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Components of an Effective Intensive Outpatient Treatment Program   

Recent developments in the field of alcohol and other drug (AOD) abuse treatment, along with a prevalent
interest in and awareness of the effectiveness of the intensive outpatient treatment (IOP) level of care, have
promoted the growth of IOP programs. This chapter primarily addresses services that are considered essential to
any IOP program, as well as services that can be described as optimal.  The chapter includes a review of the
salient clinical issues and characteristics of IOP.   A framework for considering IOP programs, rather than an
exhaustive clinical explication, is presented.  Although the needs of special groups (such as clients with dual
disorders, pregnant women, elderly people, and gay men and lesbians) are not specifically addressed in this
section (see Chapter 5), the services described here can be adapted for programs that specialize in meeting the
needs of these and other groups.
Rationale
Traditional outpatient treatment generally consists of individual or group counseling. This approach is not
sufficiently intensive to meet the needs of patients with moderate to severe AOD disorders, since clients engage
in therapy sessions only once or twice a week. Traditional outpatient treatment usually offers fewer types of
treatment services than IOP and is generally not organized to address the multidimensional needs of
AOD-dependent patients.  

At the other end of the spectrum of treatment intensity is inpatient treatment:  medically managed intensive
inpatient treatment and medically monitored intensive inpatient treatment. These two levels of care involve an
organized service of around-the-clock evaluation, care, and treatment in an inpatient setting. In this setting,
patients who have severe withdrawal, and/or medical, emotional, or behavioral problems can receive primary
medical and nursing services.

IOP represents an approach to addiction treatment at a level of intensity that is intermediate between intensive
inpatient treatment and traditional outpatient treatment.   Chapter 2 includes a discussion of the levels of care.   
When clients are appropriately placed, IOP provides a level of effectiveness at significantly less expense that is
equivalent to the effectiveness of inpatient programs.   IOP has significant advantages as a level of care
organized to treat clients with moderate to severe AOD disorders.  These advantages can be recognized in terms
of cost, attractiveness to patients, and clinical efficacy.
Advantages

Financial and Cost Benefits

AOD abuse has been shown to have a tremendous economic impact on society.  The Institute of Medicine
estimates that the annual total cost to society of alcohol problems is $117 billion.   However, less than $10 billion
is spent annually on total treatment costs for alcohol problems (Institute of Medicine, 1990), a negligible amount
when compared with the costs to society.   However, in an era of health care reform, the AOD treatment field has
the same commitment as other health care fields to cost-efficient quality care. Within the context of a continuum of
care, IOP is an example of innovative change contributing to the attainment of the national objective of reducing
the costs of health care.

The bulk of AOD abuse costs relate to morbidity, mortality, and crime.  Additional costs are for support services
and treatment for fetal alcohol syndrome, acquired immunodeficiency syndrome (AIDS), and other medical
comorbidity, as well as services to persons living with someone who has an AOD disorder.
One of the only clear and consistent indicators of positive AOD treatment outcome is the length of time an individual
is involved with AOD treatment services.  Treatment in an intensive outpatient setting can be provided for many
more weeks than in an inpatient setting, and at significantly less cost. Further, studies in which traditional 28-day
inpatient treatment programs for AOD abuse have been compared with IOP have demonstrated comparable clinical
outcomes (Fink et al, 1985).

Cost savings are also realized in IOP programs in terms of continued productivity of clients who remain able to work
and those who have fewer days lost from school or employment.  In addition, clients are able to continue functioning
in such important roles as parents and homemakers.

Additional and substantial cost savings can occur when an integrated treatment plan is used to link various service
providers, including primary health care providers.   Early intervention and preventive services can lead to the type
of savings associated with preventive medicine.  AOD intervention offered in coordination with health care
networking may ensure less complicated medical treatment and reduced comorbidity.   IOP programs can easily be
organized as a component of care within a health care system.
Consumer Benefits

In contrast to traditional inpatient treatment, IOP allows services to be provided at times that are convenient to
clients.   The flexible program design of IOP also allows the provider to tailor services in response to regional
variations and the needs of special groups, both in terms of core elements of the program and the special services
that may be added to existing programs.   The special accommodations that can be provided to patients make IOP
an attractive option, especially in situations requiring flexibility.
Clients may view confidentiality as less of an issue in IOP settings, because unlike in inpatient settings, clients are
not separated from their daily milieu—thus avoiding protracted absences from work or family. Furthermore, an IOP
approach avoids the disincentive to seek treatment that is often experienced by patients when the only AOD
treatment choice is hospitalization.  Flexibility, reduced barriers to seeking treatment, and enhanced confidentiality
all serve to increase self-referral and utilization of this level of care.
Clinical Benefits

incorporate new identities as recovering people with extended support, such as enhanced opportunities to become
part of a fellowship of recovering people.  IOP sets the stage for continuing outpatient care, which further increases
the likelihood of successful recovery; the longer patients remain in treatment, the better the prognosis for full
recovery.  

Flexible levels of care.   The severity of addiction and the intensity of symptoms vary among patients and vary
over time for each patient.  Generally, people require more intense treatment initially, followed by progressively less
intense care.   However, problems such as relapse, medical and social crises, and the emergence of psychiatric or
subacute withdrawal symptoms demand a temporary increase in treatment intensity and/or level of care.  IOP
provides significant clinical flexibility that can be used to respond to clients' individual treatment needs—especially
when these needs change over time. Thus, as a client's treatment needs become more or less intense, the IOP
program can likewise increase or decrease the intensity of treatment for that individual.

Increased duration of treatment.   Among the many advantages of IOP is the increased duration of treatment.   This
allows for a prolonged opportunity to engage and treat clients while they remain in their home community.   IOP
provides for an increased opportunity for patients to practice newly learned behaviors.   Clients in IOP are given
sufficient time to
Increased patient caseload levels and improved patient retention. When staffed appropriately, IOP
programs can usually treat a high volume of patients. A larger patient population makes it easier to create groups
devoted to special issues such as incest, sexuality, anger management, and relapse.   The IOP structure, which
relies on a team approach and a therapeutic milieu, may result in a higher retention rate than low-intensity
outpatient treatment.  This means that staff can spend more time on effective caseload management.   The flexible
nature of the IOP setting also permits the ability to modify the structure and character of special issues groups.  

Daily application of learning.  IOP promotes the daily application of what is learned in treatment. Clients can
put into immediate practice the coping strategies needed to adapt to living without AODs. They learn to confront
daily challenges—indeed, they must do so.  New behaviors are learned within the context of the client's normal
existence and environment, rather than according to prescribed strategies that are learned within a sheltered
environment and only later, after discharge, put into practice.  Changes can be made and supported incrementally
and on a daily basis, thus providing an increased likelihood for permanency-  Rather than having a hiatus from life
in the "real world," the client in an IOP system must face the daily challenges posed by recovery.  Changes thus
become internalized, applied components of the client's life.

Community-centered support. Because IOP programs promote treatment that is patient-driven and
centered on the whole person, they can assertively address problems related to family and work and to social,
psychological, and emotional well-being. Psychosocial supports from family, employer, and community can be
readily established or reestablished with an outpatient treatment experience.   Clients are in a good position to
confront challenges because not only have they learned new behavioral and cognitive responses to cravings, and
have had real-life opportunities to practice relapse prevention techniques, but they also have an established
community-based support network, including family and employer involvement with the IOP program.   

Relapse management support.  Because of the daily contact with patients afforded by IOP as opposed to
traditional outpatient treatment, relapses can be addressed during early stages, often before actual AOD use.  The
approach of most IOP programs is to view relapses less as failures and more as evidence that changes are needed
in the patient's treatment goals, lifestyle, and/or social systems.   In IOP, clients can usually identify relapse triggers
and issues with ease since they have real-world experiences to draw upon.  When relapses do occur and when they
are framed as potentially positive learning experiences rather than as stigmatizing episodes, the likelihood of
patients remaining in treatment is heightened.  Clinical assessment of the severity and duration of the relapse is
essential.

Patient responsibility.  Since clients are responsible for their participation, passive participation is difficult in
IOP programs.  IOP tends to empower clients, who must develop incentives to keep returning to treatment.  In IOP,
clients are less able to be reluctant or resistant observers. Personal responsibility is thus placed squarely on clients'
shoulders.

Enhanced self-help participation.  Self-help resources such as Alcoholics Anonymous and Narcotics
Anonymous (AA and NA) are often essential to patient recovery during and beyond the IOP level of care.  A special
advantage of IOP is that clients can establish relationships to the community self-help support programs that they
will likely rely on for extended support.   Rather than identifying local groups after the completion of inpatient
treatment, patients can be settled into an appropriate community-based resource prior to their completion of
intensive treatment.

Enhanced therapeutic milieu.   IOP programs offer patients the opportunity to develop relationships with other
clients that can be readily fostered and maintained throughout and beyond the treatment experience.  Clients can
relate to one another outside of the parameters of the program.  Since they likely live close to one another, they can
continue mutual support once IOP is completed.  

Problems and Challenges  

IOP is a level of care that exists within the broader continuum of care.  As such, IOP has limitations, disadvantages,
and potential problems.  Chief among these challenges are problems associated with the retention of patients,
reimbursement and related financial concerns, and the management of acute crises.
It is possible for an element of IOP that generally provides significant strength to occasionally become a
disadvantage.  For example, participation in treatment while living in one's normal environment provides    

                                                                                                                                                                                   
                                     
                                                                                                                                                 
                                                                                                                                              
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