Intensive Outpatient Treatment for the Addictions

Intensive outpatient treatment has not been universally recognized, let alone always reimbursed, as a legitimate treatment approach for addicted individuals. But change is afoot according to Dr. Gottheil, the editor of this brief collection of research studies related to the modality.

The beginnings of intensive outpatient treatment for the addictions are closely linked with the explosive growth in the early 1980s of cocaine addiction, which was then largely a white, middle-class affliction and now wracks our inner cities. With the federal government tallying up its wins and losses in the war on drugs and consequently shifting its policy focus away from interdiction and imprisonment and toward prevention and treatment, intensive outpatient treatment is being viewed as an innovative, measurably effective, and cost-efficient alternative for chemically dependent individuals.

Furthermore, as a result of competition spurred by managed care, intensive outpatient treatment has filled a niche created by potent market forces seeking to achieve a balance between cost-efficiency and clinical efficacy. Intensive outpatient treatment does so by broadening the continuum-of-care model that attempts to match specific levels of treatment with the patient's particular treatment needs. Basically, it provides managed care with a viable alternative to costlier, and perhaps unnecessary, inpatient stays. The traditional 28-day inpatient program is now rarer than hens' teeth; however, if the higher, inpatient level of care is clinically indicated, stays can be shortened now that the patient can be stepped down to a highly structured outpatient program where he or she can be closely followed.

Another key rationale for recommending intensive outpatient treatment to addicts, according to Gottheil, is that the traditional weekly outpatient visit allows too much time for temptation, vacillation, and relapse. He feels that early dropout rates from treatment will be reduced by scheduling more frequent visits, which will promote earlier engagement and nurture a commitment to continue in the program. Thus the gap between too much and too little treatment is presumably filled to the satisfaction of payers.

This collection, also published as issue number 2 of the Journal of Addictive Diseases in 1997, contains two "editorials" and six papers, four of which were presented at a 1995 symposium of the American Society of Addiction Medicine. Five of the papers are research studies that include data on the effectiveness of the modality and other pertinent issues. One study examines characteristics of cocaine addicts prone to pretreatment and early-treatment dropout and those who remain in treatment. Another study, coauthored by addictions research maven Thomas McLellan, one of the developers of the widely used Addiction Severity Index, compares outcomes of intensive and traditional outpatient treatment, as does another study in this collection.

Both these studies, interestingly enough, found no significant difference in outcomes between the two modalities. In addition, McLellan and associates found that outpatients in traditional treatment were more likely than their counterparts in intensive treatment to receive services addressing psychiatric, medical, employment, and social problems. Thus recipients of traditional outpatient treatment had better social functioning at follow-up, as evidenced by increased attendance at work, higher earnings, and fewer family and social conflicts.

This book would be of limited value to clinicians looking for a descriptive guide for setting up an intensive outpatient treatment program, as it does not discuss essential program elements or treatment issues. But researchers may find the sophisticated study methodologies of interest and may use the book as an impetus for future investigation of the modality.

The Center for Substance Abuse Treatment of the Department of Health and Human Services offers a free monograph on intensive outpatient treatment (1) as part of its extensive Treatment Improvement Protocol (TIP) series. It comprehensively describes the range of services and service components included in such programs.

Mr. Radosta is coordinator of dual diagnosis services for the central Massachusetts area of the Massachusetts Department of Mental Health in Worcester.