Addiction Treatment Programs: Outpatient vs. Inpatient

When an addict seeks treatement, how should they decide whether they need an inpatient or outpatient program? I’ve googled this one and get references to CIWA scales, BAC levels, and such, but nothing really specific. I’m hoping someone could describe for me how doctors go about making this judgement. I recently got into a debate with someone about how effective various treatments can be. He was of the opinion that non-residential programs are doomed to failure a large percentage of the time. I doubt this, and I suspect that the types and frequency of intoxicants used would fator in heavily on the liklihood of success. I’m basicaly trying to get an understanding of the current clinical views & criteria used to decide for or against outpatient programs, as well as the reported success such programs have when compared to inpatient treatment.

Thanks in advance. . .

DaLovin’ Dj

Not sure how they should decide, but in my cynical view, how they actually do decide is this:
Look to see if the patient’s insurance will pay enough to cover in-patient care. If so, admit them as an in-patient. If not, admit them as out-patient. If no insurance at all, refer them to a competitor.

I have several anecdotes (not real evidence) that this occurs here in Minnesota. I suspect that it’s also true in other areas.

It is very hard to find anyone who will issue statistics because success rates are so small for ANY treatment. In my experience (personally familiar with both many times) out-patient treatment is totally worthless. The “spiritual based” treatment available at these centers has been shown to have the same or worse success than no treatment at all. In-patient treatment allows a time out for people to get away from the lifestyle, and sometimes a true desire to stop takes.

I used to work for an outpatient drug clinic

There may be a bunch of theories as to who should go where, but in reality it almost never is done that way. Where a person ends up depends in part on what they use, where they live, how much (if any) they can pay, how much local charities/governments will pay, whether or not they have any other health problems, whether or not they have dependants…

We tried to help as many people as we could, but truthfully, some situations just can not be handled outpatient. People with major psychiatric problems in addition to drug addiction, for instance.

That is also true of residential programs. Fact is, ALL addiction treatment has a dismal success rate.

It’s also a fact that almost any program will work for some people, so if one doesn’t work there’s a lot to be said for trying another.

The clinic I worked at had some great successes, a lot of people cycling in and out of treatment and addiction, and some real disasters. Just like every other treatment program.

This is a timely topic for me. I just got out of an inpatient rehab program today and will start the outpatient phase tomorrow. My treatment is for alcoholism.

Most of this will be hard to prove so I will try to present facts and then throw in my beliefs. The first fact is that long-term use of some drugs usually requires inpatient treatment during the acute withdrawal phase. Many people aren’t aware that alcohol withdrawal is one of the few drugs that can and sometimes does cause death (the others are barbiturates and benzos). Drugs like heroin, speed, and cocaine have a bad reputation in the general public’s mind (for good reason) but withdrawal from them is very unlikely to cause death. If you show up at the emergency room of any hospital (and I have done this three times) and tell them that you are trying to end a lengthy drinking career on your own but are feeling symptoms, you can bet that you will be in a “detox” unit that day in the hospital that you went to or sent by ambulance to the nearest detox facility.

Detox can be considered the first stage of rehab. Its purpose is to get rid of acute withdrawal symptoms safely, and as comfortably as possible. The patient is administered ever-decreasing doses of a drug that is similar but produces a less intense high than the drug that the patient is addicted to. Drugs like Librium and Ativan are used to detox alcoholics while heroin and oxycontin users get decreasing doses of methadone. Most people are surprised to learn that cocaine addicts and those addicted to other stimulants don’t need any detox at all. The detox stage can last anywhere from three to six days and is almost always performed inpatient. I have heard of psychiatrists that have given alcoholics a prescription for Valium for example to detox themselves but that is simply malpractice IMHO because you can bet that they will take most of the pills as soon as they get home.

The next stage is rehab, which we know can be performed inpatient or outpatient. There are amazingly few inpatient rehab programs these days. New England only has a small handful left and they tend to be private hospitals. I was lucky enough to get into one right away and my insurance approved it.

The benefits of an inpatient program are:

  1. You are guaranteed a safe environment where you sobriety is enforced while you are there. Everyone is strip-searched coming in, visitation is heavily restricted and monitored, drug testing is done when you come in and anytime something is suspected, and the patients cannot leave the secure areas of the facility without a staff member. This period of enforced sobriety is a critical piece that outpatient programs cannot do nearly as well.
  2. You get intense “indoctrination”. You are there 24 hours a day and you day is heavily scheduled with AA and NA meetings, counselor meetings, subgroup meetings, special focus meetings, educational seminars, and socializing times where you just talk with fellow addicts and learn from each other (this is very helpful). Outpatient programs obviously do not have the same amount of time to teach you the skills to fight your addiction and, most importantly, do not have the benefit of being the patient’s full focus because there are still other things going on in a patient’s day.
  3. Inpatient programs provide a full range of health care. Addicts often have health problems and these are usually addressed during an intense physical. Patients also have access to nurses, psychiatrists, psychologists, counselors and other health care providers. During my inpatient stay, we all saw a doctor at least once a day and more often if we needed it. The outpatient programs that I have been to before usually have a psychiatrist on duty but the time given to each patient is extremely limited.

Insurance companies have cut way back on the amount of time that they will pay for. The movie “28 Days” is based on an old standard that rehab should last for a full four weeks to be effective. I would have loved to stay 28 days but my insurance company pulled the plug at 10 days. Some people only got seven days. The only people that got close to a month were union employees or federal employees that had very generous insurance.

My inpatient program terrified me when I first arrived. The rulebook was half an inch thick and seemed Draconian. However, I soon found that all of the rules were there for a reason (to enforce structure, discipline, sobriety, and a safe environment for a diverse group of addicts that encompassed everyone from the elite to the homeless). I was cocky when I came in because I read alot and had been to outpatient programs before. I thought “Ok, I will just sit here and listen to the same old crap while I come up with a way to straighten out my life”. I could not have been more wrong. The counselors were all former patients of the same hospital who had remained sober for a few years, gone back to school, and come back to help others. I have to say that their teaching styles, while diverse were world-class by any standard. Some of it was taught “boot-camp” style while other parts were literal stand-up comedy by a former addict who brought up absurd behaviors that all addicts engage in such as crazy stunts to hide our addiction or our drug that had everyone rolling in the floor because we could all relate to it and saw that nothing we did was unique or new and they had the same problem but found a solution and that solution would probably work for us too. I was actually sad and very scared to leave today. I made some really good friends (they are now recovering addicts, but hey, so am I) and learned things that are not in any book. I would definitely go back if, God forbid, I ever relapsed.

As an alcoholic that has tried outpatient treatment before unsuccessfully, I have a hard time believing that there is any good reason to pick an outpatient program over an inpatient program. At the very least, you will need to go through detox for some drugs. Those few days often offer “rehab light” courses that teach you things when you are too sick to go to them. Detox alone has abysmal relapse statistics however because it primarily addresses the acute physical withdrawal of certain drugs but does not offer significant sober time or enough education to even start a foundation to recovery. Addicts usually leave feeling stronger and better than when they came in and are all set to go on another binge.

I am in a much better position now to treat my addiction because of an extended inpatient program than I ever have been. My family can already see the difference and I have tried lots of different things over the years.

That being said, I believe that outpatient programs do have their place. I am starting an evening rehab program tomorrow night at the same hospital. The primary advantage that I can see for outpatient programs is that insurance companies really seem to like them. I will get to go to evening treatment for almost a month taught by several of the counselors that I already know and respect. One of the main advantages to this that it will take away time that I used to use to indulge my addiction and turn it into a productive learning time. They other advantage is that I am now humbly convinced that I cannot learn enough from these people and I should continue.

Thank you for that post, Shagnasty. I appreciate you sharing what may be painful information for the sake of spreading knoweldge. What were you allowed in the way of privelages? Books? A computer? Phone calls? It seems to me that what is required to cure addiction is not simply being forced to stop, but also nurturing other interests and strengths. I would hope that artistic endeavors, positive relationships, and education would all be stressed and encouraged as well.

You mentioned that you had read alot before you went in? What did you read? I’m curious to know the body of literature/knowledge that is taught to counselors. What are the theories of mind that they are using? Are their standardized questions and point-type systems that they use to chart progress and track successes/ failures. What schools of thought predominate? I have heard that the 12 step program is getting knocked around a bit in modern circles. What dogmas are they using? I’m basically trying to come to an understanding of the current thinking about the nature of addiction, and the leading ideas about treatment.

The more I read, the more I find this is a fascinating subject. I’ll post some links when I have more time. The methods of treatment for addiction tend to stream into conversations that deal with the general nature of self-improvement (admitting you could be better - wanting to be better - and making the change). What it takes to want to improve and what it takes to stick with changes (like a support network, environment, resources) is a matter on which there seems to be some debate . . .

DaLovin’ Dj

I will try to fill you in the best that I can. Just say if you want more information about something. The hospital I was in was a private rehab hospital with about 200 inpatients at any one time. All inpatients were addicted to alcohol and/or one of the addictive street drugs. From the second we got there, we were taught that while our drugs of choice might be different, our addictions were all exactly the same. The more discussion sessions that I attended and the more I talked to people addicted to different drugs, the more I believe that.

The rehab portion of the hospital had plenty of rules to enforce safety and sobriety while you are there but they are not really that bad once you accept your fate. Patients have free movement throughout most of the hospital but cannot leave the inside of the hospital at all. Visitation is prohibited except for a three hour period every other Saterday when friends and family get attend a pretty hard-core session on what it is like to be an addict, how hard it is going to be to break, how not to enable the addict, and guidelines on how to know when they should just cut all ties and run from the addict. The patients then come into the room and present their own plan about what they plan to do about their addiction in very concrete and measurable steps in front of their own friends and family, the counselors, and everyone else. That is very humbling. It was very sad, because we had visiting time last Saturday and only ten patients out of about two hundred had visitors (my wife came). Everyone else had either lost their family already or were too ashamed to tell anyone where they were.

As for priviledges, you could have all of the books and magazines that you wanted but computers or other electronic devices were out. Each floor had a TV room with a VCR and a supply of movies. You did your own laundry in the laundry room. There was only one pay phone per floor and you had to use a calling card. Incoming calls were not allowed at all and the hospital was not allowed to say if you were a patient there or not to anyone. I smuggled my cell phone in and that was a great idea because the phone was almost always tied up with a line and it was in the TV room where there wasn’t any privacy. We ate together in the cafeteria.

We had lots of time to socialize with other patients. There were several hours during the day that were free and the nights from 8:30 to 11:30 (bedtime) were unscheduled. We used this time to hang out in the TV room or go outside to the smoking deck and just hang out and talk. I had some really great conversations. It is heartbreaking to talk to someone and find out that they were a $500+ dollar a day heroin addict who robbed, cheated, and lied to feed their habit and now they are standing in front of you looking perfectly nice, happy, and respectable because their addiction has been temporarily arrested in the hospital. Statistics say that they are going to be right back at it within a month after they are released unless they (and I) make some drastic moves.

One interesting thing is that all of the counselors were former patients of the hospital. Most were very hard-core addicts who got clean, went back to college, and earned a degree as a certified drug addiction counselor. With the exception of one counselor, they were all very interesting and effective and cut through the bullshit. We listened because they had all been there. The program was heavily 12-step oriented.

I was a little skeptical of 12-Step programs when I first came in but I much more faith in them now. I will keep my defense simple. The first strong point is that you are supposed to get a sponsor right after you get out of the hospital. This is someone that you meet at an AA/NA meeting that has a significant amount of sober time, someone you can relate to, and who you respect. I cannot possibly see how that can be argued to be a bad thing. Secondly, twelve step programs can take up a huge amount of time. That seems like a bad thing to a person who is lazy about recovery but is actually very critical to someone early in recovery. For instance, my wife and daughter are going away tonight and I will be alone for the first time since I got out of the hospital. I know from experience that this is a recipe for disaster. I can cry, scream, and yell that I don’t want to drink, but if I am alone from 5 pm to 10 pm with nothing else to do, my addiction is going to find a way to feed itself. This is where AA meetings come in. There are about 3000 of them offered in the Boston area each week. No other program can match the sheer volume and availabilty that AA and other 12-step programs offer. I promised my counselor that I would go to several a day until my wife returns on Sunday. This is a productive learning and sharing exercise but it also just chews up time when I used to drink and would be likely be unable to fight it on my own.

Some things to keep in mind:

As with all things, people’s experiences vary a lot with rehab. It really depends on
your personality and how your brain is wired. Think of it like quitting smoking; Some people find it next to impossible no matter how what they try, while others can smoke regularly never get addicted.

Don’t dismiss outpatient programs off-hand. They are very effective for a lot of people, even those with hard-core addictions. And, yeah Shagnasty, often all it takes to transform a complete wreck into healthy, happy person is a prescription for Valium and occasional follow up visits (though other benzos are more commonly used). That’s not to say the solution is to give the person a year’s supply of Valium and say “Go wild”, but it’s not much more complicated than that.

Some people will start bingeing on the Valium and some will feel no urge to do so or no pleasure from doing so even if they try. Like I said, it depends on how your brain is wired. Some people love it at high doses, others it just puts to sleep. There’s no way to know without trying it.

Some people find that they can’t get off the benzos without going back to drinking, essentially trading one addiction for another. That’s not as bad as it sounds since, even if you end up addicted to Valium for the rest of your life, that’s far better than being addicted to alcohol. Benzodiazepines don’t destroy your brain, your liver and your social life the way alcohol does.

By all means, try a 12-step program such AA, but be aware that these things mostly work for a certain type of person. If you’re not that type of person, don’t give up but simply try something else, whether is counselling, medication or inpatient rehab.

Here I used the example of alcohol but the same idea applies for any other addiction. Keep trying different things, and if you find you tend to relapse even after the the withdrawl phase is over, don’t be afraid to “trade addictions”. Methadone maintenance for opiates, Wellbutrin for cocaine or amphetamines. Benzodiazepines help with pretty much any addiction, and are useful for alcoholism in particular .

Because people are so different, there’s no easy answer for what the best treatment is. The only rational way to approach it is, to paraphrase Truman, just try it – and if it don’t work – why then just try something else.

OK, a few points. First of all, smoking is not a mood-altering substance so it doesn’t belong in this discussion. I quit smoking when I was 19, and while it was hard, it didn’t mean that I needed to work on it for the rest of my life. I don’t even think about tobacco anymore even when I am around it. Quitting smoking is a 2 on a scale of 1-10 for addictive substance abuse. I have done both.

Basically, what you are looking at today is a small subset of drugs that will put a massive addictive hurt on your life. These include alcohol, heroin, oxycontin, cocaine, crack, other methanphetamines, prescription benzo’s. Let me know if I missed something. Please note that I didn’t that list marijuana, LSD, and several drugs because they aren’t truly addictive and require no detox.

I can promise you that it is the one alcohoic out of 1 million things that can bring a perscription used for alcohol withdrawal home and use it correctly. I ended up in a massive overdose the first day that I got that prescription and I spent the next two days in the ICU and the critical care unit although I never intended to do so. I don’t remember any of it. Letting alcoholics detox themselves is malpractice and should be prosecuted. Give me one name of a person that you know (First Name, first initial of the last name that has done this). It has not happened. I can tell that you are not an addict yourself and you have know idea what you are talking about. I cannot cure it here but the best analogy is a person invaded by a demon that fights with their will 24/7 and always wins the fight unless other resources are brought in.

Also, your kind statement that “It really depends on
your personality and how your brain is wired.” got me into world’s of hurt. I thought that I was better than rehab and 12-Step programs because I went to an Ivy League University. That almost made me lose my wife, my child, my family, my house, and pretty much everything else I had. I graduated with a degree in psychopharmocology and neuroscience at Tulane and went to graduate school at Dartmouth in the same subject. I thought I was smarter than they were but they were the ones with the sobriety and they seemed to manage it. I tried it lots of times without them and it never worked.

Do you realize that alcoholics that get prescribed bezo’s are always (and I mean ALWAYS) are going to abuse them.

I am not saying that you are ignorant as an insult; most people are. I am a multi-millionaire thanks to wife, I have a degree in psychopharmocology because I was wondering what the hell was happening to my family and then it happened to me.

I went through two detoxes before this one. The doctors and nurses were as kind and sugarcoated as you all were. I failed within a week. That was not just me. It turns out that most patients fail within a week and the others fail two years. After two, years, roughly 3% are clean. This inpatient program, run by former addicts, tells you how it really is and rails on you. For instance, I said that I would probably have a hard time tonight because my wife was away so they set up a special number that I could call on the dot and say that I was sober. I misses one by a minute and they called me.

I am in two outpatient programs right now so I don’t dismiss them at all. I just think that anyone with a serious alcohol/benzo/heroin problem should go inpatient because it is going to take some work to break to break that. Outpatient meetings and 12-Step meeting should supplement those.

The counselors in my current program are all former patients who went back to school and came back as a counselor. I think it is great. If I listen to another useless psychologist (and that was my track) tell me what I should do, I will shake my head in then kindly call one of the counseloures that actually knows what going on.

Also witalicus, my grandfather died from Valium withdrawal at the age of 55 locked in the hospital. There are only a few detoxes that may be deadly: The most common one is alcohol. The others are benzos and barbituates. As bad as cocaine, heroin, oxycontin and the like are, nobody is going to drop dead from coming off them.

Nicotene most certainly is a mood-altering substance. With a degree in psychopharmacology you should know that it mimics acetylcholine. Sure, the withdrawl syndrome is not as bad as with many other drugs, but it’s just a matter of degree.

Like I said, people’s brains are wired differently. You may have found it easy to quit but not everyone is like you. Being addicted to cigarettes may not ruin your life (at least not for a few decades) like heroin or alcohol but that doesn’t mean it’s not a “real” addiction.

Yup, it’s no coincidence that the major addictive drugs correspond to the major neurotransmitters in your brain: you’ve got your norepinephrine, endorphine, acetylcholine, GABA, serotonin and, of course, the end product in all addictive behaviours, dopamine. Which addictive drug most appeals to you and how much it appeals to you, depends how your reward centres are wired.

No, I am not an addict myself nor do I know anyone personally who has done it. But I do know a physician who has treated more than his fair share of addicts and that has been his experience.

What you seem to be forgetting is that the group of people which you met at your inpatient clinic was not a random cross-section of people who seek treatment for substance abuse. People at an inpatient clinic generally aren’t there unless they’ve already tried and failed other courses of treatment. Of course the relapse rate is bad in those cases; you are – by defintion – dealing with the hardest cases to treat.

I wasn’t taking a crack at your intelligence. Intelligence hasn’t got anything to do with it. Some people are just “wired” to enjoy and/or get addicted to certain drugs. Some people go nuts on heroin and do not enjoy it at all. Some can take cocaine regularly and just stop with no withdrawl symptoms. You can’t fake that sort of thing. That’s not intelligence or attitude. It’s biology.

Look, if you’re not convinced, go look in your local yellowpages for a medical alcohol treatment program (not AA or something of that style) and give them a call. Ask how many people they have on long term benzos.

OK, it wasn’t you. That’s my point; different things work for different people. Some people don’t get anything out 12-step programs. If you’re the kind of person that gets a lot out of religion or social support, then they will likely help you quite a bit, but they don’t help everyone and they should not be considered the only option for serious addictions.

True, but alcoholics who fail treatment can die from alcohol poisoning and liver failure too. There’s no question as to whether benzos are perfectly safe; we know they aren’t. But for many people, they’re the lesser of two evils.

Seeing that I’m currently attending a 5 day session of medical education and recovery from addiction sponsored by the American Society of Addiction Medicine (ASAM), I thought I’d chime in here.

Addiction is addiction. But there’s addiction and then there’s addiction. Hope that clears things up.

I’m pragmatic.in this area. Use what works. If an addict relapses, it means they are not using an adequate recovery progam to maintain their sobriety. But what needs to be added to their program depends on their own individual situation. Some need to attend more 12 step meetings, some need to address work or relationship issues, and some need to get their fannies into a long-term inpatient rehab program.

Me, I had to be put into long term residential treatment settngs 4 different times before I found sobriety. But now that sobriety has lasted over 14 years. I’ve got two good friends who became clean and sober by going to 12 step meetings and having some one on one sessions with a psychiatrist or addictionist, They never even missed a day of work. And they both have years of sobriety under their belts now.

It takes what it takes. And unfortunately our health care delivery system is not very good at figurng out what it takes to sober a person up.

Relapse rates are high, but relapse doesn’t automatically equal failure. There are over a thousand physicians at this conference with me with qualty long-term sobriety. And at least half of them experienced relapse after being treated initiallly.

So what is the answer to the OP’s question? I don’t know; further studies are needed. But structured inpatient treatment is definitely necessary for some if they have any hope of recovering. And some long-term studies are now starting to show that over 2/3 of chronic addict/alcoholics do eventually recover if they continue to return into some kind of continung treatment for their disease.

I can’t cite my sources at present, this internet tv keyboard hookup sucks! But visit www.ASAM.org for some decent scientific data.

QtM, MD

I can’t answer on how it is actually done, but I do have two comments (that nonetheless I feel still belong in GQ.)

One, I would say that IF the patient cannot control their impulse to obtain the item in question, inpatient would most certainly be more effective at stopping alcohol and nicotine use, for obvious reasons, and any molecule resembling morphine, for not-so-obvious reasons. Caffiene as well, but I’ll get to that in the next paragraph.

Re: the poster who said that stimulants don’t need detox: what are you smo…oops, wrong phrase in this thread ;). My personal experience with caffiene withdrawal is such that I would rather subject myself to withdrawal from almost any other drug rather than caffiene. Depression, headaches, intense craving. Cocaine probably does have fewer physical withdrawal symptoms than caffiene (:eek: ), and I know that the posters point was that it is not very physically dangerous to withdraw from stimulants, but still, it is EXTREMELY uncomfortable to withdraw from caffiene, such that if I were an addiction psychiatrist (and IANAP), I would recommend that at least extreme analgesics be available, perhaps even opiates, until the symptoms pass.

Or perhaps there are special drugs which block caffiene withdrawal symptoms, in which case I’d use those rather than opiates.

This basically my position too. If someone needs treatment for substance abuse, they should start with the most aggressive treatment available (inpatient) and work from there as long as insurance will pay for it and they can’t afford it themselves. In my experience, if the addict claims that he or she cannot afford to be in the hospital for one or more weeks, then that person is probably not taking recovery seriously. As long as your insurance company will pay for it, I cannot think of many good reasons why you shouldn’t do it. You can try outpatient treatment AFTER you get out of inpatient. That is what I am doing I am doing for the next month.

The relapse rates for substance abuse are so abysmal that the addict owes it to themselves, family, and friends to give it the most aggressive treatment possible. A comparison would be if a terminal cancer patient went to the doctor and was offered two treatment plans: hospitalization with every known treatment including chemotherapy or just outpatient chemotherapy. Which one would you choose for yourself or a family member? Substance abuse is a potentially fatal disease to.

Those are not examples of detox. Those are examples of a need for pain control. It is a subtle, yet important distinction to doctors and especially insurance companies.