Length of Treatment and Outcome
There is no question that the longer a patient is in a treatment “system,” not a treatment “program,” the better the treatment outcome is likely to be (NIDA, 2012). One example is impaired physician programs, in which physician patients are in treatment, continuing care, and follow-up for five years. While it is true that physicians have a great deal to lose by not recovering—which likely increases motivation and sets them apart from some other populations—the high percentage of impaired physicians who achieve and maintain abstinence cannot be simply explained away by case mix (Hughes et al., 1992).
Patients should remain in the least intensive, but safe level of care until they meet their treatment plan goals and objectives. The level of care to which they are admitted, and their length of service, should be determined by the severity of their illness and their treatment progress (Mee-Lee, Shulman, Fishman, Gastfriend, & Miller, 2013). Therefore, it is clinically inappropriate to have fixed length of service models, such as thirty days of residential or twenty IOP visits. The one exception to this is ASAM Level 0.5, Early Intervention. The most common example of this is a DUI program where the length of service is determined by regulations enacted by the state legislature.
During the early 1980s, the external managed care of addiction treatment made its impact felt in a big way and particularly impacted the twenty-eight-day inpatient treatment programs. Payers and managed care companies appropriately questioned the need for the same intensity of care and length of stay for all patients. The insurance industry claimed that outpatient treatment was just as effective as inpatient—which is accurate as long as you match the severity of the addict’s illness to the intensity of care—but insurers were making the comparison as a blanket statement without regard to severity of illness in an effort to do away with paying for inpatient treatment. The days when a patient could simply plunk down an insurance card and receive twenty-eight days of inpatient treatment without the need for precertification or concurrent review are long gone.
At the time, the National Association of Addiction Treatment Providers (NAATP) was the largest trade organization for addiction programs, as it still is. Its membership at that time was made up primarily of private proprietary and nonprofit twenty-eight-day inpatient treatment programs, while today their membership includes public as well as private and all levels of care. As you could imagine, when commercial third payers stated that they would no longer routinely pay for twenty-eight days of inpatient treatment for addiction, those facilities providing that fixed length of stay responded with everything from alarm to panic and accompanying anger. Many developed systems of outpatient care began to move toward clinically-driven, variable length of stay models to complement their inpatient treatment. Many others, unable to adapt to this new payment model, closed, blaming managed care.
In order to “push back,” the NAATP board voted to levy an assessment from members to raise enough money to hire MEDSTAT Systems, a medical data provider. The goal of NAATP was to prove that lengths of stay shorter than twenty-eight days resulted in poorer outcomes. Using data on length of stay and outcome from more than fifty commercial insurance companies, Blue Cross Blue Shield plans, and other sources to obtain data on length of stay and outcome, MEDSTAT compared patients who stayed one to seven days, eight to fourteen days, fifteen to twenty-one days, and twenty-two to twenty-eight days with the result that this last group had the best outcomes (“Alcohol/drug treatment,” 1991), thus “proving” that “more is better” and the case for twenty-eight days of inpatient treatment (see Table 1).
However, these conclusions merit a more in-depth evaluation and further discussion. It can be assumed that the group of patients who remained in treatment for a week of less contained some—perhaps many—who left treatment against medical advice, some possibly staying only a day or two. They were probably unmotivated and clearly did not remain in treatment long enough to gain any benefit. That group alone could drastically skew the results in favor of the longer lengths of stay.
Additionally, this was the era of fixed length-of-say, one-size-fits-all treatment in which patients were forced into preplanned treatment protocols of predetermined lengths and standardized content that often did not meet their clinical needs. Said another way, a patient who remained in treatment for two weeks received one-half of a treatment program, without regard to whether the half he or she received met his or her individualized clinical needs.
The preceding does not mean that no patients need inpatient treatment, the most common treatment provided back then by NAATP members; some do. It is also true that some patients may need twenty-eight days of inpatient treatment while other may need either fewer days or even a longer length of stay, the length to be determined by the severity of their illness and their progress is meeting their treatment goals and objectives.
Where does all of this leave us? I believe that most of us work at what we do because it is important to us to make a difference, specifically to help people with substance use disorders recover. Sixty years ago, the one-size-fits-all approach worked well because of the homogeneity of the population with little if any co-occurring psychiatric, legal or social problems (what I lovingly called “plain, old simple drunks”). They usually descended into alcoholism gradually over twenty or thirty years of drinking. As a group they had accomplished goals: they had received education, were employed, and had raised families, among other things.
If we fast-forward to today, patients presenting for treatment are very different from the population of sixty years ago. They are younger; many began using in their early adolescence if not earlier with major disruptions to their social, moral, and other areas of skill development. Many are without a high school diploma or GED, and they are often unemployed and have no job skills. Many often present to treatment with a history of criminal behavior, co-occurring mental health problems, and/or physical disease such as HIV/AIDS and hepatitis B and C. In contrast to population of sixty years ago, current patients are not able to be rehabilitated, having never had an earlier level of successful functioning to which to return. If we are to really make a difference, we must adjust the way we provide treatment—level of care, length of service, and programming—to match the severities and needs of this population.
“Alcohol/drug treatment under-utilized and less costly, NAATP report concludes.” (1991). The Alcoholism Report, 19(8).
Hughes, P. H., Brandenburg, N., Baldwin, D. C. Jr., Storr, C. L., Williams, K. M., Anthony, J. C., & Sheehan, D. V. (1992). Prevalence of substance use among US physicians. JAMA, 267(17), 2333–9.
Mee-Lee, D., Shulman, G. D., Fishman, M. J., Gastfriend, D. R., & Miller, M. M. (Eds.). (2013). The ASAM criteria for addictive, substance-related and co-occurring conditions (3rd ed.). Carson City, NV: The Change Companies.
National Institute on Drug Abuse (NIDA). (2012). Principles of drug addiction treatment: A research-based guide (3rd ed.). Retrieved from https://www.drugabuse.gov/sites/default/files/podat_1.pdf