“Rehab” for Addiction is a Problem and a Solution

For someone like me who only knew Matthew Perry from occasional glimpses of Friends during my “lost decade” of medical training, I was surprised by the attention paid to his death. After reading a few articles, however, I realized the impact that his disease, and his writing and speaking about it, had.

Stefan Kertesz is Professor of Medicine at the Heersink School of Medicine at the University of Alabama at Birmingham where his work includes leading VA and non-VA supported research focused on homeless healthcare and issues related to pain and opioids. He remains an active clinician and has done research on poor access to care for homeless persons. He also co-led the team whose work led the CDC to issue a major clarification of its 2016 opioid prescribing guideline and is currently a principal investigator of the only national study to examine individual suicides that occur after the reduction of prescribed opioids.

He was also my co-intern on “B-Firm” during one particularly difficult month during the days of the giants.

Matthew Perry was a beloved star who was inspirationally open about his addiction history. He died on October 28 of causes yet to be learned. Some have asked if his drug or alcohol use had recurred or had contributed to his death. People who knew him affirmed that Perry was sober. A harder question, discussed quietly by my fellow addiction professionals is this: did the rehab programs Perry relied on and encouraged others to use get too much favorable press, relative to the benefits they offer?

The term “rehab” is, to a great extent, a Hollywood expression. I don’t refer my patients to “rehab”, but I read about “rehab “in People magazine. As best I can tell, “rehab” is a basket term that is invoked to cover sober living homes, therapeutic communities, short-term detoxification centers and credentialed residential treatment programs. Each of these programmatic approaches is unique but many of them include keeping clients at one facility or house overnight; a 12-step mutual help group approach (e.g. “Alcoholics Anonymous”); and high prices and aggressive marketing. They also have traditionally not offered medication for addictions, even where those medicines are FDA-approved.

Criticism of these programs is both well-deserved and unfair.

There are many ways in which “rehab” programs have earned harsh criticism. For example, 5-7 day “detox” programs actually set people up to return to use after leaving the program. In my first scientific paper, looking at 470 Bostonians who went through detox, 76% returned to substance use at a median of 31 days. One study found fatal opioid overdoses were elevated in the days and months after departure from a detox program.

Other criticisms of “rehab” have been expertly outlined by the journalist Maia Szalavitz. Short-term rehab programs have long resisted providing life-saving medications, like buprenorphine, for opioid addiction. As of 2017, just 15% of patients admitted to residential programs with opioid use disorder received any of the medications approved by the US Food and Drug Administration for treatment opioid use disorder – this despite the fact that those medicines save lives. Practices are improving, but not quickly.

Also, as Szalavitz notes, many so-called “rehabs” have relied on techniques that involve confrontation or humiliation. The implicit supposition is that people who walk in their doors need to be broken down before they are built back up. Confrontational interventions are inhumane and ineffective. My sense is that residential programs have begun to shed these tactics. But the progress is difficult to measure.

Despite these well-deserved criticisms, I’ve found that residential treatment programs and therapeutic communities can be essential to my patients, and there’s evidence to support that.

I take care of people who often have no place of sanctuary from a chaotic life of predatory friends, dysfunctional families, angry dealers, and homelessness. A darkly comedic portrait of that need for sanctuary is offered in Gridlock’d, a 1997 movie featuring rapper Tupac Shakur and actor Tim Roth. In one scene Shakur asks his friend, played by Roth, to stab him because a knife wound seems to be the only way to get past the emergency room's crowded waiting area and into the hospital. Again and again, Roth tries to do it, but they’re both wimps, and the knife is too dull. I laughed when I saw the original. Even now, getting addiction treatment often requires a campaign against bureaucracy. If we made getting treatment for heart attacks as difficult as we make getting treatment for addiction, there would be federal investigations.

The evidence suggests that residential treatment programs offer something more than a sanctuary. A systematic review of studies from 2013-2018 examined 23 papers that studied residential treatment programs lasting from four weeks to 12 months. Taken together, the review found “moderate quality evidence” for their effectiveness.

The higher-quality studies described programs that offered evidence-based psychological therapies, addressed psychiatric disorders, and responded to the social challenges in their clients’ lives, like housing or criminal justice issues. These residential programs also assured enduring access to affordable medication therapies for opioid and alcohol use disorder, after the client leaves. These higher quality studies usually achieved better outcomes. The authors suggest these treatment features are likely to approximate best practice, until new research can be conducted.

Residential treatment programs remain problematically variable in quality and in the types of services they offer. They are not regulated as tightly as hospitals. Their variability is not likely to improve unless payers demand it. At present, states and counties have begun to receive billions of dollars in litigation money from opioid-related lawsuits. With those funds, they could demand evidence-based programs. They could also invest in building the professional addiction workforce necessary to staff these programs.

Ultimately, in considering the trajectory of any single person with addiction – and I’ve considered far too many – it is impossible to know in advance what will assist their recovery most. Is it a specific therapy or a new community that will help their addiction remit?

Years ago, a cherished colleague, an addiction professional, described a teenaged son with opioid use disorder. Buprenorphine, a life-saving medicine, had been offered. Despite the reams of evidence that support its use, it didn’t really work for him. Somehow, a lengthy stay in a remote treatment “camp” – precisely the thing we decry as not evidence-based -- helped him turn the corner. He found way to a life of professional accomplishment.

What happened, really? We will not know, not fully, unless he decides to write his story, much as Perry chose to do in 2022. We should keep the doors to residential programs open, provided we also insist on improving the quality of care that they offer.

If we do that, we can help the people we know, we care for, and the people we love, write their own stories. We hope they will have happier endings than Mr. Perry’s.

Stefan Kertesz is a physician in addiction medicine, a professor of medicine at the University of Alabama at Birmingham, and a physician at the Birmingham Alabama Veterans Affairs Health Care System.