So you’re two months into treatment and you’re not quite ready to go home. You’ve heard of a thing called transitional living or extended care. In layman’s terms these facilities are usually referred to as sober living facilities or even just a ‘sober house’. But where do these terms come from, and what do they really mean? In fact, what is ‘rehab’? and what is ‘treatment’? What do these words actually mean?
LEVELS OF CARE
When we talk about treatment for addiction we should really talk in terms of treatment pathways or levels of care, because treatment involves different stages or levels. The American Society of Addiction Medicine (ASAM) outlines four fairly distinct levels of care. These are broken down into many sub-sections but essentially they adhere to the following basic outline.
Level 1: Outpatient Services
Level 1 services are typically referred to as ‘outpatient counselling’. This level of care typically consists of less than 9 hours per week for recovery therapies and strategies. Level 1 services can be delivered in a wide variety of settings but they are not residential.
Level 2: Intensive Outpatient Services
IOP’s as they are often known, deliver 9 or more hours of service a week in an outpatient setting (e.g. not in a rehab). However, they should be able to treat ‘multidimensional instability.’ In layman’s terms this means “people who have more complex issues”. IOP’s may offer treatment services during the day, before or after work or school, in the evening, and/or on weekends.
Level 3: Clinically Managed Low-Intensity Residential Services
A good example of this level of care would be sober living facilities or sober houses. This level of care typically provides a 24 hour living support and a structured programme with trained staff on site offering at least 5 hours of clinical services a week.
Level 4: Medically Managed Intensive Inpatient Services
This level of care is where we would typically find rehabs and detox units, which are typically referred to as ‘rehab’ or ‘primary treatment’. This level of care must offer 24-hour nursing care and oversight by a physician. It is the appropriate setting for patients whose drug dependency is so severe that it requires inpatient treatment. Trained counsellors will be available for 16 hours a week (or more) but this will include group therapy as well as one to one sessions.
PRIMARY & SECONDARY STAGE ADDICTION TREATMENT
In common parlance you will often hear these levels called something else. Rehabs are usually referred to as the ‘primary’ stage of addiction treatment and sober houses are usually called ‘secondary’ stage treatment.
Primary stage treatment for addiction involves staying in a residential unit (a rehab or a detox facility). Often (although not always) these services are combined. Most rehabs these days have the capabilities to detox on site, although in Europe and America there are still many facilities that specialize in detox only. But most primary stage addiction treatment will have both.
The treatment pathway (the order in which we treat someone’s addiction) will always begin with separating someone from their drug dependency, which is not the same thing as their addiction. Drug dependency is just a part of the addiction. Once the drug dependency is gone we still have to deal with the addicted mindset (which is where the therapeutic part of treatment comes in). So the first part of primary stage addiction treatment is detox and/or stabilisation, which seeks to address the physical or psychological dependency on a drug.
Detox is necessary for the following drug types (depending on severity of use).
- Opioids like heroin, methadone, oxycontin
- Benzodiazepines (benzo’s) like valium and Xanax
These drugs create physical dependency when they are taken at high enough doses for a long enough time period. Stopping these drugs abruptly when you have been taking them for a long time can cause unpleasant withdrawal symptoms, and in the case of benzodiazepines and alcohol this can occasionally result in seizures which might even be fatal. Therefore, the only safe way to get off them is to go through a detoxification process.
Detox is a word you hear people use a lot these days. When most people say ‘detox’ they mean ‘to clear the body of toxins’ by way of some diet or other process. But this is a vague and unscientific term which doesn’t really mean anything beyond ‘getting healthier’. A drug detox is different. It has a precise meaning. It means, “to remove a person’s physical dependency on any drug of abuse”. This is usually done by using another (legally prescribed) drug to help wean you off the drug you are dependent on.
With the exceptions of benzo’s, this usually happens over a relatively short time period during which time the substitute drug is ‘tapered’ down until you are drug free. Usually the prescribed detox drug ‘mimics’ the effects of the drug of abuse. For example, benzodiazepines like Valium and Librium are often used to withdraw people from alcohol, and methadone is often used to withdraw people from heroin.
Whilst it might seem bizarre that someone with alcohol dependency is being given another drug of abuse (Valium) to wean them off alcohol, the difference is that this is now being done in a controlled environment. A medical team are monitoring you, and dispensing the Valium (rather than you dispensing it). And you are in a facility where you don’t have access to any other drugs. Essentially the doctor controls the amount of the drug until it reaches zero. This is something that addicted people cannot do by themselves (by definition, that’s what an addict is!)
Drugs which aren’t physically addictive can still produce unpleasant (psychological) withdrawal symptoms. The types of stimulant drugs that are not physically addictive, but can still be psychologically addictive and dependence forming include;
Even though these drugs do not cause physical withdrawal symptoms (in the strict sense of the word) they may still require a type of detox at the front end of treatment which is known as ‘stabilization’. This is especially true of the more potent ATS’s such as meth. Stabilization is quite simple and straight forward. It involves a lot of sleeping and a lot of eating, and usually also some short term medicating.
For example, the typical ‘stabilization’ period for a young meth user who enters treatment might last for 3-5 days. During this time, he or she might be given sleeping medications which will later be tapered, and they will be left to sleep through the ‘crash’ phase which comes after an intense period of smoking methamphetamine. Upon awakening they will be given food (and plenty of it) and medical and counselling staff will ‘support’ that client but not unduly pressure them. It would be inappropriate (and counterproductive) to force a client who is still stabilizing into therapy processes. This comes later, once they have ‘stabilized’.
Once a client has stabilized they are ready for the next stage which is the psycho-social phase of treatment, more commonly known as residential rehab, which centres mostly on group therapy and counselling.