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American Addiction Centers National Rehabs Directory

Who Should Go to Traditional Addiction Rehab?

In my previous column, where I reviewed evidence indicating no discernible differences in outcomes between outpatient and residential/inpatient treatment, I mentioned my intention to delve into the topic of “essential candidates for residential treatment.” Some experts I interviewed for Inside Rehab went so far as to say that residential/inpatient treatment is passé and that we should do away with it altogether, noting that for other chronic medical conditions, we don’t send people away from reality expecting a change leading to permanent recovery without continued recovery programs.

However, after visiting 15 residential/inpatient and outpatient treatment programs, I can see that there are times when people need help in a more intensive setting. One treatment professional I interviewed said, “We need that safe harbor for some people. There are advantages to having addiction, medical, and mental health care available all in one place. Sometimes, people just do better when they go away for 30 or 60 days and get right with themselves.” The director of that same program added, “Sometimes, people need to go away when they just can’t stop.”

Who Should Attend Drug or Alcohol Rehab?

When I first started writing Inside Rehab, I turned to Thomas McLellan, Ph.D., co-founder of the Treatment Research Institute in Philadelphia, thinking he could point me to a tool that determines who belongs in residential/inpatient treatment and who belongs in outpatient treatment. I was dismayed when he told me, “There is no assessment tool or test that definitively determines who should go where.”

Treatment programs widely use what are known as “ASAM criteria,” designed by the American Society of Addiction Medicine to provide a common language describing the severity of clients’ substance use and to guide their placement in the most cost-effective level of care (e.g., inpatient vs. outpatient). However, John Cacciola, Ph.D., an expert in the assessment of substance use disorder (SUD) and co-occurring disorders at the Treatment Research Institute, informed me that the placement criteria are very complicated to implement and generally not employed by treatment programs in any sort of rigorous manner.

I noted in my last column that although people with greater impairment are generally thought to have better outcomes if treated in inpatient rather than in outpatient settings, research overall doesn’t point one way or the other. The authors of a recent review of the literature as well as others I’ve consulted suggest that the need for more intensive treatment probably applies only to the most severe cases. An expert on who should be placed where in the addiction treatment system, James McKay, Ph.D., director of the University of Pennsylvania’s Center on the Continuum of Care in the Addictions, said that in his opinion, the limited segment of people who belong in residential care includes individuals who meet the criteria for a severe substance use disorder along with any of the following:

  • Current and significant major mental illness that is not reasonably controlled, such as bipolar disorder, depression, or schizophrenia along with behavior that poses a significant risk to the health or safety of themselves or others.
  • Suicidality, regardless of the nature of the underlying psychiatric disorder.
  • Significant medical problems that will be made much worse by further excessive alcohol and/or drug use and the recent inability to stop using.
  • Inability to achieve abstinence in an outpatient program, especially with a recent history of significant danger to themselves or others while intoxicated.

Who Should Consider Outpatient Rehab and Sober Living?

For people needing more structure than inpatient treatment and outpatient treatment alone, there are options other than rehab. Several experts advocate staying in a quality sober living facility while attending a good outpatient program. As Dr. McKay points out, this combination can result in much longer treatment for a fraction of the cost of residential.

One Outpatient Treatment Success Story

One patient, Anna, had great success with this option. With her long substance use disorder history, including daily methamphetamine use and multiple past treatment experiences, most would have said inpatient rehab was a must. When I met her during her intake at an intensive outpatient program while doing research, she was also living in a sober house with two of her children.

Eight months later, after she’d completed five months of outpatient treatment but was still living in the sober house, she said of the entire experience, “This was probably the best treatment I had, and it was the longest.” She reacted favorably to “still living on the outside, being part of the community and not confined to an inpatient facility.” She added, “Residential rehab is like you’re almost institutionalized and then they boot you out. Here, you have time to look for a house. You’re not kicked out of treatment to go back to only what you knew before.” Using a holistic approach, the facility had clients do community service and regular exercise, take parenting classes, and work on living skills.

About a year later, Anna bought a home and was enrolled in college. I just re-contacted her, and not only is she less than a year away from receiving her degree in corrections but she recently received her five-year medallion for being drug-free.

Some outpatient programs will facilitate a “supportive living” experience for out-of-towners. Minnesota Alternatives has accommodated clients from out-of-state who want to take part in its unique harm reduction outpatient program. Director Paula DeSanto, MA, LSW said, “Clients who come from out of state have not done well in sober homes, so typically they need to get low-cost studio apartments or hotel or motel rooms.” For those who want or need a more intensive experience, treatment time can be increased according to individual needs, and drug and alcohol testing is available.

Alternatives to Traditional Addiction Treatment

With increasing recognition that people with severe addictions don’t have the resources or wherewithal to get the help they need, some addiction treatment agencies are teaming up with healthcare providers to bring comprehensive care to the client in his or her own living setting. This is different than a traditional medical detox center or an inpatient or outpatient setting where clients leave home to attend treatment.

As a Minnesota-based addiction counselor working at a large HMO, Jason Hoffman runs such a program that’s designed for individuals who “are constantly in the system.” He explained that they’re people who often do well when they’re in treatment programs but not when they go home. Some have anxiety in group settings while others can’t access treatment programs. Others still don’t find Alcoholics Anonymous to be the right fit. Treatment with Jason is highly individualized, with a focus on life skills. And his relationship with clients can go on for months or years. As for cost, Jason told me that this model “can be just as cost-effective as sending people to treatment and then sending them home.”

The journey to recovery looks different for everyone, but fortunately, there are a range of settings to meet the needs of different patients. If you are interested in learning more about treatment options and health insurance coverage for rehab, contact American Addiction Centers at .

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