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
Running Head: INPATIENT SUBSTANCE ABUSE TREATMENT LENGTH OF STAY
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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
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
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
Running Head: INPATIENT SUBSTANCE ABUSE TREATMENT LENGTH OF STAY
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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.
Running Head: INPATIENT SUBSTANCE ABUSE TREATMENT LENGTH OF STAY
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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
Running Head: INPATIENT SUBSTANCE ABUSE TREATMENT LENGTH OF STAY
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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).
Running Head: INPATIENT SUBSTANCE ABUSE TREATMENT LENGTH OF STAY
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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
Running Head: INPATIENT SUBSTANCE ABUSE TREATMENT LENGTH OF STAY
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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
Running Head: INPATIENT SUBSTANCE ABUSE TREATMENT LENGTH OF STAY
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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.
Running Head: INPATIENT SUBSTANCE ABUSE TREATMENT LENGTH OF STAY
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