When Amy Winehouse belted out, "I don't want to go to rehab" in her Grammy-winning signature song, she may have been onto something. She reportedly did go to rehab for several short stints before alcohol poisoning tragically took her life in 2011, when she was just 27. In a section about the Amy Winehouse Foundation at the end of his book, Amy, My Daughter, Mitch Winehouse noted – with apparent dismay – that “some senior civil servants” told him they viewed residential rehabilitation as “an expensive luxury,” and that their solution was to treat people in the community.
As it turns out, despite popular thinking that rehab is the sine qua non for addiction recovery, “treating people in the community” – or outpatient treatment – is just as helpful as residential rehab for most individuals struggling with substance use disorders. Multiple studies have documented that the two forms of treatment have similar outcomes, despite the fact that the media and even many professionals continue to perpetuate the notion that if you have a substance problem, “you’ve gotta go to rehab.”
A recent review of scientific studies published in the June 2014 issue of Psychiatric Services, reaffirms that outcomes do not differ significantly between residential/inpatient and outpatient treatment.
Re-Affirmation of Old Findings
Before taking a look at the new study, it’s important to note that treatment – be it outpatient or residential/inpatient – isn’t a prerequisite for recovery. In fact, most people get a handle on substance use disorders completely on their own, by attending self-help groups, and/or by seeing a therapist individually. Of those who do seek treatment, the vast majority wind up in outpatient settings. Often it’s suggested or even required by health insurance companies that you go to outpatient treatment before going to residential. According to the most recent National Survey of Substance Abuse Treatment Services (2012), about 90 percent of all clients in treatment were in outpatient settings, and only 9 percent were in residential non-hospital treatment. (Another 1 percent were in hospital inpatient treatment.)
For the new review, a team of researchers, headed by the Oregon Health and Science University’s Dennis McCarty, Ph.D., examined studies on outpatient treatment of addiction published from 1995 to 2012, only including research that compared effectiveness of what they termed “intensive outpatient treatment” (IOP) to inpatient services for adults. For the purposes of the study, they described IOPs as programs offering a minimum of nine hours of treatment per week in three, three-hour sessions. Dr. McCarty told me that inpatient treatment was generally considered, “staying in a program and sleeping there in a bed – for instance, in some studies it was inpatient care in a hospital and in others it was residential non-hospital treatment [or what most of us think of as ‘rehab’].”
In comparing studies of inpatient treatment and IOP services, they concluded that the results “are consistent and similar: outcome measures of alcohol and drug use at follow-up show reductions in substance use and increases in abstinence, and outcomes do not differ significantly..."
What did they find? First, after reviewing the multiple high-quality studies available to them, the level of evidence for IOPs as a form of treatment was rated by the experts as “high.” In comparing studies of inpatient treatment and IOP services, they concluded that the results “are consistent and similar: outcome measures of alcohol and drug use at follow-up show reductions in substance use and increases in abstinence, and outcomes do not differ significantly between inpatient and IOP settings… Overall, studies found that 50 to 70 percent of participants reported abstinence at follow-up, and most studies found that this outcome did not differ for inpatient versus outpatient settings of care.”
Even though it’s generally thought that people treated in residential settings have more severe substance problems than those treated in outpatient treatment, and a few studies suggest that patients with greater impairment may have better outcomes if treated in inpatient settings, overall, the studies didn’t point one way or the other when it came to suggesting which form of treatment was more favorable for people in this category. The authors concluded that the need for more intensive treatment may apply only to the most severe cases. In the end, Dr. McCarty’s group emphasized that, unlike the traditional 28- to 30-day model of residential treatment (which the rehabs I visited for my book, Inside Rehab, are moving away from – toward lengthier stays), an important feature of outpatient treatment is that it typically lasts much longer. Not only that, but people in outpatient treatment remain in their everyday environments and can recover in their communities and in the context of everyday life.
...an important feature of outpatient treatment is that it typically lasts much longer... [people] remain in their everyday environments and can recover in their communities and in the context of everyday life.
Another study, published in Psychiatric Services in March of 2014, also reviewed the scientific literature from 1995 to 2012 – but this one primarily looked at studies comparing residential treatment to other types of treatment such as IOP. Overall, they found a “moderate” level of evidence for the effectiveness of residential treatment for substance use disorders, noting that “there were many methodological challenges within these studies.” One big problem overall was that there weren’t many randomized controlled trials (the gold standard type) because treatment providers had concerns about randomly assigning individuals in need of treatment to a no-treatment condition or to a type of care that might not be might be clinically appropriate.
The authors concluded that residential treatment “fills a niche for consumers who require stable living environments that incorporate therapeutic treatments to help them move toward a life in recovery.” They added that it shows value for ongoing inclusion and coverage as part of the continuum of addiction care, but that we need rigorous research “to understand how and for whom it best fits.”
What's Next: Part 2 will take a look at who really needs residential treatment and some other models of treatment.
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