As an addiction psychiatrist, I am often asked what program I would recommend. My response — that I do not typically recommend addiction rehab — often comes as a surprise.
Addiction rehabilitation envisions an intensive period of inpatient or residential treatment. The prototype was established in 1949 based on the 12 steps of Alcoholics Anonymous and later expanded to address other addictions. The model went on to gain considerable publicity for treating celebrities and has succeeded in capturing the popular imagination.
Sending people for several weeks of intensive counseling in a contained environment may seem like a good idea. But does addiction rehab actually work?
The results of well-controlled trials are far from impressive. Despite almost 70 years since the advent of rehab, and decades of research data, the signal for its potential benefit over outpatient treatment has been too weak to detect with clarity. Overall, the effects of treatment setting are inconsistent, modest when present, and diminish over time. Moreover, the original design of the rehab model — as well as the majority of research data — pertain to alcohol, which may be less applicable to other addictions. For example, opioid addiction can be successfully treated pharmacologically, with a relatively limited role for elaborate psychosocial interventions.
Or even worse, sending those who struggle with opioid addiction to rehab programs that do not offer pharmacotherapy with buprenorphine, methadone, or injectable naltrexone is a recipe for disaster. The overwhelming majority of people relapse to opioid use after such programs, but their tolerance to the lethal effects of the drug goes down. On balance, one wonders whether it may be safer to keep using than attending programs that — rather than lowering the risk of relapse — lower tolerance and thus increase the risk of overdose. But the answer is not to continue using — it is to seek evidence-based treatment. We do have life-saving medications for opioid addiction, and it is infuriating that we keep toying with people’s lives by sending them to programs that do not provide them.
So then why does addiction rehab continue to be influential?
In addition to the inertia of tradition, the turmoil caused by addiction may make intensive treatments seem intuitive. Yet the intensive treatment model is more applicable to acute health problems, such as stroke, rather than chronic illnesses, such as diabetes. Addiction is a chronic, relapsing condition that is all too often treated as if it were an acute one that can abate with a bout of intensive treatment.
Addiction is a chronic, relapsing condition that is all too often treated as if it were an acute one that can abate with a bout of intensive treatment.
But it is neither research nor inertia that built the rehab industry — a model that has thrived in a market of perceived need and business opportunity. Rehab can be a lucrative business that aims to market its product and unfortunately often misrepresents its outcomes. And it thrives on misfortune — the conclusion drawn after relapse is typically not that the treatment wasn’t effective, but rather that it wasn't enough. And thus another course of rehab is recommended.
While some rehab facilities do provide evidence-based treatments, that hardly is the rule — treatment often consists of non-evidence-based techniques provided by undertrained counselors, 12-step meeting attendance, and recreational activities. Rehabs continue to be unstandardized and poorly regulated, with numerous accounts of predatory practices gaining recent media as well as legislative and legal attention.
It remains unclear whether there is a role for rehab in addiction treatment, and the evidence for its effectiveness continues to be limited. Meanwhile, we often miss the obvious and less expensive treatments: effective relapse-prevention medications and evidence-based psychotherapies provided in an outpatient setting with adequate community support. Surely, other considerations such as safety, an unstable social or living situation, and co-occurring conditions may deem higher levels of care appropriate or necessary. And rehab may not be the best way to address such issues — for example, the need for housing can be decoupled from addiction treatment and addressed in its own right. Yet short of that, quality outpatient management provided on a regular basis can result in sustained improvement. And it may be as a good a treatment as one can possibly get. It is the content of treatment that is likely to make a difference, rather than the setting where it is delivered.
So, what do I recommend?
Talk to your physician about their expertise in treating addiction. If they are not knowledgeable in the area, then finding a physician with board certification in addiction psychiatry or addiction medicine, or a therapist with a masters or doctoral degree and addiction expertise is a good place to start. As does getting guidance from the National Institute on Alcohol Abuse and Alcoholism treatment navigator or the National Institute on Drug Abuse section for patients and families. There also is a wealth of informative writing: articles by Maia Szalavitz contain incisive information on addiction treatment, and Anne M. Fletcher’s "Inside Rehab" is a volume rich in invaluable insights into the role and limitations of rehab.
We need to approach addiction, including the opioid epidemic, using 21st-century evidence-based medicine, not a relic of the past that is far from proven. This often requires a mindset adjustment to the reality of addiction — a chronic, relapsing condition that is to be managed long-term, rather than cured with heroic, short-term measures. It is imperative that we use advances in knowledge to treat people so they have the best chance of preserving and rebuilding their lives.