NPR recently did a short piece on the origins and merits of the traditional 28-day inpatient addiction treatment program.

When I entered the addictions field, the recommended length of stay at the newly minted Alcohol and Other Drug Treatment Center was actually 21 days. That was thought to be the span required to begin altering an established behavior pattern (such as alcoholic drinking). Later on it was modified to 28 in recognition of the fact that most patients spent the first week in a fog, struggling through withdrawal.

Our many opiate patients, however, received only 5 days of detox, due to Medicaid restrictions. The vast majority were chronic heroin or polydrug users, and it wasn’t unusual for them to drive an hour or more, or take Greyhound, to get to our facility. Still, five days was it.

At discharge, we referred opiate patients to methadone maintenance or in some cases, a therapeutic community. Those who declined our recommendation (the majority) took off for parts unknown. In the discharge summary, this was referred to as ‘pursuing own plans’.

After a couple years, the State ran into budget problems, and the Medicaid benefit was summarily cancelled. I recall one of our other patients, a respected lobbyist, leading a delegation of hospital officials to the state capital in an unsuccessful attempt to restore coverage. Shortly thereafter the hospital reacted by shuttering the addiction program and transferring the remaining patients to the psych ward, where I suspect the CEO thought they belonged anyway.

Then managed care arrived. In recent years, the average length of stay at inpatient programs I’ve visited hovers around 18-19 days. Some ¬†payers limit it to 10-14. That’s for those who qualify for inpatient, which the majority do not. It’s ironic, because given the increased acuity of the inpatient population– mental health and medical problems, unstable living situations, the ever-present danger of OD fatality– it’d probably be smart to hang on to them longer. As any case manager knows, making a referral can be a challenge, since many fall by the wayside during transition to another provider, different therapist, etc.

Inpatient counselors affirm that those who go on to some type of extended residential care seem to do better than those discharged straight to outpatient. I can’t confirm that statistically. It might, however,¬† explain the rapid growth of the recovery home movement.

Although outpatient programs are far cheaper to operate, it sure looks to me as if residential services remain very much in demand. But our expectations may need adjusting. Some areas where residential treatment hasn’t met those expectations:

It doesn’t seem to make a real difference in long-term outcomes. George Vaillant made this point way back in 1988, based in a review of research. It’s still valid.

It doesn’t prevent someone from resuming use shortly after discharge. And this is a source of great disappointment to loved ones and professionals both.

It doesn’t eliminate the ‘revolving door’. Unfortunate, because that was its original purpose — to interrupt the cycle of repeat detox admissions. The 28 day length of stay may have improved things somewhat, but it clearly doesn’t qualify as a solution.

On the other hand, I can see some clear benefits to residential services:

It ensures safety during withdrawal. To me, that’s important. I’ve noticed that where residential detox isn’t available, withdrawal often occurs at home, without supervision, and involves a host of substances self-administered by the anxious, sometimes confused patient. That’s not a good thing.

It reduces the risk of further drug use during treatment. In my experience, such use is common in outpatient programs. It shouldn’t be a mystery why someone relapsed post-treatment if they never stopped using in the first place.

It can provide additional motivation for recovery. The residential experience, with its group dynamic, does seem to increase motivation for many people. Not enough to avoid future lapses, but perhaps sufficient to motivate continued treatment.

So as long as society can overcome the twin barriers of availability and affordability, I can’t see why residential programs wouldn’t qualify as a desirable component in a community’s service continuum.