For a variety of economic and historical reasons, the U.S. substance use
treatment system has become quite complicated, and in some cases separated
from the rest of psychiatry. This means that the general clinician may
not understand the treatment options available. To make matters worse, a
strong profit motive has led to the mushrooming of expensive residential
rehab centers, which can run well above the $50,000-per-month figure
quoted to your patient, M.
In some cases, you won’t be particularly involved in deciding what
treatment a patient receives; such choices are often made in the setting of
a substance use treatment program, usually during or after an acute detox.
Nonetheless, it’s helpful for you to have an overview of treatment options
available for substance-using patients. In some cases, your patient will ask
you for advice, and in others, you will be contacted by a treatment setting
about your patient; for both scenarios, you will want a clear idea of where
a program fits in the context of treatment settings.
Before describing the programs, let’s go over the variety of health care
professionals specializing in substance use treatment. You are likely to have
contact with many of them during your career.
Addiction counselors and therapists
There are many therapists with an interest or certification in addictions.
The most well-known national certifying organization is NAADAC, The
Association for Addiction Professionals (formerly called the National Association
for Alcoholism and Drug Abuse Counselors). The training requirements
for such certified counselors vary from state to state. For example, in
Texas, where I work, such counselors are called licensed chemical dependency
counselors, and their training entails having at least an associate
degree, completing 4,000 hours of supervised experience treating patients
with substance use disorders, then passing a state certification examination
to obtain a state license. You will typically find these counselors working in
rehab programs or intensive outpatient programs.
Going up the ladder of training requirements, there are clinical social
workers (who generally have a master’s degree in social work) and clinical
psychologists (who have a PhD or PsyD). Some therapists specialize
exclusively in addiction treatment, some have general practices that include
addiction treatment, and others will not treat addiction specifically but will
address issues related to relationships, coping skills, etc, all of which might
be useful for your patients. I recommend that you develop a list of good
local practitioners to whom you can refer patients. You can assemble this
list based on feedback from your patients or from colleagues.
USEFUL FACT: The ASAM Criteria
The ASAM criteria are the American Society of Addiction
Medicine’s guidelines for matching severity of
illness and level of function with intensity of service in addiction
treatment. Treatment matching means providing the patient
with the least restrictive level of care that is likely to be beneficial.
This involves assessing people in six dimensions and matching
them with the most appropriate level of care so that services are
provided in the most efficient manner. Criteria such as these help
clinicians determine and justify whether a patient requires outpatient
or residential or inpatient services with medical monitoring
(for treatment of withdrawal or comorbidities).
The ASAM criteria are used primarily by addiction specialists who
need to demonstrate to insurance companies that a certain level
of care is needed. For more details on incorporating the ASAM criteria
into your practice, see the Carlat Addiction Treatment Report,
38 THE CARLAT GUIDE SERIES | ADDICTION TREATMENT
You will likely need to refer some patients to physicians who specialize in
addiction. There are two addiction specialties for MDs: addiction medicine,
open to all specialties, and addiction psychiatry, open only to psychiatrists.
An addiction psychiatry specialist completes a one-year fellowship in
addiction psychiatry after residency, and then passes a certification exam
conducted by the American Academy of Addiction Psychiatry. An addiction
medicine specialist must complete a residency in any medical specialty
(psychiatry, internal medicine, family medicine, pediatrics, preventive medicine,
obstetrics, etc) and then complete a fellowship in addiction medicine,
or demonstrate substantial time spent delivering substance abuse care (after
2022, only those who have completed a fellowship in addiction medicine
will be eligible for certification).
Interventionists are addiction professionals who specialize in orchestrating
the sometimes-dramatic interventions that have become fodder for reality
TV shows. Usually it is the emotionally exhausted family that seeks this
kind of help. An interventionist generally offers three services: planning
and executing the intervention, finding an appropriate treatment program
for the patient, and providing “recovery coaching” after treatment, often for
a year or more. There’s usually a fee for each service, and insurance rarely if
ever pays for it.
We devote a chapter to the topic of 12-step programs, but as an introduction
you should know that these are nonprofessional mutual self-help
groups that are community-organized and free. They aren’t considered
treatments per se because they don’t involve licensed counselors providing
care to patients. Nonetheless, 12-step programs are often the first form of
help that substance-using patients seek out. Many clinicians will view a
referral to AA meetings as a convenient first step.
The following section details the types of addiction treatment services
available (see Table 3-1).
Detox is the process of quickly getting a patient off drugs or alcohol. It’s
often a prelude to rehab since it’s hard for patients to make headway in
recovery while they are actively using. While detox can be either outpatient
or inpatient, inpatient treatment is the best choice for those withdrawing
from substantial daily alcohol use (such as a pint of hard liquor or 12–24
beers per day), and for those with concurrent or preexisting medical problems,
such as heart or liver disease. How do you get patients into detox? If
you know some detox facilities in your area, the best route is to call them
directly (or have the patient or family call). Some centers will do their own
screening, whereas others will require the patient to visit the ER before
referral. Obviously, most patients will prefer to bypass the ER. Another
option is to start by calling the insurance company: It will provide the
names of local detox programs with which it contracts, and the company
may have specific hoops to jump through before it will authorize treatment.
ntensive outpatient programs (IOP)
IOP usually consists of 9 hours per week of outpatient treatment, divided
into three 3-hour sessions. They are generally group therapy sessions that
offer rehabilitative counseling and educational classes. These programs are
offered in either day or evening formats. IOP is a good option for people
who are struggling with sobriety after detox, or for those whose job or
family obligations prevent more time-intensive treatment. In some cases,
the person’s insurance may only cover IOP.
In contrast to 12-step programs, IOPs are professionally facilitated
groups, and they can be uniquely helpful for patients on several levels.
Whereas in a one-on-one setting, patients might feel uncomfortable talking
about certain behaviors, a group offers a sense of mutual permission and
support. And unlike self-help groups such as AA, having a facilitator in
charge can keep people on task and prevent certain individuals from
monopolizing the conversation.
Partial hospitalization programs (PHP)
Also known as “day treatment,” PHPs usually run 5 days a week, 6 hours per
day, and last 10–15 days. These programs are much more comprehensive
Chapter 3: UNDERSTANDING ADDICTION SERVICES 41
than IOPs. They tend to have more sophisticated therapy groups, such as
dialectical behavior therapy, cognitive behavioral therapy, and family therapy.
Psychopharmacologists are also on staff for appointments as part of the
daily treatment program. Insurance companies will approve PHP primarily
for patients with comorbid psychiatric disorders.
Residential rehabilitation programs are 30-day inpatient programs that vary
widely in cost, philosophy, and personnel. Residential rehab is for patients
who have a toxic or unsupportive home environment—they may live alone
or have family members who are actively using. Residential rehab is also
appropriate for people who have repeatedly relapsed at a lower level of care.
The classic rehab is a pricey, for-profit company providing a luxurious environment
and requiring payment up front; such programs can run $50,000
per month or more. Less pricey than residential rehab are 12-step immersion
programs, which clock in at around $10,000 per month. These facilities
can actually be fairly luxurious (think big lodges and beautiful farms);
they are cheaper because they are run primarily by people in recovery and
by addiction counselors without advanced degrees. The programming in
12-step immersion is limited to AA—from the moment patients walk in,
they will be doing AA steps. Finally, there are some bare-bones residential
rehabs covered by Medicaid. For some patients, being in a less ritzy setting
can serve as a motivator to avoid future rehab stints.
These programs are also known as therapeutic communities or recovery
house. They last 6–12 months, and are for people who relapse so frequently
that they need to be away from their community and spend significant time
in a very structured environment. They learn to incorporate recovery skills
in their lives and gain the self-esteem and confidence to create a network
of people they can depend on when they’re stressed. Some long-term residential
programs are called “working houses” because they have a returnto-work
requirement after 1 to 2 months.
A sober house, also called a halfway house, is an independent living
arrangement with minor oversight where residents can stay for 1–2 years.
Most of these residencies have a house manager, but they lack on-site
professional counselors or programming. Residents are sometimes told,
“Here’s your key; you can come and go as you want, but everyone here is
sober.” At some houses, there is a curfew or restrictions on weekends away,
especially for newcomers. At others, individuals may move up along a “levels”
system, gaining more privileges with each level. Residents are expected
to attend outside 12-step meetings frequently, at least 4 times a week, and
to undergo weekly random drug testing. As part of the living arrangement,
some sober houses require that residents find at least part-time work in
the community. Sober houses are often a good segue from a residential
program, because they provide support within the community environment
and teach people to take more responsibility for their recovery. Some
people find that they cannot maintain sobriety outside of sober houses.
Chapter 3: UNDERSTANDING ADDICTION SERVICES 43
Sadly, there is a countrywide shortage of residential beds. Because of this,
there are many transitional stabilization units, otherwise known as holding
beds. They are usually federally funded, and they provide a bare-bones
facility for people to stay while they wait for residential beds. The usual
occupant of a holding bed is a recently detoxed patient who needs residential
treatment to maintain sobriety, but does not have the necessary funds
for a rehab program, even one of the cheaper options. People may stay here
for up to a few months as they wait for a placement.
Referring patients to treatment is all well and good, but up to a third of
patients in rehab facilities are there by court order, usually involuntarily. As
a clinician, you might be involved in the process of forcing a patient into
treatment, so it’s important to understand the process.
Many states (but not all) have a provision allowing court-mandated treatment.
In Massachusetts, the process is called a “section 35,” which refers to
a section of the state law. This provision is used for patients who are out of
control with their use but refuse treatment. Most of the time in this scenario,
you have the family coming to you asking, “What can we do, Doctor?” They
explain the ways in which their family member is engaging in risky behavior
or endangering others, such as, “He’s falling and hurting himself when he’s
drunk” or, “She overdosed on heroin and we barely got her to the ER on
time.” At this point, you need to intervene to keep the person safe.
The procedure is as follows. The family has to prepare a case for involuntary
commitment. It will be in the form of testimony, but it is often augmented
by medical reports and even photographic evidence (I advise these
families to keep their phones at the ready and take video of the intoxicated
behavior). A hearing is scheduled at which a judge weighs the evidence;
if the judge agrees that the situation is dire, a writ of apprehension will be
issued. The police will then bring the person in handcuffs to court, where
the patient hears the evidence, has a chance to refute it before the judge,
and expresses willingness (or unwillingness) to enter treatment. If committed
involuntarily, the person will be taken to a state-funded residential
rehab facility for up to 90 days. Do such involuntary commitments work?
Often not so much. Patients can be released early if they agree to outpatient
counseling and AA meetings, but this may be a ruse for getting back
44 THE CARLAT GUIDE SERIES | ADDICTION TREATMENT
to substance use. Nonetheless, involuntary commitment does give the
family some respite, and it creates the chance, no matter how small, that
the patient will eventually buy into the need for treatment.
Court-mandated treatment can be initiated by the family, the police, or
any physician. The limiting factor is the requirement to go to court—something
physicians are rarely willing to do. You might be surprised to learn,
however, that involuntary commitment has similar outcomes to voluntary
treatment when looking at long-term success rates. Patients can still learn
from and benefit from treatment, even if they grumble about having to be
A final word of advice—I recommend getting to know the treatment
centers and providers in your area. Go to a local IOP or PHP and sit in on
a staff meeting. The more working relationships you have with addiction
professionals, the more efficient you will be at referring your patient to the
right treatment, at the right place, and at the right time.