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Helping Patients Step by Step

May 1, 2008
by Kristen J. Quinlan, PhD
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A program finds success with the motivated stepped care treatment model

For the past decade, the Addiction Treatment Services (ATS) Unit at Johns Hopkins Bayview Medical Center in Baltimore has been working to improve treatment outcomes for opioid-dependent patients using a motivated stepped care treatment model. The Joint Commission recognized ATS's approach a few months ago with its 2007 Ernest A. Codman Award in the behavioral healthcare category. The award is more than just a testament to ATS's success, as the model has the potential to be replicated at opioid treatment programs (OTPs) across the country.

ATS's Model

The motivated stepped care treatment model uses a four-step intervention strategy (figure). Each step represents an increase in the intensity of care. Patients who do not respond well to treatment, evidenced by positive drug screens and missed counseling appointments, are advanced to higher levels, or steps, of clinical care.

Figure. The adaptive motivated stepped care approach. Figure prepared by Robert Brooner

In the highest level of care, patients may receive up to nine hours a day of group and individual treatment. In contrast, patients who adhere to their treatment plan may receive less intensive services. At the lowest level of care, patients are seen only for individual counseling once every two to four weeks.

“The principle behind adaptive stepped care is to actually use the lowest intensity, least costly, and least demanding schedule of services necessary to initiate and sustain good clinical response,” explains Dr. Robert Brooner, a professor of psychiatry and medical psychology at the Johns Hopkins University School of Medicine and ATS director.

This stepped care approach is strengthened by a behaviorally based contingency system that motivates patients to adhere to their treatment plans. Patients who attend their counseling sessions and have drug-free screens are provided access to less demanding treatment schedules and are offered more convenient treatment times. On the other hand, patients who do not adhere to their treatment plan eventually experience a methadone taper and discharge from the program, with the opportunity for rapid re-admission (often within 24 hours) should they agree to attend all scheduled treatment sessions.

The success of ATS's approach has been well-documented. Patients treated with the motivated stepped care model demonstrate higher rates of counseling session attendance than comparison groups that do not receive reinforcement for therapy attendance (83% vs. 44%, respectively).1 Motivated stepped care patients are less likely than those in standard stepped care to produce opioid-positive urine samples (20% vs. 30%, respectively).1

The motivated stepped care model has been successfully modified to generate a variety of other positive behavioral outcomes, including reduction of marijuana use,2 employment attainment,3 and acquisition of drug-free social contacts.4

Dr. Nora D. Volkow, director of the National Institute on Drug Abuse (NIDA), which funds Dr. Brooner's research, hails the motivated stepped care model as “a practical and cost-effective approach that reflects NIDA's evidence-based research—focusing on tailoring services to fit the patient's needs and adjusting treatment based on patient progress.”


The Joint Commission issues the Codman Award to accredited applicants demonstrating innovation in using process and outcome measures to improve organizational performance and quality of care. Dr. Mary Cesare-Murphy, executive director of the Joint Commission's behavioral healthcare accreditation program, says the Codman Award selection committee focuses especially on a few key criteria: “[The program] has to be evidence-based, it has to be data-driven…. It has to be something that would be meaningful for other organizations—something that is not just the general standard of practice.

“The Codman selection committee is always interested in an activity that can be replicated,” Dr. Cesare-Murphy adds. In fact, because ATS's program has been able to sustain itself using a funding level similar to other publicly funded treatment programs, replication is feasible. “The work of Johns Hopkins is important because other OTPs can use that as an example and try it,” Dr. Cesare-Murphy concludes.


Dr. Brooner notes that replication of the motivated stepped care model is more feasible than administrators of other OTPs may initially believe. He observes that one perceived challenge to replication is program cost, but Dr. Brooner points out that the motivated stepped care approach is more cost-effective than traditional fixed-service programs. Cost savings are realized by using senior clinicians to provide the highest intensity of treatment services.