What is the recommended stepped‑care treatment plan using motivational interviewing (MI) and cognitive‑behavioral therapy (CBT) for individuals with substance‑use disorders?

Stepped-Care Treatment Plan Using Motivational Interviewing and CBT for Substance Use Disorders

Initial Screening and Stratification

After positive screening, stratify patients into three treatment tiers: hazardous use (brief counseling), substance abuse (brief counseling plus intensive follow-up), or substance dependence (counseling, specialty referral, and pharmacotherapy). 1

• Use validated screening tools like the Drug Abuse Screening Test-10 to identify problematic substance use 1
• Conduct comprehensive assessment covering physical, mental, and social factors associated with substance use 1
• Screen all patients with substance use disorders for comorbid mental health conditions, as rates exceed 50% in some settings 2

Tier 1: Hazardous Use

For hazardous substance use, deliver brief motivational interviewing counseling by a physician with ongoing assessment. 1

• Brief MI counseling alone has been shown to decrease quantity and frequency of drug and alcohol use 1
• Assessment and feedback alone can positively influence reduction of alcohol use 1
• Use motivational rather than confrontational communication style, as confrontation decreases motivation 3
• Resist the "righting reflex" - avoid telling patients what to do, as this generates resistance 3

Key MI Techniques for Hazardous Use:

• Employ the "elicit-provide-elicit" technique as a nonconfrontational approach to giving advice 3
• Use decision analysis ("pros and cons") to help patients articulate advantages and disadvantages of changing behavior 3
• Provide reflective listening to identify and mirror back statements supporting change 3
• Offer affirmations to promote self-efficacy, as most patients experience guilt and shame that undermines confidence 3

Tier 2: Substance Abuse

For substance abuse, provide brief MI counseling combined with intensive ongoing follow-up and reevaluation, with referral to treatment if abuse continues. 1

• Brief intervention consists of personalized feedback aimed to create deeper understanding of negative consequences and increase motivation for change 1
• MI delivered as standalone intervention has demonstrated significant improvement in substance use outcomes 1
• Implement Screening, Brief Intervention, Referral to Treatment (SBIRT) approach, which can be used in multiple settings 1
• Close follow-up is essential to monitor progress and escalate care if needed 1

Integration with CBT at This Level:

• Combine MI with cognitive-behavioral therapy, as these behavioral therapies demonstrate the most successful outcomes in reducing substance use 3
• CBT centers on encouraging patients to develop self-regulation, coping skills, communication, and problem-solving 1
• Previous research identifies CBT as one of the most successful treatment strategies in reducing substance use 1

Tier 3: Substance Dependence

For substance dependence, implement a combination of MI/CBT counseling, referral to specialty treatment, and pharmacotherapy, with ongoing assessment and support. 1

Pharmacotherapy Component:

• Prescribe buprenorphine/naloxone as first-line treatment for opioid dependence due to superior safety profile and ability to be delivered in outpatient settings 2
• Combine buprenorphine/naloxone with SSRI antidepressants if comorbid depression exists, as SSRIs have strong efficacy and no abuse potential 2
• Consider naltrexone, methadone, or drug tapering as appropriate alternatives 1
• Buprenorphine is the only FDA-approved medication to treat substance use disorder in adolescents (16 years and older) 1

Integrated Psychotherapy Approach:

• Deliver integrated group cognitive-behavioral therapy targeting both depression and substance use simultaneously if comorbid conditions exist 2
• Both conditions must be treated concurrently, as sequential treatment leads to worse outcomes for both disorders 2
• Implement collaborative care models, which produce significantly greater improvement compared to traditional sequential approaches 2

Contingency Management Addition:

• Add contingency management (CM), which uses reinforcers to promote desirable behaviors such as treatment attendance or reduction of use 1
• CM has demonstrated favorable outcomes in reducing substance use and enhancing treatment retention 1
• CM is simple to teach, affordable, and can easily be integrated with other practices 1

Treatment Setting Selection

Select outpatient treatment for patients with relatively stable and safe living environments; residential treatment is indicated for those needing stable, safe living environment with more severe addiction and multiple comorbidities. 2

• Early intervention to reduce or cease substance use (e.g., at first episode of psychosis) is likely to have increased benefits 1
• Intervention is recommended at any stage of the disorder 1
• Fluctuating or limited motivation to change is notable in this population, and motivation should be a focus in any intervention 1

Continuing Care and Recovery Monitoring

Encourage ongoing coordination of treatment and recovery needs with mutual support groups, peer specialists, and recovery monitoring. 1

• Support the use of sponsorship, clubhouse communities, and recovery schools 1
• Specific health events such as hospital admissions may present an opportunity to capitalize on motivation for engagement 1

Harm Reduction Strategies for Non-Abstinent Patients

For patients not committed to abstinence, frame harm reduction as an appropriate intermediate goal. 3

• Provide naloxone distribution, safe use education, and fentanyl test strips 1, 2
• Refer to needle exchange services for patients who continue injection drug use 2
• Examples include providing clean needles or avoiding driving while intoxicated 3

Evidence Quality and Comparative Effectiveness

The evidence comparing MI to no intervention shows moderate to small effects that diminish over time: strongest post-intervention (SMD 0.48), weaker at short-term follow-up (SMD 0.20), and minimal at long-term follow-up 4. When compared to treatment as usual, MI shows very small or no differences across most time points 4. However, MI demonstrates moderate-certainty evidence of benefit compared to assessment and feedback at medium and long-term follow-up (SMD 0.24) 4.

The certainty of evidence ranges from very low to moderate across different comparisons, requiring careful interpretation and expectation-setting with patients. 4

Common Pitfalls and Special Considerations

• Modification of content and delivery of therapy protocols may be required for patients with cognitive impairment or executive function deficits 1
• Address stigma, as it remains a significant issue and can negatively affect treatment engagement 1
• Ensure confidentiality is maintained when possible, as adolescents are more likely to disclose when care is confidential 1
• Support families and carers with education and both practical and emotional support to encourage sustained engagement 1
• Anticipate defensive reactions, ambivalence, guilt, shame, and lack of concern about substance use when approaching these patients 3