Continuum of Care

What are the Levels of Care for Addiction Treatment?

Traditionally, rehab or addiction treatment entails 28-day residential care. ​​​1 However, because addiction is a chronic, progressive condition, evidence-based research implies that long-term treatment for addiction yields better results. This has led to development of the continuum of care.

A continuum of care is a medical plan characterized by guiding and tracking a patient over time through a range of health services in different levels of care. ​​​2 A person is put through a continuum of care if there is an ongoing health need that requires monitoring. Importantly, continuity is the central idea of this concept because a person is transitioned through several care levels. Although a continuum of care is comprised an array of services, it does not always mimic the formal system of health care.

An appropriate continuum of care meets the continuing needs of a person since it offers a suitable type and level of health and medical, legal, and psychological care in a single or across several settings. The continuum of care is recovery-oriented and designed to help individuals overcome substance and alcohol abuse, and experience a better quality of life.

Benefits of the Continuum of Care

Benefits associated with the continuum of care include improvements in satisfaction levels and overall health along with a reduction in the costs of care. Going through a continuum of care is specifically important for individuals struggling with alcohol and substance use disorders. This approach to health care improvement is especially significant today due to the high alcohol and substance use in the U.S.

Substance Abuse Statistics

As of 2017, approximately 48.7 million individuals aged 12 and older are frequent smokers. 3 In the same year, almost 140.6 million people were alcohol drinkers, of which 16.7 million reported heavy drinking, while 66.6 million reported binge drinking.

Even though alcohol use has declined, it is still high in some populations. For instance, the percentage of African Americans who use alcohol shifted from 9.4% in 2012 to 9.9% in 2013, 7.9% in 2014, 8.5% in 2015, and 5.4% in 2016. 4

Percentage of African Americans Who Use Alcohol

  • 2012 9.4% 9.4%
  • 2013 9.9% 9.9%
  • 2014 7.9% 7.9%
  • 2015 8.5% 8.5%
  • 2016 5.4% 5.4%

Many of these people might require specialized attention through a continuum of care.

Levels of Care: Medical Detox

Medical detox is a procedure of clearing or eliminating toxins from the body of a person with alcohol use or substance use disorder. The detox process is designed to help manage withdrawal symptoms that occur and to assist the patient in overcoming drug or alcohol dependency.

In many instances, withdrawal from drugs is accompanied by life-threatening symptoms. The withdrawal symptoms vary greatly, depending on the type of drug and length of drug use. Heroin withdrawal is associated with flu-like symptoms, seizures and anxiety with benzodiazepines, restlessness and depression with cocaine, and seizures and tremors with alcohol.

Supervised Detox

A supervised detox program often helps patients navigate many of these symptoms. In rehab and detox centers, health professionals and case managers use medications to facilitate the withdrawal process and manage withdrawal side effects. Approximately 80% of detoxifications occur in treatment facilities. The Food and Drug Administration (FDA) has also approved the use of NSS-2 Bridge and lofexidine to manage withdrawal symptoms of opioids.​​​5

  • Detoxifications that Occur in Treatment Facilities 80% 80%

On Withdrawal

Withdrawal symptoms occur because of the extended use of alcohol or other drugs, which influences how the brain regulates moods and processes emotions. The influence creates a flood of neurotransmitters like serotonin and dopamine, leading to an artificial feeling of “high” or pleasure. Over time, the brain adapts to the effects of the drug or alcohol for normal functioning. Continuous use of drugs or alcohol builds tolerance, frequently resulting in consuming higher doses of the substance in order to feel the effect.

The importance of medical detox cannot be underestimated in a continuum of care. It is essential to clear drug toxins from the body in order to assess the condition and develop an effective care plan. After medical detox, care providers can determine the condition of different body systems and organs such as the cardiovascular system, heart, and liver. Most importantly,  medical detox is not a therapy to address the underlying environmental and behavioral causes of the addiction.

Levels of Care: Inpatient and Residential Treatment

The journey to recovery from alcohol use or substance abuse begins after medical detox. Recent research published in the Journal of Substance Abuse Treatment notes that people who undergo detoxification and fail to keep up with rehabilitative therapy are likely to relapse.​​​6 Inpatient and residential treatments offer safety and support for the early stages of recovery.

In certain instances, the physical, emotional, and psychological effects of alcohol and drug use remain after detoxification. Depression is a common experience during early recovery and can persist for several months. Others may experience troubling emotions that persist for long, but the situation can be addressed through the help of a therapist. An important aspect is to help patients manage symptoms and experiences during recovery.

Starting Therapy

Inpatient and residential treatment are an essential part of the recovery process because once detoxification is completed, it’s possible to start recovery education. Research indicates that ongoing care after detox is beneficial by preventing a “revolving door” phenomenon, or recurrent detox without treatment. Therapy is essential for recovery at this level of care. Residential treatment also shields patients during the early phases of recovery from potential threats to their health. In this level of care, patients might be at risk of experiencing external triggers or stressors. Effective treatment allows patients to learn and continually practice inherent recovery skills before they are tested in the outside world.

Patients are subjected to individual and group counseling sessions. Medication-assisted treatment is an essential approach to manage different types of drug addiction. Behavioral therapy programs include cognitive-behavioral therapy, multidimensional family therapy, motivational incentives, and motivational interviewing. The therapies are tailored to meet the specific needs of the patient based on the level of the substance use disorder.

The duration of this treatment may vary based on the goals and response to treatment. Nevertheless, longer treatment after detoxification is recommended for effective results.

Levels of Care: Partial Hospitalization Programs

Partial Hospitalization Programs(PHPs) are an outpatient drug recovery program that happens during the day inside or outside a formal healthcare facility. The recovery programs are created mainly for active treatment or diagnosis when it is essential to sustain the patient’s functional level of treatment and avoid relapse. PHPs are important in instances when there is a high expectation for improvement without inpatient care. Fundamentally, PHPs do not substitute inpatient care, and a patient should be evaluated carefully before being referred to this care. A PHP may shorten the period of full hospitalization or act as a transition to outpatient care. In most instances, PHPs serve as step-down care once a patient has finished an inpatient program.

When PHP is a Good Fit

A PHP is ideal for people who do not need 24-hour supervision but still require ongoing support. Patients placed under PHPs might continue working and socializing with friends and family while receiving addiction treatment. Patients with alcohol use and substance use disorder receive a high-level standard of care through PHPs. Individuals get comprehensive medical monitoring and treatment services during the day but do not stay overnight at the medical facility.

Through PHPs, patients receive an array of outpatient addiction treatment services, including individual therapy, group counseling, and pertinent medical care. Due to the nature of PHPs, the programs are often perceived as a day treatment program.

PHP Intake

Before a patient is referred to a PHP, the health care staff performs an intake evaluation. The intake evaluation is used to create a personalized care plan based on the patient’s medical health status and addiction condition. Patients in PHPs work closely with different health care professionals such as psychiatrists, social workers, nurses, and doctors.

PHPs and Medication Management

Medication management is among the most important aspects of treatment in PHPs. When medication is used together with psychotherapies or behavioral therapy, it can help reduce cravings and block the rewarding effect of drugs or alcohol. The combination of medication with individual therapy also helps manage symptoms of withdrawal, such as insomnia, dysphoria, and anxiety. Drug use among people struggling with addiction should be monitored continuously by medical professionals.

Levels of Care: Intensive Outpatient Program

Intensive outpatient care consists of medical services designed for people with substance or alcohol use disorder who do not meet diagnostic criteria for inpatient or residential substance use treatment. This medical service also works best for individuals discharged from 24-hour inpatient care facilities that require more support compared to the bi-weekly or weekly treatment sessions offered in conventional outpatient care.

Length of IOP Treatment

Research published in the Journal of Psychiatric Services observes that an intensive outpatient program provides a minimum of nine hours of care weekly in three, three-hour sessions.7 Nevertheless, certain programs offer many sessions per week or even longer sessions daily. Most intensive outpatient services become less intensive or frequent over time. Because IOPs are typically delivered in outpatient settings, their duration might be longer compared to inpatient services. IOPs enable patients to continue living in their community and with family while receiving care. This helps improve the adjustment and reentry into community life after program completion.

Goals of IOP

Even though each patient has different treatment goals, there are several common goals for inpatient outpatient services. These goals include early-stage relapse management, development of coping strategies, establishment or re-establishment of psychosocial support, and the management of problems associated with emotional, psychological, and social well-being.

IOP Services

Several services are offered to patients in intensive inpatient programs, such as:

Group Therapy

This therapy offers opportunities for individuals to create communication skills and engage in socialization experiences. Socialization experiences are especially beneficial for people whose social activities have revolved around using alcohol and drugs. Group counseling also establishes an environment for patients to help and support one another. Counseling sessions offer essential support to reinforce healthful interactions and a supportive therapeutic climate that is vital for recovery.

Individual Therapy

Individual therapy is another important service offered in intensive outpatient programs. In most cases, individual counseling involves 30 to 50-minute sessions that happen at least once per week during the early stages of treatment. Clients are assigned primary counselors who attempt to develop a close, collaborative alliance.

Medication

Medication and pharmacotherapy management is also a part of the intensive outpatient program. Effective addiction treatment should combine pharmacotherapy management with other therapies like behavior contingencies and psychosocial support. Medication targets only certain, limited elements of alcohol and drug use. Pharmacotherapy, on the other hand, does not alter lifestyle or reconstruct the impaired functioning associated with drug dependence.

Levels of Care: Outpatient

Outpatient programs involve day treatment, where patients do not spend the night at the medical facility or treatment center. According to researchers from Brandeis University, outpatient services include group or individual counseling, and the treatment’s intensity might vary by facility. Because clients do not stay at the facility, they might continue routine activities and socializing with friends and family throughout addiction treatment. However, home life should be stable enough to accommodate the patient after receiving treatment during the day.

On Dual Diganosis

Co-occurring medical conditions may need more support than typically offered in an outpatient program. Statistics released by the Substance Abuse and Mental Health Services Administration (SAMHSA) indicate that approximately 8.5 million people suffer from both substance use disorder and mental health disorder. Patients with co-occurring conditions might require an inpatient program to better support their treatment.

In Cases of Withdrawal

Withdrawal symptoms are considered when assigning patients to outpatient programs. Symptoms of withdrawal from some drugs such as Benzodiapines or opioids are life-threatening. A patient with life-threatening withdrawal symptoms requires medically monitored withdrawal (MMW) or medically supervised withdrawal (MSW). Thus, an outpatient program would not be a good alternative for people with severe withdrawal symptoms.

Determining Outpatient Eligibility

An important first step is to determine patients who are eligible for outpatient programs. The outside support system is among the most vital aspects that inform whether a patient will require an outpatient program. When a patient is placed under an outpatient program, they do not receive 24-hour supervision from the medical staff. In this regard, a sturdy support outside the facility to is required to support the recovery process.

There is typically a careful evaluation before being assigned to an outpatient program. The procedure of evaluating patients for outpatient programs is similar to that of inpatient programs. Health care providers need to understand the condition, level of addiction, and recovery progress before the patient is pronounced fit for an outpatient program.

Levels of Care: Aftercare

Approximately two-thirds of people relapse within weeks of starting treatment. 85% of people treated for nicotine, alcohol, and illicit drug use relapse within one year of treatment.​​​8 Furthermore, about 25% of marijuana and cocaine users and 35% of opiate and alcohol users abstain from drugs following one-year treatment. These statistics show that aftercare is an important part of recovery. Evidence-based research shows that aftercare services help patients to transition back to their life after substance abuse treatment.

  • People treated for Nicotine, Alcohol, and Illicit Drugs Relapse within One Year 85% 85%
  • Marijuana and Cocaine Users Abstain from Drugs Following One-Year Treatment 25% 25%
  • Opiate and Alcohol Users Abstain from Drugs Following One-Year Treatment 35% 35%

Services

Aftercare involves infrequent contact with healthcare professionals after discharge from inpatient care or termination of outpatient addiction treatment. Aftercare should be perceived as an important part of the continuum of care because it helps support independent self-sufficiency and sobriety maintenance. Aftercare offers an incentive for patients to avoid trigger situations and fight desires to use drugs. Close monitoring also serves the purpose of identifying a recent or impending relapse. Healthcare professionals get an opportunity to re-evaluate the treatment plan, which promotes ongoing safety and health.

Aftercare services also involve continuous participation in addiction treatment support. Any necessary medications can be prescribed during these services. This is why aftercare should be viewed as continued therapy with clinicians or counselors.

During these services, clinicians also establish whether the client is living in an environment that supports their recovery. If problems are identified with the current living conditions, clinicians can create a plan to move the client to a controlled living environment. Ongoing drug testing is also offered to support transparency throughout the recovery process.

Aftercare services can only be terminated when the patient recovers completely from alcohol or drug use and regains self-sufficiency to live in his or her community. However, the continuum of care is an ongoing health care program with no prescribed time or level of termination.


Resources:

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797102/
  2. https://www.himss.org/definition-continuum-care
  3. https://www.samhsa.gov/data/report/2017-nsduh-annual-national-report
  4. https://www.cdc.gov/nchs/data/hus/2017/051.pdf
  5. https://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction
  6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4096006/
  7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4152944/
  8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3674771/#R2