If a patient comes in and says, “doc, I think I need to go to rehab,” what should you do? Most people think of rehabs as residential facilities, but these days, the term “rehab” includes a broad spectrum of treatment settings, most of which, in fact, are not residential—only 10% of people receiving specialized addiction services go to residential rehab.
In this article, my goal is to help you understand the different levels of care that might be included under the rehab umbrella, so that you can get your patient the most appropriate care.
Before Rehab Treatment of addiction should begin well before rehab, and here are the commonly used options.
12-Step programs. AA or other 12-step Programs are non-professional groups provided for free in the community. These aren’t considered treatments per se since they don’t involve licensed counselors providing care to patients. But in the real world, many clinicians will view a referral to AA meetings as a convenient first step. How well AA “works” is a source of enduring debate. I often tell my patients that “it only ‘works’ if you work it—recovery is not a spectator sport.” AA is free and it provides your patient ongoing peer support from people who have achieved long-term recovery. In my opinion, everybody should at least give a 12-step program a try, because you never know who’s going to click with one.
Individual treatment. Many clinicians will start treating their addicted patients themselves. This is entirely appropriate, especially for motivated patients who are not using substances dangerously. Individual treatment can range from primary care doctors simply advising patients to cut down, to psychiatrists prescribing medications such as naltrexone or Antabuse, to therapists engaging patients in motivational interviewing or other therapeutic techniques.
Referral to a specialist. You’ve tried your best, but your patient is still using. It’s time to refer to a specialist. One of the key skills of addiction specialists is that they often understand what’s missing in recovery. For example, patients may not understand how best to use 12-step programs, and they may need guidance in how to choose the best meetings to attend. Or, they may need someone who can understand their comorbid psychiatric issues through the specific lens of addiction.
Who should you refer to? There are many therapists with an interest or certification in addictions. The most well-known national certification is through NAADAC, the Association for Addiction Professionals (formerly called the National Association for Alcoholism and Drug Abuse Counselors). In terms of MDs, there are two addiction specialties—addiction medicine, open to all specialties, and addiction psychiatry, open only to psychiatrists.
Another type of specialist is an interventionist, who is an addiction professional who specializes in orchestrating the sometimes dramatic interventions that have become popular fodder for reality TV shows. Usually it is the emotionally exhausted family that seeks this kind of help. An interventionist generally offers three services: planning and executing the intervention, finding an appropriate treatment program for the patient, and providing “recovery coaching” after treatment, often for a year or more. There’s usually a fee for each service, and insurance rarely if ever pays for this.
A great resource for locating specialists in your area is the SAMHSA treatment locator. Just type in your Zip code and you’ll get a list of nearby facilities.
Levels of Rehab Patients who have tried AA and individual treatment, but who continue to endanger themselves because of their substance use, will need some type of rehab. Here’s how the rehab landscape breaks down, with tips on who should be referred where.
Detox. Detox is the process of quickly getting your patient off drugs or alcohol. It’s often a prelude to rehab since it’s hard to make any headway in recovery while someone is actually using. While detox can be either outpatient or inpatient, inpatient treatment is best for those withdrawing from substantial daily alcohol use (such as a pint of hard liquor or 12-24 beers per day), and for those with medical problems. Inpatient rehabs usually lasts 3-5 days for alcohol and benzodiazepines and 5-7 days for opiates. How do you get patients into detox? If you know about some specific detox facilities in your area, the best route is to call them. Some centers will do their own screening, whereas others will require that your patient go first to an ER before referral.
Obviously, most patients would prefer to bypass the ER if they could. Another option is to start by calling the insurance company, which may have specific hoops to jump through before it will authorize treatment.
Intensive Outpatient Treatment (IOP). IOP is usually 9 hours per week of outpatient treatment, divided into three 3-hour sessions. These are generally group therapy sessions that offer rehabilitative counseling and educational classes. These programs are offered in either day or evening formats. IOP is best for people who are struggling with sobriety after detox, and who have a job or family obligation that prevents more time-intensive treatment. In some cases, the person may have limited insurance benefits that only cover IOP.
Partial Hospitalization Programs (PHP). Also known as “day treatment,” PHPs are usually 5 days a week, 6 hours per day, and last 10–15 days. These programs are much more comprehensive than IOPs. They tend to have more sophisticated therapy groups, such as dialectic behavior therapy, cognitive behavior therapy, and family therapy, and psychopharmacologists are available every day. In my experience, insurance companies will approve PHP primarily for patients with comorbid psychiatric disorders.
Residential Rehab. These are 30-day programs, and they vary widely in cost, philosophy, and personnel (see accompanying book review of Inside Rehab on p. 8). Residential rehabs are for patients who have a toxic or unsupportive home environment—they may live alone, or they may have family members who are actively using. They are also appropriate for those who have had repeated relapses at a lower level of care. The classic rehab is a very pricy, for-profit company providing a luxurious environment where payment is due up front. These can run $55,000 a month or more. A less expensive type of residential rehab is the 12-step immersion programs, which clock in at around $10,000/month. These less expensive facilities can actually be fairly luxurious (think big lodges and beautiful farms); they are cheaper because they are run primarily by people in recovery and by addiction counselors without advanced degrees. The programming in 12-step immersion is limited to AA—the minute you walk in you will be doing AA steps. Finally, there are some bare-bones residential rehabs covered by Medicaid. And for some patients, being in a less ritzy setting can serve as a motivator to avoid future rehab stints.
Long-Term Residential (also known as therapeutic communities or recovery houses). These programs last 6-12 months and are for people who relapse so frequently that they really need to be away from their community and spend time in a very structured environment. They learn to incorporate recovery skills in their lives and gain the self-esteem and confidence needed to create a network of people to whom they can reach out when they’re stressed. Some long-term residential programs are called “working houses” because they have a return-to-work requirement after 1-2 months.
Sober Houses (also known as halfway houses). A sober house is an independent living arrangement with minor oversight, and residents can stay for 1–2 years. Most have one full-time staff member who runs the office or a house manager but they lack professional counselors or programming. Residents are sometimes told, “Here’s your key. You can come and go as you want but everyone here is sober.” At other places, there is a curfew or restrictions on weekends away, especially for newcomers to the house. At some houses, individuals may move up along a “levels” system gaining increasing privileges with each level. There are expectations that residents will go to outside 12-step meetings frequently, at least 4 times a week, and that they will have weekly random drug testing. There is sometimes a requirement to find at least part-time work in the community. This is often a good segue from a residential program, because it provides some level of support and teaches people to take more responsibility for their recovery. Some people find that cannot maintain sobriety outside of sober houses.
Holding beds. Sadly, there has long been a shortage of residential beds. Because of this, there are many transitional stabilization units, otherwise known as holding beds. They are usually federally funded, and they provide a bare-bones facility where people wait for residential beds. The usual scenario is a patient who was just detoxed and needs residential treatment to maintain sobriety, but does not have the funds needed for a deluxe rehab. People may stay here for up to a few months as they are wait for placement.
Table: Flavors of Rehab: What Are the Options? Click to view as full-size PDF. A word on court-mandated treatment Referring patients to treatment is all well and good, but up to a third of patients in rehab facilities are there by court order, usually involuntarily. As a clinician, you might be involved in the process of forcing a patient into treatment, so it’s important to understand the process.
Many, but not all, states have a provision allowing court-mandated treatment. In Massachusetts, the process is called a “section 35,” which refers to a particular section of state law. This is used for patients who are out of control with their use but refuse treatment. The family comes to you and explains the ways in which their family member is a risk to themselves or others, such as: “He’s falling and hurting himself when he’s drunk,” “she overdosed on heroin and we barely got her to the ER on time,” etc… “What can we do, doctor?”
The procedure is the following. The family has to prepare a case for involuntary commitment. It will be in the form of testimony, but it is often augmented by medical reports, and even photographic evidence (I advise these families keep their cell phones at the ready and to take videos of the intoxicated behavior). A hearing is scheduled, and a judge weighs the evidence, and if he or she agrees that the situation is dire, will issue a writ of apprehension. The police will then go to the person’s location and bring him or her in handcuffs to court, where the patient hears the evidence, has a chance to refute it before the judge, and to state whether they will go willingly into treatment. If the person is committed involuntarily he or she will be taken to a state-funded residential rehab facility for up to 90 days. Do such involuntary commitments work? Often not so much. Patients are often released early if they agree to outpatient counseling and AA meetings, but this may be a ruse for getting back to the bottle. Nonetheless, this does give the family some respite, and it creates the chance, no matter how unlikely, that the patient will eventually buy into the need for treatment. Section 35 can be initiated by the family, the police, or any physician. The limiting factor is you have to go to court—something physicians are rarely willing to do.
A final word of advice—I recommend that you put in the effort needed to get to know the treatment centers and providers in your area. Go to a local IOP or PHP and sit in on a staff meeting. The more working relationships you have with addiction professionals, the more efficient you will be at referring your patient to the right treatment at the right place and at the right time.