INPATIENT SUBSTANCE ABUSE TREATMENT LENGTH OF STAY

Running Head: INPATIENT SUBSTANCE ABUSE TREATMENT LENGTH OF STAY

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Amount of Time Spent in Inpatient Substance Abuse Treatment and its Effects on

Sustained Recovery: A Research Proposal

Stephanie Weisenthal

Fayetteville State University


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Abstract

It needs to be proven that more days of inpatient treatment significantly improves a

patient’s ability to maintain abstinence to justify the added expense of more days of inpatient

rehabilitation. This study will have two groups of participants (250 in each group) from within

Buncombe County, NC. The participants will be between the ages of 18-50 and will have a

diagnosed substance abuse disorder. One group will be part of a 28 day inpatient treatment

program while the other will be part of a 90 day treatment program. It is predicted that the

participants from the 90 day treatment will have greater success. Support of this prediction

would suggest reconsidering substance abuse benefits for health insurance policies.

Keywords: substance abuse, inpatient treatment, abstinence, insurance benefits


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Amount of Time Spent in Inpatient Substance Abuse Treatment and its Effects on

Sustained Recovery: A Research Proposal

Addiction is a growing problem in our society. According to Closing the Addiction

Treatment Gap (CATG) initiative (2010) “drug use is on the rise in this country and 23.5 million

Americans are addicted to alcohol and drugs. That's approximately one in every 10 Americans

over the age of 12 – roughly equal to the entire population of Texas. But only 11 percent of those

with an addiction receive treatment”. Of course, it should be the goal to have treatment more

available to a larger portion of those addicted, but what we need to figure out is, is the treatment

people are receiving doing any good?

Substance abusers who enter treatment using health insurance must go by what their

insurance company is willing to cover. Often, patients are allowed detox and outpatient services.

If it is a recurring problem, inpatient services may be approved. Paying for a 28-day stay may be

less cost effective than a longer treatment program (90 days or more), but if the recidivism rate is

higher for a short term program, that would mean more payouts in the long run, as the patient

may keep relapsing, and requiring further treatment. According to the Substance Abuse and

Mental Health Services Administration (SAMHSA), Office of Applied Studies (OAS), “The

majority (64%) of persons entering addiction treatment in the USA already have one or more

prior treatment episodes, including 22% with three or four prior admissions, and 19% with five

or more prior admissions” (2003). By offering better treatment from the start, the patient will

therefore have better odds.

“Some research has shown a negative relationship between length of stay and

rehospitalization” (Thompson, Neighbors, Munday & Trierweiler, 2003). If a longer stay means

better results, it could end up being more cost-effective. Often, inpatient treatment programs will


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recommend a 28 day stay. Are they recommending that because it is the best outcome, or is that

recommended because it is the most likely to be covered by insurance? According to a study

done by Messina, Wish and Nemes (2000), it is “suggested that the longer residential treatment

program had a particularly beneficial impact.” Further evidence has suggested that “LTR (long-

term residential) research has demonstrated that clients with moderate LOS (lengths of stay) tend

to have more favorable outcomes than clients with shorter LOS” (Greenfield, Burgdorf, Chen,

Porowski, Roberts, & Herrell, 2004). In yet another study, it was shown that “treatment outcome

tended to improve with increased treatment duration from the first week of treatment onwards”

(Zhang, Friedman, & Gerstein, 2003). If so many studies show that longer stays at inpatient

treatment facilities improve a person’s chances of remaining abstinent, why are we still using

less effective ways of treating substance abusers? This study will hopefully provide more insight

as to whether or not insurance companies should change benefits at inpatient treatment facilities

from 28 day to 90 day stays to achieve a more favorable outcome.


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Method

Participants

For this study, 500 people, both men and women, of various ethnic backgrounds, who

think they have a substance abuse disorder are to be recruited. Participants will be between the

ages of 18-50. This study will only be available to subjects in the greater Buncombe County, NC

area. Once recruited, they will be evaluated by a professional using the NIDA Quick Screen

V1.0. which helps to assess how often the participant uses alcohol or other drugs. If the

participant has answered yes to the use of drugs or alcohol the screener can move on to the

NIDA-Modified ASSIST V2.0. The NIDA modified assist goes into more detail about which

drugs and how often the participant uses them. If the subject scores greater than a 27 on the

NIDA-Modified ASSIST V2.0, they will be considered in need of treatment and therefore

eligible for this study. For this study, 250 participants will be placed in a 28-day inpatient

rehabilitation treatment program and the other 250 will be placed in a 90 day inpatient

rehabilitation program. The groups will be assigned randomly.

Procedure

To recruit participants an advertisement for this study will be placed on The SAMHSA

website (Substance Abuse and Mental Health Services Administration). The participants will be

assessed and if they are determined to have a substance abuse problem, they will sign a consent

form explaining that progress reports from therapists will be made available to the researchers

and will therefore, not be entirely confidential, and they will agree to submit random urine drug

screens as well as self-reports for up to one year following treatment. All of the participants will

receive an inpatient medical detox. They will be adequately detoxed before starting their


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inpatient rehabilitation treatment. For this study, 250 participants will be placed in a 28-day

inpatient rehabilitation treatment program and the other 250 will be placed in a 90 day inpatient

rehabilitation program. The groups will be assigned randomly. Both treatment centers will

employ similar therapies such as group therapy, individual therapy, art and music therapy,

coping skills training, an introduction to twelve step programs, and informative group sessions

about addiction. Each participant will work one-on-one with a therapist while in treatment who

will determine how well they are doing.

After the participants leave treatment, they will be randomly drug tested, as well as

interviewed to determine if they have been sustaining their recovery. The goal of this study is to

determine whether length of stay at an inpatient rehabilitation treatment center has any

significant role into whether or not the participant achieves sustained recovery.

Results

The current standard amount of time allowed by insurance companies for inpatient

substance abuse treatment is no more than 28 days. I expect that if a patient is given 90 days in

inpatient treatment their success rate will be significantly better than a patient who only has 28

days of inpatient treatment. If the difference between the two is statistically significant, I feel it

should warrant a change in inpatient substance abuse treatment benefits.

I expect that patients that are given 90 days of treatment vs. 28 days, will do much better

maintaining sobriety. 28 days is not enough time to really get to a person’s core issues and work

on them. If a patient has 90 days of treatment, they have time to really get settled, to feel

comfortable opening up in group and individual settings, as well as to deal with post-acute

withdrawal symptoms. Most post-acute withdrawal symptoms do not even show up until a


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person has been free from drugs or alcohol for a month. If someone is only given 28 days in

treatment, they may have not even begun exhibiting post-acute withdrawal symptoms until they

are just about to leave treatment or have already gone home.

I plan to use a T-test to determine which has the better outcome, 28 days or 90 days. 250

patients will receive 28 day treatment and 250 will receive 90 day treatment. I will measure how

long each patient stays clean and sober following treatment using urine screens and self-reports.

The scores will fall between 0-12, representing months in one year.

Discussion

The results of this study are likely to show that patients are more likely to sustain sobriety

as the length of inpatient treatment increases. There have been many studies about residential

treatment that prove length of stay is an important factor in determining recovery from drugs

and alcohol. “Studies have consistently shown the length of time a drug user stays in a

treatment program is one of the most important predictors of successful treatment outcomes”

(Johnson et al. 2008). According to Hser et. al, “longer duration of treatment has been the most

consistent and important predictor of favorable treatment outcome” (2004). In accordance with

these statements, Greenfield et.al. found that “success rates were lower, and between-study

differences were larger, for clients with shorter stays in treatment, strong associations between

length of stay in treatment and posttreatment abstinence rate were found in all three studies,

suggesting that length of stay in residential treatment is a major determinant of treatment

effectiveness” (2004).


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So, although it has been shown that longer stays of treatment prove to be more

effective, the insurance system still makes it difficult for addicts to be approved for even 14 to 28

days of inpatient treatment. “According to A. Thomas McClellan, CEO of the Treatment

Research Institute (TRI) many insurance policies will state they cover 30 days of inpatient

treatment but no one gets all 30 days covered. The average days of stay covered under insurance

are currently between 11-14 days of that 30 days often identified in policies” (Barr, 2014). So is

11-14 days enough to treat an illness that kills “nearly 44,000 people each year, a figure that

more than doubled from 1999 to 2013” (Bowerman & Pager, 2015)? It can be argued that it is

the nature of the disease, and the mindset of the public about addiction, that allows insurance

companies to get away with not giving patients the best possible care.

In some cases, a patient must first try an outpatient program and fail before they will even

consider any inpatient rehabilitation. . This rush towards outpatient treatment has led a number of

inpatient treatment centers to shut down. “For example, in 1990, there were over 16,000

substance abuse treatment facilities operating in this country; approximately 55% of those were

residential or inpatient hospital; Figures from 2002 indicate that there are less than 14,000

programs; only 10% are residential or inpatient hospital” (McLellan, Carise, & Kleber, 2003).

With such a drastic reduction in inpatient options, many substance abusers are simply trying

detox, and are sent back out to relapse again, sometimes even before they make it to their first

outpatient appointment. “Too often, individuals with substance use disorders end up going

through short-term detoxification multiple times before beginning more long-term treatment

solutions” (Woodward, 2004). That is for those that are lucky enough to even make it to some

type of rehabilitation. “Previous research suggests that some substance users have multiple crisis

detoxification visits and never access rehabilitation care” (Carrier et.al, 2011). If given the


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opportunity after detox to participate in an inpatient treatment program, why wouldn’t a person

want the most beneficial treatment for their illness?

Besides fully insured or self-insured plans through employers, some people needing

substance abuse treatment have Medicaid. Medicaid has been known to be even worse than

managed care organizations. “State Medicaid policies may make it difficult for clients to obtain

suitable chemical dependency treatment services” (McFarland et.al, 2006) In addition, “risk for

premature termination of substance abuse treatment may be especially high for Medicaid clients”

(McFarland et.al, 2006). A considerable number of addicts and alcoholics do not generally have

insurance through an employer or private pay insurance and Medicaid may be their only hope for

insurance coverage. However, “many people with addictions lost Medicaid coverage after 1996,

when Congress acted to remove substance dependence as a qualifying disability for

Supplemental Security Income” (Mark et. Al, 2011). If inpatient substance abuse treatment has

shown to be effective, why does no one want to pay for it?

A recently implemented program in Gloucester, Massachusetts has been helping addicts

who want help, no questions asked, no strings attached. According to Chief Campanello, funds

come from money seized from drug dealers. In an article by Zachary Segal (2015) he discusses

Gloucester Police Department’s Angel Program, which states “addicts who walk into the station

and ask for help will be given detox and access to treatment.” Dozens of police departments in

other states have taken a page from Gloucester, Massachussets. Treatment could help to restore

this population of substance abusers to become productive members of society. Why should only

those with insurance or the ability to privately pay be allowed treatment?

People who get their health insurance through their employers either have fully insured or

self-insured insurance plans. Self-insured plans use a managed care organization. Managed care


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organizations have contracts with health providers and facilities for a discounted rate. “Some

posit that the growth of managed care will lead to shortened substance abuse treatment and fewer

types of substance abuse services” (McFarland et. al, 2006). Cost effectiveness seems to be the

hallmark of managed care, but cost effectiveness isn’t actually helping substance abusers who

want help. It is hurting them. When someone is ready to get help, it presents an opportunity to

change their life. Simply allowing them to go to outpatient treatment does not give them the best

odds. “Most studies on cost-effectiveness compare the more expensive residential settings with

the less expensive outpatient settings. It is probably safe to conclude that the outpatient setting is

more cost-effective for the majority of patients” (Machado, 2005). If they are only offered

insufficient treatment and relapse, there lies the possibility that they may not make it to another

treatment center. Narcotics Anonymous and Alcoholics Anonymous have an old adage about

what happens to substance abusers that don’t get help, their ends are always the same: “jails,

institutions, and death.” Insurance companies should care more about what is best for the patient

and not what is cost-effective. In a report by Galanter et.al (2000), it was determined that:

The value of substance abuse insurance coverage has declined by 75% between 1988 and

1998 for employees of mid-to large-size companies, compared with only an 11.5%

decline for general health insurance. The shift towards MC (managed care) has also been

associated with a drastic reduction in frequency and duration of inpatient hospitalization,

and there is no clear evidence that this reduction has been offset by a corresponding

increase in outpatient support. In a survey of physicians treating addiction, the majority

felt that MC had a negative impact on detoxification and rehabilitation, and on their

ethical practice of addiction medicine.


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14 days or 28 days has shown to be less effective in treating substance abuse issues. If it

does not work in the majority of the cases, then it is a waste of money that could be better spent

on effective treatment. “An important consideration is that duration of substance abuse

treatment is closely linked to positive outcomes. According to the National Institute on Drug

abuse 3 months of treatment is the threshold of significant improvement” (McFarland et.al,

2006). If all of these studies find that longer inpatient treatment is more effective, specifically a

minimum of 90 days, we should consider changing inpatient substance abuse rehabilitation

benefits. 28 day programs, being less effective, have a high recidivism rate. Substance abuse

treatment has been known to have a “revolving door”. It’s as if they come to treatment, and get

a tune-up, only to go back out and start the cycle all over again. Over time, a person returning to

treatment over and over costs more money. By investing in better treatment when a patient first

gets help, it could inadvertently keep costs down in the long run. This study could prove to be a

win-win for insurance companies as well as substance abusers.


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INPATIENT SUBSTANCE ABUSE TREATMENT LENGTH OF STAY