Substance Abuse Intensive Outpatient Programs: Assessing the Evidence
Abstract
Objective
Substance abuse intensive outpatient programs (IOPs) are direct services for people with substance use disorders or co-occurring mental and substance use disorders who do not require medical detoxification or 24-hour supervision. IOPs are alternatives to inpatient and residential treatment. They are designed to establish psychosocial supports and facilitate relapse management and coping strategies. This review assessed the evidence base for IOPs.
Methods
Authors searched major databases: PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, ERIC, and CINAHL. They identified 12 individual studies and one review published between 1995 and 2012. They chose from three levels of research evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. They also described evidence of service effectiveness.
Results
Based on the quality of trials, diversity of settings, and consistency of outcomes, the level of evidence for IOPs was rated high. Multiple randomized trials and naturalistic analyses that compared IOPs with inpatient or residential care found comparable outcomes. All studies reported reductions in alcohol and drug use. However, substantial variability in the operationalization of IOPs and outcome measures was apparent.
Conclusions
IOPs are an important part of the continuum of care for substance use disorders. They are as effective as inpatient treatment for most individuals. Public and commercial health plans should consider IOP services as a covered health benefit. Standardization of the elements included in IOPs may improve their quality and effectiveness.
Substance abuse intensive outpatient programs (IOPs) are ambulatory services for individuals with substance use disorders who do not meet diagnostic criteria for residential or inpatient substance abuse treatment as well as for individuals who are discharged from 24-hour care in an inpatient treatment facility and continue to need more support than the weekly or biweekly sessions provided in traditional outpatient care (1). IOP services offer a minimum of nine hours of service per week in three, three-hour sessions; however, some programs provide more sessions per week or longer sessions, and many programs become less intensive over time (1,2). Because services are provided in outpatient settings, the duration may be longer than that required for inpatient services. Individuals in IOPs remain in their homes, reduce the use of expensive inpatient care, and learn to recover in their community (1).
Since 2002, the annual census of specialty addiction treatment facilities in the United States has consistently identified IOPs as second in prevalence only to regular outpatient treatment for alcohol and drug use disorders. In 2011, there were 6,089 treatment programs in the United States that reported offering IOP services (44% of 13,720 addiction treatment programs), and IOPs served 141,964 patients—12% of the 1.2 million patients receiving specialty addiction treatment (3).
This article reports the results of a literature review that was undertaken as part of the Assessing the Evidence Base Series (see box on this page). The purpose of this review was to provide policy makers, treatment providers, and consumers with current information on IOPs so that they can make informed decisions when comparing these programs with alternative treatments. Public and commercial health plan administrators may use this information to assess the need to include IOPs as a covered benefit. Our assessment of IOPs defines the programs as a level of care, reviews available research, and evaluates the quality of the evidence, most notably compared with evidence for the effectiveness of inpatient treatment services.
About the AEB Series
The Assessing the Evidence Base (AEB) Series presents literature reviews for 13 commonly used, recovery-focused mental health and substance use services. Authors evaluated research articles and reviews specific to each service that were published from 1995 through 2012 or 2013. Each AEB Series article presents ratings of the strength of the evidence for the service, descriptions of service effectiveness, and recommendations for future implementation and research. The target audience includes state mental health and substance use program directors and their senior staff, Medicaid staff, other purchasers of health care services (for example, managed care organizations and commercial insurance), leaders in community health organizations, providers, consumers and family members, and others interested in the empirical evidence base for these services. The research was sponsored by the Substance Abuse and Mental Health Services Administration to help inform decisions about which services should be covered in public and commercially funded plans. Details about the research methodology and bases for the conclusions are included in the introduction to the AEB Series (5).
Description of the service
IOPs treat individuals with substance use disorders or co-occurring mental and substance use disorders who do not require medical detoxification or 24-hour supervision. IOPs provide a specified number of hours per week of structured individual, group, or family therapy as well as psychoeducation about mental and substance use disorders.
The American Society of Addiction Medicine (ASAM) defines five levels of care to guide practitioners in selecting the appropriate intensity for treating alcohol and drug use disorders: Level .5 (early intervention services), Level I (outpatient services), Level II (intensive outpatient services), Level III (residential and inpatient services), and Level IV (medically managed intensive inpatient services) (2). Thus IOPs represent a higher level of care than usual outpatient services and a lower level of care than residential and inpatient services. (A separate article in this series addresses residential treatment for individuals with substance use disorders [4].)
The Substance Abuse and Mental Health Services Administration defines a set of core services for inclusion in IOPs, such as a specified number of hours of structured programming per week; individual, group, or family therapy; and psychoeducation about substance use disorders and mental disorders (1). Table 1 provides a description of the service.
| Feature | Description |
|---|---|
| Service definition | Substance abuse intensive outpatient programs (IOPs) are direct services for people with substance use disorders or co-occurring mental and substance use disorders who do not require medical detoxification or 24-hour supervision. The programs provide treatment for symptoms or disabilities associated with these disorders. Core services generally include a specified number of hours of structured programming per week; individual, group, or family therapy; and psychoeducation about substance use and mental disorders. |
| Service goals | Learn early-stage relapse management; develop coping strategies; establish or re-establish psychosocial supports; address problems related to social, psychological, and emotional well-being |
| Populations | Adults with substance use disorders (both alcohol and drug diagnoses) |
| Settings for service delivery | Hospital-based inpatient and day treatment in community hospitals and Veterans Affairs hospitals; social model residential programs; community-based public and private substance abuse treatment centers |
IOP goals are to help the individual learn early-stage relapse management and coping strategies, to ensure that the person has psychosocial support, and to address individual symptoms and needs. However, broad variation across programs in terms of service delivery (for example, mechanisms for screening and assessment), treatment planning and provision, crisis management, discharge planning, and the intensity and duration of care limit attempts to assess the quality and effectiveness of care across IOPs. Moreover, IOP services vary by setting: hospitals, community behavioral health centers, and day treatment programs. The ASAM criteria note that the duration of treatment varies with the severity of the person’s illness and his or her response to the treatment intervention. Therefore, progress in a particular level of care, rather than a predetermined length of stay, determines an individual’s movement through the treatment continuum.
In the clinical and research literature, IOPs may also include partial hospitalization and day treatment (ASAM Level II.5), both of which are used to treat people who have serious mental illness or substance use problems. For the purposes of this review, partial hospitalization and day treatment for individuals with substance use are included in the definition of an IOP. Day treatment models operate full-day schedules five to seven days per week and may treat patients with co-occurring serious mental illness.
Methods
Search strategy
We identified and reviewed research from 1995 through 2012. We conducted a survey of major databases: PubMed (U.S. National Library of Medicine and National Institutes of Health), PsycINFO (American Psychological Association), Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature. We also examined bibliographies of major reviews and meta-analyses. We used combinations of the following search terms: intensive outpatient treatment, substance abuse treatment, addiction treatment, drug rehabilitation, and alcohol treatment.
Inclusion and exclusion criteria
This review was limited to U.S. and international studies in English and included the following types of articles: randomized controlled trials (RCTs), quasi-experimental studies, naturalistic assessments, and qualitative reviews. Studies were included if they compared levels of care (that is, inpatient or residential treatment versus IOP or day treatment) for adult study participants seeking treatment for alcohol or illicit drug use. The ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders (2) and the Treatment Improvement Protocol on intensive outpatient programs from the Center for Substance Abuse Treatment (1) were also examined. Studies were excluded that examined residential treatment only, ambulatory treatment only, aftercare only, treatment for mental disorders only, developmental disability programs, hospital-based inpatient treatment programs without comparisons to less intensive services, and treatment services for adolescents.
Strength of the evidence
The methodology used to rate the strength of the evidence is described in detail in the introduction to this series (5). The research designs of the identified studies were examined. Three levels of evidence (high, moderate, and low) were used to indicate the overall research quality of the collection of studies. Ratings were based on predefined benchmarks that considered the number and quality of the studies. If ratings were dissimilar, a consensus opinion was reached.
In general, high ratings indicate confidence in the reported outcomes and are based on three or more RCTs with adequate designs or two RCTs plus two quasi-experimental studies with adequate designs. Moderate ratings indicate that there is some adequate research to judge the service, although it is possible that future research could influence reported results. Moderate ratings are based on the following three options: two or more quasi-experimental studies with adequate design; one quasi-experimental study plus one RCT with adequate design; or at least two RCTs with some methodological weaknesses or at least three quasi-experimental studies with some methodological weaknesses. Low ratings indicate that research for this service is not adequate to draw evidence-based conclusions. Low ratings indicate that studies have nonexperimental designs, there are no RCTs, or there is no more than one adequately designed quasi-experimental study.
We accounted for other design factors that could increase or decrease the evidence rating, such as how the service, populations, and interventions were defined; use of statistical methods to account for baseline differences between experimental and comparison groups; identification of moderating or confounding variables with appropriate statistical controls; examination of attrition and follow-up; use of psychometrically sound measures; and indications of potential research bias.
Effectiveness of the service
We described the effectiveness of the service—that is, how well the outcomes of the studies met the service goals. We compiled the findings for separate outcome measures and study populations, summarized the results, and noted differences across investigations. We evaluated the quality of the research design in our conclusions about the strength of the evidence and the effectiveness of the service.
Results
Level of evidence
The level of evidence for IOPs was rated as high. Multiple RCTs and quasi-experimental studies have been conducted of IOPs that were designed for individuals with substance use disorders. We identified five reports based on four RCTs that compared IOP services or day treatment services with inpatient or residential treatment (6–10) and two studies of inpatient treatment versus IOPs that included participants who had been randomly assigned to a treatment group and those who refused randomization (11,12). Our search also found six naturalistic analyses of patients treated in inpatient and IOP settings (13–18) and one qualitative review of research published after 1995 (19). Table 2 summarizes the studies included in this review.
| Study | Design, participants, setting | IOP treatment | Comparison treatment | Primary outcome measures | Summary of findings |
|---|---|---|---|---|---|
| RCT | |||||
| Schneider et al., 1996 (6) | Day treatment (N=32) versus inpatient (N=42). Individuals seeking treatment for cocaine dependence from a large health maintenance organization in metropolitan Boston | Day treatment: 2 weeks, Monday through Friday, 5 hours of services per day; weekly aftercare for ≤6 months (47% completed 14 days of IOP services) | Inpatient care: 14 days in a nonhospital facility with 6 hours of services per day; referral to halfway house, aftercare, or a mental health provider (95% completed 14 days of inpatient care) | ASI scores at baseline and telephone interviews at 3 months (completed by 91%) and 6 months (completed by 85%) after treatment; self-report of abstinence | ASI problem severity declined for both groups at 3 and 6 months and did not differ between groups. At 3 months, inpatients were more likely to report abstinence (63%) than the day treatment group (38%); no significant difference at 6 months (46% versus 35%, respectively). |
| Guydish et al., 1998 (7) and 1999 (8) | Day treatment (N=114) versus residential treatment (N=147) in a therapeutic community drug treatment program | Day treatment: 8 hours of treatment per day, 7 days per week for 6 to 8 months | Residential therapeutic community with 1-month orientation; 3 to 6 months active treatment; 3 to 6 months reentry | ASI scores at baseline and 6-, 12-, and 18-month follow-ups; treatment retention; days of treatment | ASI problem severity scores declined significantly from baseline; improvements were maintained at 6, 12, and 18 months. Residential patients had more improvement on social and psychiatric problems; remaining outcomes did not differ. |
| Rychtarik et al., 2000 (9) | Individuals seeking treatment for alcohol dependence randomly assigned to IOP (N=63) versus inpatient and outpatient (N=58) versus outpatient (N=61) | IOP: 5 days per week for 28 days; 3 months of weekly aftercare | Inpatient and outpatient: 28 days plus 8 sessions of outpatient plus weekly aftercare; or outpatient: 8 sessions in 28 days | Percentage of days abstinent | Days abstinent increased from pretreatment for all groups, and groups did not differ at 18-month follow-up: inpatient, 37% to 81%; IOP, 50% to 75%; outpatient, 41% to 76%. Patients with high alcohol involvement had better outcomes when treated in inpatient care. |
| Weithmann and Hoffmann, 2005 (10) | Day hospital (N=56) versus inpatient (N=54) care in a German psychiatric hospital | Day hospital: same services and staff as inpatient | Inpatient: same services and staff as day hospital | Percentage of days abstinent, assessed quarterly | Days abstinent increased for both groups. There were no differences between levels of care. |
| RCT included those who refused randomization | |||||
| McKay et al., 1995 (11) | Day hospital versus inpatient care; patients randomly assigned (N=48) and patients who refused randomization and self-selected their level of care (N=96) | Day hospital: 27 hours per week for 4 weeks | Inpatient: 48 hours per week of group and individual counseling plus psychoeducation | ASI scores at baseline and at 3-, 6-, and 9-month follow-ups after treatment | ASI problem severity declined in both groups at all measurement intervals. There were no differences between levels of care. Randomly assigned and self-selected participants had similar outcomes. |
| Witbrodt et al., 2007 (12) | Day hospital versus residential care; patients randomly assigned (N=293; day hospital=154, residential care=139) and patients who refused randomization and self-selected their level of care (N=403; day hospital=321, residential care=82) | Day hospital | Social model residential care | ASI scores at baseline and at follow-up interviews at 6 and 12 months | ASI problem severity declined in both groups at both measurement intervals. There were no differences between levels of care. |
| Natural cohort analysis | |||||
| McLellan et al., 1997 (13) | Adults (N=918) from 10 outpatient programs (N=338) and 6 IOPs (N=580) | IOP: ≥3 hours per day, ≥3 days per week | Outpatient: ≤2 hours per session, ≤2 days per week | ASI scores at baseline and 7 months after baseline | ASI problem severity declined in both groups. There were no differences between levels of care. IOP patients had more severe problems at admission. |
| Harrison and Asche, 1999 (14) | Inpatient (N=1,156) versus outpatient programs (including IOPs) (N=3,007) | Outpatient: 145 programs in Minnesota providing intensive levels of care (median of 9 hours of care per week) | Inpatient: 38 programs in Minnesota (minimum of 30 hours of service per week) | ASI scores at intake and 6 months after intake | ASI problem severity declined in both groups. There were no differences between levels of care. Patients with recent suicidal ideation had better outcomes in inpatient care. |
| Pettinati et al., 1999 (15) | Alcohol-dependent patients admitted to inpatient (N=93) or outpatient (N=80) care in a psychiatric hospital | IOP: 8 weeks of 12-step program plus individual, group, and family therapy | Inpatient: 4 weeks of 12-step program plus individual, group, and family therapy | SCL-90R scores; number of drinking days; return to significant drinking (days of drinking ≥3 drinks) or return to inpatient care | Survival analysis suggested that IOP patients returned to significant drinking more quickly (50% at 2 months) than inpatients (25% at 2 months). Six months after discharge, the percentage of patients with heavy drinking stabilized at about 50% in both groups. |
| Simpson et al., 1999 (16) | Secondary analysis of data from DATOS assessing cocaine-dependent patients in 3 levels of care: outpatient drug free (including IOP) (N=458), long-term residential (N=542), short-term inpatient (N=605) | Outpatient drug free: 24 programs | Residential: 19 long-term programs; inpatient: 12 short-term programs | Weekly cocaine use 1 year after discharge | Weekly cocaine use declined from 73% before treatment to 23% at follow-up and did not differ across groups. A significant interaction between level of care, problem severity, and retention in care suggested that patients with more severe problems were less likely to report weekly cocaine use after long-term residential care (23%) versus short-term residential care (37%). |
| McKay et al., 2002 (17) | Patients in Washington state receiving inpatient plus outpatient care (N=167) versus IOP services only (N=96) | IOP: 2 programs | Inpatient: a 28-day inpatient program | ASI scores at baseline and 3 and 9 months after baseline | ASI problem severity declined in both groups at 3 and 9 months. Participants in inpatient plus outpatient programs improved more because their symptoms were more severe at baseline. |
| Tiet et al., 2007 (18) | Veterans Affairs clients receiving outpatient (N=410) or IOP services (N=601) versus inpatient and residential care (N=1,520) | IOP or outpatient | Inpatient and residential: inpatient (N=224), residential (N=390), and domiciliary (N=906) settings | ASI scores at baseline and 6 months after baseline | ASI problem severity declined in both groups after baseline. There were no differences between levels of care except for the most severe cases. |
| Review of 1995 or earlier studies | |||||
| Finney et al., 1996 (19) | Qualitative review of 14 studies of inpatient versus outpatient programs | Settings where patients do not stay over night | Residential, 24-hour settings | Varied, as reported in the publications | Treatment intensity was related to better outcomes. Inpatient outcomes were superior in 5 studies (2 based on naturalistic cohorts). Day hospital outcomes were superior in 2 studies. There were no differences in 7 randomized studies. |
a
Studies are listed in chronological order under type of research design. Abbreviations: ASI, Addiction Severity Index; DATOS, Drug Abuse Treatment Outcome Study; RCT, randomized controlled trial; SCL-90R, Symptom Checklist 90–Revised
Most of the RCTs had good internal validity and used the Addiction Severity Index (ASI), a well-validated treatment outcome measure. However, samples were sometimes small to modest, and insufficient statistical power may have contributed to a lack of strong findings. Conversely, the naturalistic studies reported large samples but had more variability in outcome measures. Nonetheless, findings from the RCTs and naturalistic analyses appeared to complement each other.
Patient populations and service settings
In studies of IOP services, alcohol dependence (9,10,15,19) and cocaine dependence (6,16) were the primary diagnoses of participants. Two RCTs (7,20) and four naturalistic analyses (13,14,17,18) included people with alcohol and drug (undefined) diagnoses. There was demographic variation across study populations, including individuals who were uninsured and homeless in inner cities (13,14), employed men and women with commercial health plans (6,12,15), patients in the Veterans Affairs (VA) health system (11,18), and men and women treated in public systems of care (7,11,14,16,17). One study compared a one-year day treatment program with a one-year residential program (7,8). African Americans were the primary racial-ethnic minority group studied, and most study populations had good racial-ethnic mixes. No studies compared the effects of IOPs across racial or ethnic groups.
Service settings for these studies included hospital-based inpatient and day treatment in VA hospitals (11,18) and community hospitals (6,9,10,15), residential programs (7,8,12), community-based public (7,8,11,14,16,17) and private (6,12,14,15) substance use treatment centers, and one drug treatment program based on therapeutic community principles (7,8). The services varied in intensity (that is, hours per week), duration, content of the sessions, and therapeutic approaches. Follow-up periods ranged from three months to 18 months. The dependent variables used to assess patient outcomes also varied, but abstinence (6,9,10) and changes in ASI scores (6,7,11–14,17,18) were most common (Table 2).
Effectiveness of the service
Variation in the operationalization of IOPs across studies and differences in outcome measures slightly tempered our assessment of the equivalent effectiveness of inpatient and IOP services. In most studies, the inpatient and IOP services differed on many dimensions (for example, setting, duration, and intensity), although one investigation used the same staff, facility, and therapeutic process between experimental and control groups and altered only the setting (inpatient versus outpatient) (9). The primary commonality was treatment in an IOP setting versus an overnight stay in a more controlled residential or inpatient setting (6–18), but variation in the operationalization of IOP services and outcome measures limited direct comparisons.
The RCTs and quasi-experimental studies consistently reported significant reductions in measures of problem severity and increases in days abstinent at follow-up interviews (between three and 18 months after baseline assessment) for study participants receiving IOP services or day treatment services and for individuals in inpatient or residential care (Table 2). One trial with small samples found higher rates of abstinence three months after treatment among individuals who received inpatient care compared with those who received day treatment (63% versus 38%), but this effect was not observed at six months after treatment (6). In addition, all RCTs reported similar reductions in ASI measures when inpatient and IOP settings were compared (7,8,11,12). Finally, the studies that included participants who were randomly assigned to treatment condition and those who self-selected levels of care reported a similar lack of overall differences in study outcomes when levels of care were compared (11,12). Indeed, a study based in the VA reported that two-thirds of the participants refused randomization, but outcomes were similar for study participants whether or not they were randomly assigned (11).
Although analyses of natural cohorts generally assume that patients treated in residential settings have more severe substance use problems than those treated in outpatient treatment settings, differential effectiveness based on problem severity was elusive in the articles we reviewed. Only two of six naturalistic analyses reported main effects for treatment setting. One was an analysis of Washington State treatment programs (17). Results showed that patients treated in an inpatient setting who stepped down to treatment in an IOP improved more than those treated only in IOP settings, because problem severity was greater at baseline among those admitted to inpatient care. Another analysis of a cohort of patients treated in a psychiatric hospital reported that patients who were alcohol dependent and treated in an IOP returned to “significant” drinking more quickly than those treated in inpatient care (15). The other four analyses did not find main effects for treatment setting (13,14,16,18).
There is some evidence that disorder severity may influence the effectiveness of IOPs compared with inpatient or residential treatment. In Minnesota treatment programs, patients with recent suicidal ideation had better outcomes after residential care than patients who participated in an IOP (14). A secondary analysis of data from clients in treatment for cocaine dependence noted that patients with more severe drug problems were more likely to benefit from long-term residential care than from less intensive levels of care (16). Finally, an analysis of patients in a VA program also suggested that those with more severe alcohol or drug problems had better response when treated in residential settings than in IOPs (18). Although there is still some debate about the equivalence of inpatient treatment and treatment in an IOP for patients with the most severe levels of dependence, there appears to be general consensus that for most patients the levels of care are equivalent.
It is noteworthy that the current assessment of IOP services echoes findings from similar reviews conducted since the 1960s (20–30). Despite changing research methods and study populations, results are consistent—patient outcomes from inpatient, residential, and intensive outpatient services are positive and more similar than different. This consistency over time enhances confidence in the stability of the findings and the value of IOP services.
Discussion
Overall, the current literature suggests that a wide range of service intensities can be effective for individuals with substance use disorders. There is a high level of evidence—with the caveats we have noted—that IOPs are as effective as inpatient and residential treatments when studies compare these approaches directly (see box on this page). IOPs have emerged as a critical facet of 21st century addiction treatment for people who need a more intensive level of service than usual outpatient treatment. IOPs allow participants to avoid or step down successfully from inpatient services. This is an important consideration for policy makers, providers, and individuals engaged in substance abuse treatment services when deciding which level of care is most appropriate for specific clinical situations.
Evidence for the effectiveness of substance abuse intensive outpatient programs (IOPs): high
Despite some variations in programming and design, substance abuse IOPs compared with control conditions demonstrate consistent evidence for the following outcomes:
• Reduced drug or alcohol use from baseline to follow-up
• Few differences between IOPs and inpatient programs
Taken together, RCTs and quasi-experimental studies consistently reported equivalent reductions in measures of problem severity and increases in days abstinent at follow-up for participants who received IOP services or day treatment services compared with those in inpatient or residential care. We found no studies comparing IOP participants with wait-list or no-treatment control groups. Reviews of the literature point out many design and treatment differences that may affect conclusions about the effectiveness of inpatient versus outpatient services. A chapter in an ASAM-sponsored text (31) reiterated the debate on inpatient versus outpatient settings and concluded that engagement in longer, less-intensive services may have greater benefit than brief, intensive interventions without ongoing support, especially among individuals with a more severe history of addiction. The important feature appears to be continuity of care over a long duration, and this perspective is consistent with emerging models of recovery-oriented systems of care. However, the interaction between severity of alcohol and drug problems and setting of care has been elusive, and the effect (when present) appears to be small. Overall, studies have found that 50%−70% of participants reported abstinence at follow-up, and most studies found that this outcome did not differ for inpatient versus outpatient settings of care. This makes cost, treatment duration, and living in the community the major points of comparison between inpatient and IOP services for individuals with substance use disorders.
It is difficult to say which aspects of IOPs are most likely to be effective with specific populations. Naturalistic studies using large samples found subtle improvements among people with the most serious substance use problems, suggesting that this level of inpatient or residential care may be helpful or necessary for a subset of people. However, a primary ongoing research need is to identify individuals with severe alcohol and drug use for whom inpatient or residential care is of greatest value. One complication is the variation in how residential care and IOP services are defined. This is an important distinction that needs clarification as provider systems move into an increasingly risk-based financing environment. Payers and providers should collaborate to define IOP services more consistently, so that effects are replicable across settings and patient populations. Likewise, there is a need for more research on the most effective length of IOP treatment. IOP models should clearly identify the type, duration, and intensity of IOP services. Researchers also need to determine the optimal type and level of stabilization services following discharge from an IOP that will sustain the gains made during the IOP treatment episode.
Although African Americans were the dominant racial-ethnic minority group in many of the investigations comparing residential and inpatient services with intensive outpatient services, race-ethnicity varied substantially across the studies. The finding that IOP services and residential or inpatient care lead to equivalent outcomes appears to generalize across racial and ethnic groups; however, we cannot make specific recommendations for IOP services related to race-ethnicity on the basis of the current literature. Future studies may systematically vary components of IOPs to determine the more critical features for efficient and effective care.
Surprisingly, none of the studies examined in this review included the use of pharmacotherapy, which improves treatment outcomes when used in conjunction with therapeutic interventions. We believe that 21st century systems of addiction treatment should provide ongoing pharmacological and behavioral therapies within a continuing care model that increasingly relies on IOP settings rather than on residential and inpatient care. Recent RCTs also document the value of enhancing IOP services with contingency management during treatment in an IOP (32) and during aftercare (33).
Without increased standardization, patients, payers, and policy makers will continue to have difficulty comparing IOP services with other levels of substance abuse treatment services. Requirements to adhere to the National Quality Forum consensus standards, for example, could help ensure that IOPs provide consistent and effective pharmacological and behavioral addiction treatments (34). Accordingly, this calls for improved assessment of the specific needs of each person requiring intensive services in order to determine the appropriate level of care. Policy makers, payers, and consumers should consider demanding these assessments, and providers across all levels of care should receive the necessary training to complete them properly.
Conclusions
This review found that studies of inpatient treatment and IOP services have yielded results that are consistent and similar: outcome measures of alcohol and drug use at follow-up show reductions in substance use and increases in abstinence, and outcomes do not differ significantly between inpatient and IOP settings. Although a few studies suggest that patients with greater impairment may have better outcomes if treated in inpatient settings than in IOPs, such differential effectiveness appears elusive and may apply only to the most severely impaired individuals. Compared with inpatient care, IOP services have at least two advantages: increased duration of treatment, which varies with the severity of the patient’s illness and his or her response, and the opportunity to engage and treat consumers while they remain in their home environments, which affords consumers the opportunity to practice newly learned behaviors. IOPs are an important service for inclusion as a covered benefit for people with substance use disorders. The diversity of settings and range of outcomes assessed, combined with the consistency of improvement over time, suggest that the effectiveness reflects the intensity and duration of treatment rather than a specific setting or patient population.
Acknowledgments and disclosures
Development of the Assessing the Evidence Base Series was supported by contracts HHSS283200700029I/HHSS28342002T, HHSS283200700006I/HHSS28342003T, and HHSS2832007000171/HHSS28300001T from 2010 through 2013 from the Substance Abuse and Mental Health Services Administration (SAMHSA). The authors acknowledge the contributions of Mary McCann, M.S.W., Andrea Kopstein, Ph.D., M.P.H., Kevin Malone, B.A., and Suzanne Fields, M.S.W., from SAMHSA; John O’Brien, M.A., from the Centers for Medicare & Medicaid Services; Garrett Moran, Ph.D., from Westat; and John Easterday, Ph.D, Linda Lee, Ph.D., Rosanna Coffey, Ph.D., and Tami Mark, Ph.D., from Truven Health Analytics. The views expressed in this article are those of the authors and do not necessarily represent the views of SAMHSA.
Dr. McCarty is the principal investigator on research service agreements with Alkermes and Purdue Pharma. The other authors report no competing interests.
References
1.
Substance Abuse: Clinical Issues in Intensive Outpatient Treatment. Treatment Improvement Protocol (TIP) Series, no 47. Rockville, Md, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 2006
2.
ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders (ASAM PPC-2R). Chevy Chase, Md, American Society of Addiction Medicine, 2001
3.
National Survey of Substance Abuse Treatment Services (N-SSATS): 2011. Data on Substance Abuse Treatment Facilities. BHSIS Series S-64, HHS pub no SMA-12-4730. Rockville, Md, Substance Abuse and Mental Health Services Administration, 2012
4.
Reif S, George P, Braude L, et al: Residential treatment for individuals with substance use disorders: assessing the evidence. Psychiatric Services, 2014; doi 10.1176/appi.ps.201300242
5.
Dougherty RH, Lyman DR, George P, et al: Assessing the evidence base for behavioral health services: introduction to the series. Psychiatric Services, 2013; doi 10.1176/appi.ps.201300214
6.
Schneider R, Mittelmeier C, Gadish D: Day versus inpatient treatment for cocaine dependence: an experimental comparison. Journal of Mental Health Administration 23:234–245, 1996
7.
Guydish J, Werdegar D, Sorensen JL, et al.: Drug abuse day treatment: a randomized clinical trial comparing day and residential treatment programs. Journal of Consulting and Clinical Psychology 66:280–289, 1998
8.
Guydish J, Sorensen JL, Chan M, et al.: A randomized trial comparing day and residential drug abuse treatment: 18-month outcomes. Journal of Consulting and Clinical Psychology 67:428–434, 1999
9.
Rychtarik RG, Connors GJ, Whitney RB, et al.: Treatment settings for persons with alcoholism: evidence for matching clients to inpatient versus outpatient care. Journal of Consulting and Clinical Psychology 68:277–289, 2000
10.
Weithmann G, Hoffmann M: A randomised clinical trial of in-patient versus combined day hospital treatment of alcoholism: primary and secondary outcome measures. European Addiction Research 11:197–203, 2005
11.
McKay JR, Alterman AI, McLellan AT, et al.: Effect of random versus nonrandom assignment in a comparison of inpatient and day hospital rehabilitation for male alcoholics. Journal of Consulting and Clinical Psychology 63:70–78, 1995
12.
Witbrodt J, Bond J, Kaskutas LA, et al.: Day hospital and residential addiction treatment: randomized and nonrandomized managed care clients. Journal of Consulting and Clinical Psychology 75:947–959, 2007
13.
McLellan AT, Hagan TA, Meyers K, et al.: “Intensive” outpatient substance abuse treatment: comparisons with “traditional” outpatient treatment. Journal of Addictive Diseases 16:57–84, 1997
14.
Harrison PA, Asche SE: Comparison of substance abuse treatment outcomes for inpatients and outpatients. Journal of Substance Abuse Treatment 17:207–220, 1999
15.
Pettinati HM, Meyers K, Evans BD, et al.: Inpatient alcohol treatment in a private healthcare setting: which patients benefit and at what cost? American Journal on Addictions 8:220–233, 1999
16.
Simpson DD, Joe GW, Fletcher BW, et al.: A national evaluation of treatment outcomes for cocaine dependence. Archives of General Psychiatry 56:507–514, 1999
17.
McKay JR, Donovan DM, McLellan T, et al.: Evaluation of full vs partial continuum of care in the treatment of publicly funded substance abusers in Washington State. American Journal of Drug and Alcohol Abuse 28:307–338, 2002
18.
Tiet QQ, Ilgen MA, Byrnes HF, et al.: Treatment setting and baseline substance use severity interact to predict patients’ outcomes. Addiction 102:432–440, 2007
19.
Finney JW, Hahn AC, Moos RH: The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on mediators and moderators of setting effects. Addiction 91:1773–1796, 1996
20.
Cole SG, Lehman WE, Cole EA, et al.: Inpatient vs outpatient treatment of alcohol and drug abusers. American Journal of Drug and Alcohol Abuse 8:329–345, 1981
21.
Armor DJ, Polich JM, Stambul HB: Alcoholism and Treatment. New York, Wiley, 1978
22.
Diesenhaus H: Current trends in treatment programming for problem drinkers and alcoholics; in Prevention, Intervention and Treatment: Concerns and Models. Alcohol and Health Monograph no 3. DHHS pub no ADM-82-1192. Rockville, Md, National Institute on Alcohol Abuse and Alcoholism, 1982
23.
Edwards G, Guthrie S: A controlled trial of inpatient and outpatient treatment of alcohol dependency. Lancet 1:555–559, 1967
24.
Institute of Medicine: Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC, National Academy Press, 1989
25.
Emrick CD: A review of psychologically oriented treatment of alcoholism. II. the relative effectiveness of different treatment approaches and the effectiveness of treatment versus no treatment. Journal of Studies on Alcohol 36:88–108, 1975
26.
Polich JM, Armor DJ, Braiker HB: The Course of Alcoholism: Four Years After Treatment. New York, Wiley, 1981
27.
Institute of Medicine: Broadening the Base of Treatment for Alcohol Problems. Washington, DC, National Academy Press, 1990
28.
Saxe L, Dougherty D, Esty K, et al.: The Effectiveness and Costs of Alcoholism Treatment. Washington, DC, Office of Technology Assessment, 1983
29.
Sells SB, Simpson DD: The case for drug abuse treatment effectiveness, based on the DARP research program. British Journal of Addiction 75:117–131, 1980
30.
Sells SB, Simpson DD: Studies of the Effectiveness of Treatments for Drug Abuse, vol 5: Evaluation of Treatment Outcomes for 1972–1973. DARP Admission Cohort. Cambridge, Mass, Ballinger, 1976
31.
Finney JW, Moos RH, Wilbourne PL: Effects of treatment setting, duration, and amount on patient outcomes; in Principles of Addiction Medicine, 4th ed. Edited by Ries RK, Fiellin DA, Miller SC, et al. Philadelphia, Wolters Kluwer/Lippincott Williams & Wilkins, 2009
32.
Petry NM, Alessi SM, Hanson T: Contingency management improves abstinence and quality of life in cocaine abusers. Journal of Consulting and Clinical Psychology 75:307–315, 2007
33.
McKay JR, Lynch KG, Coviello D, et al.: Randomized trial of continuing care enhancements for cocaine-dependent patients following initial engagement. Journal of Consulting and Clinical Psychology 78:111–120, 2010
34.
National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices. Washington, DC, National Quality Forum, 2007
Information & Authors
Information
Published In
Cover: Griselda, by Maxfield Parrish. © Copyright 2014 National Museum of American Illustration™, Newport, Rhode Island. Photos courtesy of Archives of the American Illustrators Gallery™, New York City.
History
Published in print: June 2014
Published online: 15 October 2014
Authors
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBLogin options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).