For many patients, alcohol and other drug AOD use disorders are chronic, recurring conditions involving multiple cycles of treatment, abstinence, and relapse. To disrupt this cycle, treatment can include continuing care to reduce the risk alcolismo come degradazione relapse. Alcolismo come degradazione most alcolismo come degradazione used treatment approach is initial intensive inpatient or outpatient care based on step principles, followed by continuing care involving self-help groups, step group counseling, or individual therapy.
Although these programs can be effective, many patients drop alcolismo come degradazione of initial treatment or do not complete continuing care. Thus, researchers and clinicians have begun to develop alternative approaches to enhance treatment retention in both initial and continuing care. One focus of these efforts has been the design of extended treatment models. These approaches alcolismo come degradazione blur the distinction between initial and continuing care and aim to prolong treatment participation by providing a continuum of care.
Other researchers have focused on developing alternative treatment strategies e. Alcohol and other drug AOD use disorders i. Add to that the immeasurable costs of suffering for the patients, their alcolismo come degradazione, and those around them, and the enormity of the burden resulting from AOD use disorders becomes even more staggering.
The public health effects of AOD use disorders are exacerbated further by the fact that these disorders can be chronic and therefore require constant vigilance by the patients and those around them, as well as repeated intervention.
In other words, many patients diagnosed with an AOD use disorder will experience a trajectory characterized by repeated cycles of periods of abstinence alternating with relapse to AOD use that may involve additional treatment episodes. These interventions, which may consist of group counseling, cognitive behavioral therapy, alcolismo come degradazione other approaches, are provided for some period of time following the initial acute care episode.
Although this strategy has intuitive alcolismo come degradazione, its effectiveness has yet to be determined conclusively. Moreover, several factors interfere with the delivery of continuing care to many patients. Alcolismo come degradazione include alcolismo come degradazione following:. Funding alcolismo come degradazione extended treatment often is inadequate, partly as a result of reductions in treatment duration driven by managed care and other factors.
Dropout rates are high alcolismo come degradazione the initial phase of treatment, so that only a minority of the patients who begin an acute treatment episode reach the stage at which they could transition to continuing care.
In one study, only 50 percent of the patients who began intensive outpatient treatment actually completed the entire 4-week program, and of those who transitioned to continuing care, another 50 percent did not complete that program McKay et al.
Many patients are ambivalent about their need for treatment and alcolismo come degradazione enter a treatment program because of some sort of external pressure e. Alcolismo come degradazione patients may be particularly reluctant to enter a continuing care program. Many people are not comfortable or satisfied with the current commonly available treatment options for both initial and continuing treatment, such as group therapy and self-help groups like Alcoholics Anonymous AA or Narcotics Anonymous NA.
For example, some patients are not comfortable with the religious focus that traditionally is found in step programs like AA.
Others are uncomfortable about sharing their problems or feelings in group settings. And still others may not want to adopt the goal alcolismo come degradazione total abstinence that is alcolismo come degradazione staple of many interventions. These and other factors may lead to early dropout from treatment and thereby also prevent participation in continuing care programs. For all of these reasons, most patients who begin an acute treatment episode do not receive subsequent continuing care.
This makes it difficult for researchers to study the effectiveness of these approaches and, more important, wastes a chance for many patients to break the cycle of abstinence, relapse, and treatment for their AOD use alcolismo come degradazione.
Consequently, it is evident that new approaches to continuing care are needed. Researchers and clinicians currently are developing new strategies that address some of these barriers.
This article will introduce some of these newer strategies. After first reviewing traditional approaches to AOD treatment and continuing care and summarizing evidence for their effectiveness, the article explores what is known about how patients can be retained in treatment.
It then presents new models of extended treatment and describes some example of new adaptive approaches to long-term AOD treatment and continuing care that have been assessed for their effectiveness. The article concludes with a look at the challenges associated with improving continuing care for patients with AOD dependence.
It should be noted that this review can provide only a selective overview because a full discussion of all available treatment options that might be used as a form of continuing care and of the studies of their effectiveness is beyond the scope of this publication see McKay [ a ] for a more exhaustive review of continuing care research and disease management strategies in the addictions.
The studies that were included in the present review were identified through several sources. The traditional treatment of AOD use disorders alcolismo come degradazione an initial intensive phase in an inpatient facility, followed by a less intense phase that typically is delivered in an outpatient setting, often at a different facility. It is based on the step AA principles, but with a holistic goal of treating the whole person i.
After completing the program, the patient is referred to AA for continuing care. Although this approach has been effective for many patients, it suffers from two main drawbacks. In recent alcolismo come degradazione, however, treatment programs based on the Minnesota Model have become more flexible, particularly during alcolismo come degradazione continuing-care phase.
The basic treatment approach, however, in most alcolismo come degradazione still follows the Minnesota Model i. This phase then is followed by a continuing-care component that frequently is provided at the same facility and uses the same strategies as the initial intensive intervention, just at a lower frequency and intensity. Currently, most AOD treatment is provided in outpatient settings and only patients with severe coexisting medical or psychiatric problems are treated in inpatient settings.
The initial intensive treatment phase typically lasts 30—60 days during which patients attend treatment sessions 2—3 times per week Substance Abuse and Mental Health Services Administration, Office of Applied Alcolismo come degradazione After that, patients enter the continuing-care phase, which typically involves one step— oriented group alcolismo come degradazione per week. In addition, patients are encouraged to attend self-help meetings. Although initial treatment in an outpatient setting has many advantages, it also has some disadvantages compared with inpatient treatment.
For example, a significant percentage of patients participating in IOPs continue to drink or use drugs e. Patients who fail to achieve at least several consecutive weeks of abstinence during alcolismo come degradazione initial treatment stage have poorer long-term alcolismo come degradazione than patients who do achieve abstinence Carroll et al.
Therefore, continuing care programs that treat patients who have completed an IOP may have to simultaneously accommodate both patients who have achieved abstinence and those who have not, which may impact alcolismo come degradazione effectiveness.
Approaches to continuing care that are currently available generally fall into one of three categories: self-help groups, step—oriented group counseling, and individual therapies. Self-help groups such as AA, NA, or Cocaine Anonymous CA are the most commonly available type of continuing care for people with AOD use disorders, although they should not be considered formal treatment interventions.
All of these groups are based on step programs that provide a spiritual and behavioral guide to self-improvement and offer social support for people seeking to achieve abstinence. Each of these groups offers several types of meetings e. The composition of regular attendees can vary greatly, and some groups may attract certain subgroups of addicts e.
Therefore, new members may have to try out several meetings to find a group that is most appropriate for them. In addition, self-help programs with a more secular focus e. The most common type of formal continuing care is group counseling alcolismo come degradazione on the step principles. Although the programs are not standardized, they all focus on the step alcolismo come degradazione underlying the Minnesota Alcolismo come degradazione and self-help groups.
During the sessions, participants typically report on their current status e. Other components may include feedback and support from other group members as well as planning of drug-free leisure activities for the upcoming days. The planned duration of this type of continuing care generally is 3 to 6 months; however, dropout rates are high, and most studies have found that about 50 percent of patients stop participating before 3 months McKay et al. Although the vast majority of patients receiving continuing alcolismo come degradazione for AOD use disorders participate in group sessions either self-help groups or formal group therapysome patients also receive individual therapies, primarily in private-practice settings.
Individual therapies rarely are offered in clinical settings, although some therapeutic approaches have been developed for research purposes. Based on this analysis, coping responses that the patient can use are developed and practiced in high-risk situations to avoid relapse Carroll ; Monti et al. A drawback of the CBT approach is that it requires relatively intensive training for counselors, although a newer, computer-based CBT approach may significantly reduce training times and expenses Carroll et al.
In one initial study of the computer-based CBT approach, patients receiving this intervention had fewer drug-positive samples during the followup and remained abstinent longer than patients receiving only standard care Carroll et al. Twelve-step facilitation TSF is designed to help patients engage more successfully in step programs Nowinski et al. Motivational enhancement therapy is based on the premise that responsibility and capability for change lies within the patient and change must be internally motivated Miller et alcolismo come degradazione.
Accordingly, the therapist does not guide the patient through the recovery process or offer training in specific skills. Instead, the therapist employs motivational strategies e. Marital and family therapies involve not only the patient but also his or her family. Since the late s, 20 controlled studies 2 have examined the efficacy 3 of various types of continuing care after completion of inpatient therapy or IOP for initial treatment.
Of these, 10 studies included patients with alcohol use disorders and 10 included patients with drug or AOD use disorders. Most of the continuing care approaches evaluated were based on CBT; others involved step group counseling, home visits, interpersonal therapy, and alcolismo come degradazione comprehensive interventions.
A systematic evaluation of these studies McKay ab found that 10 of the studies yielded statistically significant positive results see table —that is, one of the treatment groups exhibited a significantly improved outcome on at least one primary outcome measure, with no outcome measure favoring the other treatment group s.
Despite these caveats, some general conclusions can be drawn alcolismo come degradazione the existing controlled studies of continuing care interventions:. Studies of more recent interventions were more likely to find positive results than older studies. This suggests that both the interventions and their evaluations have improved in recent years. Alcolismo come degradazione that had a longer duration i. Although the studies provided some useful information, they still suffered from a range of limitations that point to areas to be addressed in future research.
For example, it is possible that any positive treatment effects observed result primarily from factors that can be found in all interventions, alcolismo come degradazione as an empathic and caring therapist or the structure and support provided by regularly alcolismo come degradazione treatment sessions Baskin et al. Other investigators, however, have argued that certain interventions derive their efficacy from factors other than those general factors.
For example, the positive effects of TSF appear to be mediated by effects on participation in self help groups—in alcolismo come degradazione words, patients receiving TSF are more likely to go to AA meetings, which in turn predicts better outcomes Longabough and Wirtz However, more research is needed to identify the factors that account for positive continuing care effects. A second limitation is that the rates of participation in continuing care and retention rates throughout the entire program were relatively low, particularly in studies that more closely mirrored real-life conditions.
It therefore is important to develop interventions that enhance participation and retention. Some approaches to increasing retention alcolismo come degradazione described in the next section. Third, alcolismo come degradazione magnitude of the observed effects varied substantially between studies and sometimes was relatively small.
Finally, all alcolismo come degradazione the studies focused on patients who had completed the initial stage of treatment before entering continuing care. However, it is especially those patients who do not complete inpatient therapy or IOP who might benefit most from the lower-intensity continuing-care approaches.
Thus, it will be important to design continuing care programs that enroll patients early in the initial treatment process in order to retain them in a continuing care program even if they drop out of initial treatment. Some such programs already exist and will be discussed later in this article.
As indicated above, one of the major problems in the implementation of continuing care is retaining patients for the intended duration of the intervention. A number of correlational and quasi-experimental studies 5 e. These analyses identified a wide range of variables that may have an influence. Taken together, the findings suggest that two general factors may contribute to higher retention rates:. Availability of convenient care situations e.