For a variety of economic and historical reasons, the U.S. substance use treatment system has become quite complicated, and in some cases separated from the rest of psychiatry. This means that the general clinician may not understand the treatment options available. To make matters worse, a strong profit motive has led to the mushrooming of expensive residential rehab centers, which can run well above the $50,000-per-month figure quoted to your patient, M. In some cases, you won’t be particularly involved in deciding what treatment a patient receives; such choices are often made in the setting of a substance use treatment program, usually during or after an acute detox. Nonetheless, it’s helpful for you to have an overview of treatment options available for substance-using patients. In some cases, your patient will ask you for advice, and in others, you will be contacted by a treatment setting about your patient; for both scenarios, you will want a clear idea of where a program fits in the context of treatment settings.

SPECIALIST CLINICIANS
Before describing the programs, let’s go over the variety of health care professionals specializing in substance use treatment. You are likely to have contact with many of them during your career. Addiction counselors and therapists There are many therapists with an interest or certification in addictions. The most well-known national certifying organization is NAADAC, The Association for Addiction Professionals (formerly called the National Association for Alcoholism and Drug Abuse Counselors). The training requirements for such certified counselors vary from state to state. For example, in Texas, where I work, such counselors are called licensed chemical dependency counselors, and their training entails having at least an associate degree, completing 4,000 hours of supervised experience treating patients with substance use disorders, then passing a state certification examination to obtain a state license. You will typically find these counselors working in rehab programs or intensive outpatient programs. Going up the ladder of training requirements, there are clinical social workers (who generally have a master’s degree in social work) and clinical psychologists (who have a PhD or PsyD). Some therapists specialize exclusively in addiction treatment, some have general practices that include addiction treatment, and others will not treat addiction specifically but will address issues related to relationships, coping skills, etc, all of which might be useful for your patients. I recommend that you develop a list of good local practitioners to whom you can refer patients. You can assemble this list based on feedback from your patients or from colleagues.

USEFUL FACT: The ASAM Criteria
The ASAM criteria are the American Society of Addiction Medicine’s guidelines for matching severity of
illness and level of function with intensity of service in addiction treatment. Treatment matching means providing the patient with the least restrictive level of care that is likely to be beneficial. This involves assessing people in six dimensions and matching them with the most appropriate level of care so that services are provided in the most efficient manner. Criteria such as these help clinicians determine and justify whether a patient requires outpatient or residential or inpatient services with medical monitoring (for treatment of withdrawal or comorbidities). The ASAM criteria are used primarily by addiction specialists who need to demonstrate to insurance companies that a certain level of care is needed. For more details on incorporating the ASAM criteria into your practice, see the Carlat Addiction Treatment Report, November 2014.

38 THE CARLAT GUIDE SERIES | ADDICTION TREATMENT
Specialist physicians You will likely need to refer some patients to physicians who specialize in addiction. There are two addiction specialties for MDs: addiction medicine, open to all specialties, and addiction psychiatry, open only to psychiatrists. An addiction psychiatry specialist completes a one-year fellowship in addiction psychiatry after residency, and then passes a certification exam conducted by the American Academy of Addiction Psychiatry. An addiction medicine specialist must complete a residency in any medical specialty (psychiatry, internal medicine, family medicine, pediatrics, preventive medicine, obstetrics, etc) and then complete a fellowship in addiction medicine, or demonstrate substantial time spent delivering substance abuse care (after 2022, only those who have completed a fellowship in addiction medicine will be eligible for certification).
Interventionists Interventionists are addiction professionals who specialize in orchestrating the sometimes-dramatic interventions that have become fodder for reality TV shows. Usually it is the emotionally exhausted family that seeks this kind of help. An interventionist generally offers three services: planning and executing the intervention, finding an appropriate treatment program for the patient, and providing “recovery coaching” after treatment, often for a year or more. There’s usually a fee for each service, and insurance rarely if ever pays for it.

GROUP/INSTITUTIONAL/HOSPITAL PROGRAMS
12-step programs
We devote a chapter to the topic of 12-step programs, but as an introduction you should know that these are nonprofessional mutual self-help groups that are community-organized and free. They aren’t considered treatments per se because they don’t involve licensed counselors providing care to patients. Nonetheless, 12-step programs are often the first form of help that substance-using patients seek out. Many clinicians will view a referral to AA meetings as a convenient first step. The following section details the types of addiction treatment services available (see Table 3-1).

Detox
Detox is the process of quickly getting a patient off drugs or alcohol. It’s often a prelude to rehab since it’s hard for patients to make headway in recovery while they are actively using. While detox can be either outpatient or inpatient, inpatient treatment is the best choice for those withdrawing from substantial daily alcohol use (such as a pint of hard liquor or 12–24 beers per day), and for those with concurrent or preexisting medical problems, such as heart or liver disease. How do you get patients into detox? Ifyou know some detox facilities in your area, the best route is to call them directly (or have the patient or family call). Some centers will do their own screening, whereas others will require the patient to visit the ER before referral. Obviously, most patients will prefer to bypass the ER. Another option is to start by calling the insurance company: It will provide the names of local detox programs with which it contracts, and the company may have specific hoops to jump through before it will authorize treatment.

Intensive outpatient programs (IOP)
IOP usually consists of 9 hours per week of outpatient treatment, divided into three 3-hour sessions. They are generally group therapy sessions that offer rehabilitative counseling and educational classes. These programs are offered in either day or evening formats. IOP is a good option for people who are struggling with sobriety after detox, or for those whose job or family obligations prevent more time-intensive treatment. In some cases, the person’s insurance may only cover IOP. In contrast to 12-step programs, IOPs are professionally facilitated groups, and they can be uniquely helpful for patients on several levels. Whereas in a one-on-one setting, patients might feel uncomfortable talking about certain behaviors, a group offers a sense of mutual permission and support. And unlike self-help groups such as AA, having a facilitator in charge can keep people on task and prevent certain individuals from monopolizing the conversation. Partial hospitalization programs (PHP) Also known as “day treatment,” PHPs usually run 5 days a week, 6 hours per day, and last 10–15 days. These programs are much more comprehensive Chapter 3: UNDERSTANDING ADDICTION SERVICES 41 than IOPs. They tend to have more sophisticated therapy groups, such as dialectical behavior therapy, cognitive behavioral therapy, and family therapy. Psychopharmacologists are also on staff for appointments as part of the daily treatment program. Insurance companies will approve PHP primarily for patients with comorbid psychiatric disorders.

Residential rehab
Residential rehabilitation programs are 30-day inpatient programs that vary widely in cost, philosophy, and personnel. Residential rehab is for patients who have a toxic or unsupportive home environment—they may live alone
or have family members who are actively using. Residential rehab is also appropriate for people who have repeatedly relapsed at a lower level of care. The classic rehab is a pricey, for-profit company providing a luxurious environment and requiring payment up front; such programs can run $50,000 per month or more. Less pricey than residential rehab are 12-step immersion programs, which clock in at around $10,000 per month. These facilities can actually be fairly luxurious (think big lodges and beautiful farms); they are cheaper because they are run primarily by people in recovery and by addiction counselors without advanced degrees. The programming in 12-step immersion is limited to AA—from the moment patients walk in, they will be doing AA steps. Finally, there are some bare-bones residential rehabs covered by Medicaid. For some patients, being in a less ritzy setting can serve as a motivator to avoid future rehab stints.

Long-term residential These programs are also known as therapeutic communities or recovery house. They last 6–12 months, and are for people who relapse so frequently that they need to be away from their community and spend significant time in a very structured environment. They learn to incorporate recovery skills in their lives and gain the self-esteem and confidence to create a network of people they can depend on when they’re stressed. Some long-term residential programs are called “working houses” because they have a returnto-work requirement after 1 to 2 months.
Sober houses A sober house, also called a halfway house, is an independent living arrangement with minor oversight where residents can stay for 1–2 years. Most of these residencies have a house manager, but they lack on-site professional counselors or programming. Residents are sometimes told, “Here’s your key; you can come and go as you want, but everyone here is sober.” At some houses, there is a curfew or restrictions on weekends away, especially for newcomers. At others, individuals may move up along a “levels” system, gaining more privileges with each level. Residents are expected to attend outside 12-step meetings frequently, at least 4 times a week, and to undergo weekly random drug testing. As part of the living arrangement, some sober houses require that residents find at least part-time work in the community. Sober houses are often a good segue from a residential program, because they provide support within the community environment and teach people to take more responsibility for their recovery. Some people find that they cannot maintain sobriety outside of sober houses.

Chapter 3: UNDERSTANDING ADDICTION SERVICES 43
Holding beds
Sadly, there is a countrywide shortage of residential beds. Because of this, there are many transitional stabilization units, otherwise known as holding beds. They are usually federally funded, and they provide a bare-bones facility for people to stay while they wait for residential beds. The usual occupant of a holding bed is a recently detoxed patient who needs residential treatment to maintain sobriety, but does not have the necessary funds for a rehab program, even one of the cheaper options. People may stay here  for up to a few months as they wait for a placement. Court-mandated treatment Referring patients to treatment is all well and good, but up to a third of patients in rehab facilities are there by court order, usually involuntarily. As a clinician, you might be involved in the process of forcing a patient into treatment, so it’s important to understand the process. Many states (but not all) have a provision allowing court-mandated treatment. In Massachusetts, the process is called a “section 35,” which refers to a section of the state law. This provision is used for patients who are out of control with their use but refuse treatment. Most of the time in this scenario, you have the family coming to you asking, “What can we do, Doctor?” They explain the ways in which their family member is engaging in risky behavior or endangering others, such as, “He’s falling and hurting himself when he’s drunk” or, “She overdosed on heroin and we barely got her to the ER on time.” At this point, you need to intervene to keep the person safe. The procedure is as follows. The family has to prepare a case for involuntary commitment. It will be in the form of testimony, but it is often augmented by medical reports and even photographic evidence (I advise these families to keep their phones at the ready and take video of the intoxicated behavior). A hearing is scheduled at which a judge weighs the evidence; if the judge agrees that the situation is dire, a writ of apprehension will be issued. The police will then bring the person in handcuffs to court, where the patient hears the evidence, has a chance to refute it before the judge, and expresses willingness (or unwillingness) to enter treatment. If committed involuntarily, the person will be taken to a state-funded residential rehab facility for up to 90 days. Do such involuntary commitments work? Often not so much. Patients can be released early if they agree to outpatient counseling and AA meetings, but this may be a ruse for getting back 44 THE CARLAT GUIDE SERIES | ADDICTION TREATMENT to substance use. Nonetheless, involuntary commitment does give the family some respite, and it creates the chance, no matter how small, that the patient will eventually buy into the need for treatment. Court mandated treatment can be initiated by the family, the police, or any physician. The limiting factor is the requirement to go to court—something physicians are rarely willing to do. You might be surprised to learn, however, that involuntary commitment has similar outcomes to voluntary treatment when looking at long-term success rates. Patients can still learn from and benefit from treatment, even if they grumble about having to be there. A final word of advice—I recommend getting to know the treatment centers and providers in your area. Go to a local IOP or PHP and sit in on a staff meeting. The more working relationships you have with addiction professionals, the more efficient you will be at referring your patient to the right treatment, at the right place, and at the right time.