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
- 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).
- 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 (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
- 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.
- 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.
- 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.
- 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).
- 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.
Cite This Article
Proctor, S. L. & Lupianez Merly, N. (2019, March). Continuing care: Treating addiction as the chronic Medical condition it is. Web article]. Retrieved from http://www.societyforpsychotherapy.org/continuing-care/
Alcoholics Anonymous World Services, Inc. (1989). Twelve steps and twelve traditions. New York, NY: Alcoholics Anonymous World Services.
Baker, T. B., Piper, M. E., McCarthy, D. E., Majeskie, M. R., & Fiore, M. C. (2004). Addiction motivation reformulated: An affective processing model of negative reinforcement. Psychological Review, 111(1), 33–51. doi: 10.1037/0033-295X.111.1.33
Barnett, N. P., Tidey, J., Murphy, J. G., Swift, R., & Colby, S. M. (2018). Contingency management for alcohol use reduction: A pilot study using a transdermal alcohol sensor. Drug & Alcohol Dependence, 118(2), 391–399. doi: 10.1016/j.drugalcdep.2011.04.023
Benishek, L. A., Dugosh, K. L., Kirby, K. C., Matejkowski, J., Clements, N. T., Seymour, B. L., & Festinger, D. S. (2014). Prize-based contingency management for the treatment of substance abusers: a meta-analysis. Addiction, 109(9), 1426-1436. doi: 10.1111/add.12589
Brown, T. G., Seraganian, P., Tremblay, J., & Annis, H. (2002). Matching substance abuse aftercare treatments to patient characteristics. Addictive Behaviors, 27, 585-604. doi: 10.1016/S0306-4603(01)00195-2
Burke, B. L., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology, 71(5), 843-861. doi: 10.1037/0022-006X.71.5.843
Carroll, K. M., Ball, S. A., Nich, C., Martino, S., Frankforter, T. L., Farentinos, C.,…Woody, G. E. (2006). Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: A multisite effectiveness study. Drug and Alcohol Dependence, 81(3), 301–312. doi: 10.1016/j.drugalcdep.2005.08.002
Carroll, K. M., Easton, C. J., Nich, C., Hunkele, K. A., Neavins, T. M., Sinha, R.,…Rounsaville, B. J. (2006). The use of contingency management and motivational/skills-building therapy to treat young adults with marijuana dependence. Journal of Consulting and Clinical Psychology, 74(5), 955-966. doi: 10.1037/0022-006X.74.5.955
Carroll, K. M., Rounsaville, B. J., & Gawin, F. H. (1991). A Comparative trial of psychotherapies for ambulatory cocaine abusers: Relapse prevention and interpersonal psychotherapy. The American Journal of Drug and Alcohol Abuse, 17(3), 229–247. doi: 10.3109/00952999109027549.
Donovan, D. M., & Wells, E. A. (2007). ‘Tweaking 12-Step’: The potential role of 12-Step self-help group involvement in methamphetamine recovery. Addiction, 102, 121-129.
Dutra, L., Stathopoulou, G., Basden, S. L., Leyro, T. M., Powers, M. B., & Otto, M. W. (2008). A meta-analytic review of psychosocial interventions for substance use disorders. American Journal of Psychiatry, 165, 179-187. doi: 10.1176/appi.ajp.2007.06111851
Fiorentine, R. (1999). After drug treatment: are 12-step programs effective in maintaining abstinence? American Journal of Drug and Alcohol Abuse, 25, 93-116.
Higgins, S. T., & Petry, N. M. (1999). Contingency management: Incentives for sobriety. Alcohol Research & Health, 23, 122–127.
Harrison, P. A., Hoffmann, N. G., Hollister, C. D., Gibbs, L., & Luxenberg, M. G. (1988). Determinants of chemical dependency treatment placement: Clinical, economic, and logistic factors. Psychotherapy: Theory, Research, Practice, Training, 25(3), 356–364. doi: 10.1037/h0085356
Hendershot, C. S., Witkiewitz, K., George, W. H., & Marlatt, G. A. (2011). Relapse prevention for addictive behaviors. Substance Abuse Treatment, Prevention, and Policy, 6, 17. doi: 10.1186/1747-597X-6-17
Hoffmann, N. G., Harrison, P. A., & Belille, C. A. (1983). Alcoholics Anonymous after Treatment: Attendance and Abstinence. International Journal of the Addictions, 18(3), 311–318. doi: 10.3109/10826088309039350
Institute of Medicine (2006). Improving the quality of health care for mental and substance use conditions: Quality chasm series. Washington, DC: National Academies Press.
Irvin, J., Bowers, C. A., Dunn, M. E., & Wang, M. C. (1999). Efficacy of relapse prevention: a meta-analytic review. Journal of Consulting and Clinical Psychology, 67(4), 563-570. doi: 10.1037/0022-006X.67.4.563
Kahler, C. W., Ramsey, S. E., Read, J. P., & Brown, R. A. (2002). Substance-induced and independent major depressive disorder in treatment-seeking alcoholics: Associations with dysfunctional attitudes and coping. Journal of Studies on Alcohol, 63(3), 363–371. doi: 10.15288/jsa.2002.63.363
Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. The American Journal of Psychiatry, 142(11), 1259–1264. doi: 10.1176/ajp.142.11.1259
Lussier, J., Heil, S., Mongeon, J., Badger, G., & Higgins, S. (2006). A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction, 101(2), 192-203. doi: 10.1111/j.1360-0443.2006.01311.x
Magill, M., & Ray, L. A. (2009). Cognitive-behavioral treatment with adult alcohol and illicit drug users: A meta-analysis of randomized controlled trials. Journal of Studies on Alcohol and Drugs, 70(4), 516–527.
Marlatt, G. A., & George, W. H. (1984) Relapse prevention: Introduction and overview of the model. British Journal of Addiction, 79, 261-273.
Marlatt, G. A. (1985). Relapse prevention: Theoretical rationale and overview of the model. In G. A. Marlatt & J. R. Gordon (Eds.), Relapse prevention (pp. 250–280). New York: Guilford Press.
McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive-behavioral therapy for substance use disorders. The Psychiatric Clinics of North America, 33(3), 511–525. doi: 10.1016/j.psc.2010.04.012
McKay, J. R. (2009). Special article: Continuing care research: What we have learned and where we are going. Journal of Substance Abuse Treatment, 36, 131-145. doi: 10.1016/j.jsat.2008.10.004
McLellan, A. T., Lewis, D. C., O’Brien, C. P., & Kleber, H. D. (2000). Drug Dependence, a Chronic Medical Illness: Implications for Treatment, Insurance, and Outcomes Evaluation. JAMA, The Journal Of The American Medical Association, (13), 1689-1695.
McLellan, A., McKay, J., Forman, R., Cacciola, J., & Kemp, J. (2005). Reconsidering the evaluation of addiction treatment: from retrospective follow-up to concurrent recovery monitoring. Addiction, 100(4), 447-458. doi: 10.1111/j.1360-0443.2005.01012
Miller, N. S. & Hoffmann, N. G. (1994). Addictions Treatment Outcomes. Alcoholism Treatment Quarterly, 12(2), 41–55. doi: org/10.1300/J020v12n02_03
Miller, W.R., Zweben, A., DiClemente, C.C., & Rychtarik, R.G. (1994) Motivational Enhancement Therapy Manual. Washington, DC: National Institute on Alcohol Abuse and Alcoholism, Project MATCH Monograph Series, Volume 2
Moos, R., & Timko, C. (2008). Outcome research on 12-step and other self-help programs. In M. Galanter, & D. Kleber (Eds.), Textbook of substance abuse treatment (4th ed., pp 511-521). Washington, DC: American Psychiatric Press.
National Institute on Drug Abuse. (2018, January 17). Principles of Drug Addiction Treatment: A Research-Based Guide (3rd Ed.). Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition on 2018, March 7.
Ouimette, P. C., Moos, R. H., & Finney, J. W. (1998). Influence of outpatient treatment and 12-step group involvement on one-year substance abuse treatment outcomes. Journal of Studies on Alcohol, 59(5), 513–522. doi: 10.15288/jsa.1998.59.513
Petry, N. M., & Martin, B. (2002). Low-cost contingency management for treating cocaine- and opioid-abusing methadone patients. Journal of Consulting and Clinical Psychology, 70, 398-405.
Petry, N. M., Tedford, J., Austin, M., Nich, C., Carroll, K. M., & Rounsaville, B. (2004). Prize reinforcement contingency management for treating cocaine users: How low can we go, and with whom? Addiction, 99, 349-360. doi: 10.1111/j.1360-0443.2003.00642
Prochaska, J. O., & Velicer, W. F. (1997). The Transtheoretical Model of Health Behavior Change. American Journal of Health Promotion, 12(1), 38–48. doi: 10.4278/0890-1171-12.1.38
Proctor, S.L., & Herschman, P.L. (2014). The continuing care model of substance use treatment: What works, and when is “enough,” “enough?” Psychiatry Journal, 2014, 1-16. doi: 10.1155/2014/692423
Project MATCH Research Group. (1997). Matching alcoholism treatments to patient heterogeneity: Project MATCH post-treatment drinking outcomes. Journal of Studies on Alcohol, 58, 7–29.
Project MATCH Research Group. (1998). Matching alcoholism treatment to patient heterogeneity: Project MATCH three-year drinking outcomes. Alcoholism: Clinical and Experimental Research, 22(62), 1300–1311.
Rollnick, S., & Miller, W. R. (1991). Motivational Interviewing: Preparing people to change addictive behavior. New York: Guilford Press.
Sampl, S., & Kadden, R. (2001). Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions. Cannabis Youth Treatment Series, Volume 1 (SMA-01-3486). Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.
Schwarz-Stevens, K. S., & Cunningham, C. L. (1993). Pavlovian conditioning of heart rate and body temperature with morphine: Effects of CS duration. Behavioral Neuroscience, 107(6), 1039-1048. doi: 10.1037/0735-7044.107.6.1039
Secades-Villa, R., García-Rodríguez, O., López-Núñez, C., Alonso-Pérez, F., & Fernández-Hermida, J. R. (2014). Contingency management for smoking cessation among treatment-seeking patients in a community setting. Drug and Alcohol Dependence, 140, 63–68. doi: 10.1016/j.drugalcdep.2014.03.030
Tevyaw, T. O., & Monti, P. M. (2004). Motivational enhancement and other brief interventions for adolescent substance abuse: Foundations, applications and evaluations. Addiction, 99, 63-75. doi: 10.1111/j.1360-0443.2004.00855.x
Trudeau, K. J., Black, R. A., Kamon, J. L., & Sussman, S. (2017). A randomized controlled trial of an online relapse prevention program for adolescents in substance abuse treatment. Child & Youth Care Forum, 46(3), 437–454. doi: 10.1007/s10566-016-9387-5
Weiss, R. D., Griffin, M. L., Gallop, R. J., Najavits, L. M., Frank, A., Crits-Christoph, P.,…Luborsky, L. (2018). The effect of 12-step self-help group attendance and participation on drug use outcomes among cocaine-dependent patients. Drug & Alcohol Dependence, 77(2), 177–184. doi: 10.1016/j.drugalcdep.2004.08.012
Zemore, S. E., Kaskutas, L. A., Mericle, A., & Hemberg, J. (2017). Comparison of 12-step groups to mutual help alternatives for AUD in a large, national study: Differences in membership characteristics and group participation, cohesion, and satisfaction. Journal of Substance Abuse Treatment, 73, 16-26. doi: 10.1016/j.jsat.2016.10.004