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Continuing care for addiction

Continuing care for addiction
Author:
James R McKay, PhD
Section Editor:
Andrew J Saxon, MD
Deputy Editor:
Michael Friedman, MD
Literature review current through: May 2024.
This topic last updated: Apr 16, 2024.

INTRODUCTION — For many individuals, addiction is a chronic, relapsing condition. The traditional treatment model for addiction has emphasized episodic intensive treatment (such as medically supervised withdrawal or stabilization), followed by time-limited outpatient care. Over the past decade, public and private health care systems and clinicians are coming to recognize that addiction, like chronic physical conditions such as diabetes or hypertension, typically requires continuing, long-term care.

Continuing care for addiction provides continued treatment after initial stabilization (ie, initial goals of abstinence or reduction of use have been reached) and is customized to the needs of the patient [1]. As the addiction waxes and wanes, we adjust the treatment to be more or less intensive. The patient’s clinical status and risk of relapse are monitored throughout the treatment. Patients also receive training in self-management skills and linkage to other sources of professional and community support.

Continuing care for chronic or relapsing addiction is discussed here. The treatment of specific substance use disorders (SUDs) and determining the appropriate level of care for patients with SUDs are reviewed separately.

(See "Alcohol use disorder: Treatment overview".)

(See "Opioid use disorder: Treatment overview".)

(See "Cannabis use disorder: Clinical features, screening, diagnosis, and treatment".)

(See "Stimulant use disorder: Treatment overview".)

(See "Benzodiazepine use disorder".)

ADDICTION: A CHRONIC, RELAPSING DISORDER — The conceptualization of addiction as a chronic disease is supported by comparison of its manifestations, course, and response to treatment with other chronic medical illnesses (eg, type 2 diabetes mellitus, asthma, and hypertension) [2-8].

Early onset addiction can severely disrupt the development of effective life skills and cause chronic deficits in psychosocial functioning. Even patients who achieve abstinence may have difficulty developing the kinds of meaningful and satisfying lives that can provide a buffer against relapse.

Addiction causes predictable and persistent structural and functional changes in the brain. Volume loss of brain tissue has been found in individuals with SUDs, including alcohol use disorder [9,10], cocaine use disorder [11], opioid use disorder [12], and polysubstance use disorder [13]. Numerous neurotransmitter systems involved in reward and stress pathways in the brain are affected by chronic use of alcohol and other drugs, including dopamine and endorphins [14,15].

CONTINUING CARE FOR ADDICTION: FEATURES AND COMPONENTS — The continuing care model for addiction provides continued treatment after initial stabilization (ie, initial goals of abstinence or reduction of use have been reached) and is customized to the needs of the patient. Self-management skills and linkages to other sources of support are provided. (See 'Choosing intensity of care' below.)

Customization and flexibility — The continuing care model emphasizes that care of substance use disorders (SUD) needs to be adjusted up or down in intensity and frequency over time as patients go through alternating periods of abstinence and use at varying levels of SUD severity [16,17]. Brief, infrequent clinical contact may be sufficient during extended periods when a patient is doing well. However, when the patient’s risk of relapse rises or an episode of substance use begins, treatment needs to be escalated to a higher level of care (eg, more frequent sessions, additional modalities, and/or more intensive setting) that is adequate to interrupt and address the processes putting the patient at risk [18].

Self-management skills — Effective management of chronic addiction requires that patients are able learn and to practice good “self-care” [8]. For example, we encourage patients to engage in healthy behaviors, such as a nutritious diet and exercise, monitor their symptoms, learn effective coping skills, and enhance or develop sources of support. We review the patient’s barriers to treatment and, using cognitive strategies, develop skills to overcome them [19-23].

Linkages to other sources of support — We provide individuals in continuing care for addiction with linkage to community-based and professional sources of support [24]. In our experience, involvement by patients in prorecovery activities such as employment, education, volunteer work, pursuit of hobbies and seeking profession support such as parenting classes, medical and mental health care, mutual help groups, and childcare are crucial for sustained recovery. We encourage participants in continuing care to maintain contact with supports for extended periods of time. These supports provide encouragement and opportunities for continued treatment, even if the individual has lost motivation for recovery. Outreach techniques include telephone calls, home visits, and care managers.

Components — The principal components of continuing care for SUD are discussed below. In most individuals we suggest all of the components; however, this approach is modified based on the patient’s treatment response to initial stabilization, patient preference, and ongoing response to treatment. For example, in an individual who has reached their initial treatment goals without pharmacotherapy, we would treat with continuing care including mutual help groups, addiction counseling and psychotherapy. In an individual who has reached their treatment goal without psychotherapy we would continue to treat them with mutual help groups, addiction counseling, and, if indicated, pharmacologic management. Additional interventions are also suggested depending on patient preference and response. (See 'Additional interventions that may further improve efficacy' below.)

Addiction counseling — The vast majority of continuing care provided in community-based clinics and rehabilitation programs consists of group counseling based on a 12-step approach. This is discussed in greater detail separately. (See "Substance use disorders: Psychosocial management", section on 'Addiction counseling'.)

Mutual help groups — We stress participation in mutual help groups for all patients who are participating in continuing care. We encourage individuals to participate in mutual help groups at least three times per week, especially in the first several years of recovery. Mutual help groups are described in more detail separately. Patients should be instructed that 12-step groups vary greatly and that meetings and even programs with less of an emphasis on spiritual or religious teachings can be found for those patients who are uncomfortable with this focus. For patients who, despite gentle encouragement, remain uninterested in participating in mutual help groups, we make an intensive referral intervention to mutual help groups. (see 'Intensive referral to mutual help groups' below). However, we do not make participation in mutual help groups a requirement for receiving continuing care. Limited evidence from randomized trials supports the efficacy of mutual help groups. This is discussed elsewhere. (See "Alcohol use disorder: Psychosocial management", section on 'Mutual help groups' and "Substance use disorders: Psychosocial management", section on 'Facilitating mutual help group engagement'.)

Pharmacotherapy — We continue pharmacologic management in continuing care in individuals who have reached their initial treatment goals with pharmacotherapy. Patients who were not treated with pharmacotherapy initially but are now interested in it can also be offered this intervention if it seems appropriate. Pharmacotherapy for SUDs are described separately.

(See "Stimulant use disorder: Treatment overview" and "Opioid use disorder: Treatment overview", section on 'Patients with physical dependence (moderate to severe disorder)'.)

(See "Alcohol use disorder: Treatment overview", section on 'Moderate or severe disorder'.)

(See "Stimulant use disorder: Treatment overview" and "Opioid use disorder: Treatment overview", section on 'Patients with physical dependence (moderate to severe disorder)'.)

(See "Cannabis use disorder: Clinical features, screening, diagnosis, and treatment", section on 'Potentially beneficial pharmacologic/neuromodulation treatments'.)

Psychotherapy — We continue psychotherapy, in addition to mutual help groups and addiction counseling, for all individuals in continuing care who have responded to psychotherapy during initial treatment and stabilization of the disorder. This intervention is also appropriate for patients who did not get it initially and did not establish stable recovery in earlier phases of care. We prefer cognitive-behavioral therapy; however, other forms of psychotherapy such as psychodynamic psychotherapy or supportive counseling are alternative options. (See "Substance use disorders: Psychosocial management" and "Opioid use disorder: Psychosocial management" and "Alcohol use disorder: Psychosocial management" and "Cannabis use disorder: Clinical features, screening, diagnosis, and treatment".)

ADMINISTERING CONTINUING CARE — As there is an absence of research evidence regarding the optimal frequency, intensity, and duration of continuing care, our preference is based on clinical experience [25]. Our experience tells us treatment is more productive if the patient is agreeable to the treatment intensity and approach. (See "Substance use disorders: Clinical assessment", section on 'DSM-5-TR diagnostic criteria'.)

Choosing intensity of care — We use several factors in determining the initial intensity of the continuing care program. These include, the severity of the substance use disorder (SUD; ie, the number of American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision [DSM-5-TR] criteria present at the initial meeting) [26], the presence of other clinical features suggesting potential for recurrence of use or need for higher level of care, and current substance use status. (See "Substance use disorders: Clinical assessment", section on 'DSM-5-TR diagnostic criteria' and 'Features suggesting higher level of care needed' below.)

As the treatment progresses the ongoing response to treatment and patient’s motivation to engage in treatment are also considerations for adjustment in intensity. We prefer a stepped care approach, or “adaptive treatment” approach which formalizes the principles of flexible customization of care based on patient clinical status and risk of relapse. The intensity of the care is adjusted throughout the course of continuing care. Components include [16]:

Monitoring the patient with standardized and validated assessment tools.

Algorithms are used that specify the scores on these measures indicating a need for more intensive treatment.

Guidance is provided on what changes to the frequency or levels of care the clinician should consider making, or what treatment modalities they should consider adding or switching to.

Features of higher-intensive treatments include meeting with greater frequency, spending more time in components and the addition of one or more interventions below. Examples of programs for moderate and severe SUD are provided below. Programs vary based on location, availability of treatments, and patient populations.

Moderate or severe SUD – We consider individuals with four or five diagnostic criteria for SUD to have a moderate SUD (see "Substance use disorders: Clinical assessment", section on 'DSM-5-TR diagnostic criteria'). We consider individuals with six or more diagnostic criteria or with physical dependence on the substance to have severe SUD. The intensity of the program is typically based on the severity of the SUD; however, other factors are considered.

An example of a high-intensity program includes intensive outpatient at least three times per week for up to two months. This is followed by outpatient treatment with the appropriate components or interventions (see 'Components' above and 'Additional interventions that may further improve efficacy' below), two to three times per week for up to six months. If the patient continues to reach treatment goal, we decreased the frequency of visits to monthly for up to six months, after which we encourage less frequent check-ins.

A moderate-intensity program would include less frequent or shorter duration of intensive outpatient followed by outpatient visits for up to six months with progressively less frequent visits and check-ins thereafter.

Mild SUD – Individuals with up to three criteria for SUD are considered to have a mild SUD [26]. Individuals with a mild SUD do not necessarily need treatment in continuing care. Our preference is to monitor these individuals monthly or more frequently for at least one year. We encourage continuing care treatment if the symptoms worsen (eg, craving) or there is a return to use.

Features suggesting higher level of care needed — Clinical features suggesting the need for more intensive continuing care treatment include one or more of the following:

Sustained sleep difficulty

Poor social support

Low motivation for recovery

High levels of personal stress or high reactivity to stress

History of multiple prior treatments followed by relapse

Ongoing self-reported substance craving

Continued use of substances early in treatment [27-29]

Spending time in places or with people who might increase the risk for relapse (eg, bars, neighborhood where substances were used, contacts who are currently using substances)

MONITORING — We regularly assess the patient’s clinical status during treatment. Routine use of a quantitative assessment can facilitate continuing care of addiction by:

Providing the patient and clinician with a shared language and indicators of progress or deterioration that requires more intensive intervention.

Facilitating communication about the patient’s course and current status among clinicians involved with their treatment and across levels of care.

Enabling clinicians (or care managers) to monitor caseloads of patients receiving low-burden, infrequent treatment during periods of clinical stability, and to identify patients at an early stage of deterioration. In our clinical experience, patients are often resistant to more intensive interventions once they are well into a state of relapse. Catching deterioration before it becomes too severe may allow for discussion about a less intensive intervention with a more receptive patient.

Measures of clinical status may include recent use (eg, by toxicology), extent of use (eg, percentage of days and average amount per day use over past month), severity of associated symptoms (eg, percentage of days with urges or craving to use), measures of behaviors encouraged in treatment plan (eg, percentage of days adherent to medication, percentage of days attending mutual help group).

Specific instruments for quantitative assessment of the severity of individual substance use disorders are reviewed separately. (See "Screening for unhealthy use of alcohol and other drugs in primary care".)

EFFICACY — Reviews and meta-analyses of trials have shown a benefit of continuing care on substance use disorder (SUD) outcomes in most studies [1,25,30]. As examples:

A meta-analysis of 19 randomized trials comparing treatment for SUD found a small benefit on SUD outcomes, at end of intervention and subsequent follow-up, for those treated with continuing care as compared with minimal or no SUD treatment (g = 0.19 at end of treatment; g = 0.27 at subsequent follow-up) [25]. The interventions, which may not have been explicitly labeled continuing care, were based on continuing care principles and were provided after more intensive, initial episodes of care. Among the activities studied were clinic-based counseling sessions, telephone calls, home visits, care managers couples counseling, and assertive linkage to services. Trials that led to improved substance use outcomes were more likely to have longer planned duration of care and included active efforts to provide treatment.

In a meta-analysis including 12 studies of treatments for SUD, longer-term treatment and support interventions (eg, at least 18 months in duration) produced better substance use outcomes as compared with patients who received shorter, standard care [30]. Individuals who received long-term treatment had a 23.9 percent greater chance of abstaining or consuming moderately, compared with patients who received shorter, standard care (odds ratio 1.35, 95% CI 1.09-1.67).

DURATION OF TREATMENT

Good response — For patients who are achieving their goal we taper the treatment according to the schedule above (see 'Choosing intensity of care' above). We encourage ongoing participation in mutual help groups for all individuals whether they are successful in reaching their goals. (See 'Mutual help groups' above.)

For a patient who has maintained abstinence for a very prolonged period (eg, two years), and has few risk factors for relapse, the frequency of brief check-ins would be reduced further (eg, to twice yearly visits with a primary care clinician); these should continue indefinitely. If early warning signs of relapse emerge or if the patient has a relapse, we encourage a return to more intensive treatment.

Inadequate response — For individuals who have not successfully reached their treatment goal (eg, increase in symptoms, return to use), we suggest more intensive treatment. We do this by increasing the frequency or time spent in the components, by adding additional interventions, or both. (See 'Additional interventions that may further improve efficacy' below.)

ADDITIONAL INTERVENTIONS THAT MAY FURTHER IMPROVE EFFICACY — We use the following interventions to improve the efficacy of treatment. These additional interventions may be added at any time during the treatment. While there are no data indicating what sequence or combinations are most effective, each of the following interventions have been found to be more effective than minimal or no continuing care [31-57]. There are no data at this point to indicate what sequence or combinations are most effective for nonresponders. Our choice is based on clinical experience, patient preference, and availability.

Contingency management — Contingency management interventions for substance use disorders (SUDs), which offer incentives to encourage abstinence or discourage substance use are reviewed separately [31]. (See "Substance use disorders: Training, implementation, and efficacy of treatment with contingency management" and "Substance use disorders: Principles, components, and monitoring during treatment with contingency management" and "Stimulant use disorder: Psychosocial management", section on 'Contingency management'.)

Social reinforcement — We use social reinforcements to increase attendance in continuing care programs [32]. These include treatment contracts, personal letters from counselors with congratulations for attending sessions, certificates for completion of treatment milestones, and medallions for attending a specific number of sessions. Certificates and medallions are typically presented in front of other patients in therapy groups.

Intensive referral to mutual help groups — We encourage attendance in mutual help groups throughout the continuing care. While a brief suggestion to do so is given in treatment sessions, a more formal three-session intervention, delivered by an SUD counselor is used to encourage those who are reluctant to attend them [33]. Components of the intervention include providing detailed lists of local self-help meetings that have been preferred by other patients, directions to the meetings, educational material about the program. Additionally, the counselor arranges a meeting between the patient and a participating member of the group. Another option to consider is Twelve-Step Facilitation, a 12-session intervention that promotes attendance at and participation in Alcoholics Anonymous and other 12-step programs and helps patients complete the first few steps of the 12-step program. Twelve-Step Facilitation is the most studied of the interventions designed to increase participation in mutual help groups and has been shown to produce greater increases in participation in these groups and in abstinence rates, relative to comparison interventions [58,59]. (See "Substance use disorders: Psychosocial management", section on 'Facilitating mutual help group engagement'.)

Network support — For individuals with ongoing difficulty maintaining abstinence, a treatment intervention, referred to as “network support,” was designed to help patients change their larger social networks to become more supportive of abstinence [34-36]. The intervention provides help with identifying and engaging in mutual help programs and other positive sources of social support in the community. Barriers to involvement with these groups are identified and addressed. Network support seeks to connect patients with a wide range of prorecovery activities. The program is given over 12 weekly sessions by a therapist trained in the intervention.

Intensive continuing care — This is an intensive continuing care program originally developed for treatment of pilots and physicians and is now more widely available. The main components are typically the same (monitoring with random urine tests, counseling, re-entry into treatment for return to use or skipped random urine test, family involvement, web platforms for monitoring progress); however, the course is longer term (eg, up to five years).

An observational study of the program, “My First Year in Recovery,” included 198 participants with a mix of SUDs. Participants completed 70 percent of random urine tests. During the 12-month follow-up period, 54 percent relapsed. Of those, 70 percent remained engaged in the intervention after relapsing and were able to complete the intervention [37]. This and other similar programs may be useful for patients who have the resources to pay for them and are willing to provide urine samples randomly over long periods of time.

Extended telephone-based continuing care — This intervention (also called “Telephone Monitoring and Counselling”) is an evidence-based treatment that provides cost effective long term monitoring that is lower in burden. It is often used for patients that want or need prolonged/extended treatment but cannot keep coming to the clinic weekly. The treatment provides frequent phone contacts and linkage to other treatments [38]:

An initial face-to-face visit followed by telephone calls or telemedicine sessions for a duration of 20 minutes.

Brief structured assessment of current risk and protective factors to monitor patient clinical status and determine the focus of the remainder of the session.

Problem-focused counseling using cognitive-behavioral therapy (CBT) techniques, such as identification of high-risk situations and rehearsal of improved coping behaviors.

Weekly contacts for the first eight weeks, then biweekly for 12 months, and then monthly.

Patients whose risk of relapse increased received stepped-up care, which included more frequent telephone contacts, in-person relapse prevention (a form of CBT), or linkage to other treatment.

Trials of extended telephone-based continuing care for patients with SUDs have found some positive results as compared with treatment as usual; however, the effects have not persisted at follow-up [29,38-41,60].

Recovery management checkups — Recovery management checkups is a continuing care intervention that provides “checkups” at three-month intervals for patients who have completed an initial phase of care. Rather than attending weekly treatment sessions in an effort to prevent relapse, this approach brings the individual back into clinic every three months and attempts to get them more intensive care if they have return to use or increase in symptoms. Active in-person techniques to get the patient into treatment are used, such as motivational interviewing or discussion of barriers to entering treatment and potential solutions.

Randomized trials comparing the recovery management checkup intervention with treatment as usual have found mixed results on substance use outcomes [45-48]. In one four-year trial, 448 adults with chronic substance use were randomly assigned to receive recovery management checkups or standard outpatient treatment (control) [46]. Subjects assigned to recovery management checkup were more likely than those assigned to the control group to return for treatment, receive more total days of treatment, have fewer substance-related problems per month, and have more days of abstinence.

Technologic innovations — Online resources are playing a growing role in continuing care. There is evidence that digital programs running on smartphones and texting interventions can improve outcomes in continuing care for alcohol use disorder [49-53,57]. Improved outcomes such as reduction in substance use, as compared with standard care, have been reported in other studies of automated programs [55,56]. The diminished burden and added convenience of these new technologies has the potential to increase rates of sustained participation in extended treatment.

The A-CHESS smartphone app provides a menu of recovery-oriented tools, including rapid connections with support people, suggestions for coping with high-risk situations and other stressors, relaxation aids, GPS-based alerts when near a location where prior use occurred, daily and weekly assessments, and a chat room where others using the app can be contacted.

A-CHESS appears to be effective in the treatment of alcohol use disorder [39,50,54]. For example, in a randomized trial 349 subjects with alcohol use disorder who were graduates of residential treatment programs were randomly assigned to treatment as usual versus treatment as usual plus a smartphone application A-CHESS [50]. Patients receiving A-CHESS reported 49 percent fewer days of risky drinking in the prior 30 days at 4-, 8-, and 12-month assessments compared with those in treatment as usual (mean of 1.39 versus 2.75 days respectively). Rates of alcohol abstinence within the prior 30 days were higher with A-CHESS compared with treatment as usual at eight-month (78 versus 67 percent) and 12-month (79 versus 66 percent) assessments. Additionally, a secondary analysis showed that A-CHESS was associated with an increased participation in outpatient continuing care during the follow-up period [54].

Mindfulness-based relapse prevention — This is a mindfulness-based therapy that combines training in mindfulness medication, self-care, and compassion. This is typically provided weekly for eight weeks after completion of initial treatment [61]. (See "Unipolar major depression: Treatment with mindfulness-based cognitive therapy", section on 'Delivering mindfulness-based cognitive therapy'.)

PRIMARY CARE SETTINGS — Some patients are reluctant to receive treatment at substance use disorder (SUD) specialty setting, which they associate with stigma or do not like aspects of traditional programs, such as the emphasis on total abstinence, pressure to embrace the 12-step philosophy, and/or reliance on group therapy.

Some primary care practices may provide an alternative to addiction treatment centers as a setting in which to receive continuing care for addiction. Primary care clinicians can receive specialized training in continuing care (eg, workshops through the American Society of Addiction Medicine or other similar organization). However, finding clinicians who are trained in continuing care or other similar models of addiction may be difficult in many geographical areas.

Primary care clinicians without specialized training in continuing care can participate in such care for selected patients, such as milder patients who are doing well, or check-ins with patients with more severe SUDs who have successfully completed more intensive continuing care.

A number of research studies supported the efficacy of primary care for the provision of continuing care for SUD [62-68]. However, not all have shown positive effects. As an example, in a randomized trial including 563 individuals with alcohol or other drug use disorder, chronic care management for their SUDs in primary care versus standard primary care only led to similar rates of abstinence from opioids, stimulants, or heavy drinking [69].

Principles of continuing care for addictions have been incorporated into extensive programs for specialized populations, including homeless persons with SUDs [70-72] and clinician health programs, which coordinate oversight and treatment of substance-impaired clinicians. (See "Substance use disorders in physicians: Assessment and treatment", section on 'Physician health programs' and "Health care of people experiencing homelessness in the United States", section on 'Housing interventions'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Alcohol use disorders and withdrawal" and "Society guideline links: Benzodiazepine use disorder and withdrawal" and "Society guideline links: Opioid use disorder and withdrawal" and "Society guideline links: Stimulant use disorder and withdrawal" and "Society guideline links: Cannabis use disorder and withdrawal".)

SUMMARY AND RECOMMENDATIONS

Addiction is a chronic relapsing disorder – The conceptualization of addiction as a chronic disease is supported by comparison of its manifestations, course, and response to treatment with other chronic medical illnesses (eg, type 2 diabetes mellitus, asthma, and hypertension. (See 'Introduction' above and 'Addiction: A chronic, relapsing disorder' above.)

Continuing care for addiction – The continuing care model for addiction provides continued treatment after initial stabilization (ie, initial goals of abstinence or reduction of use have been reached) and is customized to the needs of the patient. As the addiction waxes and wanes we adjust the treatment to be more or less intensive. Patients also receive training in self-management skills and linkage to other sources of professional and community support. (See 'Continuing care for addiction: Features and components' above.)

Components of continuing care – The principal components of continuing care for substance use disorder (SUD) are addiction counseling, mutual help groups, psychotherapy, and pharmacotherapy. All of the components are typically given; however, this may be modified based on the history, response and patient preference. (See 'Components' above.)

For all patients with SUD, we continue the treatment that brought about their initial stabilization whether it be pharmacotherapy, psychotherapy, or a combination.

For most patients with SUD, we suggest participation in mutual help groups as a component of ongoing care for addiction (Grade 2C). We encourage patients to participate at least three times per week especially in the first years of recovery. However, some patients are opposed to such treatment because of stigma or religious beliefs. We do not make participation a requirement for continuing care and manage such patients with other treatments.

Ongoing administration of continuing care – The intensity of the continuing care program (ie, the frequency of monitoring and interventions) are determined by the severity of the SUD, as determined by the number of American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria present, the response to continuing care as the treatment progresses, and the patient’s motivation to engage in treatment. (See 'Choosing intensity of care' above.)

We typically increased the intensity of the continuing care (eg, increased components, increase time spent in session) for individuals with any features suggesting the need for higher level of care. Features of higher-intensive treatments include meeting with greater frequency, spending more time in components and the addition of one or more interventions. (See 'Features suggesting higher level of care needed' above.)

We regularly assess patients’ clinical status during the course of continuing care. We use a standardized quantitative instrument that reliably detects improvement or deterioration over time. (See 'Monitoring' above.)

Additional interventions – We typically add one or more interventions for individuals who have not achieved treatment goals (eg, ongoing craving symptoms, return to use) or in patients that express an interest in them. (See 'Additional interventions that may further improve efficacy' above.)

Primary care settings – Providing continuing care for addiction in the primary care setting may provide an attractive alternative to addiction treatment centers due to the potential stigma associated with traditional programs or some aspect of the program that they may not desire (total abstinence, pressure to embrace the 12-step philosophy, and reliance on group therapy). (See 'Primary care settings' above.)

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Topic 16754 Version 30.0

References

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