Breaking Away from the 28-Day Treatment Model
History of 28-Day Treatment Programs
Surely you’ve heard of the movie “28 Days” or generally heard about 28 to 30-day alcohol and drug treatment programs. This is a “one-size-fits-all” model that has existed in the substance abuse treatment industry since the 1950s when originally developed by Dan Anderson in Minneapolis, Minnesota.
The 1950s saw a lot of changes in the world of addiction, including the widespread success of Alcoholics Anonymous and the beginnings of acceptance of alcoholism as a disease. Prior to this decade, alcoholics were seen as degenerates and were often seen as the lowest of the low in the medical field of any other, potentially co-occurring, mental health or behavioral disorders.
The U.S. military generally adopted a 30-day treatment model in the 1970s, as thousands of servicemen and women returned from Vietnam with substance use problems. In the over 200-page document The DoD Experience in Drug Abuse Programs, this model is explained in detail. As practiced, servicemen who “successfully” completed this program were returned to active duty, and those who could not were placed on administrative leave and sent to continue treatment under a Veterans Administration program.
Shift in Substance Abuse
There is plenty of evidence to suggest that the extent and the substances to which people are addicted today is far different from the 1950s, or even the 1970s. From the 1950s where alcohol abuse was the most publicly prominent issue, the climate changed in the late 1960s and 1970s as more and more people became addicted to opiates.
Today in 2017, there are synthetic variables in almost all drug categories, a factor with the potential to subject substance abusers to potentially harsher consequences when using, such as a significantly longer detoxification period than the approximate 4 week timeframe commonly associated with alcohol.
There are many factors over the last century that have changed the way that people use drugs and alcohol . The include legislation outlawing drug use, advances in prescription medicine technology, shifts in FDA regulations, and advances in medicine and the study of these substances and their effects, to name a few.
In the late 1800s into the early 1900s, some drugs that are well-known as being addictive, illegal, and dangerous today, were widely used in prescriptions and for military effectiveness:
“The Pure Food and Drug Act of 1906 mandated that all ingredients must be labeled and the Harrison Narcotic Tax Act in 1914 brought these addictive substances under the control of doctors, requiring a prescription (and payment of a tax) for their distribution. These two laws eliminated the casual distribution of opiates, alcohol, cannabis and cocaine…Of course, as these laws went into effect, some drugs dropped fully out of prescription drug status for many years. Cocaine, marijuana, opium and heroin stopped being used medically for many years.” (reference)
After these regulations were put into effect, amphetamines replaced cocaine in wartime, when servicemen and factory workers were given this drug to help them stay awake and be more productive.”
Birth of Medical Institutions
With all of these shifts in substance abuse came the birth of the many different private and government organizations focused on substance abuse and treatment. ASAM (American Society of Addiction Medicine) was formed in the 1950s, although ASAM was not approved and accepted into membership by the House of Delegates of the American Medical Association (AMA) as a national medical specialty society until 1988.
The lack of evidence-based knowledge around addiction necessitated the formation of organizations such as ASAM, an entity that has pioneered major shifts in how we treat addiction.
ASAM’s Mission is:
- to increase access to and improve the quality of addiction treatment;
- to educate physicians (including medical and osteopathic students), other health care providers and the public;
- to support research and prevention;
- to promote the appropriate role of the physician in the care of patients with addiction;
- and to establish addiction medicine as a specialty recognized by professional organizations, governments, physicians, purchasers and consumers of healthcare services, and the general public.
There has also been continual advancement in health insurance policy for the coverage of treatment for substance use disorder. There is a growing acceptance of the characterization of substance use disorder as a disease, in alignment of the ASAM definition of SUD: “Addiction is a chronic brain disease and there are treatments available to help patients.”
Out of the foregoing conclusions came the “Mental Health Parity Act of 1996” in which the federal government prohibited discrimination against the coverage of treatment for a number of mental health disorders. While this was a step in the right direction, this act still did not cover addiction treatment.
Another act, the Mental Health Parity and Addiction Equity Act of 2008 “requires health plans that cover addiction treatment…to cover it to the same extent that they cover a patient’s medical and surgical needs.” The Affordable Care Act is governed by these laws and requires that substance abuse care be covered by insurers, and additionally providers cannot legally increase copay amounts or place annual or lifetime limits on substance abuse care, as it now qualifies as an essential health need.
The Heartland House Direction
And how has Heartland House acted upon these dynamics? By implementing, over the past two years, a variety of organizational development programs to meet demands of the changing world of addiction treatment.
Imagine being ready and willing to go to treatment but being limited by a 28-day program. What if you have a job and a family and can only take two weeks off? What if you need much longer term care but can’t afford anything past the 28 days? Previously treatments centers turned such people away saying “Come back when you are ready. Our program is X days.”
We have recognized the need to meet our clients where they are right now. We believe we are the first residential facility in San Diego following a person-centered, non-time bound, treatment program.
“Our multi-dimensional treatment program tailors an individual program for each man depending on his unique needs. We seek to continually improve our treatment program, using evidence-based therapy models and providing trauma-informed, culturally competent care. Our program components are listed below, by category.” Heartland House Program
We utilize ASAM’s risk rating checklist in our client intake process, as well as continually throughout a client’s stay. The areas we look at when assessing an individual’s change plan are:
- Acute intoxication and/or withdrawal potential (level of intoxication, detox requirements, etc.)
- Biomedical conditions and complications (physical medical status)
- Emotional, behavioral, or cognitive (EBC) conditions and complications (EBC status, impulse control, coping skills, level of treatment needed, etc.)
- Readiness to change (level of willingness to engage in treatment activities)
- Relapse, continued use, or continued problem potential (level of risk of recurrence)
- Recovery environment (ability to cope with social-model recovery environment)
A comprehensive list of ASAM assessments is available on their website.
Upon assessment, we create a collaborative, SMART (Specific, Measurable, Attainable, Relevant and Time-limited) recovery plan for each individual client. We have recognized that a standard time-bound program may not fit the specific needs of the individual. With this assessment, we meet our clients with equality and work together addressing their change plan to achieve their specific goals.
“Our mission is to serve men recovering from substance use disorder and related co-occurring conditions. Our overall goals are to provide a living environment conducive to continued recovery, conduct an educational program that helps the newly recovering alcoholic/addict establish a long-term support system, and generate attitudes that enhance self-sufficiency, self-worth and an ongoing quality of life.”
The achieving of self-sufficiency, self-worth, and an ongoing quality of life requires the use of a different program for each unique man. Some men may need additional care for co-occurring disorders, while others may need a social-model care system while they go back to school. These various programs can take anywhere from a few weeks to many months of monitored care in our program at Heartland House.
http://prhome.defense.gov/Portals/52/Documents/RFM/Readiness/DDRP/docs/36%20The%20DoD%20Experience%20in%20Drug%20Abuse%20Programs.pdf (pages 41-42)