Longer addiction treatment is a key to ending relapse-rehab cycle
Thirty days' treatment is the norm, but more facilities are offering programs to patients that extend to 45 days, 90 days and even longer.
By Shari Roan, Los Angeles Times
We love quick, tidy solutions in this country. With health problems, in particular, we're impatient.
Pills to ease each and every symptom? Great.
Same-day surgery? Terrific. A scheduled cesarean section? Bring it on.
But in the case of drug and alcohol dependence, it's becoming increasingly clear that there is no such thing as get-well-quick therapy.
Instead, with scientific evidence showing that the longer the treatment, the better the chance of lasting sobriety, addiction centers nationwide are lengthening their programs and firmly discouraging patients from early checkouts.
For more than a year, the Betty Ford Center in Rancho Mirage has offered a 90-day residential treatment program, in addition to shorter programs, that attracts about one-third of all clients.
Promises Treatment Center in Malibu now provides more than half of its clients with 45- to 90-day treatments and last year extended its young-adults program from 30 days to 90 days.
Visions, which provides adolescents with addiction treatment in Malibu, increased its program's length from 30 days to 45.
Hazelden, the legendary treatment program based in Minnesota, has added beds in nearly all of its facilities over the last two years to meet a growing demand for treatment programs of 90 days or more.
Addiction experts say that longer treatments -- with the length of stay based on the client's specific needs -- will lead to fewer people cycling between 30-day hospitalizations and relapses for years on end. From 40% to 60% of people relapse after drug treatment, according to the National Institute on Drug Abuse.
"Treatment is dose-related," says Dr. Harry Haroutunian, director of the licensed professional program at the Betty Ford Center. "More is often better, depending on what you do with the time."
Treatment programs of 28 or 30 days are still common. But this template was never based on medical evidence, says Dr. David Lewis, Vision's medical director.
Lewis, who in the 1970s helped establish the first addiction treatment program in the U.S. Air Force, says 30-day stays were scheduled for bureaucratic reasons -- men and women didn't need to be reassigned if they were away from duty for no more than 30 days. Other treatment centers followed suit, and insurers adopted the standard of 28 or 30 days of inpatient care.
Today, addiction experts recognize that it's foolish to treat every patient the same way.
"There was a belief that 30 days was the right number," says Dr. David Sack, chief executive of Promises and an addiction psychiatrist.
"But there was absolutely no data to say 30 days was the right number. . . . The programs were cookie cutters. What we're seeing now is this much broader view for how to manage addiction. There isn't this naive optimism that people will reach 30 days and they'll be fine."
In fact, data suggest 30 days aren't nearly enough.
* Research published in 1999 by Bennett Fletcher, a senior research psychologist at the National Institute on Drug Abuse, has shown that though 90 days isn't a magic number, anything less than that tends to increase the chances of relapse.
One study, of 1,605 cocaine users, looked at weekly cocaine use in the year after treatment. It found that 35% of people who were in treatment for 90 days or fewer reported drug use the following year compared with 17% of people who were in treatment for 90 days or longer. The study was published in the Archives of General Psychiatry.
* Another study, part of an NIDA-funded project called Drug Abuse Treatment Outcome Studies, followed 549 patients who had several problems in addition to their drug use and who entered a long-term residential program.
Those who dropped out of treatment before 90 days had relapse rates similar to those who stayed in treatment only a day or two. After 90 days, however, relapse rates dropped steadily the longer a person stayed in treatment.
* Studies of youth also reflect the connection between longer care and a greater chance of recovery. A 2001 UCLA study of 1,167 adolescents receiving substance-abuse treatment found that those in treatment for 90 days or more had significantly lower relapse rates than teens in programs of 21 days.
Some of the earliest evidence emerged from high success rates in treatment of addicted health professionals, says Haroutunian: The Federation of State Physician Health Programs has long recommended 90-day treatments and continued follow-up care for doctors who abuse drugs.
Longer treatment reflects the fact that addiction is a chronic, relapsing disorder, says Lisa Onken, chief of NIDA's behavioral and integrative treatment branch.
"The more you have a treatment that can help you become continuously abstinent, the better you do," she says.
"You have to figure out how to be abstinent. You still have cravings. You still have friends offering you drugs. You still have to figure out ways not to use. The longer you are able to do that, the more you are developing skills to help you stay abstinent."
Additional time in treatment allows people to learn to handle stress, develop ways to cope with environmental cues that could trigger drug use and improve relationships that are needed to sustain recovery.
However, time alone isn't a solution. Many addicts stop using for long periods of time while incarcerated but relapse after being released.
"There is no real evidence that just locking someone up, denying someone access to drugs alone, will cure an addiction," Onken says. "It's not just length of treatment that is important. It's length of treatment that is working."
28 days later
The first month of treatment is now viewed as a first step, Fletcher says. It often consists largely of coping with withdrawal symptoms and establishing a relationship with a therapist.
"People are often detoxifying for 28 days," Haroutunian says. "Their mind is not right. Their temperament is not right. They have emotional instability, poor judgment, physical complaints, sleep problems -- things that keep them in a very delicate state of vulnerability to coping with life stresses. If they are out there in the world after only 28 days and get flooded with these things, they are vulnerable to relapse."
Brain scans of recovering addicts support the idea that changes are still taking place three months or more after treatment. Chronic drug use damages the brain, such as reducing the number of dopamine receptors, chemical pathways that allow for normal brain functioning.
Changes in the brain during recovery correlate to clearer thinking and more honesty on the part of the patient, Haroutunian says. It's often only at that point that therapists discover other problems, such as physical or mental-health problems, eating disorders, gambling issues, relationship problems or a history of abuse or molestation.
"If that is not identified and treated, it can easily bring someone back to their original drug of choice," he says.
Haroutunian notes that Alcoholics Anonymous, founded more than 70 years ago, recommends: "90 meetings in 90 days."
"I think the founders of the 12-step program were divinely inspired in their wisdom, which science and data are now supporting," he says.
Trying to get clean
Drug abuse became a way of life for Steve Owens at age 11. After being molested as a child, he says, "I found drugs the only way to have comfort."
Owens abused cocaine, alcohol and prescription drugs, and later, heroin. By age 21, after numerous arrests on drug-related charges, he entered a 30-day treatment program. It was the first of 34 hospital stays he would experience over the next two decades, each time relapsing after the monthlong treatment ended.
"They would clean me up and I would start to get back on my feet again, mentally, physically and spiritually," he says. "Then I would get out and go right back where I came from -- the same friends and the same places. With these rehabs, you just get started before they let you go."
At one point, Owens, who is now 50, stayed clean for seven years. But after his brother died unexpectedly, he relapsed. He was living in Atlanta at the time and heard of Promises in Malibu. Twice he entered for 30-day stays -- stints that were followed by relapses.
When he flew to Los Angeles for a third try -- about five years ago -- he was so addled by drugs that he got on the wrong plane and ended up in restraints in a hospital psychiatric ward. He was released to Promises and told a therapist, "If you let me stay here, I'll do anything you say."
He agreed to 30 days of hospitalization followed by five months in a sober-living house from which he was free to come and go but where he also received daily counseling. After leaving the sober-living house, he attended a nine-month intensive outpatient group and completed a 12-step program.
The year he devoted to getting well "was the best thing that ever happened to me," says Owens, who now lives in Los Angeles and runs a nonprofit group that supports rehab for people who are homeless, as well as women with children.
"I got a chance to get on my feet the first 30 days and then I got a chance to get used to being clean and sober and staying away from the people I used to drink and use with. I was able to let go of the past and apologize to the people I've hurt. I became a free man."
However, it's tough to convince some addicts or their family members that three to six months of treatment offers the best chance of success. People argue that they can't leave their jobs, school or families for that long, Sack says. They want to put the problem behind them as quickly as possible.
"They want to believe it will be fixed up very quickly and they can go back to normal and not have to talk about it," he says.
Instead, he compares addiction to any chronic disease, such as heart disease or diabetes, in terms of the attention and perseverance needed to remain healthy.
Longer-duration treatment doesn't necessarily mean a hospital or residential stay, experts say. Some treatment centers and hospitals offer transition to a sober-living residence, where residents are free to go about their lives but also receive daily counseling.
The Betty Ford Center has about 15 houses, with six people to a home, to continue long-term care. The residences are designed to allow clients to return to more normal lives while offering support and advice in remaining drug-free.
"The supervision is light," Haroutunian says. "They go into the community. But they more or less report in every day for their program."
Some people would like to commit to a longer period of treatment but can't afford it.
Most states, including California, have laws mandating that group health insurance plans include addiction-treatment coverage, but insurance programs vary widely in the amount of inpatient care that is covered. Some plans cover 30 days of inpatient care per year, although other insurers will discontinue inpatient coverage after a week or two if a patient is physically stable. A few will pay for treatment that lasts more than 30 days.
Care is typically most expensive in the first month, Haroutunian says. At Betty Ford, the first month of inpatient treatment costs $24,000; the second and third months cost $8,000 each.
People without insurance coverage often pay out-of-pocket. The cost is overwhelming to most people, he acknowledges. "But we tell them it may save their life. Most people see the wisdom in that."
Intensive outpatient programs are becoming more common for people who cannot afford the steep price of long inpatient or residential care, Fletcher says. Successful care of that nature, he says, "means, on average, at least every other day having contact with a group or therapist."
In his counseling work, Owens says, he encounters resistance to the idea of spending three months or more devoted to nothing but recovery. People view it as a sacrifice, but he tries to reassure them they'll gain more than they lose.
"Even if you have to lose a job, so be it," Owens says. "You're trying to save your life. And what comes next could be the best part of your life."
Los Angeles Times November 10, 2008
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Photo by Dan Chavkin for Newsweek: Renaissance Malibu is one of a new generation of holistic, residential healing centers that can cost between $40,000 and $100,000 for a 30-day stay.
NOTE by AddictionInfo editor: Most rehab facilities are based on a twelve-step program. According to the article AA Is Not The Only Way, by Melanie Solomon, "The 12-step success rate is approximately 3 percent."