Sign up as a user (no pun intended) and receive emails with new articles (Click Here). "Drug rehab" is the usual term used to refer to intensive "treatment programs" for alcoholism or addiction. These same facilities and programs often also include mental health treatment, which is highly useful, given the close relationship between addictions and mental health disorders (see "The Link Between Mental Health and Addiction / Alcoholism" Click Here). These treatment programs can be residential (inpatient) - where the person lives at the facility under 24 hour monitoring during the program - and outpatient - where the person lives on their own but attends the treatment program during the day on weekdays. We will discuss each of these types of program separately below. A drug "rehab" program may be preceded by detoxification, if warranted. Most programs require people to attend a separate detox facility prior to attending, or to provide clean urine samples prior to attending. Most are not geared to detox, and don't want people having detox health issues while at the facility. Residential treatment should be followed by an ongoing program of recovery so that there is a continuum of care (such as a Twelve Step program Click Here, or SMART recovery Click Here). Graduating from an intensive rehab program is just the beginning of recovery, and no one comes out of it "cured." I have seen many times, many times, when people come out of a rehab program and just insert themselves back into their lives as if all was well and they end up back in the throes of their drug or alcohol use in short order... they had no plan for ongoing support and recovery. Many rehab programs have a once a week "after-care" program for a short while, but this isn't enough. Fortunately, many - if not most - rehab programs are Twelve Step based, so people come out of the program already grounded in that ongoing program, although it is up to them to carry on with the Twelve Step program after leaving rehab.

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I write articles that closely tie in the research evidence, and I was surprised at how little research has gone into looking at the effectiveness and proper use of various rehab options. Two aspects really stood out: 1) the lack of research to identify who would benefit most from residential rehab versus outpatient rehab, and 2) the effectiveness of combining medication therapies (such as Methadone, Suboxone, etc.) with rehab programs. Certainly we researchers have a lot more work to do.

The gap between who needs rehab and who gets it

(Note about the statistics presented here: NSDUH is the primary source of statistical information on the use of illegal drugs, alcohol, and tobacco by the U.S. civilian, noninstitutionalized population aged 12 or older. Conducted by the Federal Government since 1971, the survey collects data through face-to-face interviews with a representative sample of the population at the respondent's place of residence. The survey is sponsored by SAMHSA, U.S. Department of Health and Human Services, and is planned and managed by SAMHSA's Center for Behavioral Health Statistics and Quality (CBHSQ). All of the statistics and facts presented are taken from the references listed at the bottom of this article.) In 2013, in the United States, 22.7 million persons aged 12 or older needed treatment for an illicit drug or alcohol use problem (8.6 percent of persons aged 12 or older). Of these, 2.5 million (0.9 percent of persons aged 12 or older and 10.9 percent of those who needed treatment) received treatment at a specialty facility. Thus, 20.2 million persons (7.7 percent of the population aged 12 or older) needed treatment for an illicit drug or alcohol use problem but did not receive treatment at a facility. Of the 20.2 million persons aged 12 or older in 2013 who were classified as needing substance use treatment but did not receive treatment at a specialty facility in the past year, 908,000 persons (4.5 percent) reported that they felt they needed treatment for their illicit drug or alcohol use problem. Of these 908,000 persons who felt they needed treatment, 316,000 (34.8 percent) reported that they made an effort to get treatment. Based on combined 2010-2013 data, the most commonly reported reason for not receiving treatment among this group of persons was a lack of insurance coverage and inability to afford the cost (37.3 percent). Sadly, there have been reports in the media about people is some U.S. states deliberately committing crimes and getting arrested so as to be able to access state-funded rehab programs that are available to prison inmates but not to the general public. It's bad out there.

Inpatient (Residential) Programs

Residential treatment is for individuals with substance use and/or co-occurring mental and substance use disorders who need structured care. Treatment occurs in non-hospital, licensed residential facilities. Residential treatment provides structured 24-hour care that provides a safe and supervised place to live - removed from the person's potentially toxic home environment - and enables a focus on intensive recovery activities. Its purpose is to help people to become stable in their recovery before returning to an unsupervised environment. These facilities are staffed by addiction and mental health professionals who run a program involving counselling, education, and mutual- and self-help group meetings. There are usually strict rules regarding behavior, curfews, and attendance, and contravention of the rules often results in expulsion from the facility. The length of stay in residential treatment varies program-by-program, but in general the duration of stay has shortened considerably over time; most planned stays now range from weeks to months, depending on the program and the person’s needs. Most are between 3 weeks and 3 months. Continuity-of-care for substance use treatment is critical. After completion of residential treatment, participants really need to step down to an ongoing program and plan of recovery on a continuing basis. A specific type of residential treatment is a "therapeutic community." The U.S. National Institute on Drug Abuse (NIDA) defines a therapeutic community as a residential treatment facility with prolonged lengths of stay: six to 12 months. The research on the effectiveness of residential treatment services produced mixed results, with some studies indicating positive findings and others showing no significant differences in outcomes between people in residential treatment settings and those in other types of treatment. However, it must be pointed out that there is a wide variety among residential treatment facilities and each facility may have different success rates for different people. For example, I am aware of one facility - a very expensive one - where the approach to recovery is based on "hydrotherapy." The patients are dehydrated every day with prolonged sauna baths and then rehydrated with bottled water after. The idea is that the body is "de-toxified" of the things that make one use drugs. Needless to say, the effectiveness of that program would be very low. On the other hand, some of the Twelve Step based programs with a serious well-rounded science-based approach to care with good transitions to continuing in a Twelve Step program after discharge can be very effective indeed. There is a dark side to residential treatment programs that must be mentioned. Almost all these facilities are privately owned and operated enterprises, and inevitably there will be situations where the choice between what will make the most profit and what is best for the patients will be in conflict, and the profit will win out pretty much every time. Sometimes the profit-seeking amounts to outright scandal and fraud. In May 2016, in Canada, there was a hugely publicized arrest of a man who owned and operated a chain of residential rehab facilities, known as Addiction Canada, for defrauding patients to the tune of $6.1 million by using fake doctors, and for submitting fake health insurance claims for payment. Interestingly, he was also charged with drug trafficking, money laundering, and possession of the proceeds of crime. Reportedly, he recruited patients from his rehab programs to distribute drugs. More famously, in the U.S., the self-proclaimed “Rehab Mogul” and owner of a chain of high-end L.A. rehab facilities, was arrested in 2016 for drug transport and sale, and has been charged with insurance fraud and illegal operation of facilities. I think it is safe to say that both these highly placed rehab “gurus” were not making decisions for the benefit of their patients. Several facilities that I am quite familiar with in my capacity as a doctor are quite motivated by profit and there is a tremendous push on the doctors who work there to keep the beds filled with patients with private insurance coverage - the highest payors. Either way, the important thing is this: will a residential treatment facility help YOU? Residential treatment programs are especially suitable for people who must get away from their present living situation if they wish to recover, those who have failed outpatient rehab programs, those who know nothing about addiction and recovery and are motivated to learn, and those with other health problems besides addiction, especially mental health problems. If in doubt, a residential rehab program is probably the best way to start out in recovery, if a person can afford it. Having said that, many people for whom residential treatment is not an option find a strong and life-long recovery without it. I am one of those people. The key to success for the person attending a residential rehab program is this: attitude. People get out of them what they put into them. If they go there with a negative attitude (the bed here is uncomfortable, I hate my roommate, the food here sucks, that couselor is stupid, I can't believe I'm stuck here for three weeks, etc.) then they will probably not succeed. If, however, they go there with a positive attitude (this is my chance to save my own life, I'm going to learn everything I can, I will succeed, I'm going to do everything they suggest to me, etc.) then the chance of success is much higher. Another rehab option involves outpatient rehab.

Intensive Outpatient Programs (IOPs)

Substance abuse intensive outpatient programs (IOPs) are basically rehab programs where the participants live at home and attend classes and meetings during the day. IOPs are alternatives to inpatient residential treatment. They are designed to establish  supports and facilitate relapse management and coping strategies. IOPs treat individuals with substance use disorders or co-occurring mental and substance use disorders who do not require medical detoxification or 24-hour supervision. They provide a specified number of hours per week of structured individual, group, and/or family therapy as well as education about substance use and recovery. IOP services offer a minimum of 9 hours of service per week in three, 3-hour sessions; however, some programs provide more sessions per week and/or longer sessions per day, and many programs become less intensive over time. Because services are provided in outpatient settings, the duration may be longer than that required for inpatient services. IOPs allow individuals to remain in their own homes and communities, which may improve their adjustment to community life. All studies reported substantial reductions in alcohol and drug use between baseline and follow-up. However, substantial variability in the operationalization of IOPs and outcome measures was apparent. IOPs are an important part of the continuum of care for alcohol and drug use disorders. They are as effective as inpatient treatment for most individuals seeking care.  There is a high level of evidence—with the caveats previously noted—that IOPs are equally effective when compared with inpatient and residential treatments. Compared with inpatient care, IOP services have at least two advantages: increased duration of treatment, which varies with the severity of the patient's illness and his or her response, and the opportunity to engage and treat patients while they remain in their home environments, which affords the opportunity to practice newly-learned behaviors.

Recovery housing

Access to stable and supportive housing is an important component of establishing and maintaining recovery. Research suggests that maintaining recovery gains may be difficult for individuals who are not living in stable housing situations, and environmental cues may play a role in triggering relapse. This is especially important for people new to recovery who do not have somewhere safe (from drugs or alcohol) to live. If someone comes home from detox or rehab and lives in an apartment with a roommate who is still using and with friends who keep coming by with a case of beer, then the chances of maintaining recovery are greatly diminished. Recovery housing generally consists of alcohol- and drug-free residences, such as sober living houses. Recovery housing is often provided to individuals after they have been in an inpatient or residential treatment program or during their first few months of recovery or sobriety. Recovery housing is not a formal treatment; rather, it is a service that supports recovery during or after treatment. Sober living houses are usually peer-run residences where small- to medium-sized groups of individuals in recovery live in single or shared bedrooms with common living areas. Individuals are expected to work, contribute rent, and participate in the responsibilities of running the household. Abstinence is an expectation, and individuals who relapse may be asked to leave the house because their behavior threatens the recovery of others. Sober living houses generally do not incorporate a structured recovery program, although residents often are required or strongly encouraged to attend 12-step meetings, and they may choose to participate in formal treatment (IOP) or aftercare.  ...and because... who needs the extra drama! Recovery housing is an essential part of preparing for or transitioning to an independent life in the community. Recovery housing frequently facilitates access to support services and treatment utilization, such as case management, therapeutic recreational activities, and peer coaching or support. Often working in partnership with treatment or recovery programs, recovery housing options may provide transportation, in-house counselling, or mentoring. Recovery housing is often used by individuals who do not or no longer require higher levels of care, such as hospitalization or long-term residential treatment. Individuals who utilize recovery housing may need assistance with activities of daily living (such as managing finances) or reminders and support to attend treatment, take medications, or abstain from alcohol and drug use. For these individuals, recovery housing may be a step on the way to independent living. It should be noted that there is concern that individuals who utilize abstinence-contingent housing may be at risk for housing instability if relapse occurs and they are asked to leave the house. The research literature suggest that recovery housing can have positive effects on many aspects of recovery and that this service has an important role to play in supporting individuals with substance use disorders. Studies indicate that outcomes were better with longer stays in the recovery house. I am a big supporter of recovery housing, and I have seen many people with disastrous life circumstances pull their lives together and get a great start on life while staying at a recovery house. Many of them have not attended a rehab facility and went straight into recovery housing from detox. The individuals staying at these houses tend to pull together and provide an excellent mutual support system. I have noticed that there is a tendency for people to leave the recovery house early, eager to get started in independent living, only to fall because they were not yet ready. Usually, they leave prematurely against the advice of the counsellors at the house. There is no right or wrong reason to choose residential rehab, IOP, and/or recovery housing. The important thing is for each individual to make an informed choice. Many people have no choice, because rehab is not a viable financial option for them. Many people, myself included, found stable long-term recovery solely by involvement in a recovery program, such as a Twelve Step program. References: McCarty, D., Braude, L., Lyman, D. R., Dougherty, R. H., Daniels, A. S., Ghose, S. S., & Delphin-Rittmon, M. E. (2014). Substance Abuse Intensive Outpatient Programs: Assessing the Evidence. Psychiatric Services (Washington, D.C.), 65(6), 718–726. http://doi.org/10.1176/appi.ps.201300249 Reif, S; George, P; Braude, L; Dougherty, R; Daniels, A; Ghose S; & Delphin-Rittmon M. (2014, March). Residential treatment for individuals with substance use disorders: Assessing the evidence. Psychiatric Services (Washington, D.C.), 65(3), 301-312. http:// DOI: 10.1176/appi.ps.201300242 Reif, S; George, P; Braude, L; Dougherty, R; Daniels, A; Ghose, S; & Delphin-Rittmon, M. (2014, March). Recovery housing: Assessing the evidence. Psychiatric Services (Washington, D.C.), 65(3), 295-300. https://doi.org/10.1176/appi.ps.201300243 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality. (Spetember 2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf