14 November 2018

They tried to make me go to rehab … I said ‘What works best?’

Addiction Clinical

Amid a plethora of options for rehabilitation programs, continuity of care emerges as the key constant for successful treatment

You’re a sexual assault victim and the trial is approaching. You’ve come off drugs in the past, and right now you know you’re at risk of relapsing, because as the trial date approaches the cravings increase.

But when you turn to the rehab clinic that helped you once before, they turn you away, saying it might be possible if you were taking something already, such as buprenorphine or methadone. It feels like things have to get worse before they get better.

Dr Kathryn Daley, lecturer in RMIT’s School of Global, Urban and Social Studies tells this woman’s story to highlight the gaps in the system that people find when seeking treatment. When waiting lists in the public sector can be six months, the critical window to help people is often long gone.

Rehab facilities also vary in their admission criteria, approaches to treatment and outcomes, but patients may not have that information until they are there, says Dr Daley, whose work focuses on drug and alcohol treatment and chronic disadvantage.  

In an under-resourced and under-evaluated field, it’s hard to get a handle on what’s out there for Australians who are grappling with alcohol and drug problems, and importantly whether it works, and whether it’s worth remortgaging the family home for.

As the opioid epidemic sweeps across the United States, alarming stories have emerged of entrepreneurs setting up shop in a booming, and unregulated, market. 

Scam artists preying on families in distress are offering subpar services, bribing addicts to come to their services and even offering clean urine to evade drug testing.

Australia has seen some similar stories, with Victorian families coming forward with stories of exploitative billing where they were charged tens of thousands of dollars for a service, only to receive little to no refund when the client dropped out within days.

In a 2016 episode of the ABC’s Four Corners, journalists described families being pressured into signing over their superannuation, remortgaging their homes, taking personal loans and being billed for dubious extras, such as an $18 alarm clock.

Other rehab therapists have been exposed for offering clients drugs and clean urine during their stay.

The government asks public residential rehabs to provide some data on the clients that come through, but there is no oversight of the rehab centres in the private sphere.

Though doctors, nurses and clinical psychologists are all held accountable by a regulator, anyone can hang out a shingle and call themselves an addiction therapist.

In fact, some services wear it as a mark of pride that they aren’t part of the medical establishment. As a result, experts don’t even know how many rehab centres are running in the country, nor how many beds there are, let alone how well they’re performing.

What government data does show is that the number of agencies dedicated to treating alcohol and other drugs has grown substantially over the last decade. 

In rehab and in other services, an estimated 127,000 Australians were treated for substance use in a year, to a total of more than 200,000 treatment episodes. Some experts estimate the need, however, is far higher.

That being said, thousands of Australians do go to rehab each year, and many benefit from the service. But how do you know which services good and which aren’t?

The main message is that one size doesn’t fit all, says Dr Matthew Smout, program director of the Master of Clinical Psychology Program at the University of South Australia.

Individuals seeking rehab often do need to take time out from mainstream society

And there are many types of rehab on offer.

Residential rehabs can last anywhere from a few weeks to a year or two, and participants are usually kept busy with individual and group counselling. This may take the form of CBT or motivational interviewing, but many services also offer meditation, massage, art therapy and other complementary services.

Some services offer detox, where patients withdraw from a dangerous dependency such as alcohol under medical supervision. For some residents, rehab can be a space to get pharmacological treatment, such as opioid substitution therapy or medication for other psychological problems.

Some services allow smoking, some are non-smoking, some approaches take a less favourable view of pharmacotherapy and others might push all residents with opioid dependence onto substitution therapy.

Therapeutic communities tend to be structured less like an institution and have more of a focus on the importance of the community itself in healing the individual.

Clients tend to be more active in the day-to-day running of the community and have responsibilities. They may be asked to be involved in running the garden, cooking and cleaning, and often more responsibility and freedoms are given as they progress through treatment. 

For people who grew up with challenging childhoods or in toxic families, this kind of community and positive socialisation might be a first. 

Privileges, such as seeing family and day leave, are earned.

“It’s tricky, because it runs the risk that if someone leaves they come back with substances and then everyone gets access to substances,” Dr Daley says. “But people need to be trusted. There needs to be safety of course, but if you’re going to divulge everything [in therapy], you need to feel like you’re trusted.”

Alcoholics Anonymous (AA) had a strong hand in the early drug and alcohol treatment sector in the 1940s and 1950s in this country and globally. Though often criticised, AA principles underpin many services currently on offer. 

The 12-step approach and abstinence-based attitude are central to some services, with some shuttling residents to AA meetings, which themselves are free. The religiosity, hard-line approach and abstinence focus of AA can be off-putting to many.

“Residential rehab is a bit controversial in scientific circles because there are not randomised controlled trials,” Dr Smout says.  

You’re getting people at their most chaotic, not necessarily just at their rock bottom. 

Rehab services are for anything from heroin use to alcohol to cannabis (or all of the above), and someone could be a user of 20 years, or for only a few.

It’s also difficult to take a scientific approach to rehab. 

Do you randomly assign people to a treatment? It’s certainly not possible to blindly allocate somebody to half a year of either community-based counselling or residential rehab, nor is it necessarily ethical. 

People are going to choose what they want, and possibly not what they’re better suited for.

People who want or need rehab may very well not have the capacity for counselling either. They might be homeless or facing legal consequences if they don’t accept rehab. 

So it’s hard to get robust RCT studies up and going.

In Australia, two in three patients who go through public-sector rehab complete their residential stay. In the private sector it’s impossible to know, but some institutes, such as The Cabin in Thailand, boast completion rates as high as 96%. 

International data suggests around one in two clients relapse after a residential stay, although most people with substance use disorders do appear to get better with time and good treatment.

Those that take an evidence-based approach, perhaps focusing on CBT, resilience training and mindfulness, tend to do better, Dr Smout says.

“There are some really controversial services out there,” Adjunct Professor Nicole Lee, at Curtin University’s National Drug Research Institute, says. She gives the example of Shalom House – which boasted being the country’s “strictest drug rehab” – and takes a strongly Christian, militaristic, boot-camp approach.

The Western Australian centre has clients quit their drugs cold-turkey, prohibits smoking and confiscates mobile phones and other personal belongings in the beginning. Only men can apply, and they have to commit to a 12-month minimum stint, which involves manual labour Monday to Friday.

Former residents are divided in opinion, Professor Lee says, with some being evangelical supporters and others trying to get the facility shut down.

Some addiction specialists look at the variation in services as an overall positive for patients, in that people need to find something that works for them, and innovation might lead to something that works. 

Professor Lee isn’t sure that having such a strict approach, without good evidence backing it, is worth it. And the argument that saving one person’s life doing it this way makes up for it, doesn’t sit well with her.

“My concern is that one person might think it’s really great, but it might turn two people off treatment and they never go back. That’s a big problem. It’s a vulnerable population.

 “They are stigmatised in community, and if they don’t get a good treatment experience first off they may not come back. There’s no evidence at all that a tough love approach is effective.”

So what does work?

The main premise of rehab is an extended period away from the outside world and the stresses and triggers for an addicition.

For those seeking a luxury experience, one Byron Bay rehab offers a month-long stay for upwards of $100,000. But typically, private rehabs services may be more like $10,000 to $30,000 a month and public ones are often almost entirely paid for by the client’s Centrelink benefit.

A lot of the rehab facilities  are basic and bare, and are not very comfortable places to be in, Professor Lee says. “I really believe you need to be in a nourishing environment to do well.”

One criticism of residential rehab is that a substantial portion of the money patients spend has to go to paying for the roof over their head, toilets that flush and clean linen. As it’s not clear that the residential rehab is superior to cheaper options like day rehab or outpatient treatment, it raises questions over the efficiency of healthcare resources being spent in this way.

Some of the benefits of the private sector is that it’s much more comfortable, but the downside is it’s much less regulated, she adds. 

The ongoing success of residential rehab as a business is likely underpinned by the ability the private sector has in dedicating resources to effective advocacy and lobbying for funding, says addiction medicine specialist Associate Professor Nick Lintzeris.

It’s a bind, because while they are effective at advocacy, they are not necessarily the most efficient use of resources, the University of Sydney professor says.

Many experts worry that because residential rehab is one of the most well-known alcohol and other drug treatment options – thanks to high profile celebrity stints – people may turn to this over other, more efficient and possibly effective options.

Professor Lintzeris also offers another issue: “The downsides are that we’re not investing in alternative models of care adequately, and we’re not delivering other more effective forms of healthcare.

“So where does that leave us? I’m suggesting the role of residential rehab is becoming less important than it was 20 years ago.” 

This is partly reflected in the shrinking time people tend to spend in rehab these days. Where two years may have initially been the norm, we’re often seeing three- and six-month programs now.

In part, this is because there’s little evidence to suggest a longer stint is more effective than a shorter one, Professor Lintzeris says.

Also it’s because there’s a better understanding of substance use disorders and how they operate as chronic disease.

When thinking about whom residential rehab would be good for, Professor Lintzeris paints the picture of a patient who has poor social support, poor community support and for who a period outside of mainstream society would not be too disruptive.

For example, if you’re holding down a job, or have family commitments, such as caring for children or elderly parents, “the idea that you’d pack everything up and live for six months at a residential rehab is kind of unrealistic and might be one step forward and two steps back”, he says. 

“We know some of the strongest predictors of long-term recovery are those social connections. If you’ve got work or family commitment, residential rehab is probably not going to work.”

Historically, the way we treat addicts has changed over the years.

Half a century ago the approach to addicts had a strong abstinence bent. “There was often an element of social control,” Professor Lintzeris says.

“The general models were basically to take these people who were a blight on the community and lock them up somewhere, get them out of the communities, so they are also isolated from substances. They would be taken to a farm far away from the rest of society, to a place where there weren’t drug dealers or a pub on the way home.

However, as researchers develop more and more effective treatments the medical community turns less and less to the locking up model.

“For people with substance use problems, where we have really effective treatment approaches, there is much less role for the residential rehab model,” Professor Lintzeris says.

Take a look at the world of opioid dependence.

“Thirty or 40 years ago the main models of treating heroin addicts was to lock them up, in a therapeutic community. The idea was that these people had been programmed poorly, and we’ll strip them down to their core and build them up again,” he says. 

This often relied on confrontational therapy, which hasn’t been supported by the growing body of evidence.

Enthusiasm for this type of approach has dropped off over the years, as more effective treatments have emerged. Highly effective substitution therapies, such as buprenorphine and methadone exist, and patients do well on these, so treatment doesn’t need to happen within a rehab clinic.

But residential rehab and therapeutic communities still have a role, Professor Lintzeris says.  Individuals often do need time out from mainstream society, especially those with bad housing situations where they are at risk of homelessness, surrounded by other drug users or are experiencing domestic violence.

“It makes a lot of sense for someone to be taken out of a really poor social environment and have a period of respite care away from all the difficulties they are encountering,” he says.

Professor Lintzeris makes the analogy of a six-week admission into a psychiatric ward for someone with schizophrenia. 

“That six weeks may well be life-saving, and without that admission that patient might have spiralled out of control,” he ays.

So a residential program can help the patient with medication, sort out social issues and avert legal ramifications, but have you cured the person of schizophrenia? he asks.

“No one would say, ‘You’ve gone six weeks without a hallucination, you’re fixed’,” he says. “Yet that’s been the model traditionally for substance use disorders.”

With growing recognition of addiction as a chronic disease comes an increasing emphasis on the importance of choosing rehab with an “after care” program that provides clients with support to help them move back into the real world. 

Addiction medicine specialist and GP, Professor Moira Sim, says general practice is a great opportunity for a non-judgemental approach that can help patients find the service that best matches them.

She encouraged doctors to call the local drug and alcohol service to get information on how best to treat their patients, and seek out the state or local area’s 24-hour  phone help line for guidance if they want to be involved in the management of the patient themselves.

“We often end up supporting the families, and it’s important that we don’t take the role of telling them what to do. Is the right thing to do be supportive, or hard love?” the executive dean of the School of Medical and Health Sciences at Edith Cowan University says. 

Unlike recommending asthma medication, this is a space where there isn’t a clear cut answer as to what is better. 

“The single thing that defines whether someone is likely to do well, is continuity of care.”