Inpatient v. Outpatient Treatment? For Opioid Addiction, It’s the Medication That Matters

During a decade of hardcore heroin and cocaine use, Shante checked into a half-dozen residential treatment centers in New Orleans. Each time she checked out, she relapsed quickly.

“Sometimes it took a few weeks, but usually I went straight to get high on the same day,” recalls Shante, now age 37 and living in Washington.

Today, Shante is a full-time college student who cares for her 5-year-old daughter and pays her rent and car insurance “just like everyone else.” She hasn’t used drugs in a year.

Her long journey to recovery has involved just about every type of addiction treatment, including residential, intensive outpatient counseling, 12-step programs, and office-based treatment with Suboxone.

“I gained something from each one,” Shante says. But when she reflects on what has made sustained recovery possible, she points to two factors: her readiness to change and Suboxone.

Early in her addiction, Shante went to rehab to appease her family, not because she wanted to stop using. She believes Suboxone, had it been offered, would have sped up her recovery but that she might have kept relapsing anyway.

But when she genuinely felt ready to change, about six years into her addiction, she was not offered medication-assisted treatment (MAT) in rehab.

Without medication such as Suboxone, almost everyone with opioid use disorder (OUD) will relapse. Suboxone cuts the relapse rate in half by suppressing the agonizing withdrawal symptoms — nausea, vomiting, diarrhea, anxiety, body aches, insomnia — and the intense cravings that fuel opioid addiction. Over the long run, Suboxone rewires brain chemistry, paring down the overabundance of opioid receptors until the brain returns to its normal state.

There’s no single best treatment setting for OUD; different environments can help different patients at various points in their recovery. For patients to have a real shot at recovery, however, medication must be part of the equation, no matter the setting.

“Treating OUD without medication is akin to medical malpractice,” asserts Jeff Allgaier, M.D., a veteran emergency-room physician and Ideal Option’s Chief Medical Officer. “A positive environment is critical, but without the right medication, it doesn’t matter. Patients will relapse.”

Recovery Without Rehab?

Family members, devastated by their loved one’s addiction, may assume an inpatient stay of at least 30 days is critical for recovery from opioid addiction. After all, rehab has been the standard for addiction treatment for decades. It’s what we’re all familiar with. The inpatient setting — with its scheduled meals, group meetings, and daily counseling — offers the structure, the uninterrupted time, and the distance from drug-using friends that might seem necessary for patients to stabilize, reflect, and gain skills for recovery.

But when it comes to opioid addiction, research has upended the conventional wisdom. Residential treatment, while helpful for some OUD patients, is not necessarily the only or best route to recovery, research shows.

Turns out, it’s not the setting that matters most; it’s the medication.

That’s because OUD affects the brain in a fundamentally different way from alcoholism, cocaine addiction, and other substance use disorders. Without medication to rewire the opioid-addicted brain, all that counseling and structure will likely not make a difference.

In fact, residential treatment without medication may leave patients worse off.

“When inpatient treatment does not include medication, people with OUD die at much higher rates than they die on the street using heroin,”

“When inpatient treatment does not include medication, people with OUD die at much higher rates than they die on the street using heroin,” says Dr. Allgaier. “It’s because they lose their tolerance. If someone was using one gram of heroin a day, and then they use just one-tenth of that when they get out of rehab, they’re dead.”

This isn’t to say the inpatient approach lacks value, especially for certain populations.

“If you have someone whose psychological issues are preventing them from being successful with medication in an outpatient setting, it might be important to get them into residential treatment,” says Skyler Glatt, Ideal Option’s Director of Special Projects.

Shante believes that inpatient treatment is also hugely helpful for long-time, hardcore opioid users.

“Anybody who was into their addiction as heavily as I was needs that time in inpatient to work on yourself, to be able to move to the next level,” she says.

Shante credits her inpatient stays for teaching her to cope with stressful situations.

“I learned how to close my eyes and breathe deeply to put myself right in the moment,” she says. “Even today, I still do that. It helps me ground myself.”

Shante also gained “responsibility and accountability” from residential treatment, and she learned to set simple, attainable goals for her future.

“I used to look back at my life thinking I hadn’t accomplished anything, and that would put me into depression,” she says. “What I learned in rehab was that just because life took a different turn doesn’t mean I can’t continue to move forward and be what I want to be.”

However, Shante says, the structure and stability of residential treatment also posed challenges for her transitions afterward. “With inpatient, you’re being shielded from the real world.”

For many OUD patients, it’s more helpful and practical to recover while dealing with the realities and responsibilities of daily life.

“One of the great things about office-based MAT is that it does not take you away from your kids, your significant other, or your job, so you don’t lose your income while you’re recovering,” says Skyler. “You still have the duties of having your house and paying your bills.”

You also have the benefit of privacy.

As Sklyer notes, disappearing for 30 days can raise questions at work and in social circles, and given the stigma of addiction [LINK TO STIGMA POST], a stint in rehab may not be news you want to share with people outside your immediate orbit.

“Everyone is going to know you went somewhere for a month,” Skyler says, “and that’s an incredibly long time to say it’s a vacation.”

With office-based MAT, patients receive prescriptions for medication in a typical medical setting, first every few days, and eventually every three or four weeks. Patients also are referred to the type of counseling and/or social support they need, whether that’s group meetings, individual counseling, mental health treatment, or help finding stable housing and employment.

For many OUD patients, the combination of medication and social support is enough to bring about lasting recovery.

“You always want to go with the least restrictive level of care,” says Skyler. “If you had a broken leg, they wouldn’t say, ‘let’s keep you in the hospital.’”

For Shante, recovery has involved a progression of treatment environments. After her six residential programs, she enrolled in an intensive outpatient program that offered Suboxone and frequent group counseling, first three times a week and eventually once a week.

When a trip home to New Orleans ended with a visit to old friends and another relapse, she was able to rely on the coping skills she’d gained from her intensive treatments. “I had a brief lapse in judgment, but I quickly got my butt home and contacted my sponsor. I didn’t want to lose everything.”

Her sponsor referred her to Ideal Option. “I got in the next day and got my life back on track. I knew I didn’t need intensive outpatient anymore. I already had the tools and go to a weekly recovery group. What I needed was to get stabilized on medication.”

Shante was put on a higher dose of Suboxone than what she’d been prescribed before her relapse. Now she takes her medicine daily and visits the clinic monthly. Meanwhile, she has the freedom to care for her daughter, attend school, work, and live her life.

“You’re not sheltered you from anything,” she says. “You’re accountable and responsible, but no one is breathing down your neck to go to group.”

At one point, Shante says, she did need that higher level of accountability. But no longer. Some folks never need it.

“It used to be that patients’ lives had to revolve around treatment, and they were forced into group counseling,” says Dr. Allgaier. “Now they can come in and see a doctor, and their disease gets treated like any other chronic disease. They can just live normal lives.”

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