When the subject of residential treatment comes up in the addiction treatment field, there is a response I hear often (but not always). It’s a frustrating refrain. It goes like this: ‘there’s no evidence that rehab works.’
This view can and should be challenged, but what is true is that complex interventions like residential rehabilitation for drug and alcohol problems are difficult to study, say in comparison to a medication intervention. The evidence base needs to grow.
Commentators have been calling for more research for at least a decade and a half. While it’s fair to say we could do with knowing more about residential treatment, there is evidence around already. It could do with having a higher profile.
The Scottish Government have looked at this three times over the last sixteen or so years. Firstly, in 2004 the Effective Interventions Unit (EIU, now disbanded) published a paper reviewing detoxification and rehab services. Residential detoxification and rehabilitation services for drug users: A review.
The EIU found that the elements influencing effectiveness were – time in treatment, retention in treatment, client characteristics, and the provision of community aftercare. They said treatment should be at least three months long.
The authors made a recommendation: ‘Further research in this area may focus on undertaking a more detailed mapping of residential services in Scotland, improving retention rates and investigating models of good pathways of care between community and residential services.’ That mapping, it turns out, would be a long time coming.
Research for Recovery
In 2010, the Scottish Government published a paper ‘Research for Recovery’ which reviewed the evidence base. What did the researchers have to say?
‘Residential rehabilitation programmes are one of the longest established forms of treatment for drug addiction. Studies from the UK and the USA have shown improved outcomes after treatment in residential rehabilitation programmes. In DATOS, drug use outcomes after one year were good for clients who were treated in long-term residential and short-term inpatient treatment modalities in the USA.’
They also found that: ‘Regular cocaine use…was reduced to about one-third of intake levels among clients from both the long-term and short-term residential programmes, as was regular use of heroin.
In terms of opiates and harm reduction: ‘Rates of abstinence from illicit drugs have also been found to improve after residential treatment. In the UK, NTORS found that 51% of the drug misusers from residential rehabilitation programmes had been abstinent from heroin and other opiates throughout the three months prior to 2-year follow-up: rates of drug injection were also halved, and rates of needle sharing were reduced to less than a third of intake levels.’
Treatment in Scotland
In the Scottish treatment outcome study, DORIS, undertaken between 2001 and 2004, low rates of sustained abstinence were reported from stabilisation-focused community treatment. While abstinence is not necessarily the goal of medication assisted treatment, it is the goal of some seeking help for opiate problems.
What the DORIS researchers did find was that ‘residential rehabilitation treatment is more effective in promoting abstinence thirty-three months on [from the start of treatment] than other treatments outside prison. Ex-residential rehab clients were twice as likely as those who had undergone different treatments at baseline to be abstinent – apart from cannabis.’
In our mapping of residential treatment services in Scotland, the majority of those responding reported using a therapeutic community model of treatment. A review of the published literature (from 2000) on therapeutic communities (TCs) in 2014 found: ‘TCs are generally effective as a treatment intervention, with reductions in substance-use and criminal activity, and increased improvement in mental health and social engagement evident in a number of studies reviewed.
The researchers also commented that the research ‘suggests individuals with severe substance-use disorders, mental health issues, forensic involvement and trauma histories, will benefit from TC treatment.’
Sheffield Hallam University published a review of Residential Treatment services in 2017. They found:
‘There is a strong and consistent evidence base supportive of the benefits of residential treatment that derives both from treatment outcome studies and randomised trials. Although more expensive, there is evidence that the initial costs of residential treatment are to a large extent offset by reductions in subsequent healthcare and criminal justice costs.
There is a clear dose effect for residential treatment with longer duration of treatment and treatment completion both strong predictors of better outcomes. A much stronger evidence base exists around attaining employment, stable housing, and ongoing support and aftercare as predictors of success.’
But treatment doesn’t stand alone:
‘There is a strong supportive evidence base around continuity of care, whether this takes the form of recovery housing or ongoing involvement in mutual aid groups.’
Their bottom line:
Overall, it is clear that an effective and recovery-oriented treatment system must include ready access to residential treatment for alcohol and drug users both to manage the needs of more complex populations and for those who are committed to an abstinence-based recovery journeyResidential Treatment Services Evidence Review 2017
A review of recent studies on residential treatment found that research was limited, but they did identify 23 studies of which 8 were rated as methodologically strong (including our study of a cohort of patients from Scotland). They found that the results of their research provided moderate quality evidence for the effectiveness of residential treatment in improving outcomes across a number of substance use and life domains.
They also said there is also some evidence that treatment may have a positive effect on social and offending outcomes, concluding with caution, that results suggest that best practice rehabilitation treatment integrates mental health treatment and provides continuity of care post-discharge.
2020 Working Group
Following in the footsteps of the 2004 EIU report on residential services and the 2020 review of the evidence for recovery, new work commissioned by the Scottish Government has just been completed. It was already clear that access to rehab was patchy and funding complex. The principle that residential rehab should be available to those Scots who need it was the starting point set by government. It may have taken 14 years for Scotland to answer that EIU call to map residential treatment services, but we’ve just done it and you can find a summary of what we found here. Our group also found evidence for the effectiveness of residential treatment.
As I’ve indicated, everybody who has looked at this has said the same thing – we need more research! Getting methodologically rigorous studies up and running to improve our knowledge is important. Indeed, the Residential Rehabilitation Working Group called for more research earlier this month in our recommendations.
In the service I work in, although we published one year outcomes, we now have data to five years after treatment in a cohort of patients we have been following up. Five years follow up in addiction treatment is not common!
It’s been a challenge to get resources to get the data published though I am hopeful this might change this coming year. We need long term outcome data particularly to evidence economic impacts and value for money.
Although we have questions about residential treatment that remain unanswered, there is already a body of evidence for its effectiveness and a commitment from the Scottish Government to make rehab more accessible. The recommendations of our group have been welcomed which is good news and we are currently developing a good practice guide. There are signs that more work may be commissioned.
Despite all I’ve written, it is important for us to remember that in terms of recovery journeys, rehab if accessed, will play a relatively small part. There is a lot of truth in the observation, that if recovery is the journey from Edinburgh to London on the train, detox is equivalent to calling the taxi and rehab is the taxi ride to the station. While there is much focus on the telephone call and that taxi journey, the largest part of recovery takes place in communities with support of mutual aid, families and community recovery resources.
That said, a significant number of people in Scotland in recovery today will acknowledge the key role rehab has played in their journey and will support efforts to make it more accessible – not in opposition to other interventions, but as well as other interventions.
I hope in 2021 that there will be more of an appetite to explore what part residential treatment should play in Scotland and that the response, ‘there’s no evidence that it works’ will be heard less and less – because it is simply not true.
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