Evidence-based practices (EBPs) are “in” throughout health care, including the treatment of addiction, preferably referred to as “substance use disorders” (SUDs). EBPs are specific treatments or therapies that have been tested with empirical research of various kinds. The gold standard for an EBP is that is has been tested by at least one high quality randomized controlled study. However, it’s best if there are multiple such studies, which are then collectively examined with a process called a meta-analysis to determine the overall level of support for effectiveness. In SUD treatment the evidence base for specific treatment approaches is better than in most areas of health care.
But what is the evidence in favor of “rehab” itself?
By rehab I am referring to the common practice of providing a relatively intensive and time-limited bundle of services as a first-line treatment for SUDs, whether provided in an outpatient or residential setting. Rehab stands in contrast to low-intensity outpatient services – for instance, once or twice weekly sessions or less. Rehab services usually combine education, group counseling and often participation in community support groups such as those based on the 12 steps of Alcoholics Anonymous (AA.)
…most research on behavioral treatments such as motivational enhancement, cognitive behavioral therapy and 12-step facilitation has been done with individual, low-intensity therapy, and it is difficult to know how well the evidence generalizes to a group setting.
– MARK WILLENBRING
Criticism has been raised by renowned addiction researcher, William Miller, Ph.D., Emeritus Distinguished Professor of Psychology and Psychiatry, University of New Mexico; Anne Fletcher, author of Inside Rehab; and many others that the specific services offered in many programs are not evidence-based. For example, there is good evidence that education does not add value towards positive outcomes. Another problem is that most research on behavioral treatments such as motivational enhancement, cognitive behavioral therapy and 12-step facilitation has been done with individual, low-intensity therapy, and it is difficult to know how well the evidence generalizes to a group setting.
Furthermore, when counseling sessions are audio recorded and examined, research suggests that it’s common for almost no actual therapeutic techniques to be used, even when the counselors report they are using them. Most of the time is spent on general “chat.” Very few programs routinely recommend and prescribe anti-relapse medications even though they have clearly been shown to improve outcomes.
For opioid addiction (to such drugs as heroin and pain killers), long-term maintenance (not “detox”) on the medications buprenorphine/naloxone (e.g., Suboxone, Zubsolv and others) or methadone are the only treatments with solid empirical support, and opioid maintenance therapy is among the most powerful and cost-effective treatments in health care. There is no high quality evidence supporting the use of either residential or outpatient rehab for treating opioid addiction. Not only are these maintenance medications seldom prescribed, many rehab programs discourage them! They routinely recommend “abstinence-based” treatment (i.e., without the medications just mentioned.) If an oncologist failed to prescribe a life-saving chemotherapy for cancer because she “didn’t believe in it,” she would not stay in practice long. Why do we tolerate this practice in treatment for addiction?
In response, many government and private organizations are working to increase adoption and implementation of EBPs in rehab. This seems like an obvious thing to do, but would it improve 6 or 12 month outcomes?
I have always had my doubts, but recently, I had the opportunity to work with patients after they completed rehabs where evidence-based behavioral treatments of high quality were fully implemented. It didn’t seem to matter. The work didn’t seem to begin until they got back home and started working with me (in a non-rehab setting), one-on-one, on an outpatient basis. Recovery is usually a stop-start process marked by regressions and progress, until hopefully sustained remission is achieved. Depending upon the severity and chronicity, it can often take months or years before this occurs.
The work didn’t seem to begin until they got back home and started working with me (in a non-rehab setting)… on an outpatient basis.
– MARK WILLENBRING
There is No Empirical Support for Rehab
The problem is not only with the types and quality of services provided in rehab, it’s with the whole concept of rehab. After thinking long and hard about empirical support for rehab I’ve concluded that there is none. Thus, rehab is not and can never be evidence-based.
Now, before you immediately shift to a game of Candy Crush in disgust, let me explain further how I came to that conclusion. First, there is very good evidence that intensive treatment adds no value over non-intensive treatment. As far back as 1977, British psychiatrist and researcher, Griffith Edwards, conducted a randomized controlled trial of a non-intensive approach called “evaluation and brief advice” compared to a combination of inpatient and outpatient treatment for alcohol use disorders and found no differences in outcomes one year later.
More recently, two large, well-designed studies both found that a few sessions of motivational interviewing yielded similar outcomes to more intensive counseling and service approaches. In a large naturalistic study in the VA system published in 2012, longer residential stays actually were associated with worse outcomes.
Second, residential and outpatient treatments have similar one- and two-year outcomes, with most studies comparing intensive approaches in both settings. For opioid addiction, there is strong and consistent evidence that, except for very minimal counseling or medical oversight, more intensive counseling adds no value to maintenance on buprenorphine or methadone alone. (Psychotherapy might be indicated to address co-existing psychiatric disorders, which is another matter.)
In some circumstances, such as complicated alcohol withdrawal, homelessness, or severe chronic mental and/or medical illnesses, structured, sober housing or even hospitalization is required.
– MARK WILLENBRING
In some circumstances, such as complicated alcohol withdrawal, homelessness, or severe chronic mental and/or medical illnesses, structured, sober housing or even hospitalization is required. Structured housing may also be required when someone is simply unable to remain abstinent long enough to engage in treatment. And at times, intensive time-limited treatment is required, much like a partial psychiatric hospital program for bipolar disorder or depression, in lieu of hospitalization or following it. But in those cases, the continuum of care includes ongoing outpatient care of indefinite length and intensity varying from weekly to once or twice a year. Overall, low-intensity outpatient, individual treatment has the most empirical support and is the only truly evidence-based practice.
A Different Model of Care for Substance Use Disorders
Given all of these considerations, when I started Alltyr Clinic in 2012, I structured it to operate as a clinic, not a program, and to offer outpatient services tailored to the individual patient. Length of treatment is also individualized. A majority of my patients have had prior exposure to rehab whether residential, outpatient or both. As one patient put it, “It was easy when I was in rehab, but when I got home, life happened!” The important work is struggling to recover when “life is happening.”
Most people have to make multiple quit attempts – that is, they suffer recurrences. We work with them to minimize the frequency, length and severity of recurrences, and then to learn from them to help prevent the next one. We change our approach if the current one is not working. Most patients are eventually able to achieve sustained recovery, but it often takes one to two years or more of continuous or intermittent treatment. And there really is no “end date” – they can come back for help, be it one year, five years, or whenever and for whatever length of time they require. (They don’t have to start all over again or make a time commitment.)
Long-term, low-intensity outpatient treatment that fully integrates mental health treatment, pharmacotherapy… achieves superior outcomes with greater patient satisfaction at a fraction of the cost.
– MARK WILLENBRING
Rehab is expensive, disruptive (because of the time involved, being unable to work, etc.) and by its very nature, difficult to modify for each patient. Long-term, low-intensity outpatient treatment that fully integrates mental health treatment, pharmacotherapy, and, when needed, family and couples therapy achieves superior outcomes with greater patient satisfaction at a fraction of the cost. And it’s the only treatment for substance use disorders that is truly evidence-based.