11/07/2021 Continuing care for addiction: Implementation - UpToDate

Official reprint from UpToDate®

www.uptodate.com © 2021 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Continuing care for addiction: Implementation

Author: James R McKay, PhD
Section Editors: Richard Saitz, MD, MPH, FACP, DFASAM, Andrew J Saxon, MD
Deputy Editor: Michael Friedman, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jun 2021. | This topic last updated: Mar 15, 2018.

INTRODUCTION

Addiction is a chronic condition for many patients. Yet the traditional treatment model for
addiction has emphasized intensive treatment for medically supervised withdrawal from
substances/stabilization, followed by time-limited outpatient care. In recent years, public and
private health care systems and clinicians have begun recognizing that chronic or relapsing
addiction, like chronic physical conditions such as diabetes or hypertension, typically
requires continuing, long-term care.

Continuing care for addiction includes routine assessment and treatment customized to the
needs and preferences of the individual patient. The patient’s clinical status and risk of
relapse are monitored systematically. The intensiveness of treatment is adjusted as the
addiction waxes and wanes over time. Patients receive training in self-management skills
and linkage to other sources of professional and community support.

This topic describes the implementation of continuing care in chronic or relapsing addiction
and strategies for treatment resistant patients. Other topics describe indications for
continuing care in addiction, components of continuing care, and the efficacy of multimodal
continuing-care interventions; treatment issues specific to individual substance use
disorders (SUDs); and determining the appropriate level of care for patients with SUDs. (See
"Continuing care for addiction: Context, components, and efficacy" and "Pharmacotherapy
for opioid use disorder" and "Alcohol use disorder: Pharmacologic management" and
"Alcohol use disorder: Psychosocial treatment" and "Cannabis use disorder in adults" and
"Cocaine use disorder in adults: Epidemiology, pharmacology, clinical manifestations,
medical consequences, and diagnosis" and "Psychosocial interventions for stimulant use
disorder in adults" and "Determining appropriate levels of care for treatment of substance
use disorders".)

https://www.uptodate.com/contents/continuing-care-for-addiction-implementation/print?search=homeless&topicRef=103550&source=see_link 1/12
11/07/2021 Continuing care for addiction: Implementation - UpToDate

FIRST LINE INTERVENTIONS

Intensity of care — The intensiveness of care for patients with chronic addiction is based on
the severity of the patient’s substance use disorder, risk of relapse, and willingness to
engage in treatment. Below we describe our general, initial approach to care for patients
with three levels of substance use disorder (SUD) severity, consistent with DSM-5 subtypes
[1]. There is an absence of research evidence of the optimal frequency and duration of
continuing care [2]; the suggestions below are based largely on our clinical experience. (See
"Continuing care for addiction: Context, components, and efficacy".)

These initial continuing care plans are proposed for the patient who remains abstinent as
care proceeds through successively less intensive levels of care. The frequency and duration
of the latter stages of continuing care would be adjusted based on the patient’s response to
earlier stages. A patient who has a poor response to initial treatment or has repeated
relapses, for example, will need longer continuing care at a higher intensity than the patient
who responds well to treatment.

Low intensity — Patients who have received treatment for a mild SUD are not typically
candidates for continuing care, but should be monitored for 12 months and offered
additional treatment if they fail to maintain their initial improvement.

Moderate intensity — Patients with a moderate SUD and one or more co-occurring
problems (such as poor sleep or insufficient family support for recovery) would receive
continuing care consisting of:

• Intensive outpatient treatment (IOP) for one to two months, followed by

• Weekly counseling sessions for at least another four to six months, followed by
• Monthly check-ins for six months
• Less frequent check-ins thereafter

High intensity — Patients who are physically dependent on alcohol or drugs, have a
severe SUD, or have an SUD with an active co-occurring psychiatric disorder may require:

● Inpatient or residential treatment to address withdrawal and achieve initial abstinence

● IOP three times per week for one to two months, followed by
● Outpatient treatment one to two times per week for four to six months
● Monthly check-ins for six months and less frequent check-ins thereafter

Research indicates that for patients receiving outpatient treatment, the first few weeks are
critical for determining the optimal intensity of continuing care. In three clinical trials of
continuing care for patients with DSM-IV diagnoses of alcohol and/or cocaine dependence,
patients who are able to stop using alcohol and drugs during the first weeks of IOP were

https://www.uptodate.com/contents/continuing-care-for-addiction-implementation/print?search=homeless&topicRef=103550&source=see_link 2/12
11/07/2021 Continuing care for addiction: Implementation - UpToDate

more likely to do well with less intensive continuing care [3-5]. Patients who continued using
the substances were likely to require more intensive continuing care. The failure to achieve
other early treatment goals — such as committing to abstinence, attending Alcoholics
Anonymous meetings, developing better coping behaviors and increased confidence in their
efficacy, and identifying reliable sources of social support — may indicate a need for more
intensive continuing care [6].

Treatment components — The principal components of SUD treatment in continuing care

are addiction counseling and mutual help groups. The use of these and other treatment
components are described briefly below in the context of implementing continuing care, and
in greater detail separately. (See "Continuing care for addiction: Context, components, and
efficacy".)

In general, a patient with a less severe SUD can begin continuing care at a lower intensity;
the type of treatment selected is less important. If the patient deteriorates, then a more
structured, evidence-based approach is warranted. Higher severity patients should start with
the most structured and evidence-based program available. If such a patient fails in that
kind of continuing care, the clinician should switch to a different approach.

Selection among treatment components is subject to patient preference. Use of mutual help
groups should always be stressed for more severe patients; however if the patient is
adamant about not going to, for example, Alcoholics Anonymous, further pressure from the
clinician may be counterproductive. Availability of some treatments (eg, certain medications
and therapists trained in specific forms of psychotherapy) varies geographically and is based
on patients’ health insurance and other resources.

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 "Continuing care for addiction:
Context, components, and efficacy".)

Mutual help groups — Patients with a moderate to severe SUD participating in

continuing care should be encouraged to participate in a 12-step or other abstinence
oriented mutual help group, at least three times per week. Mutual help groups are described
in more detail separately. (See "Alcohol use disorder: Psychosocial treatment", section on
'Mutual help groups'.)

Pharmacotherapy — Patients with moderate to severe opioid use disorder (in DSM-5;
opioid dependence in DSM-IV) almost always need pharmacotherapy, with adjunctive
psychosocial treatment (ie, counseling/psychotherapy and other continuing care) to prevent
relapse. (See "Pharmacotherapy for opioid use disorder" and "Continuing care for addiction:
Context, components, and efficacy".)

https://www.uptodate.com/contents/continuing-care-for-addiction-implementation/print?search=homeless&topicRef=103550&source=see_link 3/12
11/07/2021 Continuing care for addiction: Implementation - UpToDate

Patients with moderate-to-severe alcohol use disorder (in DSM-5; alcohol dependence in
DSM-IV) should initially be offered both pharmacotherapy (eg, naltrexone, vivitrol, disulfiram,
or acamprosate) and psychosocial treatment. For patients who do not achieve remission or
an adequate reduction in heavy drinking, switching or combining modalities is
recommended. (See "Alcohol use disorder: Pharmacologic management" and "Continuing
care for addiction: Context, components, and efficacy".)

Psychotherapy — For patients in continuing care who prefer treatment other than group
counseling based on a 12-step approach, or do not achieve their treatment goals with this
approach, an individual psychotherapy such as cognitive behavioral therapy can be used.
(See "Alcohol use disorder: Psychosocial treatment" and "Psychosocial interventions for
stimulant use disorder in adults" and "Psychosocial interventions for opioid use disorder"
and "Continuing care for addiction: Context, components, and efficacy".)

Research indicates that there are common factors that cut across different evidence-based
therapies, which may account for much of the variance in outcome. Therapists who know
how to work with ambivalent patients, and who are warm, supportive, non-judgmental, and
non-confrontational, typically get better results, regardless of what kind of therapy they
provide.

Subsequent continuing care — Following the completion of more intensive continuing

care, described above, routine clinical contacts should be maintained to monitor the
patient’s clinical status and substance use. As the patient remains abstinent, these contacts
can become successively infrequent and less burdensome (eg, by telephone). If the patient
relapses or shows early warning signs of potential relapse, the patient should receive more
intensive care. (See "Continuing care for addiction: Context, components, and efficacy",
section on 'Flexibility' and "Continuing care for addiction: Context, components, and
efficacy".)

After the completion of weekly outpatient visits for low-severity patients, continuing care can
be provided through the patient's participation in a mutual help group and occasional brief
visits with an addiction-treatment counselor, eg, a 20 minute visit or telephone contact every
three months. (See 'Mutual help groups' above.)

For a patient who has maintained abstinence for a very prolonged period, eg, two years, and
does not have many risk factors for relapse, the frequency of brief check-ins would be
reduced further, for example, to twice yearly visits with a primary care clinician; these should
continue indefinitely

STRATEGIES FOR TREATMENT RESISTANT PATIENTS

https://www.uptodate.com/contents/continuing-care-for-addiction-implementation/print?search=homeless&topicRef=103550&source=see_link 4/12
11/07/2021 Continuing care for addiction: Implementation - UpToDate

For patients who do not respond to first-line continuing care, or are at high risk for relapse,
additional approaches are described below, with varying levels of supporting evidence. (See
"Continuing care for addiction: Context, components, and efficacy", section on
'Customization'.)

Contingency management — Contingency management interventions for substance use

disorders (SUDs), which offer incentives to encourage abstinence or discourage substance
use., are reviewed separately. (See "Contingency management for substance use disorders:
Efficacy, implementation, and training" and "Contingency management for substance use
disorders: Theoretical foundation, principles, assessment, and components".)

Intensive referral to mutual help groups — A three-session intervention, delivered by a

substance abuse counselor during outpatient treatment for an SUD, has been used to
encourage attendance at mutual help groups [7]. Components of the intervention include
providing:

● Detailed lists of local self-help meetings that had been preferred by other patients

● Directions to the meetings

● Materials that described self-help meetings and addressed common questions and
typical concerns about the program

The counselor also arranges a meeting between the patient and a participating member of
the group. (See "Continuing care for addiction: Context, components, and efficacy".)

Other interventions designed to increase participation in mutual help programs are

described separately. (See "Psychotherapies for substance use disorders", section on
'Facilitating mutual help group engagement'.)

Stepped care — Stepped care or “adaptive treatment” formalizes the principles of flexible
customization of care based on patient clinical status and risk of relapse. Components
include [8]:

● Patient clinical status is monitored in a systematic and standardized fashion, using

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 he or she should consider
adding.

https://www.uptodate.com/contents/continuing-care-for-addiction-implementation/print?search=homeless&topicRef=103550&source=see_link 5/12
11/07/2021 Continuing care for addiction: Implementation - UpToDate

Social reinforcement — An intervention employing contracts, prompts, and social

reinforcements have been found to increase attendance in continuing care [9]. In the
contracting procedures, patients are provided with information on the success rates of
patients who do and do not attend continuing care, and are asked to commit to participate
in a specified amount of continuing care using specified modalities (eg, Alcoholics
Anonymous and individual therapy). Social reinforcement consisted of personal letters from
counselors with congratulations for attending sessions, certificates for completion of
treatment milestones (eg, 90 days of treatment), and medallions for attending specified
numbers of sessions. Certificates and medallions are typically presented in front of other
patients in therapy groups.

Network support — A treatment intervention, referred to as “network support,” was

designed to help patients change their larger social networks to become more supportive of
abstinence [10,11]. The intervention provided help with identifying and engaging in mutual
help programs and with identifying other positive sources of social support in the
community. Barriers to involvement with these groups were identified and addressed.

Intensive continuing care — Intensive continuing care programs, as long as 12 months,

are modeled after extended SUD-treatment programs for pilots and medical personnel.
Most of these interventions consist of the same core components:

● Random urine testing for drug and alcohol use

● Outpatient continuing care
● Recovery coaching
● Family involvement
● Use of web platforms to monitor progress and connect the patient to others (eg,
treatment providers, family members, and employers)

An observational study of the program, “My First Year in Recovery,” included 198 participants
with a mix of substance use disorders. Participants completed 70 percent of random urine
tests. During the 12 follow up period, 54 percent relapsed. Of those, 70 percent remained
engaged in the intervention after relapsing and were able to complete the intervention [12].

Technological innovations — Online resources are playing a growing role in continuing

care. Text messaging, video telephony, and smartphone applications have begun to be
tested [13,14] and used in much the same way as the telephone in continuing care [15,16].
The diminished burden and added convenience of these new technologies has the potential
to increase rates of sustained participation in extended treatment.

As examples:

https://www.uptodate.com/contents/continuing-care-for-addiction-implementation/print?search=homeless&topicRef=103550&source=see_link 6/12
11/07/2021 Continuing care for addiction: Implementation - UpToDate

● A smartphone app supporting recovery increased the proportion of subjects with DSM-
IV alcohol dependence who achieved abstinence during eight months of treatment as
usual [17]. The app, the Addiction-Comprehensive Health Enhancement Support System
(A-CHESS), has multiple functions:

• A “panic button” that provides immediate connections to family, peers, and others in
recovery

• A GPS function that alerts others when individuals get near a location where they
formerly used alcohol or drugs

• A library of suggestions for ways to deal with stressful situations

• A locator of nearby Alcoholics Anonymous/Narcotics Anonymous meetings

• Access to a chat room where others using the app can communicate

• Inspirational stories

• Daily and weekly assessments of status and progress than can be seen by
counselors via a “dashboard”

The clinical trial randomly assigned 349 participants with DSM-IV alcohol dependence
who had completed residential treatment to receive treatment as usual (ie, continuing
care referral) or treatment as usual plus use of A-CHESS for eight months [17]. Patients
receiving A-CHESS reported 49 percent fewer days 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 compared with treatment as usual. Rates of alcohol abstinence
within the prior 30 days were higher with A-CHESS compared with treatment as usual at
8-month (78 versus 67 percent) and 12-month (79 versus 66 percent) assessments [14].
In addition, A-CHESS increased participation in outpatient continuing care during the
follow-up period, which partially mediating the positive effect of the app.

● To provide technological facilitation of continuing care, Hazelden, a well-known,

nonprofit addiction treatment center, developed an online recovery support program
called “My Ongoing Recovery Experience,” which provides recovery services including:

• Access to online communities of persons in recovery

• Educational videos and articles
• Help with identifying coping strategies
• Links to recovery coaches

http://www.hazelden.org/web/public/more_works.page

https://www.uptodate.com/contents/continuing-care-for-addiction-implementation/print?search=homeless&topicRef=103550&source=see_link 7/12
11/07/2021 Continuing care for addiction: Implementation - UpToDate

Primary care settings — Some primary care practices provide an alternative to addiction
treatment centers as a setting in which to receive continuing care for addiction. Some
patients are reluctant to receive treatment at 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.
These patient preferences need to be taken seriously and not viewed as simply indicative of
resistance or denial.

Continuing care is provided in some primary care clinics or practices by a primary care
clinician with specialized training and in other sites by a behavioral health clinician [18-25].
Primary care physicians can receive training in continuing care at continuing medical
education courses, and in workshops or courses at meetings of the American Society of
Addiction Medicine, Society of General Internal Medicine, or similar organizations. Finding
physicians who are well trained in this or similar models of addiction care can be difficult in
many geographic 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.

Although a number of research studies supported the efficacy of primary care for the
provision of continuing care for SUD [18-20], a 2013 large trial did not generate positive
outcomes [26]. The trial randomly assigned 563 individuals with alcohol or drug dependence
to receive chronic care management for their substance use disorders in primary care versus
standard primary care only. No differences were seen between groups on primary self-
report measures or biological substance use outcomes.

Specialized populations — Principles of continuing care for addictions have been

incorporated into extensive programs for specialized populations, including homeless
persons with SUDs [27-29] and physician health programs, which coordinate oversight and
treatment of substance-impaired physicians. (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: Opioid use disorder
and withdrawal" and "Society guideline links: Alcohol use disorders and withdrawal" and
"Society guideline links: Benzodiazepine use disorder and withdrawal" and "Society guideline

https://www.uptodate.com/contents/continuing-care-for-addiction-implementation/print?search=homeless&topicRef=103550&source=see_link 8/12
11/07/2021 Continuing care for addiction: Implementation - UpToDate

links: Cannabis use disorder and withdrawal" and "Society guideline links: Stimulant use
disorder and withdrawal".)

SUMMARY AND RECOMMENDATIONS

● Continuing care for addiction includes routine assessment and treatment customized to
the needs and preferences of individual patients. The patient’s clinical status and risk of
relapse are monitored systematically. The intensiveness of treatment is adjusted as the
addiction waxes and wanes over time. Patients receive training in self-management
skills and linkage to other sources of professional and community support. (See
'Introduction' above and "Continuing care for addiction: Context, components, and
efficacy".)

● Following acute medically supervised withdrawal and/or stabilization of a patient with a

moderate-to-severe substance use disorder (SUD), we suggest continuing care rather
than short term treatment of acute exacerbation (Grade 2C). (See "Continuing care for
addiction: Context, components, and efficacy", section on 'Components' and
"Continuing care for addiction: Context, components, and efficacy".)

● The intensity of SUD care should be adjusted based on the patient’s SUD severity, risk of
relapse, and treatment engagement. (See 'Intensity of care' above and "Continuing care
for addiction: Context, components, and efficacy".)

● Patients receiving continuing care for a chronic, relapsing SUD should be encouraged to
participate in a mutual help group for such addictions as part of continuing care. Daily
attendance is recommended for the first three months, followed by attendance three
times weekly thereafter. (See "Alcohol use disorder: Psychosocial treatment", section on
'Mutual help groups' and "Continuing care for addiction: Context, components, and
efficacy".)

● Following the completion of more intensive continuing care, abstinent patients should
continue to have routine clinical contacts to monitor the patient’s clinical status and
substance use. As the patient remains abstinent, these contacts can become
successively infrequent and less burdensome (eg, by telephone). If the patient relapses
or shows early warning signs of potential relapse, the patient should receive more
intensive care. (See 'Subsequent continuing care' above.)

● Patients in continuing care for addiction who relapse, or show early warning signs that
they may relapse, should receive more intensive treatment. This may include:

• A greater frequency of counseling or psychotherapy sessions and mutual help

group meetings (See 'Intensity of care' above and 'Mutual help groups' above.)
https://www.uptodate.com/contents/continuing-care-for-addiction-implementation/print?search=homeless&topicRef=103550&source=see_link 9/12
11/07/2021 Continuing care for addiction: Implementation - UpToDate

• Additional treatment modalities (See 'Pharmacotherapy' above and 'Psychotherapy'

above.)

• Treatment at a higher level of care (See 'Intensity of care' above and "Continuing
care for addiction: Context, components, and efficacy".)

● Patients who experience multiple relapses despite high intensity continuing care may
benefit from the addition of approaches such as intensive referral to a mutual help
group, financial or other incentives, or more structured stepped care. Further
investigation of these interventions in the context of continuing care is needed. (See
'Strategies for treatment resistant patients' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,

Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.

2. Blodgett JC, Maisel NC, Fuh IL, et al. How effective is continuing care for substance use
disorders? A meta-analytic review. J Subst Abuse Treat 2014; 46:87.
3. McKay JR, Lynch KG, Shepard DS, Pettinati HM. The effectiveness of telephone-based
continuing care for alcohol and cocaine dependence: 24-month outcomes. Arch Gen
Psychiatry 2005; 62:199.

4. McKay JR, Alterman AI, Cacciola JS, et al. Continuing care for cocaine dependence:
comprehensive 2-year outcomes. J Consult Clin Psychol 1999; 67:420.

5. McKay JR, Van Horn DH, Lynch KG, et al. An adaptive approach for identifying cocaine
dependent patients who benefit from extended continuing care. J Consult Clin Psychol
2013; 81:1063.
6. McKay JR, Van Horn D, Oslin DW, et al. Extended telephone-based continuing care for
alcohol dependence: 24-month outcomes and subgroup analyses. Addiction 2011;
106:1760.
7. Timko C, Debenedetti A, Billow R. Intensive referral to 12-Step self-help groups and 6-
month substance use disorder outcomes. Addiction 2006; 101:678.
8. McKay JR. Treating Substance Use Disorders With Adaptive Continuing Care, American P
sychological Association Press, Washington, DC 2009.
9. Lash SJ, Burden JL, Fearer SA. Contracting, prompting, and reinforcing substance abuse
treatment aftercare adherence. J Drug Addict Educ Erad 2007; 2:455.
10. Litt MD, Kadden RM, Kabela-Cormier E, Petry N. Changing network support for drinking:
initial findings from the network support project. J Consult Clin Psychol 2007; 75:542.
https://www.uptodate.com/contents/continuing-care-for-addiction-implementation/print?search=homeless&topicRef=103550&source=see_link 10/12
11/07/2021 Continuing care for addiction: Implementation - UpToDate

11. Litt MD, Kadden RM, Kabela-Cormier E, Petry NM. Changing network support for
drinking: network support project 2-year follow-up. J Consult Clin Psychol 2009; 77:229.
12. McKay JR, Knepper C, Deneke E, et al. An Initial Evaluation of a Comprehensive
Continuing Care Intervention for Clients with Substance Use Disorders: My First Year of
Recovery (MyFYR). J Subst Abuse Treat 2016; 67:50.
13. Blankers M, Koeter MW, Schippers GM. Internet therapy versus internet self-help versus
no treatment for problematic alcohol use: A randomized controlled trial. J Consult Clin
Psychol 2011; 79:330.

14. Gustafson DH, McTavish FM, Chih MY, et al. A smartphone application to support
recovery from alcoholism: a randomized clinical trial. JAMA Psychiatry 2014; 71:566.

15. Gustafson DH, Palesh TE, Picard RW, et al. Automating addiction treatment: Enhancing t
he human experience and creating a fix for the future. In: Future of Intelligent and Extell
igent Health Environment, Bushko R (Ed), IOS Press, Amsterdam 2005.
16. Squires DD, Bryant, MD. Substance use disorders. In: Using Technology to Support Evide
nce-Based Behavioral Health Practices: A Clinician’s Guide, Cucciare MA, Weingardt KR (E
ds), Routledge, New York 2009.

17. Glass JE, McKay JR, Gustafson DH, et al. Treatment seeking as a mechanism of change in
a randomized controlled trial of a mobile health intervention to support recovery from
alcohol use disorders. J Subst Abuse Treat 2017; 77:57.

18. Lieber CS, Weiss DG, Groszmann R, et al. I. Veterans Affairs Cooperative Study of
polyenylphosphatidylcholine in alcoholic liver disease: effects on drinking behavior by
nurse/physician teams. Alcohol Clin Exp Res 2003; 27:1757.

19. Willenbring ML, Olson DH. A randomized trial of integrated outpatient treatment for
medically ill alcoholic men. Arch Intern Med 1999; 159:1946.
20. Kristenson H, Ohlin H, Hultén-Nosslin MB, et al. Identification and intervention of heavy
drinking in middle-aged men: results and follow-up of 24-60 months of long-term study
with randomized controls. Alcohol Clin Exp Res 1983; 7:203.

21. Kristenson H, Osterling A, Nilsson JA, Lindgärde F. Prevention of alcohol-related deaths

in middle-aged heavy drinkers. Alcohol Clin Exp Res 2002; 26:478.

22. Miller WR, Weisner C. Integrated care. In: Changing Substance Abuse Through Health a
nd Social Systems, Miller WR, Weisner CM (Eds), Kluwer Academic/Plenum, New York 20
02. p.243.
23. Weisner C, Mertens J, Parthasarathy S, et al. Integrating primary medical care with
addiction treatment: a randomized controlled trial. JAMA 2001; 286:1715.

24. Mertens JR, Flisher AJ, Satre DD, Weisner CM. The role of medical conditions and primary
care services in 5-year substance use outcomes among chemical dependency treatment
patients. Drug Alcohol Depend 2008; 98:45.
https://www.uptodate.com/contents/continuing-care-for-addiction-implementation/print?search=homeless&topicRef=103550&source=see_link 11/12
11/07/2021 Continuing care for addiction: Implementation - UpToDate

25. Chi FW, Parthasarathy S, Mertens JR, Weisner CM. Continuing care and long-term
substance use outcomes in managed care: early evidence for a primary care-based
model. Psychiatr Serv 2011; 62:1194.

26. Saitz R, Cheng DM, Winter M, et al. Chronic care management for dependence on
alcohol and other drugs: the AHEAD randomized trial. JAMA 2013; 310:1156.
27. Milby JB, Schumacher JE, Raczynski JM, et al. Sufficient conditions for effective treatment
of substance abusing homeless persons. Drug Alcohol Depend 1996; 43:39.

28. Milby JB, Schumacher JE, McNamara C, et al. Initiating abstinence in cocaine abusing
dually diagnosed homeless persons. Drug Alcohol Depend 2000; 60:55.
29. Milby JB, Schumacher JE, Wallace D, et al. Day treatment with contingency management
for cocaine abuse in homeless persons: 12-month follow-up. J Consult Clin Psychol 2003;
71:619.
Topic 89215 Version 13.0

Contributor Disclosures
James R McKay, PhD Nothing to disclose Richard Saitz, MD, MPH, FACP,
DFASAM Grant/Research/Clinical Trial Support: Alkermes [Alkermes provides study medication for a
clinical trial supported by NIH on alcohol use disorder]. Consultant/Advisory Boards: Checkup &
Choices [Electronic interventions for alcohol use in primary care]. Andrew J Saxon,
MD Consultant/Advisory Boards: Alkermes Inc [Opioid use disorder]; Indivior [Opioid use disorder].
Other Financial Interest: Alkermes Inc [Opioid use disorder]. Michael Friedman, MD Nothing to
disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

https://www.uptodate.com/contents/continuing-care-for-addiction-implementation/print?search=homeless&topicRef=103550&source=see_link 12/12