Evidence-Based Reviews

Substance abuse: 12 principles to more effective outpatient treatment

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Addiction is a complex biopsychosocial problem that requires long-term outpatient treatment. Even after extended abstinence, individuals with substance use disorders are vulnerable to relapse. The case is made for an open-door approach to treatment.



Outpatient treatment of substance abuse is changing as research and experience teach us more about the nature of addictive illness and the principles of recovery. The recommended approach now emphasizes ease of access, chronic rather than acute treatment, and collaboration rather than confrontation.

As psychiatrists, we should be familiar with these changes, so that we can offer our addicted patients effective treatment and referrals. In particular, those of us who lead multidisciplinary teams in mental health clinics and outpatient programs need strategies that will help us make sound clinical decisions on detoxification, medical or psychiatric stabilization, and rehabilitation goals.

A new protocol that addresses these needs is being developed by a consensus panel of the Center for Substance Abuse and Treatment (Box 1).1,2 Two of us (RFF, RR) are members of that panel, and we all are recognized experts in the outpatient treatment of addicted individuals, with combined experience of more than 70 years. Based on available evidence and expert opinion, we offer you 12 principles of outpatient substance dependence treatment that can help you achieve the most favorable results (Table 1).

Box 1


Many Americans are seeking outpatient treatment for substance dependence, according to recent federal surveys. In 1999, at least 1 million people were admitted to state-funded outpatient substance abuse treatment programs,1 and an additional unknown number sought treatment from psychiatrists in private practice. Outpatient treatment, including intensive outpatient care, is the most common form of treatment and is offered at 82% of all addiction treatment facilities.2

A federally-sponsored national consensus panel on intensive outpatient treatment of substance abuse is revising the existing Treatment Improvement Protocol (TIP) on Intensive Outpatient Treatment. Dr. Forman is the chair and Dr. Rawson is a member of the consensus panel. The draft TIP is under review and planned for release in 2003 by the Center for Substance Abuse Treatment, a center of the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.

Principle 1: Open the doors wider

Outpatient clinics were once considered inappropriate for addicted individuals with significant psychosocial problems (such as homelessness) or co-occurring psychiatric disorders. Successful outpatient treatment was thought possible only for high-functioning, employed addicts who were free of significant psychiatric comorbidity.

Today, it is accepted that outpatients with a wide range of biopsychosocial problems can be effectively treated IF they receive case management and housing support and their co-occurring medical and psychiatric conditions are stabilized.

Efforts to ease the addicted patient into treatment should begin the moment a potential patient or family member seeks help. The pleasure that substance abusers derive from drug use makes them typically ambivalent about stopping their compulsive behaviors, and delays or obstacles to admission lead to “no shows” and drop-outs.3 Admissions increase when patients are given appointments the day they call for help.

From the initial outpatient encounter, the patient should feel like a welcomed participant who is responsible for his or her recovery. Access to outpatient programs increases when:

  • child-care assistance is provided as needed;
  • hours of operation are designed for the patient’s (rather than the staff’s) convenience;
  • transportation assistance is provided, particularly for adolescents;
  • the treatment plan is flexible and individualized to meet each patient’s specific needs.

Principle 2: Do a comprehensive initial evaluation

The open-door approach is most successful when the psychiatrist performs a comprehensive initial psychiatric and medical evaluation and works closely with a specialized treatment team. The initial medical and psychiatric evaluation is beyond the scope of this article and has been previously reviewed.4 Determining the need for medical detoxification is a priority during this phase of treatment.

Drug use patterns The treating physician should maintain a high index of suspicion for conditions associated with drug use. Cocaine causes seizures and cardiac arrhythmias, as well as vasoconstriction that leads to tissue necrosis (i.e., myocardial infarction, stroke, spontaneous abortion, and renal failure). Alcohol abuse affects brain, liver, cardiac, and endocrine tissue. Heroin produces acute overdose through respiratory depression, and its IV route of administration increases the risk of AIDS, viral hepatitis, pneumonia, sepsis, and endocarditis.

Function Structured interviews such as the Addiction Severity Index (ASI)5 can be used to assess functional impairment. Because addicted patients may be reluctant to disclose sensitive personal information, it is important to collect collateral information from family and friends, laboratory tests, and medical records.

Psychiatric concerns Many psychiatric syndromes are caused by substance abuse. Cocaine intoxication is often associated with psychosis (paranoia, auditory and tactile hallucinations), panic anxiety, and aggressiveness, whereas cocaine withdrawal produces depressed mood. Depression is also highly associated with chronic alcohol and opiate dependence. Withdrawal from opioids, alcohol, and sedatives produces anxiety.


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