An Overview on Intensive Outpatient Programs for Addiction

The Commission on Accreditation of Rehabilitation Facilities (CARF) International, an independent nonprofit accrediting group involved in drug and alcohol rehabilitation program quality, defines intensive outpatient programs (IOPs) for substance abuse as a scheduled series of therapy sessions and services to help people overcome addiction and focus on sobriety. Unlike other outpatient programs, intensive outpatient rehabilitation is designed to help people in dire need who might otherwise need partial hospitalization or residential services, but who need or want to remain living at home.

IOPs are time-limited, usually very short-term, and highly structured, but do not have an inpatient component. Instead, people attending this form of therapy spend several hours per day in one or more therapy sessions, and they return home each evening.

Specifics of Intensive Outpatient Programs

Intensive outpatient programs focus on group-based educational and therapy sessions, with some individual therapy options, to improve the person’s understanding of addiction as a disease and rapidly change behaviors from maladaptive reactions to stress or emotional changes to positive reactions that maintain sobriety and health. An individual will spend several hours per day, several days per week, attending required IOP sessions but will be able to live at home rather than at a hospital or rehabilitation facility. IOPs can also help a larger group of individuals because people often drop out of inpatient or traditional outpatient treatment early; if more intensive therapy were offered earlier, they may experience a greater benefit.

The intention of intensive outpatient programs for drug and alcohol addiction was to match the individual and group therapy offered for people entering inpatient rehabilitation without the requirement that the person live at the facility for 30-90 days. This helps to lower overall costs because people attending IOPs do not need to pay for housing and most meals. The downside of IOPs compared to inpatient programs is that the person at the IOP will not be removed from an environment that could potentially trigger substance abuse cravings. People who are likely to be triggered by family, friends, housemates, or their residence’s location should consider inpatient programs instead.

Traditional outpatient rehabilitation options require fewer hours of therapy, which allows the individual to work at least part-time, go to school, or take care of other needs, like children or aging family members. They may be less expensive than an IOP, too; however, they may not provide the same intensive focus on therapy and in-depth understanding of the root causes of one’s addiction. Each individual’s needs should be evaluated with the help of a medical professional or therapist, so they can enter the best possible program to meet all their treatment objectives.

Basic criteria for concluding an IOP include:

  • Treatment goals, as created by the individual with the help of their physician or therapist, have been met.
  • The individual no longer meets the guidelines for outpatient treatment and requires inpatient treatment.
  • The person has better support at home or shows greater change in behaviors, and can be released from intensive treatment to less intensive outpatient treatment.

History of Intensive Outpatient Programs

The Substance Abuse and Mental Health Services Administration (SAMHSA) developed a Treatment Improvement Protocol (TIP) to help clinicians, lawmakers, and potential patients understand intensive outpatient treatment. According to SAMHSA, the first largescale use of IOPs began in the 1980s, with an influx of busy professionals struggling with cocaine addiction who did not want to take a lot of time away from work to overcome addiction. With a reduction in cost due to no required residential stay, IOPs became popular throughout the 1990s and continue to expand with a greater, evidence-based understanding of addiction as a disease.

Although IOPs are intensive, they are compatible with many kinds of therapy, including:

  • The 12-Step Model: Using the 12 Steps like homework assignments and group discussions of results, attendees can change behaviors, increase their understanding of addiction, and improve their relationship with God or a higher power.
  • Cognitive Behavioral Therapy:This form of therapy has adapted to many different psychological needs, including helping people who are overcoming addiction to understand the relationship between their emotional and behavioral reactions. The therapist guides their client to change behavioral reactions to internal struggles through better self-understanding.
  • Motivational Interviewing and Motivational Enhancement Therapy:Trained therapists help resolve clients’ ambivalence toward treatment, so they are motivated to change behaviors around intoxicating substances and understand the harm that addiction can do to the body and interpersonal relationships.
  • The Matrix Model: A combination of several forms of therapy, including CBT, Motivational Interviewing, and peer-led support groups, these IOPs offer a variety of approaches to overcoming addiction, which can cover all kinds of clients’ needs.
  • Contingency Management:Some behaviors are rewarded with short-term prizes, like money or vouchers, to reinforce positive behavioral changes. These awards are often associated with meeting specific goals, trending toward long-term behavioral changes and a sober lifestyle outside of the rehabilitation program.

How Long Is an Intensive Outpatient Program, and What Services Are Offered?

While IOPs may offer several types of therapy and educational options, each focuses on 14 overarching principles of treatment:

  1. Treatment must be readily available.
  2. The program must be easy to enter.
  3. Evidence-based approaches work best.
  4. Therapists must build their clients’ motivation.
  5. The alliance between therapist and client should grow.
  6. Retention is a priority, until the client has completed the program.
  7. Individual treatment needs should be continually assessed.
  8. Abstinence must be monitored to detect potential relapse.
  9. Ongoing care should be provided as needed, including referral to other programs.
  10. Peer support groups should be provided.
  11. The use of medications helps many people.
  12. Education must include evidence-based understanding of addiction, recovery, and relapse.
  13. Families, employers, friends, and community members should be engaged as part of long-term recovery.
  14. Program administration should benefit, not frustrate, the client.

Traditional intensive outpatient rehabilitation involves at least nine hours of treatment per week, delivered in three-hour sessions, with some longer sessions stretching into six hours. The loose regulations require 6-30 hours of therapy per week, depending on client needs, for a minimum of 90 days.

While the intensity of treatment is similar to partial hospitalization programs (PHP), most clinicians currently agree, according to SAMHSA, that a PHP begins at six hours or more of treatment per day on consecutive weekdays. There is no required minimum length of stay in an IOP, but a timeframe of at least 90 days for most rehabilitation programs works best for most people.

A person entering an IOP can expect help with:

  • Program orientation
  • Intake procedures, including case management
  • Individualized treatment planning
  • Group therapy and counseling sessions
  • Individual counseling sessions
  • Family therapy (depending on the client)
  • Psychoeducational programming to understand addiction
  • 24-hour crisis coverage outside regular program hours
  • Medical treatment, including prescriptions, and management as needed
  • Drug tests to ensure no relapses
  • Psychiatric evaluation for co-occurring mental illness
  • Discharge planning
  • Transition into mutual support groups and peer assistance

Some programs may also offer vocational training, help finding educational and job resources, and financial management. Typically, detox is a separate program; a person can attend medically supervised detox in a hospital or work with a doctor in an outpatient setting if they meet the requirements for ambulatory detox programs. Some intensive outpatient rehabilitation programs include detox, but this is rare.

An Average Week in an Intensive Outpatient Program

Because a person working in an intensive outpatient treatment program does not live in the same building where their therapy sessions are located, their day will be structured differently than a day in an inpatient program. IOPs are more like traditional outpatient programs in the structure of days or weeks, but therapy sessions are longer in IOPs than in other outpatient options. A week of IOP will typically include:

  • Three blocks of therapy, each lasting three hours with breaks in between (These sessions could be the same kind of therapy in group and individual sessions or different kinds of therapy, like an individual CBT session and a Motivational Enhancement Therapy session.)
  • Meeting with a case manager to evaluate the program and needs being met
  • Attending other sessions on other days, like vocational training or family therapy, structured similarly to the day of therapy
  • A randomized drug test

The American Society of Addiction Medicine (ASAM) suggests that, to start, a week of IOP will include three hours of rehabilitative therapy per day, five days per week. This will be tapered to nine hours per week total, for 10-30 sessions, depending on what the client was assessed to need. Sessions for non-therapy help can be scheduled separately. Additionally, family therapy can be scheduled through the IOP, but outside of regular therapy days.

Success Rates for Intensive Outpatient Programs

Different approaches to treatment work better for different people, but intensive outpatient rehabilitation has worked well for countless people in overcoming addiction. A study published in 2007 found that those attending outpatient programs, including IOPs, did better than those in a standard residential treatment program: 73 percent experienced favorable outcomes for IOP and outpatient treatment compared to 60 percent for residential treatment at a nine-month follow-up point after program completion.

Intensive Outpatient Programs Covered by Insurance

Because intensive outpatient rehabilitation costs less than inpatient rehabilitation while providing a high level of therapeutic support and incentivization, many insurance programs are willing to cover this therapy, at least in part. Insurance companies usually require prior authorization or approval before reimbursement, and services for one person cannot be billed twice on the same day. Different insurance companies may work with different providers, like specific hospitals, mental health facilities, or physicians to provide treatment, so check with the specific insurance company regarding IOP treatment providers.

Each state has different certification requirements for IOPs as well, so check local laws to ensure a high quality of treatment. If the providers covered by insurance are not offering state-certified treatment, it may be worthwhile to find other IOP options. Medicaid will cover state-certified options for those who require additional coverage or different coverage.

If, for some reason, a certain IOP meets individual needs but is not covered by insurance, it is worth asking about payment plans or sliding scale options. One of the foundational principles of IOPs is accessibility, so they may be more willing to work with some clients.

Who Will Benefit from Intensive Outpatient Rehabilitation?

IOPs were originally developed around Caucasian, predominantly male, middleclass people struggling with cocaine addiction; however, the format has proven both popular and successful, and is being adopted for all kinds of substance abuse and addiction problems. Populations with specific IOPs serving them include:

  • People overcoming alcohol use disorder or problem drinking
  • Women struggling with addiction
  • People who are incarcerated
  • Those struggling with co-occurring disorders, or a mental illness alongside an addiction
  • Non-religious individuals

In general, those who have moderate medical needs, like a person tapering off an opioid dependence with buprenorphine, can do well in IOPs; however, people with more intense medical needs, like a person trying to end a long-term alcohol use disorder, will need more supervision. As a result, they should consider an inpatient detox and rehabilitation program to monitor their risk of dangerous withdrawal symptoms like seizures.

NIDA also notes that different forms of therapy work better for different substances.

  • CBT works well for those overcoming problem drinking as well as abuse of cocaine, methamphetamines, marijuana, and nicotine.
  • Contingency Management works best for those ending addictions to alcohol, stimulants, opioids, marijuana, and nicotine.
  • Community Reinforcement works well for those overcoming addictions to alcohol, cocaine, and opioids.
  • Motivational Enhancement Therapy is effective for those struggling with abuse of alcohol, marijuana, and nicotine.
  • The Matrix Model was designed specifically for those overcoming addiction to stimulants, from cocaine to synthetic cannabinoids.

An IOP may focus on a few types of therapy, so getting a referral to a program based on the type of drug the client has abused makes sense. However, other individual factors, like a sense of personal safety and community will also influence whether the type of therapy will meet the individual’s needs.

IOPs are not for everyone, but the format is flexible enough to work with many different populations who need help overcoming addiction or substance abuse problems. Insurance programs are also likely to cover them, at least partially, making access easier for more people.