Forms of Addiction Treatment
In this blog, I will break down the most common forms of addiction treatment and explain their purpose in plain English for you to understand so you can make informed decisions about treatment.
Before we proceed, I need to remind you that nothing I talk about in today's blog should be considered medical advice. If you need medical advice about addiction, please consult with a medical professional.
With that disclaimer out of the way, let talk addiction treatment programs!
Inpatient Versus Outpatient
The biggest division among forms of treatment is inpatient versus outpatient. Simply put, inpatient refers to a facility where clients stay 24 hours a day under direct supervision of trained professionals. Well, at least in theory.
Outpatient refers to a facility that treats clients who only visit for treatment and otherwise live in their community.
Get it? IN-patients live on the IN-side and OUT-patients live outside the facility. Good!
Hospital Treatment
The hospital is the classic inpatient treatment venue. Hospitals are not typically built or designed for addiction treatment, but due to EMTALA, they don't get to pick and choose the patients they see.
EMTALA is the Emergency Medical Treatment And Labor Act; it forces hospitals which take federal funds from Medicare to evaluate and treat all comers to their emergency departments, regardless of ability to pay or any other factor.
Due to this, the hospital emergency department is the site of last resort for many with substance use disorder who are in crisis and don't know where to turn. They have to evaluate your medical condition and stabilize any emergency conditions, even if that means admitting the patient to the hospital.
Hospitals are best at treating the medical complications of substance use disorder, such as infections or overdoses and the treatment of complicated alcohol withdrawal.
As an aside, alcohol withdrawal can be life threatening and complicated alcohol withdrawal can require ICU level treatment.
The hospital is the most appropriate form of treatment if a patient is suffering a medical complication of their addiction, an overdose, or complicated alcohol withdrawal.
However, the primary focus of hospital care is not treatment of substance use disorder but rather the underlying medical condition which necessitated admission in the first place. Therefore the level of addiction care varies greatly between one hospital and another. Some provide professional and empathetic addiction treatment whereas others consider addiction treatment an afterthought or only pay mouth service to addiction services. The level of care depends greatly on local resources and culture.
Hospital care can also be incredibly expensive. Even though they may be obligated to treat you under the mandate of EMTALA, hospitals don't provide that care for free. Even short hospital stays can cost tens of thousands of dollars and insurance rarely covers the entire bill.
Therefore, if a person with addiction simply seeking substance treatment, then it is better to bypass the hospital in favor of other forms of treatment.
When people think of addiction treatment, many picture either an inpatient rehab or detoxification center. As I mentioned in my addiction myths blog, it is a common misunderstanding that addiction treatment must begin with inpatient treatment at a rehab or detox center.
Inpatient Rehab and Detox
Needless to say, these facilities are a popular form of substance use treatment. So what is an inpatient rehab or detox?
First, we need to disentangle the two definitions. Many think that rehab and detox are synonymous, but they actually refer to two slightly different forms of treatment.
Lets start with detoxification centers. Also known as “detox,” these facilities specialize in treating the initial withdrawal from drug and alcohol use. They admit patients who are ready to stop using substances and manage their withdrawal.
Clients in a detox are, in theory, observed 24/7 and receive medical treatment aimed at easing the symptoms of withdrawal. This keeps patients safe during a potentially harmful time.
Once the patient has completed the worst of withdrawal symptoms and is stable, they are discharged from the facility. A typical detox stay is a few days to a week. The patient then transitions to another form of treatment in order to receive continued care.
In contrast, an inpatient rehab facility offers a more comprehensive array of services. Some accept patients from detoxification centers, but other rehabs operate their own detox unit.
Clients treated at an inpatient rehab are under 24/7 observation and participate in treatment for their substance use disorder on a daily basis. Since they live at the rehab and are not allowed to leave, this treatment takes up the majority of their day.
The exact treatment services offered depends on the philosophy of the operators and owners. Some practice scientifically validated treatments, while others practice alternative techniques. Many offer both standard medical treatment, like Suboxone for opioid use disorder and counseling, alongside alternative medical practices such as acupuncture and aromatherapy.
Many rehabs advertise as destination treatment centers located in desirable locales such as South Florida or San Diego. These destination treatment centers also offer five star amenities such as spa services, room service by professional chefs, and adventure tours.
Alongside these Hilton rehabs, you will also find Marriott level rehabs in less desirable locations which offer fewer amenities. Regardless of the fringe benefits, almost all rehabs in the US are regulated at the state level and as such, offer an acceptable level of patient safety and predictable treatment.
This is not necessarily true for rehabs outside the US or treatment centers operated by religious organizations.
International rehabs vary in their consistency as each nation has a different degree of regulation and enforcement of that regulation; it's therefore hard to judge the quality of care at these rehabs. Buyer beware, as you are on your own to determine the quality of treatment and if you make a misjudgment in your assessment, you'll be in a bad situation in a foreign country.
Religious treatment centers are often exempt from state regulations and as such, are similarly problematic. Unfortunately, some of these rehabs adhere to non-scientific ideas and offer treatment informed by faith rather than medicine. Frequently, these treatments are based on the idea that abstinence from all substance use, including medications for treatment, is the overarching goal of treatment.
Assuming you pick a US based rehab or detoxification center, you can be assured of a decent level of addiction care. Almost all of these facilities have an addiction physician on staff and trained staffers to provide treatment for substance use disorder. You may only ever see the addiction physician once during intake, but you can at least be assured that there is a doctor supervising the care and available for emergencies.
These facilities are also cheaper than a hospital stay of the same length. Pay careful attention to how I phrased that. Even though a rehab or detox may be cheaper per day compared to a hospital, patients in a hospital typically only spend a few days or a week there, whereas it is common for a patient to spend months at an inpatient rehab.
The total cost of such a treatment course runs anywhere from $30,000 to $100,000 or more per month. The cost depends very much on the amenities, location, and reputation of the facility. The fancier the amenities, more desirable the location, and greater the reputation, the more expensive the stay.
Medical insurance rarely, if ever, covers the entire cost of inpatient rehab. Almost all clients pay at least some of the cost out of pocket, if not all of it. This forces many to either drain their life savings or take out loans to afford the cost of treatment.
You better believe that these facilities will discharge a client as soon as they run out of funds. Unlike a hospital, they are not mandated to provide treatment in any way. This leads to many clients finding themselves alone in an unfamiliar city with only the clothes on their back and no way back home.
Unfortunately, relapse is a common outcome of these scenarios and for this reason, the overdose rate in counties with a large number of rehabs, such as Miami-Dade and Broward county in South Florida, is measurably higher than counties with fewer such facilities.
As I mentioned in my addictions myth blog, many inpatient rehab clients fail to learn the skills and behaviors they need to maintain recovery outside the facility, which means they will relapse on release. Some people in extreme situations benefit from inpatient rehab and sometimes a short detox admission is necessary, but inpatient rehab alone is not sufficient for long-term recovery.
Crisis Stabilization Unit (CSU)
You may ask, “are there inpatient rehabs for people without the financial means to pay?” The answer to your question is called a “crisis stabilization unit.”
These facilities are typically funded by municipal governments or charities through grants, donations, and tax revenue. Crisis Stabilization Units are intended to provide treatment for individuals in crisis from substance use disorder who otherwise have no means to pay for their own treatment.
In this way, CSUs exist as a public service to help ease stress on other healthcare services. Compared to private inpatient rehabs, CSUs offer basic treatment services and spartan accommodations. Clients live in dormitory housing segregated by gender, eat cafeteria food, and bathe in communal showers. Compared to commercial rehabs, there are fewer staffers and patients receive less individual attention. They are safer than on the street but the overall atmosphere is closer to a homeless shelter than a hotel. To clients forced into a CS by court order, it can feel like a prison.
CSU's can be lifesaving to their clients, but there are very much an option of last resort for the reasons I listed above. It costs about $300 a day for CSU treatment, but this cost is not typically passed on to the client as these facilities operate as a public service for the destitute. Due to low capacity and high demand, there is often a waiting list for beds, especially for people who identify as women.
(Note: sometimes an inpatient rehab or detox facility will use the term CSU to describe their initial course of inpatient treatment; these “CSU's” are much nicer than the publicly funded facilities that the term more often describes.)
Intensive Outpatient Program (IOP)
We'll start with a form of treatment which straddles the line between inpatient and outpatient—the intensive outpatient treatment program.
Clients in these programs live in their own home, but come to the facility on a daily basis (or six days a week) for intensive treatment as if they were being treated at an inpatient rehab. Since clients don't stay at the facility 24/7, this is strictly speaking a form of outpatient treatment. Depending on the program, clients of an IOP stay for 3-8 hours a day at the facility. Some IOPs have a graduated approach where clients spend the entire day in treatment initially and gradually progress to fewer hours of treatment per day as they work through the program.
IOPs do not typically provide inpatient treatment for withdrawal and therefore are frequently a second step in treatment after a patient is discharged from a detox or inpatient rehab. Other times, IOPs can be the first step in treatment, provided that the patient does not require inpatient detoxification.
IOPs can be a good option for addiction treatment which is significantly cheaper than inpatient rehab. Pretty much every service offered by inpatient rehab can be provided through an IOP, with exception of inpatient detox. Medical insurance is also more likely to cover the cost of an IOP, whereas insurance rarely pays for the entire cost of inpatient rehab.
The major downside of an IOP is that they limit patient’s ability to work or participate in their community during treatment. Even though it is cheaper than treatment at an inpatient rehab, few people can afford to take several months off from work to participate in an IOP, even insurance covers the entire cost of the program (which is rare as clients are usually on the hook for their deductible or a copay).
IOP's also suffer from the same problem that I critiqued inpatient rehab programs about: namely that patients don't get to practice the skills and behaviors necessary to sustain their recovery in the real world. IOP's give patients more opportunity to practice these skills, but it is still an artificial, controlled setting. A patient may find success in an IOP only to relapse shortly after completing the program.
Opioid Treatment Program (OTP)
Another common form of outpatient addiction treatment is the methadone clinic. Methadone is a medication prescribed for the treatment of opioid use disorder and can only be dispensed for this purpose from a specially licensed clinic.
The legal name for a methadone clinic is “Opioid Treatment Program” or OTP. OTP is a better term because nowadays these programs also offer buprenorphine (brand name Suboxone) and naltrexone (brand name Vivitrol) in addition to methadone.
OTP's typically require patients to present to the clinic daily in order to receive their dose of methadone or Suboxone each morning which they must take under direct observation. As patients progress through treatment and demonstrate improvement, they are allowed additional liberties such as take-home doses so they may only need to come to clinic every other day or only every week.
OTP patients are closely monitored with regular urine drug screening and reassessments. These programs also provide additional treatment services such as individual and group counseling, treatment of other chronic medical conditions, social services, and job placement programs. An OTP may also offer CSU and IOP services, as these programs are complementary.
A physician must be present to supervise the program but patients typically only see that physician during intake and then every few months after that. The majority of treatment is provided by other trained professionals and peer specialists, who are individuals who have recovered from their own addiction.
Compared to an inpatient rehab, Opioid Treatment Programs are substantially cheaper. The cost varies depending on whether the OTP is a privately-owned for-profit business or a publicly funded non-profit. Non-profit OTP's often offer sliding scale fees based on client income. Medical insurance often covers OTP treatment, even at the fancier for-profit OTPs. Patients who pay out of pocket can expect to pay $300-$1,200 a month.
Many patients dislike Opioid Treatment Programs due to their reputation, impersonal service, and inflexible schedule.
There is a strong stigma regarding OTPs and therefore many are located in less desirable areas that you may not want to travel to. High-end communities have strict zoning regulations prohibiting these facilities without explicit approval from the local government (so called “NIMBY” or “Not In My Backyard” policies).
By their nature, OTP's serve a large volume of patients daily and therefore the level of service can be substantially less compared to other forms of treatment. It is also common for a single patient to interact with multiple different staffers who rotate in and out of the clinic. Clients are less likely to form a strong therapeutic relationship in such a scenario and their treatment feels impersonal.
Finally, OTP's demand that clients bend their schedule to fit the clinic's dispensing hours. If you miss the cut-off for dosing, you miss your dose for the day. Most clients commute to their OTP clinic early every morning to line up and wait for their dose. This can easily take an hour or two out of every day and it makes it difficult to keep a regular job. It is also difficult to travel for work or enjoy a vacation, as the client must arrange guest dosing in an OTP at their destination.
Telehealth Substance Use Treatment
Compared to OTP's the next form of addiction treatment offers much greater freedom, though it also has its own drawbacks. Telehealth Substance Use Treatment purports to offer treatment for addiction through a convenient app.
These telehealth programs became popular during the COVID-19 pandemic when the DEA lifted the restriction on the telehealth prescribing of controlled substances for treatment of substance use disorder. This exemption allowed medical providers to prescribe Suboxone for patients with opioid use disorder without the need for an in-person evaluation.
Telehealth programs offer patients regular appointments with medical professionals using teleconferencing software. Since these companies do not need a physical presence, they can offer treatment for a substantial discount compared to other forms of treatment. Patients are also free to schedule appointments at times which are convenient for themselves and don't need to travel to receive care.
This model may sound appealing but there are important limitations to consider.
First, now that the COVID-19 exemption on telehealth prescribing of controlled substances has expired, these programs are required to now arrange for an initial in-person evaluation before establishing a telehealth relationship with their patients. Patient who have been using the service are exempted from this requirement but new patients will need to be seen at a physical location first in order to enroll.
Second, the quality of care is not uniform across the apps or between medical providers on the app. These companies pay their staff relatively little and as a result, they don't attract top talent. Most prescribers are nurse practitioners rather than physician and these nurse practitioners are rarely addiction specialists but rather generalists looking for a side gig. As a result of the low pay, turnover is high and therefore patients are not guaranteed to see the same professional. These patients miss out on the therapeutic relationship that develops over time with seeing a single medical professional.
Third, these apps are developed largely by individuals who are interested in making as much money as possible, rather than providing the highest quality of care. Thus, they are motivated to share your demographic data with marketing partners in order to make a quick buck. Even if they are not selling your data (selling patient data can be legal under HIPAA), tech companies have a bad track record when it comes to security of private data; addiction treatment is a subject that many wish to keep confidential and trusting your private health information to a tech start-up seems counter to that goal.
Bottomline, these companies are not interested in investing in quality of care but instead focused on volume, which is not conducive to good medical care.
Addiction Treatment from a Physician
A better option for outpatient treatment compared to a telehealth app is addiction treatment from a doctor.
There are many physicians who treat addiction. Some primary care doctors offer addiction treatment to their patients as an additional service, but other physicians treat addiction as a full time job.
In contrast to a physician working at a rehab or detox, these physicians care directly for their patients and see them on a regular, recurring basis. This helps nurture a physician-patient in which the patient can feel safe and supported. For some people, this is preferable to being passed between a rotating cast of characters at an OTP or IOP program. The physician also gains a deeper understanding of their patient's life and their problems through this close working relationship, which facilitates effective treatment.
Another advantage of treatment at a medical clinic is flexibility. Patients are not removed from their homes and can continue working and spending time with their friends and family. After an initial in-person evaluation, many patients can follow up using telehealth and they don't have to worry about a large corporation selling their demographic data or losing it in a data breach. Patient who prefer discretion can attend treatment in person, which is the best way to keep their health information confidential.
Most importantly, clinic patients have the opportunity to practice the skills and behaviors they learn in treatment in the real world, rather than a controlled, artificial setting. This practice helps them achieve durable recovery from substance use disorder.
Compared to a methadone clinic, a medical clinic is typically more comfortable and usually located in a nicer part of town. There are fewer restrictions on medical clinic zoning compared to addiction treatment facilities.
Finally, the cost of treatment at a medical clinic is substantially less compared to inpatient rehab or even an intensive outpatient program. One year of clinic treatment costs about one-tenth the cost of a single month of treatment at an inpatient rehab. Depending on the clinic, treatment may be covered by insurance; even if it is not, patients can use Healthcare Saving Accounts to pay, which allows them to pay for care with pre-tax dollars.
Some patients may not be suitable for treatment in a medical clinic. Namely those who lack stable housing or transportation. Patients with severe withdrawal symptoms may require detoxification in a hospital or inpatient detox before starting clinic treatment. A small minority of patients whose addiction is very severe may benefit from inpatient treatment, but most people with substance use disorder can be successfully treated as an outpatient in a medical clinic.
Sober Living Housing
There is one last form of addiction treatment program which you may have heard about. I saved it for last, because it's really more a service than a treatment program itself. I am speaking about Sober Living Housing.
A Sober Living House is a living space which is provided for recovering addicts. The philosophy behind Sober Living is that by removing the person from their prior living arrangement, the cycle of problematic substance use can be interrupted.
Often Sober Living is treated as a “step-down” from inpatient rehab. Sober Living is less restrictive than inpatient rehab and allows residents to leave in order to work. There are typically curfews and residents need to check in and out. They are also observed closely for any signs of drug use or interaction with people who are actively using drugs.
Sober living programs are typically more expensive than renting an apartment but less than the cost of inpatient rehab. The exact price depends on the location and amenities. Sober Living can range from a publicly-funded halfway house to a privately-owned luxury condominium that is run like a five-star hotel.
These programs benefit people with substance use disorder by providing stable housing and social support. For people with no close friends or family invested in their recovery, Sober Living can be a real asset. They also allow people in recovery to work and generate an income. Their downsides are similar to those of inpatient rehabs, namely the cost and the fact that they are an artificial environment which prevent patients from fully applying the skills they need to create lasting recovery. Sober Living programs can also expose people in recovery to more drugs than outside the program, if they are not policed by their operators.
More worrisome, some Sober Living programs take the stance that complete abstinence from mind altering drugs is the only goal of recovery. This includes all drugs, including methadone and Suboxone used for treatment of opioid use disorder. These policies have resulted in vulnerable people being kicked out to the street when it is discovered they are taking Suboxone prescribed by a physician.
The main takeaway is that the quality of Sober Living can vary widely and is very much a buyer beware scenario. Almost all states regulate these programs, but the degree of regulation and the enforcement of that regulation can and does vary.
Conclusion
So there you go, we just learned the basics of addiction treatment programs and the major forms of inpatient and outpatient addiction treatment. There are certainly more forms of treatment, but these are the major categories. I hope you learned something useful or at least interesting today.
If you or someone you love is suffering from problematic drug or alcohol use and is seeking treatment, please contact us at North Tampa Executive Health in order to schedule a discovery call to discuss treatment options. Call, email, or click the contact button in order to schedule an appointment.
We are here to help.
North Tampa Executive Health Clinic is directed by Dr. Jack McGeachy. He provides confidential and comfortable addiction treatments and therapy for opioid and alcohol use disorder. Rather than a rehab or detox, meaning that each patient is cared for one-on-one by a medical doctor, in contrast to other treatment programs. Heed Help? Book your in office appointment in the Tampa office or via video conferencing today.
Helping patients with addictions in Tampa Florida, Temple Terrace, Brandon, Bloomingdale, Carrollwood, Thonotosassa, Town N Country, Lutz, Wesley Chapel, Land O Lakes, St. Pete, Clearwater, Oldsmar, Westchase, Palm Harbor, Tarpon Springs and surrounding areas.
