H.  Determine Appropriate Initial Intensity Level Of Treatment

OBJECTIVE

Identify the appropriate level of initial treatment intensity that will help the patient achieve early remission and prevent relapse.

ANNOTATION

No standard dose or modality of treatment has been found to be uniformly sufficient for recovery (Critts-Cristoph et al., 1999; Finney & Moos, 1998).  The initial intensity of treatment should:

1.       Complement recovery support in the patient's community (e.g., Alcoholics Anonymous) and/or facilitate development of community support.

2.       Coordinate with intervention(s) for other biopsychosocial problems.  Increasing the intensity of addiction-focused treatments may not improve outcomes as effectively as addressing identified concurrent problems.

3.       Provide care in the least restrictive setting necessary for safety and effectiveness (ASAM, 1996).

4.       Focus on promoting initial engagement and maintaining retention over time.  This includes attention to appropriate housing and access to treatment, as addressed in Annotation I.

5.       Consider multiple treatment contacts per week (including medication dispensing) for severely dependent patients in early recovery (ASAM, 1996).

6.       For DoD active duty, command or operational concerns may be taken into consideration.

DISCUSSION

Rehabilitation programs should provide individualized psychosocial therapy, often combined with pharmacotherapy, complementing the patient's recovery support in the community.  As noted in Annotation K, addiction-focused treatment should proceed concurrently with intervention(s) for other biopsychosocial problems that may require careful coordination of adjunctive services of varying intensity.

Consistent with patient goals, addiction-focused treatment should be individualized in terms of intensity (session length and frequency), setting (inpatient, residential, partial hospital, and outpatient), duration (time from initial to final scheduled session), and modality or type of therapy (Finney & Moos, 1998; IOM, 1990).

The appropriateness of treatment intensity should be considered in terms of the least restrictive, least intensive level of care in which treatment goals can be effectively and safely achieved (ASAM, 1996).  For example, treatment setting and intensity should be "unbundled" rather than requiring patients to be hospitalized in order to receive intensive addiction-focused services or treatment for concurrent biopsychosocial problems.

Considerable evidence shows that even brief interventions (i.e., one to four brief sessions) can be effective for many patients with alcohol dependence, particularly as early interventions for those with mild to moderate dependence severity (Finney & Moos, 1998 Wilk et al., 1997).  Comparable findings have not been reported for brief intervention with other substance dependence (e.g., opioid and cocaine dependence), which typically require intensive treatment early in recovery (Crits-Cristoph & Siqueland, 1996).

Severely dependent patients typically may require multiple treatment contacts per week, in order to stabilize early remission.  While the initial intensity of treatment is one factor, actual retention in treatment is the factor most consistently associated with successful treatment outcome (Crits-Cristoph & Siqueland, 1996; Gerstein & Harwood, 1990; Onken et al., 1997; Simpson et al., 1997).  This suggests that for many patients following initial stabilization, it may be appropriate to provide a lower intensity of addiction-focused treatment extending over a longer duration (e.g., six months or more) (Finney & Moos, 1998).  This longer duration presents opportunities to adjust the intensity of psychosocial interventions (e.g., frequency of group sessions), pharmacotherapy (e.g., dose amount and monitoring frequency), and community recovery support (e.g., Twelve-Step meeting attendance) consistent with treatment response over time.

EVIDENCE TABLE

QE = Quality of Evidence; R = Recommendation (See Introduction)