Continuing Care

What is Continuing Care?

Continuing care for substance use disorders (SUDs) encompasses any services delivered on an outpatient basis after the initial or “primary” treatment episode, which serve to help patients move towards their goal of recovery (McKay, 2009). The treatment of SUDs has historically been comprised of two phases. The primary phase typically consists of detoxification, residential/inpatient treatment, and/or intensive-outpatient treatment (IOT). Level of care placement for the primary phase depends on a number of factors, including most notably, the patient’s substance use severity (e.g., frequency and quantity of substance use), as well as the presence of withdrawal symptoms. The secondary phase (hereafter referred to as continuing care) consists of less intensive, tapered care, delivered in the context of an outpatient treatment setting. Continuing care involves both community-based self-help support groups (e.g., Alcoholics Anonymous [AA], Narcotics Anonymous [NA], SMART Recovery) as well as formal aftercare programming, which are delivered by peers and licensed staff, respectively. In general, patients with a severe SUD per the DSM-5 (or substance dependence per the ICD-10) first receive care in a residential or inpatient treatment setting, and subsequent to discharge, step down to IOT care, followed by standard outpatient treatment. All continuing care models are characterized by the receipt of lower intensity treatment after formal primary treatment completion.

The treatment of SUDs is increasingly being contextualized within a disease management framework similar to that of other chronic medical conditions such as hypertension, diabetes, and asthma (Institute of Medicine [IOM], 2006; McLellan, Lewis, O’Brien, & Kleber, 2000) due to the nearly identical course and relapse rates evidenced for all of these conditions. Accordingly, there has been a shift in focus in recent years from the primary to secondary (or continuing care) phase of treatment.

Continuing Care Model

Effective continuing care models are often characterized by such elements as regular attendance at community-based mutual-help support groups (e.g., Alcoholics Anonymous) or formal aftercare treatment offered on an outpatient basis through the initial service provider, with a combination of both found to be of most benefit to patients (e.g., Fiorentine, 1999; Harrison, Hoffmann, Hollister, & Gibbs, 1988; Hoffmann, Harrison, & Belille, 1983; Miller & Hoffmann, 1994; Ouimette, Moos, & Finney, 1998). Research has consistently demonstrated that continuing care over an extended period of at least 12 months is often required for robust recovery (for reviews see McKay, 2009; Proctor & Herschman, 2014). The findings from prior research suggest that primary treatment providers may be best suited to place a high priority on the design and implementation of approaches that increase patient contact and engagement in the continuing care process immediately following discharge.

Goals of Continuing Care

• Achieve abstinence or reductions in substance use
• Maintain gains attained in the primary treatment episode
• Increase patient engagement/retention
• Increase self-efficacy
• Improve quality of life and social functioning
• Promote fellowship/citizenship

Evidence-Based Approaches

Cognitive-Behavioral Therapy

• Cognitive-Behavioral Therapy (CBT) is a structured treatment approach that focuses on understanding a patient’s behavior in the context of his or her environment, cognitions, and emotions. This is in line with principles from the “self-medication hypothesis” (Khantzian, 1985) and learning theories regarding the development of SUDs.
• The self-medication hypothesis suggests that individuals use various substances to cope with negative affect, presumably due to maladaptive cognitions (Kahler, Ramsey, Read, & Brown, 2002; Khantzian, 1985), while learning theories suggest that both classical and operant conditioning principles can be applied to substance use behaviors (Baker, Piper, McCarthy, Majiskie, & Fiore, 2004; Schwarz-Stevens & Cunningham, 1993).
• CBT incorporates both cognitive and behavioral techniques. A key tenet of CBT for SUDs is the belief that patients manifesting maladaptive behaviors may be able to learn appropriate coping strategies that would allow them to more effectively deal with negative affect and ultimately cut down or abstain from substance use.
• The main goals of CBT in the treatment of SUDs include developing basic drug refusal skills, coping with high-risk situations, challenging maladaptive cognitions, and establishing a social network that will support recovery (Sampl & Kadden, 2001).
• The effectiveness of CBT as a continuing care approach for SUDs is well-documented (Magill & Ray, 2009; McHugh, Hearon, & Otto, 2010; Project MATCH Research Group, 1997, 1998).

Motivational Enhancement Therapy

• Motivational Enhancement Therapy (MET) is a non-confrontational, therapeutic approach whereby patients are led through the process of assessing their current situation and determining what strategies might be employed to assist them in identifying and achieving behavior change (Miller, Zweben, DiClemente, & Rychtarik, 1994; Rollnick & Miller, 1991).
• Motivational Interviewing (MI), a component of MET, is a style of communication that operates on the premise that patients are best suited to achieve change when motivation comes from within themselves, rather than being imposed by the clinician (Rollnick & Miller, 1991).
• MET is a transtheoretical model that encompasses elements from the stages of change theory and patient-centered approaches (Miller et al., 1994; Prochaska & Velicer, 1997) which provides normative-based feedback and explores patient motivation to change in light of the feedback.
• The main goals of MET are to build self-efficacy and elicit “change talk” through the use of various techniques with the ultimate objective of resolving ambivalence regarding changing a particular problem behavior (e.g., substance use).
• MET is an effective approach for SUDs (Burke, Arkowitz, & Menchola, 2003; Carroll et al., 2006; Project MATCH Research Group, 1997, 1998; Tevyaw & Monti, 2004).

12-Step Mutual-Help Support

• 12-Step mutual-help support programs represent readily available, and perhaps most importantly, no cost, community-based group interventions for individuals with a SUD. Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are among the largest and most popular of the 12-Step mutual-help support groups.
• Both AA and NA are non-profit fellowships comprised of individuals either in the active or recovery phase of addiction. The foundation of AA/NA includes the “12 steps” and “12 traditions” (for more information see Alcoholics Anonymous World Services, Inc., 1989).
• Extant research indicates that 12-Step programs (and 12-Step facilitation) are an effective continuing care approach in the treatment of SUDs (Brown, Seraganian, Tremblay, & Annis, 2002; Donovan & Wells, 2007; Moos & Timko, 2008; Project MATCH Research Group, 1997, 1998; Weiss et al, 2018; Zemore, Kaskutas, Mericle, & Hemberg, 2017).

Relapse Prevention

• The Relapse Prevention (RP) model posits that both immediate determinants (e.g., high-risk situations, outcome expectancies) as well as covert antecedents (e.g., lifestyle factors, cravings) can contribute to relapse (Marlatt, 1985). RP includes specific interventions or techniques to assist individuals in more effectively anticipating and coping with high-risk situations, as well as more global lifestyle interventions aimed at promoting improved health and well-being (Marlatt & George, 1984).
• The main goals of RP are to learn appropriate coping strategies to manage high-risk situations (increase self-efficacy), identify and respond appropriately to internal and external cues or triggers, and implement self-control strategies to reduce the risk of relapse (Marlatt, 1985).
• Results from a number of randomized controlled trials and literature reviews support the efficacy and effectiveness of RP in the treatment of SUDs (Carroll, Rounsaville, & Gawin, 1991; Hendershot, Witkiewitz, George, & Marlatt, 2011; Irvin, Bowers, Dunn, & Wang, 1999; Trudeau, Black, Kamon, & Sussman, 2017).

Contingency Management

• Contingency Management (CM) is a systematic, incentive-based approach. Largely based on operant conditioning principles, CM for SUDs consists of reinforcing desired behaviors and withholding reinforcement or punishing undesired behaviors (Higgins & Petry, 1999).
• CM is appropriate for individuals with problems related to a number of substances, including alcohol, nicotine, marijuana, cocaine, and opioids (Barnett, Tidey, Murphy, Swift, & Colby, 2018; Carroll et al, 2006; Petry et al., 2004; Petry & Martin, 2002; Secades-Villa, García-Rodríguez, López-Núñez, Alonso-Pérez, & Fernández-Hermida 2014).
• CM can be delivered as a standalone treatment or as an adjunctive in combinationwith other treatment approaches. A number of meta-analyses support CM as an efficacious adjunct to treatment for SUDs (e.g., Benishek et al., 2014; Dutra et al., 2008; Lussier et al., 2006).

Recommendations for Practice

1. Primary treatment programs (e.g., residential/inpatient, intensive-outpatient) must provide the patient with sufficient education about available continuing care options prior to discharge, including medication treatment (methadone, buprenorphine, or naltrexone), if applicable.
2. Primary treatment programs must incorporate some form of lower-intensity continuing care services into existing standard primary treatment programming, in which essential continuing care elements such as community-based mutual-help support groups are introduced.
3. Should the primary treatment program not offer formal continuing care services (i.e., is a standalone residential/inpatient program), patients must be linked with appropriate outpatient supportive services in their home community to ensure continuity of care.
4. Continuing care discharge planning must be a collaborative effort between patients and treatment staff, and be initiated well before a patient is scheduled to discharge. Continuing care discharge plans should include a combination of both formal aftercare (e.g., outpatient individual therapy, medication management) and community-based mutual-help support groups (e.g., Alcoholics Anonymous, Narcotics Anonymous, SMART Recovery).
5. SUD treatment programs should regularly and systematically follow-up with patients post-discharge at pre-determined intervals (e.g., 30 days, 6 months) for a minimum of 12 months. Additionally, post-discharge follow-up efforts must include a well-designed and valid outcomes monitoring system in which data from numerous relevant areas of functioning are used to inform patients’ treatment plans and the intensity of treatment can be adjusted accordingly based on patient-reported outcomes.