Early on in medical training, one of us cared for Cara, a young woman with opioid addiction who was unhoused and wanted to stop using fentanyl. We started her on methadone—one of the most effective treatments for opioid addiction. But Cara (not her real name) had also been waiting for a bed in a treatment facility for over a week. One of the hospital case managers told the team that getting a rehab bed was Cara’s only chance at a sustained recovery from fentanyl. The case manager noted that while some facilities could be quite strict, structure and accountability were what these patients needed the most.
Every member of this person’s care team—from nurses and social workers to residents and attendings—nodded in agreement. But this later gave us pause. Was it Cara’s only chance at recovery? Would inpatient treatment facilities even accept people like her taking effective medications like methadone or buprenorphine, which some people in health care view as “substituting one drug for another”? Where would she go after completing treatment? And, most importantly, what did Cara actually want?
Politicians, health care providers and the businesses behind addiction treatment are desperately calling for more addiction “treatment beds”—also known as “residential treatment,” “inpatient treatment” or “rehab.” These calls for more beds are occurring nationwide, in cities like Boston and San Francisco (where Governor Gavin Newsom recently promised to build over 10,000 “behavioral health beds”) to more rural parts of the U.S. But building more addiction treatment beds is a stopgap to a more permanent solution.
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As overdose deaths take more than 100,000 U.S. lives annually, the medical profession needs to reexamine our country’s inpatient addiction treatment system, one that is often well-intended but not always rooted in evidence, particularly when it comes to treating patients with opioid addiction. To promote the health and dignity of people with substance use disorders, we need an addiction treatment landscape with different priorities, one that invests in expanded access to medication, behavioral therapies, proven harm reduction interventions and permanent affordable housing for people experiencing co-occurring addiction and homelessness. Most of all, we need to stop thinking that people with addiction are unable to be involved in their own treatment. Rather than mandating types of care, we need to partner with patients in what they want their treatment to look like.
In the 1940s, people with opioid addiction were treated at federally run facilities, at that time known as “narcotic farms.” These facilities resembled prisons with extensive security and cell blocks, and patients were mostly admitted through court-mandated treatment as part of their sentences for criminal charges. While clinicians staffed these facilities and led mandatory counseling sessions, patients spent a lot of time performing various types of labor as a form of addiction treatment, including farming, chores and taking care of animals. In the 1950s and 1960s, smaller therapeutic communities (TCs), which were long-term, abstinence-only residential programs, gained popularity. TCs—which emphasize behavioral modification techniques like attack therapy that are at odds with a patient-centered medical model—became mainstream largely because the medical community had abandoned the problem of addiction.
Therapeutic communities—made infamous by Synanon, one founded in 1958 that later devolved into a cult—did not have medical professionals on staff and enacted strict rules that routinely subjected participants to humiliation tactics, for example wearing dunce caps, if they did not comply. While far less common, they still exist today and are largely court-mandated. The only facility with a bed for Cara was a therapeutic community. She declined because it reminded her of jail: no cell phones, no interaction with different genders, and daily chores.
The data on treatment outcomes within residential treatment facilities are limited. But we do know one thing that works. For patients with opioid addiction in particular, outpatient treatment with methadone or buprenorphine significantly reduces overdose rates and recurrence of opioid use when compared to no treatment or treatment that did not offer medications for opioid addiction. A 2020 survey of residential treatment programs across the U.S., however, revealed that only 29 percent of residential treatment programs offered medications.
General medical providers receive little to no education on what substance use treatment programs offer and what works best. Many treatment facilities incorporate 12-step programming, such as Narcotics Anonymous/Alcoholics Anonymous (NA/AA), and most are focused on psychoeducation. While 12-step programming may be helpful for some, it is not formal treatment and philosophically tends to eschew medication, which is the gold standard treatment for opioid addiction. Many 12-step and NA/AA programming also have a spiritual focus and Christian roots—a turn off for individuals of other faiths or anyone who is atheistic.
Instead many addiction treatment facilities have been charged with exploitative practices. A 2021 audit study led by health policy researchers at Yale University, Harvard T.H. Chan School of Public Health and Johns Hopkins Bloomberg School of Public Health showed that 33 percent of callers (researchers posing as uninsured patients with opioid addiction seeking residential treatment) were offered spots at facilities before they were clinically evaluated. Most facilities required massive up-front payments. And most callers were turned down if they had any psychiatric comorbidities, a subset of the substance use disorder population shown to benefit most from inpatient treatment. Some 20.4 million U.S. adults suffer from co-occurring mental health issues and substance use disorders, according to the 2021 National Survey on Drug Use and Health.
Residential addiction treatment beds are not the panacea for our addiction crisis. Approximately 97 percent of patients with a substance use disorder who responded to past federal surveys indicated that they did not want to seek treatment. Members of the medical community look at this data and are quick to blame people who use drugs. Instead, clinicians and hospital administrators should interrogate how the treatment we are offering falls short. To be sure, many people find residential addiction treatment programs helpful and credit them with their recovery. But they need more options.
Addiction treatment should encompass more than building facilities. We must fully integrate addiction treatment into medicine, so we approach it like any other health condition, offering treatment based in rigorous science while also addressing patients’ social determinants of health. Cara did not require residential treatment; she was already on methadone, one of the best treatments available. But what she didn’t have was a reliable place to live. On my last day caring for Cara, she got a bed. One of us checked her chart two weeks later: she was back in our Emergency Department. We didn’t feel surprised, just hopeless and frustrated because what Cara really needed was a home, a job and close follow-up, not a facility.
This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.