Whenever someone thinks of “rehab” or “addiction treatment”, the typical thought process involves someone “going away” from their home environment for 30 days and getting admitted to either a hospital building with staff in white coats or a picturesque setting of a beautiful college-like campus. They will usually require a medical detox and then they sit in circular groups and lecture halls and talk about their feelings. We could even cue a long, introspective walk down a path on a fall day, as they take in all they are learning in treatment and recognize how detrimental their addiction has been to themselves and others. There may even be a scene with an insightful doctor or therapist who wraps the patient’s experience into a nice little bow. There is typically a breaking point, an emotional freak out, and then catharsis, at which point the patient gets discharged. They are then assumed to be happy and healthy and ready to go home to their family and restart their lives in their new found recovery.
Prior to discharging there will inevitably be a scene with patients standing in a circle when a counselor or therapist says something along the lines of “look to your right and to your left. In a short time after leaving, one of you won’t be here”. Typically some short time after leaving treatment there will be a stressful life situation followed by a relapse. Perhaps a scene that shows the patient sitting in a 12 step meeting once or twice, if at all. For years, this has been the standard of care for addiction treatment: 28 or 30 days of inpatient treatment followed by some information by a discharge coordinator of local 12 Step meetings and perhaps a local therapist or outpatient treatment provider, little to no follow up by the patient or family on that aftercare plan, a relapse and the detrimental and potentially fatal idea that “treatment doesn’t work.”
This is certainly the idea of rehab and recovery that plays out in the movies and on television, but where did we as a society get this idea that this is what addiction treatment looks like? Well, the short answer is because usually, it is. This is what treatment for addiction has looked like in America for many years and often continues to look like for those people who seek help for a substance use disorder. The question we should be asking is “Why?” The answer, although way more complex an issue and not so black and white, is that we have been treating addiction incorrectly for a very long time.
The “traditional” 28-day model of addiction treatment, the model that everyone knows and instantly recognizes from movies and TV, was never a clinically-driven model. Since the 1980’s (and in some cases, long before that), we have been removing people from their lives for a month, treating them, and sending them back to life, to their families, and to work. But why? Why is this the case? Why have we been treating a chronic, progressive disease like addiction with an acute care model of 28-day inpatient rehab? If a patient was suffering from heart disease, diabetes, cancer or any number of other life-threatening diseases, would we send them away for 30 days to be treated and then have them return to life with no thought of long-term, follow-up care? Of continuing care? Of aftercare? Of course not. We would demand that all necessary treatment be given that would result in the best possible recovery outcome. However, due to the stigma surrounding mental health and substance abuse, this has not been the standard of treatment. For addiction, we have been treating a chronic, progressive illness with a short term educational model. Furthermore, thanks to the insurance companies who do everything in their power to deny treatment and to not pay necessary reimbursement for treatment, most patients can rarely get 30 days of inpatient treatment covered anymore. Many 28 and 30-day inpatient and residential treatment centers now struggle to get more than half that time covered by a patient’s insurance.
Why did the standard of Addiction Treatment become a 28-day inpatient model? According to many, there were several factors. The most important point to remember, however, is that the traditional 28-day inpatient programs were never based on clinical necessity or medical evidence. According to Dr. David Lewis, Medical Director of Visions in Malibu, California, this 28 or 30-day model was created first in the 1970’s for bureaucratic reasons. Dr. Lewis helped establish the first addiction treatment program in the United States Air Force in the 1970’s and, according to Lewis, that program and others like it were created because military personnel would have needed to be reassigned if they were away from duty for more than 30 days. Therefore, military personnel in need of treatment would not need to be reassigned if their treatment lasted 30 days or less. Thus, the 30-day treatment model was born. Around the same time, from a financial perspective, insurance companies began to adopt this 28 or 30-day model as the standard of care and would create contracts for treatment centers that would keep patients for that length of time. In short, treatment centers would get paid and therefore be able to treat patients if they would keep them for 30 days, while anything longer than that would make it more difficult for the treatment facilities to collect payment from the insurance companies. So bureaucratic and financial reasons are behind why the chronic, progressive disease of addiction (of course, as always, along with the stigma of addiction) began and still continues to be treated in a short term setting. Therefore, in an effort to stay open and operational, the majority of treatment centers were forced into what became the industry standard: 28 and 30-day models. Many provided high quality, comprehensive treatment but often were still handtied by having to work with patients for such a short period of time.
So what is the problem? Well, the answers to that question are too numerous to list. However, there are some major issues. First is this idea that inpatient treatment doesn’t work, relapse rates are through the roof and therefore, it seems fairly obvious that substance use disorder sufferers don’t recover. This idea that everyone knows someone who has been to treatment but they eventually relapsed. This idea that everyone struggles after treatment. This idea that when someone finally decides to seek help for their addiction, that treatment begins and ends with 30 days of inpatient. This idea that years of an addiction (and often underlying mental health, behavioral and trauma issues) can be adequately treated with 30 days of treatment. This idea that addicts consistently have trouble staying sober. Well, if the treatment they are receiving is not the most adequate, then yes, the results we would see as a society are those results we have been seeing for decades: Poor success and high relapse rates. Growing numbers of overdoses. Additionally, because the statistics show treatment typically “doesn’t work” and relapse is likely, then a scared population eventually turns to outside-the-box efforts. Things like “The Cure”, rapid medical detoxes, Ibogaine and now the ever popular “evidence-based” pharmaceutical model of addiction treatment, Medication AS Treatment (it is important to note here that Medication-Assisted Treatment certainly has a role to play in the treatment of addiction, but it is certainly not by an individual doctor with 9 hours of online addiction training who is “treating” 200 patients, purely with just medicine) are what a terrified population turns to in the middle of an opioid epidemic. The traditional way of treating addiction hasn’t been working overwhelmingly well because it couldn’t possibly work well for the majority of patients. We have been working from behind the eight ball this whole time.
Fortunately, over the course of the last several decades, some of the most world renowned 28 and 30-day treatment facilities saw the need to expand services and offer a way for those in need to get treatment that lasted longer and was more effective than just 28 or 30 days. Best-in-class treatment facilities like Caron Treatment Centers (www.caron.org) and Hazelden Betty Ford (www.hazeldenbettyford.org) found ways to innovate, expand and increase their services in order to offer more comprehensive and individualized treatment, extended care and transitional models of treatment. Other traditional 28 and 30-day model facilities began partnerships with centers that offered extended care services in order to send discharging patients back home but in a way that they could receive longer term treatment.
So what is the answer? The issue is we have been treating a chronic, progressive, ultimately fatal illness with an acute model for many years, so the answer is to treat such an illness with longer-term comprehensive treatment that is individualized for the patient in terms of clinical work, medical need, recovery support, family engagement, and scheduling. The answer is a continuum of care that BEGINS with an acute level of treatment (detox, residential rehab) but then continues through extended care, intensive outpatient and structured sober living; a model that incorporates intensive family engagement throughout the treatment process, full involvement in some sort of recovery community and a transitional model that has the patient working or enrolled in school and fully self-supporting when they finally disengage from treatment. The answer is that recovery from addiction takes time, effort and support and therefore time is our friend. The answer is that addiction is a complex illness that impacts the rewards center of the brain, behaviors, personality, decision-making, relationships, coping skills, trust, and family dynamics. Addicts and alcoholics have taken years to build up walls to protect themselves, habits, pathologies, manipulative practices and most likely have some form of trauma that all needs to be dealt with in order to heal and to recover. Does this complex illness with so many moving parts and so many spokes on the wheel of addiction sound like something that can be adequately and effectively treated in 28 or 30 days?
Fortunately, there are many amazing quality providers throughout the country that also recognized the need that a complex illness like addiction needs a truly long-term, comprehensive solution. They have worked, as a single entity or through partnership with like-minded, quality providers at different levels of care, to create the long-term, comprehensive solutions necessary to treat addiction. However, we as an industry and we as a society need to begin to educate individuals, families and the public what to expect when someone seeks treatment: that 28 days is the beginning but that the best possibility to overcome the addiction successfully is with long-term care. When a patient and their family walk into a doctor’s office to discuss their loved one’s heart disease, they are given a plan for immediate treatment, as well as a long-term comprehensive plan of action and follow-up care. They are given information on what the next several years of their life will look like in terms of treating the disease and receiving support in terms of ways to positively impact physical and mental health, diet, behavioral modification needs and stress. Addiction should be no different. When someone in need of treatment or their loved one calls a treatment center, an interventionist, a counselor or (God forbid) a generic 800 help line that they found on Google, what should happen is direction to the most clinically-appropriate facility where they receive a fully comprehensive, long-term transitional plan of action that details at minimum with what the next year should look like for the patient and family. Research indicates that individuals suffering from addiction need AT LEAST 3 months in treatment and that the best recovery outcomes occur the longer a patient is in treatment. So 90 days minimum is the clinical starting point.
We have been treating addiction all wrong—28 and 30 day programs were forced into a box from a bureaucratic and financial standpoint and insurance companies continued the practice by limiting funding to this inadequate timeframe. Now those same insurance companies claim things such as inpatient detox isn’t a “medical necessity” for opioid addiction and that patients only need 15-20 days of residential treatment. Then those same insurance companies turn around and authorize 3-5 days of less intensive care, all the while those suffering from a chronic, progressive disease are in need of MORE care and LONGER-TERM care. Addiction impacts every aspect of a person’s life, both internally and externally, and therefore in order to be successful and effective, treatment needs to be comprehensive and long-term. So throw out all the statistics you want about “poor success rates” and “high relapse” rates but where is the outrage? Where is the anger over insurance companies refusing to pay for treatment or cutting off treatment early? Where is the disgust when a patient or family is told by an insurance company that the patient “needs to fail at a lower level of care” before they will authorize inpatient treatment? Where is the education for parents and families about the need for longer treatment? If the clinically appropriate treatment for a certain type of cancer was 12-16 weeks of chemotherapy but we were only treating it for 4 weeks, how successful would those recovery outcomes be? How high would the “relapse rates” be with that “standard of care”?
Additionally, where is the outrage within our own industry? When does the industry start taking some responsibility to regulate itself and say, “We are going to provide what we believe is the best possible treatment for our patients regardless of the pressures from BIG insurance and Big pharma.” Where is our outrage? When will we begin to say enough is enough? That we won’t let companies more concerned with their margins and their bottom lines dictate patient care? When will we as an industry decide that what is best for the patient needs to supersede the standards set by insurance companies and begin to set our own standards, in turn forcing the insurance companies to begin paying for adequate treatment? Our children, our loved ones, our citizens are dying. We can no longer sit idly by and say this is how things have always been done so let’s just keep doing it, hope for the best, hope insurance companies will pay for some treatment, because after all some is better than none. We need to demand the highest quality, most effective treatment for addiction regardless of how it has always been done.
By some accounts addiction is taking 115 lives a day in this country and those numbers will continue to rise unless we begin to change the paradigm. We need longer term, comprehensive, effective treatment that not only creates remission of the addiction but also creates and sustains a high quality of life. We need treatment solutions that not only talk about treating the substance abuse but deal with all aspects of the patient’s life, because their addiction negatively impacts all aspects of their life. Addiction is a fatal disease if left untreated and it impacts millions of people in this country. Those people deserve to be offered what actually works and therefore we need to advocate that the best and most effective treatment options be available to all.
If you or someone you know is in need of help because of drug and/or alcohol abuse or addiction, please give us a call. Maryland Addiction Recovery Center offers the most comprehensive dual diagnosis substance abuse treatment in the Baltimore, Maryland, Washington, DC and Virginia area. If we aren’t the best fit for you or your loved one, we will take the necessary time to work with you to find a treatment center or provider that better fits your needs. Please give us a call at (410) 773-0500 or email our team at [email protected]. For more information on all of our drug addiction and alcohol addiction services and recovery resources, please visit our web site at www.marylandaddictionrecovery.com.