This post was originally published on October 31, 2016.
Very early into my recovery, a non-sober friend lobbed question after question at me about my whole no-more-drinking thing. She asked me if I’d seen a movie called 28 Days. I very quickly answered “Yes” and recounted its plot: virus, abandoned London and zombies. Just as quickly, she countered that I was thinking of the wrong movie. Turns out, her movie was with Sandra Bullock and about alcoholism and rehab. I hadn’t seen it (and still haven’t). She asked me if its 28-days-in-treatment story-line was anything like my stint in treatment, and I said absolutely not. That’s no knock against the movie 28 Days and its depiction of rehab (or 28 Days Later, for that matter)—it’s just that treatment is different for everyone and, truth be told, my time in treatment certainly didn’t have any sort of Hollywood ending.
When it comes to recovery, though, “28” is a number that gets thrown around a lot. A fascinating new NPR feature explores how “28-day treatment” became the traditional model, why it’s a curiously familiar idea to most Americans and whether this formula is successful in helping addicts and alcoholics achieve sobriety.
What’s in a Number?
According to the NPR story, experts agree that the 28-day model isn’t rooted in hard science or medical research, even though it’s the average amount of time people spend in treatment. “As far as I know, there’s nothing magical about 28 days,” Kimberly Johnson, the head of the Center for Substance Abuse Treatment, said. In the same feature, author Anne Fletcher agreed: “It certainly is not scientifically based,” she insisted. “I live in Minnesota where the model was developed and a lot of treatment across the country really stemmed from that.” Minnesota is actually the heart of American addiction treatment, having given birth to the so-called “Minnesota Model” in the 1950s. Also known as the abstinence model, it was created by two men (“one who was to become a psychologist, the other who was to become a psychiatrist, neither of whom had prior experience treating addicts or alcoholics”) in a state mental hospital, of all places.
According to NPR, the original program had “alcoholics living in locked wards, leaving only to be put to work on a farm.” The treatment site had 500 acres of farmland with a patient population “of less than 80.” The “essentials” of their treatment program involved outdoor work, routine, discipline and a proper diet. There, the model centered around “an individualized treatment plan with active family involvement in a 28-day inpatient setting and participation in AA both during and after treatment.” Educating clients and their family members about addiction proved to be a full-time job. The inpatient program ran “from morning to night, seven days a week,” and gave rise to the modern month-long treatment model. The longevity of the 28-day standard is either a testament to its success, or the fact that two men with no experience somehow—blindly—got it right.
Then and Now
NPR observed that the one-month period was a direct answer to alcoholism—not the wide range of addictions that exist today. “It made sense to people that it took about four weeks to stabilize somebody,” the NPR feature said. Still, the month-long standard has survived even in the face of addictions to heroin and painkillers. Martin Ventrell, director of the National Association of Addiction Treatment Providers, contends that one-month treatment gained traction because of insurance coverage. “It became the norm because the insurance industry was willing to pay for that period of time,” Ventrell said. The month-long model has, of course, extended to include opioid addiction, despite criticism that alcohol and opioids are two completely different beasts and, as such, require two completely different treatment methods.
While experts argue over how to compress opioid treatment into a 28-day model, it’s worth noting that the history of the treatment program isn’t entirely grounded in insurance policies. A 2008 Los Angeles Times report says that 28- or 30-day treatment programs were actually developed in the 1970s for military purposes: “30-day stays were scheduled for bureaucratic reasons—men and women didn’t need to be reassigned if they were away from duty for no more than 30 days,” the story said. “Other treatment centers followed suit, and insurers adopted the standard of 28 or 30 days of inpatient care.”
As it stands now, modern-day treatment programs may need a facelift, the NPR story suggests. Many alternatives exist, such as Medication-Assisted Treatment (MAT) using synthetic opioids such as methadone or Suboxone. “Especially when paired with strong outpatient counseling and other support,” the story said. As one story argues, a month in treatment is something of a pipe dream to begin with. It’s an eyebrow-raising claim, but one that seems sadly accurate: “With managed care and rising costs, those struggling with opioid addictions are likely to spend no more than three to five days in an inpatient setting, if that.” If accurate, it’s as much a sobering reality check as a call to overhaul the entire system.
Is 28 the Right Number?
While many treatment programs have long since adopted 28- and 30-day treatment models, the truth of the matter is that no one knows for sure what the right amount of time is—especially when it comes to the added wrinkle of opioid addiction. In the NPR feature, Martin Ventrell says there’s simply too little research out there to say whether a month is too long, too short or just right. Also, Anne Fletcher believes that the default program length may work just fine for some patients, but it “isn’t the case for most people,” she said. “It’s like any other chronic disorder, it waxes and wanes.” There’s simply no real barometer for what works across the board nor any one-size-fits-all solution.
Even the 2008 Times article suggests that month-long treatment programs aren’t long enough to be effective: “A senior research psychologist at the National Institute on Drug Abuse, has shown that though 90 days isn’t a magic number, anything less than that tends to increase the chances of relapse.” It cites a study of nearly 2,000 cocaine users, where “35% of people who were in treatment for 90 days or fewer reported drug use the following year compared with 17% of people who were in treatment for 90 days or longer.”
As the NPR feature estimates, the US government will spend a staggering $42 billion on “treatment for all substance abuse” by the year 2020. In the meantime, experts need to determine what the most effective length of time for treatment is—especially in terms of what people are spending on it. When it comes to recovery, though, one thing is for certain: it’s not the amount of time we spend, but what we do with that time that truly matters.