MODULE 6COMPONENTS OF

TREATMENT: THE CONTINUUM OF

CARE
Treatment for Substance Use
DisordersThe Continuum of Care
for Addiction Professionals
The Colombo Plan Asian Centre for Certification and Education of Addiction Professionals Training Series
Curriculum 2
6.2
Continuum of Care
From Module 3, What is Treatment:
What were some of the ways that people view
SUD treatment in your community?
6.3
Continuum of Care
The whole range of services a client may
receive directly from a treatment program or
coordinated by the treatment program
6.4
Module 6 Learning Objectives
Provide a general description of an effective
continuum of care for SUDs
Identify differences between screening and
assessment
Describe detoxification options
6.5
Learning ObjectivesPart II
Define case management
Name and briefly describe at least five
interventions typically offered in primary SUD
treatment
Name and briefly describe four types of groups
often used in SUD treatment

6.6
Learning ObjectivesPart III
Name and briefly describe the self-
help/mutual-help options available in the
community/area
Define continuing care
Apply the concept of continuum of care by
identifying an appropriate continuum for a
client via a case study

6.7
Four Parts of a Continuum of Care
Pretreatment
Primary treatment
Case management
Continuing care, including ongoing recovery
management

6.8
Pretreatment Components
Outreach
Screening and brief intervention
Assessment and treatment planning
Detoxification
6.9
Outreach Definition
Reaching out to build connections from one
group or program to another
Extension of services or assistance to persons
or groups not previously served

6.10
SUD Outreach
Organized efforts to identify and screen
individuals who may have a problem with
substance use

Photo credit: Family Health International, Hanoi,
Vietnam
6.11
Outreach Goals
Establish contact
Build trust
Develop relationships
Provide needed health care linkages
Engage individuals in SUD brief interventions
or treatment
6.12
Why Outreach?
Because many people who use substances
see treatment programs as:
Intimidating
Difficult to get to
Too rigid or judgmental in their approach
Irrelevant to an individuals immediate needs
Too costly
6.13
Outreach Methods and Settings
Community education with other agencies
Talking with those who use substances at
homeless shelters, HIV or other medical
clinics, community centers, and drop-in
centers
Education and screening at schools, social
centers, and clinics

6.14
Other Outreach Efforts
Paraprofessionals can go where substance
use is encouraged, such as dance clubs
Peer educators can visit places frequented by
those who use substances
Medical staff can provide brief interventions
and referrals wherever they work

6.15
Screening Purpose
Screening tries to identify only whether a
problem exists and whether further
assessment is needed

6.16
Screening vs. Assessment
Screening tries to identify only whether a
problem exists and what follow-up is needed
Assessment tries to identify as closely as
possible the nature of an SUD and other
issues and the level of intervention that may
be needed
6.17
Validity of a Screening Instrument
The degree to which the instrument actually
measures what it claims to measure
Internationally validated instruments:
The AUDIT, a 10-item screening tool for alcohol
The Alcohol, Smoking, and Substance
Involvement Screening Test (ASSIST)

6.18
Other Screening Instruments
Many other instruments have been designed
for adults and adolescents
See Resource Page 6.1 for additional
screening instruments that have not been
validated for use with all populations
6.19
Screening
Screening
No or Low
Risk
No Further
Intervention
Moderate
Risk
Brief
Intervention
Severe Risk
or Active
Addiction
Assessment
and Primary
Treatment
6.20
Brief Intervention
Focuses on increasing a persons insight into
and awareness of substance use and
behavioral change
Can be provided through a single session or
multiple sessions of motivational interventions
by SUD or other professional or peer staff

6.21
Assessment Goals
Provide a foundation for treatment planning
Establish a baseline for measuring a clients
progress
Prioritize a clients problems
Set priorities for treatment and case
management interventions
Identify client strengths and other recovery
capital that can support recovery

6.22
Assessment Tasks
Engaging the client
Obtaining the clients history
Collecting data on the client
Observing the client during the first visit

6.23
Areas of AssessmentPart I
The clients reason for seeking treatment and
his or her opinion of the problem
Current and past substance use and drug
treatment
Family history of substance use
Medical conditions or complications

6.24
Areas of AssessmentPart II
Risk of withdrawal and need for supervised
detoxification
Suicide, health, and other crisis risk
assessment
Emotional/behavioral/cognitive status,
including the presence of a mental disorder
Educational and vocational background


6.25
Areas of AssessmentPart III
Legal status
Readiness to change
Natural supports within the family, workplace,
and community
Relapse or continued-use potential
Recovery environment (e.g., living situation,
barriers and supports for recovery)

6.26
Assessment Methods
Clinical interview
Assessment interventions
Collateral sources, with clients permission:
Family
Friends
Employer
Referral sources
Urine or other testing for substances

6.27
Treatment Plan
An individualized outline for treatment and
services based on the clients specific needs
6.28
Treatment Plan Identifies Needs That
Will be addressed during treatment
Require referral to other treatment providers
Will be deferred to a later time

6.29
Effective Treatment Plan
Individualized
Flexible
Realistic
Simple
Useful
Solution focused
Clear
Responsive to changes and progress

6.30
Treatment Planning
Determining the level of care the client needs
and is willing to accept
Includes
Intensity
Duration
Setting


6.31
Treatment Planning Determinations
This first step of treatment planning includes
determining whether:
The program can meet the clients needs or
should be referred
Treatment for co-occurring mental or medical
disorders is needed
The client is in need of supervised detoxification


6.32
Detoxification
The process of:
Stopping substance use
Clearing the substance from the body
Managing the withdrawal syndrome
6.33
Withdrawal
The particular signs and symptoms, the
intensity of them, and the risk involved in
withdrawal depend on:
The substance used
The amounts taken over time
The length of time the substance was used
regularly

6.34
Medications to Help with Detox
Medications can help with detoxification from:
Opioids
Benzodiazepines
Barbiturates
Other sedatives

6.35
Goals of Detoxification
To provide a safe withdrawal from substances
of dependence and to enable the person to
become drug free
To provide a withdrawal that is humane
To prepare the person for ongoing treatment

6.36
Types of Detoxification Services
Outpatient, home-based, or residential
services without medication but with
psychosocial support (social detox)
Outpatient services with medication and
periodic monitoring (medication-supported)
Inpatient services with medication (medically-
managed)

6.37
Detoxification
Detoxification is ONLY a first step toward
recovery; it is NOT treatment
6.38
Small-group Exercise: Pretreatment
Components
Summarize the key elements of your assigned
content area
Write these key elements on newsprint to be
used for a 3-minute presentation
Write these key elements on white paper to
post on the Continuum of Care wall graphic



6.39

Break
15 minutes
6.40
Case Management
An integral part of treatment



Ongoing
recovery
Screening and
Assessment
6.41
Case Management
The coordination of professional, social,
and medical services to assist people with
complex needs, often for long-term care
and protection

6.42
Case ManagementPurpose
Monitor transitions of clients between levels
of care to assure there are no gaps in service
Coordinate the range of services needed by
clients
Serve as a single point of contact for each
client to find and mobilize needed resources

6.43
Case Management



Services tend to be scattered
or difficult to access
6.44
Case Management
Case managers help put the pieces together
for clients
6.45
Case Management Functions
Assessment
Service planning
Linkage and referral
Monitoring
Advocacy


6.46
Assessment and Service Planning
Assessment and service planning are closely
related to the initial assessment and treatment
plan discussed earlier
A case management plan can be incorporated
into a clients overall treatment plan or can be
done as a separate process

6.47
Linkage and referral
Linkage and referral are critical because no
one program can meet all of a clients needs
Inter-program case management connects
programs to one another to provide more
services to clients
6.48
Linkage and Referral
Through linkages and referrals, counselors
can help clients obtain:
Treatment for mental disorders
Family therapy
Child care
Transportation


6.49
Linkage and ReferralII
Housing assistance
Financial assistance
Legal assistance
HIV/AIDS or other medical testing and care
Educational or vocational services

6.50
Monitoring Functions
A case manager:
Ensures that the client engages in services and
monitors the clients progress
Identifies barriers and works with the client and
referral sources to overcome them
Coordinates communication with the
multidisciplinary team

6.51

Advocacy

Speaking out on issues of concern to apply
influence on behalf of a person or persons
6.52
Advocacy: Where?
Case managers interact with many systems to
advocate for their clients, including:
Other organizations
Health care providers
The legal system
Families
6.53
Advocacy Tasks
Case managers can educate nontreatment
service providers about a client or substance
use problems in general
At times, the case manager must negotiate
with a program on behalf of a client


6.54
Large-group: Advocacy Questions
How has advocacy fit into the work you do with
your clients?
In what ways does the concept of advocacy fit
or not fit into the context of your communities?
What difficulties have you encountered while
advocating for your clients?


6.55
Small-group Tasks
Summarize the key elements of your case
management component
Write these key elements on newsprint to be
used for a 2-minute presentation
Write these key elements on white paper to
post under the Continuum of Care wall
graphic



6.56
Group Counseling Purpose
Provides opportunities for clients to develop
communication and socialization skills
Creates an environment in which clients help,
support, and confront one another
Introduces structure and discipline into the
often chaotic lives of clients
Provides healthful norms and a supportive
environment

6.57
Group Counseling PurposePart II
Helps clients broaden understanding of their
recovery capital and barriers to recovery
Supports individual assessment of critical risk
and protective factors
Advances individual recovery
Provides a venue for group leaders to transmit
new information, teach new skills, and guide
clients as they practice new behaviors

6.58
Group Counseling Cautions
Some clients should never be assigned to the
same groups:
Perpetrators and victims of domestic violence
must be in separate groups
Neighbors, friends, relatives, spouses, or
significant others should not be assigned to the
same group (with the exception of family groups)
Group size between 8 and 15 members
Meet no more than 1.5 hours


6.59
Small-group Tasks
Prepare a brief presentation on your assigned
types of groups
Use newsprint, markers, colored paperbe
creative!
Summarize key elements on white paper to
post on the wall graphic

*Psychoeducation: Resource Page 6.3
*All other types of groups: Resource Page 6.4



6.60

Lunch
60 minutes
6.61
Group Counseling Is Not for
Everyone
Some socially anxious or very introverted
clients cannot tolerate groups well
Some clients with severe mental disorders
cannot participate in groups
Clients who violate group principles or who
cannot control their impulses might respond
better to individual counseling

6.62
Individual Counseling Focus
Individual counseling sessions vary depending
on:
The type of program
The clients stage of recovery
The clients individual needs
Photo credit: Family Health International, Hanoi,
Vietnam
6.63
Individual Counseling ContentPart 1
A counselor may:
Ask how the client is feeling
Ask the client about reactions to a recent group
meeting
Explore how the client spent time since the last
session

6.64
Individual Counseling ContentPart 2
A counselor may:
Inquire about drug use
Ask whether there are any urgent issues
Review treatment plans and coping strategies
Address fears and anxieties related to change


6.65
Individual Counseling ContentPart 3
The counselor may:
Provide personalized feedback on substance
testing results
Probe into sensitive issues that are difficult to
discuss in a group
Help clients access services
Give clients individual assignments
6.66
Ending a Session
A counseling session usually ends with a
summary of the clients plans and a schedule
for the next few days

6.67
Primary TreatmentOther
Components
Testing for drug use
Pharmacotherapy
Orientation to mutual-help groups

6.68
Substance Testing
Testing can:
Verify, contradict, or add to a clients self-report of
substance use
Identify a relapse to substance use
Help assess the efficacy of the treatment plan
and the current level of care
Encourage abstinence

6.69
Types of Substance Testing
Laboratory testing
Point-of-care testing (POCT)
6.70
POCT Advantages
Reveal results quickly
Can be less expensive than laboratory testing
Are relatively simple to perform

6.71
POCT Disadvantages
Some kits test for only a few substances
Those that test for many substances may be
more expensive than laboratory testing
Usually limited to indicating only positive or
negative test results

6.72
POCT DisadvantagesPart II
Require secure storage facilities and regular
staff training
Usually cannot be used in court
Can be misleading (as can laboratory testing)
in monitoring abstinence if not testing for an
entire array of drugs

6.73
Pharmacotherapy Is Used To
Aid in acute withdrawal or tapering
Discourage use of a substance by reducing its
reinforcing properties or by creating negative
effects when the substance is used
Aid early recovery by reducing cravings or
counteracting longer-term symptoms of
withdrawal
6.74
Pharmacotherapy: Opioids
One of the best-known pharmacotherapies for
opioids is methadone
Methadone can be used short term, to aid
withdrawal, or long term as a maintenance
therapy
Not always available or even legal
6.75
Pharmacotherapy
Typically used along with counseling and other
treatment services, not in place of them

Counseling
& Other
Services
Pharmaco-
therapy
6.76
Mutual-Help Programs
Mutual-help programs are alternatives or
enhancements to professional counseling
Participants in mutual-help groups support and
encourage one another to become or stay
drug free
12-Step programs are perhaps the best known
of mutual-help programs

6.77
First Mutual-Help Groups
Alcoholics Anonymous (AA): 1930s
Narcotics Anonymous (NA): 1950s
6.78
AA and NA Meeting Types
Can be open or closed to the public
Discussion meetingsleader shares a topic
Speaker meetingsspeaker shares his or her
story
12-step study meetings discuss a particular
step
6.79
Sponsorship
A sponsor is an AA or NA member who:
Has had successful experience with the program
Works personally with a member with less
experience


6.80
Other 12-Step Mutual-Help Programs
Marijuana Anonymous
Cocaine Anonymous
Nicotine Anonymous

6.81
12-Step Programs for Family and Friends
Nar-Anon (for all family members)
Al-Anon (for adult or older adolescent family
members and friends)
Alateen (for older children and younger
adolescents)
Alatot (for young children)

6.82
12-Step Program Research
Research results are mixed on whether they
are an effective program of recovery
But they are very difficult to study due to:
Confidentiality
Voluntary nature blocks controlled studies


6.83
12-Step Programs Are Not for
Everyone
Some people are uncomfortable with the
spiritual aspects of the programs
Those who have difficulty in group and social
situations may not be able to effectively use a
group recovery program

6.84
Other Mutual-Help Programs
Women for Sobriety
SMART (Self-Management and Recovery
Training) Recovery
Rational Recovery
Celebrate Recovery (Christian)
Millati Islami
Native American Wellbriety Movement
6.85
Women for Sobriety and Rational Recovery
Both based in rational-emotive-behavioral
principles
Women for Sobriety believes that women with
alcohol use disorders require a different kind of
recovery program than do men
Rational Recovery has no mutual-help groups,
but provides online educational supports to
address irrational beliefs

6.86
SMART Program
Off-shoot of Rational Recovery
Focuses on motivation, urges, thoughts,
feelings, behaviors, and satisfactions
Teaches increasing self-reliance, rather than
powerlessness
Uses no sponsors

6.87
Celebrate Recovery
One of several Christian-based recovery
programs based on Bible scriptures and
worship
Typically address a variety of issues, not
merely SUDs
Replaces the sponsor with the pastor/priest
and the congregation as a support network

6.88
Millati Islami
World-wide fellowship of men and women
joined together on the Path of Peace
Based on spiritual principles of the Quran
Groups combine requirements of both Al-Islam
and 12-step approach to addressing all SUDs

6.89
Native American Wellbriety
Movement
Created by White Bison Society in response to
lack of success of American Indians in regular
treatment and recovery programs
Based on the 12-Step model, but rooted in
traditional culture, spirituality, and rituals


6.90
Awareness of Mutual-Help Programs
Counselors need to be familiar with self- and
mutual-help programs in their areas so that
they can:
Orient clients to what is available
Encourage clients to try different programs
Assist clients in selecting a useful support
program
Advocate for group creation where not available


6.91
Other Components of Treatment
Medically managed treatment and general
health services
Treatment for mental disorders
General schooling for adolescents or young
adults
6.92
Other Components of Treatment
Part II
Employment skills training
Child care for group or individual sessions
Transportation to treatment activities and/or
mutual-help group meetings
6.93


Break
15 minutes
6.94
Small-group Exercise: Primary Treatment
Other Components
15-minute discussion on how these components
are incorporated into SUD treatment in your
community:
Testing for drug use
Pharmacotherapy
Mutual-help groups
Other components
List 3 findings in each area
Reporter will have 1 minute to share findings in
each component

6.95
Continuing Care Plan
Documented plan of action developed before
discharge or transfer to another level of care
Structured, goal-oriented list of services
Developed jointly by client and counselor
Includes recovery capital and possible
challenges

6.96
Continuing Care Goals
Sustain abstinence
Develop continuing recovery supports
Gain community living

6.97
Continuing Care GoalsPart II
Gain employment skills
Gain education
Obtain employment or schooling
Obtain counseling for co-occurring mental
disorders

6.98
Continuing Care GoalsPart III
Develop a deeper understanding of self and
others
Increase responsibility
Work on resolving family difficulties
Consolidate, reinforce, and become
comfortable with life changes
Integration into the community with a
meaningful role
6.99
Continuing Care Groups
Exploring substance-free social and
recreational activities
Continued work on life skills, such as solving
problems
Relapse prevention training
Health and wellness
Education and career planning
Supportive counseling
Leadership skills development

6.100
Continuing Care Supports
Mutual-help group attendance
Individual therapy
Treatment/medication management for mental
disorders
Methadone maintenance
Phone therapy or monitoring


6.101
Continuing Care SupportsPart II
Religious/spiritual institutions
Cultural traditions and values that support
recovery
Periodic home visits or booster sessions
Intensive case management monitoring and
supports
Job training or other schooling


MODULE 6COMPONENTS OF
TREATMENT: THE CONTINUUM OF
CARE
Treatment for Substance Use
DisordersThe Continuum of Care
for Addiction Professionals
The Colombo Plan Asian Centre for Certification and Education of Addiction Professionals Training Series
Curriculum 2
6.103
Continuing Care SupportsSmall-
Group Exercise
15 minutes to list existing resources on white
paper
15 minutes to list wished for services on
newsprint
Reporter will have 3 minutes to report out each
list


6.104
Small-Group Exercise: Continuum of
Care Case Study Assignments
Read your assigned case study
Take a few minutes to dress your figure
appropriately, using the markers
Develop a presentation that illustrates your
clients movement through an appropriate
continuum of care
Use your assigned case study as a starting
point, then add information about the persons
movement through the continuum (as needed)



6.105


Break
15 minutes