O.  Provide Periodic Reassessment Of Problems, Goals, And Response To Psychosocial Treatment And Pharmacotherapy

OBJECTIVE

Periodically reassess response to treatment, change in treatment goals, or other indications for change in the treatment plan.

ANNOTATION

1. Reassess and document clinical response throughout the course of treatment:

§      Daily in the acute inpatient setting, including reevaluation of the continued need for that level of care.

§      At least weekly in the residential setting, including reevaluation of the continued need for that level of care.

§      In the outpatient setting:

—Within the first 10-14 days for a new episode of care

—After the first 90 days of continuing care

—At least annually for long-term care

2. For patients receiving pharmacotherapy with disulfiram or naltrexone, transaminase levels should be reassessed monthly for the first 3 months and then every 3 months thereafter (see Module P, Annotation J).
3. Modify treatment plans individually based on changes in a patient’s clinical and psychosocial condition rather than imposing uniform treatment plans (ASAM, 1996)
4. Indications to change treatment intensity or provide adjunctive treatments may include:

§      Relapse based on self-report or urine toxicology

§      Increased risk of relapse (e.g., craving or personal loss)

§      Emergence or exacerbation of comorbid medical and psychiatric conditions

§      Suboptimal response to medication

§      Emergence of medication side effects

5. Discuss relapse as a signal to reevaluate the treatment plan rather than evidence that the patient cannot succeed or was not sufficiently motivated (Miller & Rollnick, 1991).
6. Target services to identified problems (e.g., psychiatric, medical, family/social, legal, vocational, and housing) that increase the risk of relapse, rather than increasing drug and alcohol counseling alone (McLellan et al., 1997).
7. Consider care management for patients with persistently sub-optimal response, rather than routinely intensifying rehabilitation or discharging (See Module C: Care Management).
8. Consider reduced treatment intensity or discontinuing some treatment components based on:

§      Full, sustained remission

§      Greater involvement in community support

§      Improvements in other associated problem areas

9. Coordinate follow-up with the patient's primary medical or behavioral health provider during transitions to less intensive levels of care in order to reinforce progress and improve monitoring of relapse risks.

EVIDENCE TABLE

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