that 40 to 60 percent of patients
treated for alcohol or other drug dependence return to regular use within a year following
treatment [4-6].
The conceptualization of addiction as a chronic disease is supported by comparison of its

manifestations, course, etiologic factors (genetic and environmental), pathophysiology, and
response to treatment with other chronic medical illnesses (eg, type 2 diabetes mellitus,
asthma, and hypertension) [7].
Addiction causes predictable and persistent structural and functional changes in the brain.
Volume loss of numerous types of brain tissue and structures has been found in DSM-IV
alcohol dependence [8,9], DSM-IV cocaine dependence [10], DSM-IV opiate dependence [11],
and polysubstance abuse [12]. Numerous neurotransmitter systems involved in reward and
stress pathways in the brain are affected by chronic use of alcohol and other drugs,
including dopamine and endorphins [13,14].
Early onset addiction can severely disrupt the development of effective life skills in many
areas of functioning, leading to chronic deficits. Even patients who achieve abstinence may
have difficulty developing the kinds of meaningful and satisfying lives that can provide a
buffer against relapse.
Chronic care model — The chronic care model, which has transformed the management of
chronic illnesses such as asthma and diabetes in many health care systems [15], provides the
conceptual foundation for continuing care for addiction. The model includes:
● Continuing contact over time between patients and service providers, rather than short-
term interventions during acute episodes
● Interventions to promote patient self-management of his or her addiction (see 'Self-

management skills' below)
● Links to patient oriented community resources (see 'Linkages to other sources of

support' below)
● Using accurate and timely patient data to monitor progress and guide intervention (see
'Measuring and monitoring clinical status' below)
COMPONENTS
Customization — Individuals with chronic addiction vary in their clinical status and needs.
Some patients are at high risk for relapse and need long-term, highly-structured continuing
care. Patients who have been abstinent for long periods may only need brief, periodic check-
ins to monitor for changes in substance use or risks of relapse. Patients at intermediate risk
of relapse may need more active treatment and more frequent monitoring of progress.
Assessment of patients with substance use disorders is described separately. (See "Clinical
assessment of substance use disorders".)
Risk factors for relapse in substance use disorder (SUD) patients during periods of
abstinence include [16]:
● Co-occurring psychiatric problems (eg, depression, anxiety)

● Sustained sleep difficulties
● Poor social support for recovery
● Low motivation for recovery
● High levels of personal stress or high stress reactivity
● History of multiple prior treatments followed by relapse
Clinical factors in actively-treated patients suggesting the need for more intensive treatment
include:
● Ongoing self-reported substance craving.
● Low motivation to stop using drugs or drinking after several weeks of treatment.
● Continued use of alcohol or drugs early in treatment.
● Spending time in places or with people who might increase the risk for relapse (eg, bars
[even if not consuming alcohol], neighborhoods where substances were previously
used, contacts who are currently using substances).
● Continued presence after several weeks of treatment of one or more individuals who are
important to the patient who support or encourage continued substance use.
Flexibility — Continuing care emphasizes that SUD care needs to be adjusted up or down in
intensity and frequency over time as patients go through alternating periods of abstinence
and use at varying levels of SUD severity [17,18]. Brief, infrequent clinical contact may be
sufficient during extended periods when a patient is doing well. However, when the patient’s
risk of relapse rises or an episode of substance use begins, treatment needs to be ratcheted
up to a higher level of care (eg, more frequent sessions, additional modalities, and/or in a
more intensive setting) that is adequate to interrupt and address the processes putting the
patient at risk [19].
The failure to achieve other early treatment goals, such as committing to abstinence,
attending mutual help or other meetings, developing better coping behaviors and increased
confidence in their efficacy, and identifying reliable sources of social support, may also
indicate a need for more intensive continuing care [20].
Addiction counseling, for example, is titrated to the patient’s clinical status and risk of
relapse. Counseling is provided in increasingly diverse formats that vary in intensiveness, for
example, face-to-face or by telephone, individual or group sessions. The duration of a
counseling session is typically between 30 to 60 minutes for individual sessions and 60 to 90
minutes for groups, while the duration of a brief check-in is typically 15 to 30 minutes.
Self-management skills — Treatment of patients with a chronic condition such as addiction

optimally includes preparing patients to manage their health and health care. This involves
helping them to develop confidence and skills in activities such as:
● Goal setting
● Identification of barriers to reaching goals
● Development of plans to overcome barriers
Many of these self-management skills are described in cognitive-behavioral therapy manuals

[21-24]. Tips for patients are also available [25].
Effective management of chronic addiction requires that patients are able to make good use
of nonclinical supports, both within themselves and in the community. The ability to learn
and to practice good “self-care” is an important part of the management of chronic disorders
of all types [15]. One of the key goals is to equip patients to engage in healthy behaviors,
such as a nutritious diet and exercise, and other basic tasks of good self-care. Although
some of these tasks vary from disorder to disorder, they generally include:
● Self-monitoring of status and symptoms

● Coping with stressors
● Interacting effectively with service providers and other sources of support
Linkages to other sources of support — Providing continuing care for addiction includes
providing patients with successful linkage to community-based and professional sources of
support [26]. Whenever such activities are feasible for a patient, they should be encouraged,
supported, and monitored.
In our clinical experience, involvement by patients in pro-recovery activities, such as those

listed below, are crucial for sustained recovery:
● Employment
● Education
● Mutual help groups
● Volunteer work
● Pursuit of hobbies or other meaningful activities
Professional services/sources of support include:
● Parenting classes
● Child care
● Medical care
● Mental health care
All patients who complete the acute phase of treatment should have a relapse prevention
plan that documents potential triggers of relapse and early warning signs, along with
strategies to respond. The plan should name sponsors, family members, or friends who
have agreed to help, in addition to clinicians and their contact information.
A variety of active outreach efforts have been included in continuing care interventions to
maintain contact with patients over extended periods of time. These contacts can provide
opportunities for the continuation of treatment after patients have relapsed, even if they
have lost motivation for recovery. Outreach techniques include telephone calls, home visits,
care managers, home visits, couples counseling, and assertive linkage to services.
Measuring and monitoring clinical status — Clinicians should regularly assess patients’
clinical status during the course of continuing care, ideally using a standardized quantitative
instrument that reliably detects improvement or deterioration over time. Routine use of
quantitative assessment can facilitate continuing care of addiction in multiple ways:
● To provide the patient and clinician with a shared language and indicators of progress or
deterioration that requires more intensive intervention.
● To facilitate communication about the patient’s course and current status among
clinicians involved with his/her treatment and across levels of care.
● To enable clinicians (or care managers) to monitor caseloads of patients receiving low
burden, infrequent treatment during periods of clinical stability, and to identify patients
at an early stage of deterioration. In our clinical experience, patients are often resistant
to more intensive interventions once they are well into a state of relapse. Catching
deterioration before it becomes too severe may allow for discussion about a less
intensive intervention with a more receptive patient.
Instruments for quantitative assessment of the severity of individual SUDs are reviewed
separately. (See "Risky drinking and alcohol use disorder: Epidemiology, pathogenesis,
clinical manifestations, course, assessment, and diagnosis", section on 'Screening' and
"Cocaine use disorder in adults: Epidemiology, pharmacology, clinical manifestations,
medical consequences, and diagnosis", section on 'Assessment' and "Methamphetamine use
disorder: Epidemiology, clinical manifestations, course, assessment, and diagnosis", section
on 'Assessment' and "Cannabis use disorder in adults", section on 'Assessment'.)
Relevant measures of clinical status assess:
● Recent use (eg, by toxicology).
● Extent of substance use (eg, based on patient self-report and other sources of
information):
• Percentage of days with substance use over prior month
• Average amount of substance use per day of use over prior month
● Severity of associated symptoms – Including craving, depression, or sleep difficulties:
• Percentage of days with urges to use (craving) over prior month
● Adoption of behaviors encouraged in the patient’s treatment plan – Including reduced

exposure to high risk situations or people, confidence in being able to cope with
problems without using alcohol or drugs, attendance and participation in treatment
programs, employment status, social support, and participation in activities that provide
meaning and a sense of purpose:
• Percentage of days with participation in mutual help group (out of number set as
monthly goal)
• Percentage of days with SUD medication compliance over past month
EFFICACY
Continuing care — A meta-analysis of 19 randomized trials compared continuing care for

substance use disorders with minimal or no substance use disorder (SUD) treatment; it
found a small benefit to continuing care on SUD outcomes at the end of the intervention and
at subsequent follow-up [27]. Participants in the trials typically had heavy alcohol or drug
use or a DSM-IV SUD. The interventions, which may not have been explicitly labeled
continuing care, were based on continuing care principles. They tested interventions that
began at the end of initial episodes of treatment and continued beyond. Multimodal
interventions included a variety of active outreach techniques to enhance motivation for
treatment and increase engagement and continuation of care over an extended period.
Among the activities studied were telephone calls, home visits, care managers couples
counseling, and assertive linkage to services. (See 'Components' above and 'Linkages to
other sources of support' above.)
Approximately half of these trials showed positive findings [17,18]. Compared with trials with
negative findings, intervention trials that led to improved substance use outcomes were
more likely to have:
● Been published since the late 1990s

● Had longer planned durations of care
● Included active efforts to provide treatment
A systematic review of six methodologically more rigorous trials of continuing care for DSM-
IV alcohol use disorders found mixed results [1]. The trials tested multimodal interventions
based on the chronic care model following initial treatment in a more intense psychiatric
setting. The interventions included a range of active outreach techniques, from telephone
calls to follow-up by nurses, and included various forms of individual or couples counseling.
Four of six trials found that patients receiving continuing care supplemented by an active
outreach intervention had better drinking outcomes than patients receiving usual
continuing care.
Specific models of continuing care are described below and separately. (See "Continuing care
for addiction: Implementation".)
Recovery management checkups — Recovery management checkups (RMC) is a

continuing care intervention that provides patients with chronic substance use with routine
monitoring of their substance use and treatment participation, and active attempts to
engage and retain the patient in treatment, or to intervene if the patient relapses [28-30].
Initial active techniques to get the patient in for the check-up include multiple phone calls to
patient and family members/peers. Then active, in-person techniques to get the patient into
treatment are used, such as motivational interviewing or discussion of barriers to entering
treatment and potential solutions.
Specific components of the intervention included:
● An in-person clinical assessment every three months using standardized instruments, as

well as urine or blood testing for substance use.
● When the clinical assessment indicates a need for active treatment, immediate transfer
to a linkage manager, who:
• Uses motivational interviewing techniques to help the participant recognize and

acknowledge his or her resumption of substance abuse and need for treatment (see
"Motivational interviewing for substance use disorders")
• Addresses barriers to reentering treatment
• Arranges scheduling and transportation to treatment
● SUD treatment consisted of 12-step oriented counseling and participation in mutual

help groups.
Randomized trials comparing the RMC intervention with treatment as usual have found
mixed results on substance use outcomes [28-30]:
● A two-year trial randomly assigned 448 adults with chronic substance use to receive
RMC plus standard treatment or standard treatment alone [28,30]. Over 90 percent of
those randomized to RMC were seen at each quarterly assessment and received the
intervention if they had relapsed. In intent-to-treat analyses, patients assigned to the
RMC group had fewer quarters in which they were in need of SUD treatment beyond the
check-ups. There were no significant differences in substance-related problems per
month or total days of abstinence.
● A four-year trial randomly assigned 446 adults with chronic substance use to receive
RMC plus standard treatment or standard treatment alone [29]. Four hundred and
nineteen patients (94 percent) completed the study. In intent-to-treat analyses, patients
assigned to the RMC group had fewer quarters in which they were in need of SUD
treatment beyond the check-ups, fewer substance related problems per month, and
more total days of abstinence (932 versus 1026 days) compared with patients in the
control group.
● A three-year trial randomly assigned 480 female offenders referred from incarceration
to community-based substance use disorder treatment to treatment as usual versus
treatment as usual plus RMC provided for three years [31]. Results indicated that RMC
was beneficial for women who were not on probation. For example, among women not
on probation, those who received RMC were more likely to receive any days of SUD
treatment (8.9 versus 4.5 percent, odds ratio = 2.12, p <0.01), less likely to engage in
weekly alcohol and drug use (47 versus 60 percent, odds ratio = 0.59, p <0.05), and less
likely to engage in any HIV-risk behavior (66 versus 73 percent, odds ratio = 0.72, p
<0.05). Conversely, there were no significant positive effects for RMC in women on
probation.
Extended continuing care — The extended continuing care intervention provides patients
with addiction with ongoing clinical care that includes [32]:
● An initial face-to-face visit followed by telephone calls for a duration of 20 minutes.
● Brief structured assessment of current risk and protective factors to monitor patient
clinical status and determine the focus of the remainder of the session.
● Problem-focused counseling using cognitive-behavioral therapy (CBT) techniques, such

as identification of high-risk situations and rehearsal of improved coping behaviors.
● Weekly contacts for the first eight weeks, then biweekly for 12 months, and then
monthly.
● Patients whose risk of relapse increased received stepped-up care, which included more
frequent telephone contacts, in-person relapse prevention (a form of CBT), or linkage to
other treatment.
Randomized trials of extended continuing care for patients with DSM-IV substance
dependence have found mixed results. A trial of 252 patients with DSM-IV alcohol
dependence resulted in clinically significant reductions in alcohol use compared with the
control condition [32]. Two trials with a total of 473 patients with DSM-IV cocaine
dependence did not find reductions in cocaine use in response to the active interventions
compared with controls [33,34].
As an example, a clinical trial of extended continuing care enrolled 252 adults with DSM-IV
alcohol dependence (49 percent with concurrent DSM-IV cocaine dependence) who were
participating in a public intensive outpatient program (IOP) [32]. All patients received
treatment as usual, which consisted of continuation of IOP treatment for up to four months
and, for a small number of patients, one to three months of weekly outpatient group
counseling after the completion of IOP. After completing three weeks of IOP treatment,
patients were randomly assigned to receive continuing care with counseling (largely
telephone-based), continuing care with briefer telephone calls providing monitoring and
feedback but not counseling, or treatment as usual alone, without continuing care.
At 18-month follow-up, patients assigned to receive continuing care with counseling in

addition to treatment as usual reported reduced alcohol use and heavy alcohol use
compared with the group receiving treatment as usual alone. During months 12 to 18 of the
follow-up period, rates of any alcohol use in each three-month segment were lower in the
counseling and the monitoring/feedback groups compared with the control group
(approximately 30 versus 50 percent). No clinically significant effects were seen in cocaine
use. Treatment effects from the 18-month intervention were no longer present at 24 months
[20].
Telephone continuing care provided for shorter durations may not always be effective. A
study randomized 406 patients with co-occurring substance use and mental health disorders
to receive usual postdischarge care or usual care plus three months of weekly telephone
monitoring sessions [35]. Results indicated there were no differences between the treatment
conditions on days of alcohol use, drug use, or psychological problems over a 15-month
follow-up.
Other interventions — Other continuing care interventions (of two months or more
following initial treatment) have demonstrated evidence of efficacy using a variety of
different modalities to monitor patients following acute treatment [36-46]:
● Intensive case management in individuals with substance dependence on public

assistance over 12 to 15 months [37,38].
● Home visits by a nurse over 12 months [39].
● Couples relapse prevention – Provided continuing care over 12 months in patients who
had completed an initial phase of treatment [40].
● Extended employee assistance programs visits and telephone contacts over 12 months
in patients who had completed couples behavioral marital therapy [41].
● Mindfulness-based relapse prevention provided weekly for eight weeks following

completion of initial treatment [47]. Mindfulness-based relapse prevention combined
mindfulness meditation, application of mindfulness practices in the presence of relapse
triggers, and self-care and compassion.
● Assertive aftercare for adolescents over three months that aggressively linked
adolescents to continuing care treatment services and resources in the community
following discharge from residential treatment [42].
● Maintenance check-up sessions at one and three months following psychosocial

intervention [48].
● Mobile texting recovery support (daily self-monitoring, data-based feedback,

informational and wellness recovery tips, and social support resources) for adolescents
and young adults for three months following initial treatment [49].
● An automated intervention delivered by interactive voice response provided for four

months after completion of 12 weeks of group CBT [50]. The intervention provided daily
monitoring of alcohol consumption, targeted feedback, CBT skills, opportunities to
practice coping skills, and a monthly personalized recorded message from a therapist.
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● Smartphone-based, automated recovery support for eight months following residential

program discharge [51].
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Alcohol use disorders
and withdrawal" and "Society guideline links: Benzodiazepine use disorder and withdrawal"
and "Society guideline links: Opioid use disorder and withdrawal" and "Society guideline
links: Stimulant use disorder and withdrawal" and "Society guideline links: Cannabis use
disorder and withdrawal".)
SUMMARY AND RECOMMENDATIONS
● Moderate-to-severe substance use disorders are typically chronic or relapsing

conditions; however, treatment of addiction has traditionally been short-term and
focused on acute episodes of care. Chronic or relapsing addiction, like chronic physical
conditions such as diabetes or hypertension, typically requires continuing, long-term
care. (See 'Chronicity of addiction' above.)
● Continuing care emphasizes ongoing monitoring after an initial period of treatment

with the intensiveness of treatment adjusted to the patient’s clinical status and risk of
relapse as the patient’s addiction waxes and wanes over time. (See 'Components' above.)
Patients with a mild substance use disorder are not typically candidates for continuing
care, but they should receive follow-up assessment during the year following treatment.
Continuing care may be indicated for those who relapse and experience a worsening of
symptoms. (See 'Efficacy' above.)
● Patients treated in a continuing care model are provided training in self-management

skills, linkage to other sources of support, and measuring/monitoring of their clinical
status over time. (See 'Self-management skills' above and 'Linkages to other sources of
support' above and 'Measuring and monitoring clinical status' above.)
● Continuing care for patients with addiction should be customized to the individual
patient’s needs and preferences. Treatment needs are determined through assessment
of the patient’s clinical status, risk factors for relapse, and clinical indications for more
intensive treatment. (See 'Customization' above.)
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Topic 16754 Version 22.0
Contributor Disclosures
James R McKay, PhD Nothing to disclose Richard Saitz, MD, MPH, FACP,
DFASAM Grant/Research/Clinical Trial Support: Alkermes [Alkermes provides study medication for a
clinical trial supported by NIH on alcohol use disorder]. Consultant/Advisory Boards: Checkup &
Choices [Electronic interventions for alcohol use in primary care]. Andrew J Saxon,
MD Consultant/Advisory Boards: Alkermes Inc [Opioid use disorder]; Indivior [Opioid use disorder].
Other Financial Interest: Alkermes Inc [Opioid use disorder]. Michael Friedman, MD Nothing to
disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
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Continuing Care For Addiction - Context, Components, and Efficacy - UpToDate

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11/07/2021 Continuing care for addiction: Context, components, and efficacy - UpToDate

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Continuing care for addiction: Context, components,

Chronicity of addiction — Treatment of addiction has traditionally been short-term and

The conceptualization of addiction as a chronic disease is supported by comparison of its

● Interventions to promote patient self-management of his or her addiction (see 'Self-

● Links to patient oriented community resources (see 'Linkages to other sources of

● Co-occurring psychiatric problems (eg, depression, anxiety)

● Ongoing self-reported substance craving.

● Continued use of alcohol or drugs early in treatment.

Self-management skills — Treatment of patients with a chronic condition such as addiction

Many of these self-management skills are described in cognitive-behavioral therapy manuals

● Self-monitoring of status and symptoms

In our clinical experience, involvement by patients in pro-recovery activities, such as those

Professional services/sources of support include:

Relevant measures of clinical status assess:

● Recent use (eg, by toxicology).

• Percentage of days with substance use over prior month

● Severity of associated symptoms – Including craving, depression, or sleep difficulties:

• Percentage of days with urges to use (craving) over prior month

● Adoption of behaviors encouraged in the patient’s treatment plan – Including reduced

• Percentage of days with SUD medication compliance over past month

Continuing care — A meta-analysis of 19 randomized trials compared continuing care for

● Been published since the late 1990s

Recovery management checkups — Recovery management checkups (RMC) is a

Specific components of the intervention included:

● An in-person clinical assessment every three months using standardized instruments, as

• Uses motivational interviewing techniques to help the participant recognize and

• Addresses barriers to reentering treatment

• Arranges scheduling and transportation to treatment

● SUD treatment consisted of 12-step oriented counseling and participation in mutual

● An initial face-to-face visit followed by telephone calls for a duration of 20 minutes.

● Problem-focused counseling using cognitive-behavioral therapy (CBT) techniques, such

At 18-month follow-up, patients assigned to receive continuing care with counseling in

● Intensive case management in individuals with substance dependence on public

● Home visits by a nurse over 12 months [39].

● Mindfulness-based relapse prevention provided weekly for eight weeks following

● Maintenance check-up sessions at one and three months following psychosocial

● Mobile texting recovery support (daily self-monitoring, data-based feedback,

● An automated intervention delivered by interactive voice response provided for four

● Smartphone-based, automated recovery support for eight months following residential

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● Moderate-to-severe substance use disorders are typically chronic or relapsing

● Continuing care emphasizes ongoing monitoring after an initial period of treatment

● Patients treated in a continuing care model are provided training in self-management

Use of UpToDate is subject to the Subscription and License Agreement.

3. Vaillant GE. A 60-year follow-up of alcoholic men. Addiction 2003; 98:1043.

9. Sullivan EV, Pfefferbaum A. Neurocircuitry in alcoholism: a substrate of disruption and

28. Dennis M, Scott CK, Funk R. An experimental evaluation of recovery management

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