Improving treatment engagement in opioid-dependent outpatients with a motivated stepped-care adaptive treatment model

Background: Substance abuse treatment programs that provide long term care that includes methadone routinely treat patients with both the chronic and severe form of opioid dependence disorder. In the early 1990s the Addiction Treatment Services clinic at Johns Hopkins Bayview Medical Center began experiencing a growing problem with poor counseling attendance and high rates of continuing opioid and other drug use, primarily cocaine. Methods: A comprehensive and adaptive treatment model was developed that adjusts the amount of individual counseling and group therapy, medication dose, and overall monitoring, and integrates them with clinic-based behavioral reinforcement procedures to increase patients' attendance. This model of care (Motivated Stepped Care [MSC]), an adaptive stepped-care treatment approach, was implemented in 1995. Results: The MSC model has demonstrated large improvements in counseling attendance and rates of urine specimens testing negative for drug use. Additional work has extended the model's evaluation to other common problems - continuing unemployment and limited access to and participation in drug-free social support. Conclusion: The MSC adaptive treatment model is a viable and effective alternative to standard treatment approaches. It is integrated with performance improvement monitoring to inform and adjust the amount of services necessary to achieve and sustain good clinical response to treatment during months and years of care.