Drug and Alcohol Findings home page in a new window Druglink entries for March 2012

Residential rehabilitation; the high road to recovery?

Digital version with links of the Effectiveness Bank entries in the March/April 2012 edition of DrugScope's Druglink magazine. The focus this issue was on residential rehabilitation. Key issues include who needs this level of care and whether it really does do more than other modalities to promote recovery from addiction.

Residential rehabilitation; the best route to recovery? ...

Rehabs promote abstinence in Scotland ...

Is the therapeutic community an evidence-based treatment? ...

Needy clients do as well in day hospital as in residential care ...

Methadone patients benefit from therapeutic communities as much as other residents ...



 Residential rehabilitation: the high road to recovery?

"I would like to ... try to provide – difficult though it will be given the shortage of money we have been left – more residential treatment programmes. In the end, the way you get drug addicts clean is by getting them off drugs altogether, challenging their addiction rather than just replacing one opiate with another." These comments made by the Prime Minister in August 2010 reflect and promise to embed in policy the current emphasis on treatment which explicitly aims for recovery, reintegration and abstinence, trends which in turn have focused attention on what has traditionally been seen as the royal route to all three – residential rehabilitation. Add the claim that these programmes have been sidelined in the pursuit of 'manage the problem' objectives, and the fact that they are among the most expensive options at a time of financial cutbacks, and you indeed have a combustible mixture.

So concerned were British residential services that in 2011 some banded together in a Concordat to promote their cause as "providers of full recovery", defined as moving towards a drug-free, productive and socially integrated life. Their terminology was echoed the following year in a highly contested follow-up to the national drug strategy entitled Putting full recovery first, described by the chair of the Inter-Ministerial Group on Drugs as "the Government's roadmap for building a new treatment system based on recovery". What it meant by "full recovery" was never spelt out, nor how it differs from plain "recovery", but adopting this objective was said to entail an "increased focus on abstinence-based treatment" and a relegation of "indefinite maintenance, which is a replacement of one dependency with another" to the periphery rather than the centre of opiate addiction treatment.

In 2011 the temperature of this already heated debate had been raised by a survey of the then 28 members of the Concordat, of whom 16 provided usable responses. The report on these English residential rehabilitation services highlighted the lack of referrals, meaning that "All but four of the respondents reported that their service was under threat of closure for 2010/11". In turn this was related to the common insistence by local authority funders of residential care that prospective residents must first have exhausted other treatment options, and unrealistically proved their commitment to rehabilitation by complying with preparatory work, when the reason for their referral is precisely that they have been unable to overcome their dependence without the shelter of a residential setting.

Commissioners who insist residential care should be a last resort can and do claim the authority of Britain's National Institute for Health and Clinical Excellence (NICE). Based partly on not even a handful of studies recording no overall advantage for residential care over alternatives, NICE's experts advised that residential treatment be reserved for substance users with "significant comorbid physical, mental health or social (for example, housing) problems", who should have "not benefited from previous community-based psychosocial treatment." Critics of NICE's 'last resort' position argue that the reason why some clients are in such poor mental, physical and/or social states is that residential rehabilitation had been denied them earlier in their drug using careers when they had a greater chance of succeeding before the deterioration became too deep. The opposing argument is that trying residential services first risks unnecessary expenditure which drains treatment resources because it is impossible to predict with any certainty who will do well and who badly after their spell at the rehabilitation centre.

Most influential among the studies reviewed for NICE was a randomised comparison of a day versus residential therapeutic community for US crack users. It found no lasting anti-relapse benefits from the residential setting but – as in several other trials – the researchers had to limit the severity of their subjects so that all could safely be sent to either residential or non-residential care. The result was that nearly three quarters of potential participants could not join the study, and those who could were the ones least likely to need and differentially benefit from residential care.

A contrary line of argument is that non-residential rehabilitation in the area where the client is going to have to live may be harder, but also more realistic and more likely to stick than 'recovery' achieved in a protected environment far removed from the temptations and pressures which helped sustain the client's addiction. Contenders on this side of the argument can cite William White, US guru of re-orienting treatment and allied systems to recovery objectives and principles. In his key work on systems of care he points out that the non-recovery oriented systems he seeks to transform "grew out of a tradition of isolating addicted persons from their natural physical and social environments [to] enter a closed therapeutic environment" such as a residential treatment programme or therapeutic community. The problem as he sees it that learning to live without drugs there is likely to be unlearnt on transfer to a different environment: "The greater the physical, psychological, social, and cultural distance between the treatment environment and the natural environment of the client, the greater will be this transfer-of-learning challenge." Part of the solution, he argues, is a "greater emphasis on delivering home- and neighborhood-based (eg, health clinics, neighbourhood centers) addiction treatment and recovery support services" – the antithesis to the traditional model of residential rehabilitation in Britain.

See what the researchers have discovered by running this hot topic search – but beware that no conclusive answer to the residential v. non-residential question can be found. Non-randomised studies are generally confounded by differences between clients who find their way to residential services, and those who do not, while randomised studies can only ethically include people who will accept and can safely be allocated to either. Not surprisingly, they also tend to do equally well in either. Our reading of the research is that while non-residential care is sufficient for many clients, residential care has particular benefits for the minority who are most severely affected. For this topic we are also making available these unpublished notes on studies comparing residential and non-residential care.

Last revised 29 August 2013. First uploaded 29 March 2010

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Concern over abstinence outcomes in Scotland's treatment services

A study of drug users starting treatment in Scotland revealed low rates of abstinence nearly three years later, findings which have been widely misinterpreted. The figures derived from the Drug Outcome Research in Scotland study (DORIS). Like NTORS in England, this sampled patients entering different types of treatments and observed their progress during and after normal treatment delivery.

The study's most significant outcome report to date documented the progress 33 months later of 695 (all who could be reinterviewed) out of 1033 people who started treatment in 2001.1 Though using other drugs, most saw their main problem as heroin. Abstinence was the sole drug use outcome reported, defined as totally avoiding drugs except alcohol or tobacco over the preceding three months. DORIS excluded from this designation anyone prescribed legal substitutes such as methadone.

On this criterion, overall just 8%2 of the sample were abstinent. For patients who had started treatment at detoxification or counselling services, it was 6%, for prison-based services, 5%, and for residential rehabilitation 25%, significantly higher than the other modalities.

No corresponding figure was presented for patients who started the study in methadone maintenance. Instead a figure was given for patients who had started methadone after their first DORIS treatment, about 3% of whom were abstinent. Another 8% confined their (non-alcohol, non-tobacco) drug use to prescribed methadone, meaning that 11% were no longer using illegal drugs. For residential rehabilitation this figure was 33%.

Abstinence was associated with positive outcomes in terms of social integration (education/employment and crime), self-perceived health and mental health. For example, 39% of non-abstinent (ex)patients had committed acquisitive crimes over the past 17 months compared to 9% who were abstinent, and 11% and 2% respectively had attempted suicide or harmed themselves.

These associations were said to underline "the benefits ... of drug users having an extended period of abstinence", implying that abstinence caused or enabled other improvements. Yet abstinence was measured over the past three months, associated " benefits" over the past 17. To establish causality, cause must be shown to come before effect. It seems equally conceivable that other life changes enabled abstinence or that there was a complex multi-way interaction. Also, an analysis based on drug use frequency or severity might have found similar improvements associated with less than total abstinence.

As DORIS researchers warned, potential caseload differences make it unsafe to assume that the various treatment modalities caused the associated differences in abstinence rates. Similar considerations led NTORS to avoid using statistical tests to compare the performances of different modalities because a level playing field in terms of caseload could not be assured.3 Since so few patients enter residential care in Scotland, and since selection procedures should ensure that this expensive option is reserved for those who could benefit most, it seems likely that they differ from the average methadone patient. Another complication is that in DORIS as in other studies, over the years patients traversed several treatment modalities, complicating the assessment of what led to the eventual outcomes.

Nevertheless the research has highlighted how few drug users enter residential rehabilitation in Scotland and how few become abstinent from illegal drugs after an episode in methadone maintenance, raising questions over the balance of investment in treatment modalities. However, for the reasons given above, it would be unsafe to reset the balance solely on the basis of these findings. Internationally, research on residential rehabilitation is sparse, methodologically weak and ambiguous about its benefits relative to less expensive treatment options, while that favouring methadone is more extensive and more convincing.4 5 6 Evidence for the special benefits of residential care is mainly confined to multiply problematic and more severe cases.7

For similar reasons it would be unsafe to assume that the findings support the diversion of methadone patients to services aimed at abstinence from illegal drugs and legal substitutes. Compared to well run methadone services, such services have been associated with an extremely high rate of relapse and resultant deaths because the short spell of abstinence has left patients unprotected by tolerance to opiate-type drugs yet failed to create the circumstances in which they could do without them.8

Rather than or in addition to rebalancing there may be a case for reviewing the resourcing of methadone treatment in Scotland and the services provided by the clinics. English figures show that nearly three times as much is spent on an episode of residential care as on an episode of methadone treatment.9 From its inception social reintegration has been a major benefit of effective methadone maintenance.10 In this and other respects, services vary widely. Among the critical factors are adequate, flexible dosing, procedures which minimise both drop-out and throw-out, sufficiently comprehensive services able to draw on wider social resources, staff committed to the welfare of patients and if indicated to indefinite maintenance, and good organisation.

In 2007 an official report on Scottish methadone services suspected that insufficient resources were devoted to rehabilitating patients, found patchy adherence to UK dosing guidelines, differing views on the desirability of long-term prescribing, and widely differing policies on supervised consumption.11 Such differences are bound to affect patient retention and outcomes and the possibilities for rehabilitation.

Thanks for their comments on this entry in draft to Neil McKeganey of the University of Glasgow, David Best of the University of Birmingham, Mike McCarron of the Scottish Alcohol and Drug Action Team Association, and the staff of Glasgow Addiction Services. They bear no responsibility for the text including the interpretations and any remaining errors.

1 FEATURED STUDY McKeganey N. et al. Abstinence and drug abuse treatment: results from the Drug Outcome Research in Scotland study. Drugs: Education, Prevention & Policy: 2006, 13(6), p. 537–550.

2 Probably fewer given the numbers not followed up. This applies also to other abstinence estimates.

3 Gossop M. et al. The National Treatment Outcome Research Study in the United Kingdom: six-month follow-up outcomes. Psychology of Addictive Behaviors: 1997, 11 (4), p.324–337.

4 Simoens S. et al. The effectiveness of treatment for opiate dependent drug users: an international systematic review of the evidence. Scottish Executive Effective Interventions Unit, 2002.

5 Drug misuse: psychosocial interventions. National Clinical Practice Guideline Number 51. National Collaborating Centre for Mental Health, 2007.

6 Mattick R.P. et al. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database of Systematic Reviews 2003, Issue 2.

7 Systematic but simple way to determine who needs residential care. Nugget 8.9. Drug and Alcohol Findings: 2003, 8, p. 13.

8 Best D. et al. Overdosing on opiates parts I and II. Drug and Alcohol Findings: 2000, issues 4 and 5.

9 Healey A. et al. Criminal outcomes and costs of treatment services for injecting and non-injecting heroin users: evidence from a national prospective cohort survey. Journal of Health Services Research and Policy: 2003 8, 134–141.

10 Ashton M. Methadone maintenance: the original. Drug and Alcohol Findings: 2006, issue 14.

11 Scottish Advisory Committee on Drug Misuse Reducing harm and promoting recovery: a report on methadone treatment for substance misuse in Scotland. SACDM, 2007.

Last revised 07 January 2008

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Is the therapeutic community an evidence-based treatment? What the evidence says.

De Leon G.
Therapeutic Communities: 2010, 31(2), p. 104–128.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr De Leon at Geodeleon@aol.com.

By means of this review of prominent North American trials and meta-analyses, a leading researcher in to therapeutic communities tries to settle the issue of whether these effectively and cost-effectively treat addiction, so research can move on to how to make them more effective.

Summary Despite decades of therapeutic community outcome research, critics have questioned whether these are an evidence-based treatment for addictions. Given the relative lack of randomised, double-blind control trials, it is asserted that effectiveness has not been 'proven'. Such assertions have serious implications for the acceptance and future development of the therapeutic community. The purpose of this paper is to foster consensus among researchers, policy makers, providers and the public as to the research evidence for the effectiveness of the therapeutic community. Main findings and conclusions are summarised from multiple sources of outcome research in North America, including multi-programme field effectiveness studies, single programme controlled studies, meta-analytic statistical surveys, and cost-benefit studies. The weight of the research evidence from all sources is compelling in supporting the hypothesis that the therapeutic community is an effective and cost-effective treatment for certain subgroups of substance abusers. However, full acceptance of the therapeutic community as a bona fide evidence-based approach will require a generation of studies that include randomised controlled trials as well as other quantitative and qualitative research designs.

Last revised 05 January 2011

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Day hospital and residential addiction treatment: randomized and nonrandomized managed care clients.

Witbrodt J., Bond J., Kaskutas L.A. et al.
Journal of Consulting and Clinical Psychology: 2007, 75(6), p. 947–959.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Witbrodt at jwitbrodt@arg.org. You could also try this alternative source.

By selecting clients at the very edge of ethically requiring referral to residential care, this US study confirms that unless there are pressing contraindications, intensive non-residential options deliver equivalent outcomes. Often of course, there ARE pressing contraindications.

Summary Male and female managed care clients randomised to day hospital (154 clients) or community residential treatment (139) were compared on substance use outcomes at six and 12 months. To address possible bias in naturalistic studies, outcomes were also examined for clients who self-selected day hospital (321) and for clients (82) excluded from randomisation and instead directed to residential treatment because their home environments placed them at high risk of alcohol and/or drug use. American Society of Addiction Medicine criteria for referral to residential care defined whether clients were eligible for the study and for randomisation. More than 50% of followed-up clients reported past-30-day abstinence at follow-ups (unadjusted rates, no significant differences between groups). Despite differing baseline severity, randomised, self-selecting, and directed clients displayed similar abstinence outcomes in multivariate longitudinal models. Number of days spent in the initial treatment episode and 12-step attendance were associated with abstinence. Although 12-step attendance continued to be important for the full 12 months, treatment beyond the initial episode was not, suggesting an advantage for engaging clients in treatment initially and promoting 12-step attendance for at least a year. Other prognostic effects (including gender and ethnicity) were not significant predictors of differences in outcomes for clients in the treatment modalities.


Findings logo commentary Studies of whether residential care betters non-residential are limited by the ethical requirement that clients assessed as being at high risk in the absence of a protected environment cannot deliberately be denied it. As a result, studies usually only randomly allocate clients who can practically and with reasonable safety be referred to either setting. Not surprisingly, such studies rarely find an advantage for residential/inpatient options. However, some studies have suggested that high severity Factors relevant to the decision to provide residential/inpatient care probably include drug problem severity, psychiatric problems and perhaps especially suicidal tendencies, the degree of support for non-use (or non-problem use) in the home environment and among the client's family and social circle, housing, and the client's ability to support themselves in the community. How severe and multiple these problems need to be to justify residential care will depend partly on the intensity and adequacy of the non-residential alternatives. Most studies have compared inpatient versus outpatient settings rather than residential versus non-residential rehabilitation. clients do differentially benefit from residential/inpatient care.

The featured study went as far as it could to overcome this methodological limitation by including only clients who met at least five of the six standard US criteria Most were to do with not needing to be hospitalised but one criterion also required a history suggesting the potential for relapse if referred to non-residential programmes and another required there to be an unacceptably high risk of substance use due to the home environment. for residential care, but who fell short of criteria for hospitalisation. Clients who also met the optional sixth criterion – an unacceptably high risk of substance use due to the home environment – were directed to residential Generally up to three months with daily group therapy and practical activities. care. The rest were asked to accept randomisation to this or to intensive Clients spent from three to five and a half hours a day in group therapy over an intended two or three weeks. non-residential care, ethically as close as the study could get to randomising clients judged in need of residential care. Despite this profile, most refused randomisation and opted instead for the less disruptive (to their family, social and working lives) non-residential services, a sign of how important it is to maintain both residential and non-residential options.

In line with earlier research, the study confirmed that unless there are pressing reasons for residential care, non-residential alternatives result in equivalent outcomes at lower cost and less disruption to the client's life. It also confirms that at least in the short-term (often the extra benefits dissipate), the protection of a residential setting enables the most needy In this case, those who met all six criteria for residential care. and least promising clients to do as well as more promising clients, perhaps by eliminating the extra environmental risks they face out in the community.

What the balance should be between these options will depend on the population being served. In some areas most of the referred caseload do have a pressing need for residential care; in others (as in the featured study, all of whose subjects were beneficiaries of prepaid health care plan) this will be a minority.

Thanks for their comments on this entry in draft to Jane Witbrodt of the Alcohol Research Group. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 05 January 2009

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Methadone patients in the therapeutic community: a test of equivalency.

Sorensen J.L., Andrews S, Delucchi K.L. et al.
Drug and Alcohol Dependence: 2009, 100, p. 100–106.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Sorensen at James.Sorensen@ucsf.edu.

Are therapeutic communities incompatible with methadone maintenance? Not when staff have been prepared to accept and work with methadone patients and programmes adapted to accommodate them. Then patients stay as long and sustain abstinence from illegal drug use just as well as other residents.

Summary Residential therapeutic communities have demonstrated effectiveness, yet for the most part they adhere to a drug-free ideology incompatible with the use of methadone. This study used equivalency testing As explained in the source paper, equivalence testing is a statistical technique often used to show that a new medication is indistinguishable from an approved standard medication. Outcomes from the two treatments (in this case therapeutic community residence with versus without methadone maintenance) are declared equivalent if the confidence interval for the difference between them is completely within 20% plus and minus the value of outcomes from the standard treatment. An equivalence test can find that two treatments are not equivalent yet a traditional test can also find that they fail to differ to a statistically significant degree (for an illustration see http://www.mors.org/meetings/test_eval/presentations/C_Warner.pdf). In other words, a finding of equivalence is not the same as simply finding a failure to differ. to explore the consequences of admitting opioid-dependent clients currently on methadone maintenance treatment into a therapeutic community. The study compared 24-month outcomes between 125 methadone patients and 106 opioid-dependent drug-free clients with similar psychiatric histories, criminal justice pressures and expected lengths of stay, who were all newly enrolled in a therapeutic community. Statistical equivalence was expected between groups on retention in the therapeutic community and illicit opioid use. Secondary hypotheses posited statistical equivalence in the use of stimulants, benzodiazepines, and alcohol, as well as in HIV risk behaviours. As hypothesised, the average number of days in treatment was statistically equivalent for the two groups (166.5 for the methadone group and 180.2 for the comparison group). At each assessment, the proportion of the methadone group testing positive for illicit opioids was indistinguishable from the proportion in the comparison group. The equivalence found for illicit opioid use was also found for stimulant and alcohol use. The groups were statistically equivalent for benzodiazepine use at all assessments except at 24 months where 7% of the methadone group and none in the comparison group tested positive. Injection- and sex-risk behaviours were equivalent at all observation points. The authors concluded that in these therapeutic community settings, methadone patients fared as well as other opioid users, providing additional evidence that therapeutic communities can successfully be modified to accommodate methadone patients.


Findings logo commentary Generally considered incompatible treatment modalities, this is one of the few studies to show that a therapeutic community environment can be combined with methadone maintenance, and the first to do so in respect of a residential community. As the authors stress, it is important to remember that these were not the usual run of communities. For decades they had embraced methadone patients and made modifications Among those mentioned in the source article are the designation of a methadone counsellor who plays a vital role in the process of helping the programme modify its services to accept and treat methadone patients. Counsellors periodically offer methadone sensitivity training sessions to staff and patients, providing education and confronting stigma about methadone maintenance. They also conduct weekly methadone therapy groups for residents on methadone. Residents who opt to attempt withdrawal from methadone have greater access to alternative therapies and medical services. to meet their particular needs and increase their acceptance by staff and residents. It's also possible that these modifications and the presence of methadone patients changed the environment for non-methadone residents too. Residents were not randomly allocated to the two regimens but entered the facilities in the normal way. All had the kind of experience of opiate use which would have made them eligible for methadone maintenance, they were matched However, the three key variables identified in the abstract were very simply matched in an either/or way rather than in terms of degrees. on some key variables and differed little on most others, yet before, during and after leaving the communities, far more of the methadone group were in methadone treatment. The implication is that the major remaining difference between the two groups of residents lay in their preferences for alternative routes to recovery – complete abstinence, or abstinence from illegal drugs supported by substitute prescribing. The outcomes seem to suggest that in welcoming and suitably modified communities, residents who favour these different routes end up abstinent from illegal drugs in roughly the same numbers and converge somewhat Two years after joining the communities 70% of the methadone group were still being prescribed methadone compared to 30% of the non-methadone group, a narrowing of the gap of 95% versus 12% recorded at entry to the programmes. in their preferences for how to attempt to maintain this. They also show that many from both camps At six months after treatment entry, when most of the residents had left the therapeutic community treatment system, about a third tested positive for opiates rising to about a half at 18 months. Stimulant use showed the same upward trajectory but at a lower level, reaching about 40% positive by 18 months. do not totally succeed. What we don't know, however, is how the residents fared in other ways such as reintegration and mental and physical well being.

Though this study seems unique, previous reports have documented the integration of non-residential day care therapeutic communities with methadone programmes, demonstrating that patients who opt for this additional support evidence Perhaps because of their greater motivation and in this study, degree of psychological distress, as well as any impact of the community. greater remission in opiate and cocaine use. Other studies have established that with staff facilitation, 12-step mutual aid groups can (but not always See for example an account of the initially low take-up and stuttering progress of such groups in a Norwegian clinic in: Espegren O. Twelve step programme and methadone maintenance treatment. In: Waal H., Haga E., eds. Maintenance treatment of heroin addiction: evidence at the crossroads. Oslo: Cappelens, 2003, p. 321–333. smoothly) be integrated with methadone treatment and that patients who choose this option seem to benefit. Such initiatives are line with the cooperation between the founders of Alcoholics Anonymous and Vincent Dole, founder of methadone maintenance, who served on AA's board.

Simultaneous integration of residential rehabilitation and methadone is by no means unknown in Britain, In particular in the form of the ROMA rehabilitation houses in London which specialised in methadone patients. Their work was documented in: Glanz A. ROMA; Talgarth road. Report of an information-gathering exercise. London: DHSS, 1983. but far more common is the serial integration of these modalities within a client's treatment journey. In Scotland's DORIS study of drug treatment services, within 33 months most clients starting residential rehabilitation had left and spent a period on methadone. In England's similar NTORS study, perhaps a third had done so within a year. In neither case do we know how many rehabilitation clients had traversed the opposite route, though its seems likely In NTORS three-quarters of the total sample (ie, not just those entering residential rehabilitation) had been prescribed methadone in the past two years. that many had.

Thanks for their comments on this entry in draft to James L. Sorensen of the UCSF at San Francisco General Hospital. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 25 December 2008

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