How will you know if an addiction program is any good?
As you or your loved one searches for a reputable substance use treatment program, remember that you are employing them and should conduct an interview just as you would with an individual you plan to hire in your company.
Finding effective help for an alcohol or other drug disorders starts with reliable and valid screening for the range of substance use disorders and related conditions, as well as physical and mental health conditions.
If the program receives funding from the Utah Division of Substance Abuse and Mental Health, then the program must use criteria from the American Society of Addiction Medicine (ASAM) to determine the best level of care to begin treatment. ASAM criteria are not used just when your loved one first enters treatment, but are designed to be used continually during treatment. How your loved one is rated on the ASAM criteria determines when your loved one is able to enter into a lower level of care, meaning less treatment hours, or enter into a higher level of care, meaning more treatment hours. If the program requires that your loved one complete certain assignments before moving to a lower level of care, this should be a red flag because no matter how much the program may try to convince you, the program is not based on ASAM. A program that requires assignments to be completed before your loved one can progress is referred to as “program driven” and is not individualized (discussed further down) no matter how much they try to convince you otherwise.
Once detected, more in-depth comprehensive measurements are needed that assess substance use history and related disorders, as well as medical, psychiatric history and individuals’ family and social networks, and available recovery resources. Careful and comprehensive assessment can help prevent missing or minimizing important aspects of a person’s life, inattention to which, could compromise the chances of recovery.
If your loved one has a heroin or opioid addiction (i.e., pain pills), does the program teach her/him about naloxone and teach them how to use it? Naloxone is a great medication that should your loved one overdose, can counter the effects of the overdose if given soon enough. Since the drop-out rate is high for those in substance use treatment, this needs to be done very soon after admission.
In addition to substance use disorders patients in treatment may have co-occurring psychiatric disorders, like depression and anxiety, as well as other medical problems like hepatitis C, alcoholic liver disease, or sexually transmitted diseases. Programs incorporating comprehensive approaches that directly address these additional concerns, or otherwise assertively link patients to needed services, improves the likelihood of substance use disorder remission.
It should be a red flag if the program just suggests or tells the client to go see Dr. “X”. The successful program will have a case manager that not only helps your loved get the needed appointment but will follow-up to ensure your loved one attends the appointment. The case manager might also obtain information from the attended appointment, with your loved one’s permission, if it will help them in substance use treatment.
Once your loved one has completed the program, what ongoing services are offered? At a minimum there needs to be an ongoing group either offered though the program or one to who they readily refer. This group can have many names but it is held at least weekly and is a place for your loved one to receive continued support while being fairly independent from treatment. It can be either staff or client run, but if the latter needs to have some type of overall staff supervision.
Should your loved one leave the program before completion, prior to leaving what does the program do to help your loved one enter into a different program? Things to look for include not just making a referral to “X” program, but contacting “X” program with your loved one and arranging for an intake. This is referred to as a “warm hand-off.” Programs that are willing to keep your loved one until there is an opening at the new treatment facility, if your loved one is willing to stay, deserve extra consideration.
Regardless of the reason your loved one leaves the program, including successful completion, if your loved one has a heroin or opioid addiction (i.e., pain pills), does the program give them naloxone and teach them how use it?
Continuing care is essential to provide recovery-specific social support and necessary recovery support services after the patient transitions from the initial phase of care. Programs that strongly emphasize this continuing care aspect and that provide assertive linkages (not just passive referral) to community resources, on-going health care providers, peer-support groups, and recovery residences, tend to produce substantially better outcomes.
Does the environment feel welcoming when you visit? If it feels hectic or chaotic, chances are that is how it usually is vs. “just having a bad day.”
Does the program employ Certified Peer Specialists? While it can be a help to have therapists or substance use counselors who are in recovery, this is not the same as having a Certified Peer Specialist. These are individuals who not only are in recovery, but have had specific training to be a Peer Specialist. They can act as special advocates for your loved one.
Other things to consider include how are you greeted when you visit? Also, purposefully leave a voicemail and see how quickly the program calls you back. If you can talk to some of the clients about how they feel about the program that could also be useful.
The treatment program should possess at least the same type of quality environment as one might see in other medical environments (e.g., oncology or diabetes care). It does not need to contain chandeliers and oriental rugs, but should be clean, bright, cheerful, and comfortable. Creating a respectful and dignified environment can help addiction patients, in particular, who often feel as if they’ve lost their own self-respect and dignity, regain it.
If the program utilizes “shaming” as a therapeutic intervention, this should be a red flag. Shaming involves purposefully making our loved one feel guilty about what they have done. Though they may not show it, most likely your loved one already feels an extreme amount of guilt. Instead, the program should be helping your loved one deal with the guilt they have and how they can remedy their guilt.
As you are already aware, substance use affects everyone around the person using substances. While it may be a few weeks before this takes place, involving immediate family such as the significant other and children is crucial. Additionally, if you or your loved one desires it, will they involve extended family who have been affected by your loved one’s substance use. While it is very important to deal with this while your loved one is in treatment, if your loved one has been in residential treatment (meaning living at the facility full-time while in treatment), everyone needs to be prepared for having your loved one back home. It is a complicated transition and NOT just a matter of having your loved one back home. If your loved one has been in outpatient treatment (meaning living independently while attending treatment), then the family needs to understand the changes your loved one is making and how you can best support him/her in their treatment and recovery. Because substance use does affect everyone around the person, everyone may have unknowingly developed ways of behaving that perhaps were useful while your loved one used substances, but are no longer useful now that your loved one is no longer using substances.
Engaging significant others in the person’s life in treatment increases the likelihood that the patient will stay in treatment and that treatment gains will be sustained after treatment has ended. Techniques to clarify family roles, re-frame behavior, teach management skills, encourage interventions, and access community services all help strengthen the entire family system and help family members cope with, and adjust to, the family system changes that occur in recovery.
Does the facility talk about and use “Recovery Capital” and know its benefits? This will be crucial during and after treatment.
Dropout from addiction within the first month of care is around 50% nationally. Because those who dropout tend to have worse outcomes, it is vital to employ strategies to enhance engagement and retention. These include creating an atmosphere of mutual trust through clear communication and transparency of program rules, regulations, and expectations. Also, by providing empathic counseling and motivational incentives that reward patients for continued attendance and abstinence/reductions in substance use.
Programs that deliver services founded on scientific research and principles and that are delivering the available “best practices” tend to have better outcomes. This is referred to as evidenced-based practice or evidence-based treatment. In addition to psychological interventions, these should include accessibility to FDA approved medications for addiction (e.g., buprenorphine/naloxone, methadone, naltrexone/depot naltrexone, Acamprosate as well as psychotropic medication for other types of psychiatric conditions (e.g., SSRIs etc.).This is typically combined with qualified staff (see below).
Ask what specific evidence-based practices (EBP) the program uses. Stay away from generic program descriptions or a “one-size fits all” type of program. There are hundreds or EBPs. Find out the specific name of the EBP and then you can look at the Substance Abuse and Mental Health Services Administration website that is officially responsible to approve all EBPs for more information about the practice. If you cannot find information about this EBP there, tell them you went to SAMHSA (pronounced “SAM-SA”) and could not find it. If they do not know what SAMHSA is without you explaining it, that should be a red flag. You should also ask what they do to ensure the EBP is done in a way that it is meant to be (commonly stated as “done to fidelity”). Every EBP has different requirements, but the answer should be something that demonstrates they are aware of the requirements. If the program happens to say “we follow all the requirements”, ask what those requirements are.
What are the qualifications of the staff? Staff need to be licensed by the Utah Department of Professional and Occupational Licensing. You can check if any disciplinary action has been taken against any licensed person in the resource below.
What specific training have staff received? All licensed staff will have completed requirements to graduate from school. Do not settle for this as an answer. Ask about specific training staff have received since graduation and then do a google search to find out more about that training. And ask how long staff have been out of school. If recent, ask them for specific details as to how staff are supervised. At a minimum, there needs to be weekly, face-to-face supervision and the supervisor should be available to answer questions from the supervisee on an informal basis during the week.
Having multi-disciplinary staff (e.g., addiction, medicine, psychiatry, spirituality) can help patients uncover and address a broad array of needs that can aid addiction recovery and improve functioning and psychological well-being.
Staff with adequate certification/licensing or board certification in these specialty areas are indicators of higher quality programs. Clinical supervision and team meetings should take place at least once or twice a week for outpatient programs and three to five times a week for residential and inpatient programs.
Stemming from individualized comprehensive screening and assessment, programs should treat all patients as individuals attending to their needs accordingly, recognizing the potentially different needs of men and women and those from different communities (LGBT) or cultural backgrounds.
As part of this, each client needs to have an individualized treatment plan. This means the therapist sits down with your loved one and discusses the goals your loved one wants to accomplish while in treatment. These goals need to be on the treatment plan. A program that tells the client what their goals are should be a red flag. Every client is to be given a copy of their treatment plan and so you can always ask your loved one to see it.
Additionally, treatment needs to be individualized. While it is not pragmatic to have specialized groups for every single client, it is a red flag if everyone needs to attend the same groups in order to complete the program. Example: Anger management is a commonly offered group, but perhaps your loved one does not have an anger issue. If so, your loved one should not be required to attend this group.
Probably no one knows your loved one better than you. Perhaps s/he has experienced trauma. Ask if the program gives trauma-informed care and what this specifically means. You can find out more about trauma-informed care below.
Or perhaps your loved one has a heroin or opioid (i.e., pain pill) addictions and wants to be on a medicine that will be helpful. The research is very strong that those with this type of addiction typically are more successful than those who do not use these medications. Some of the more commonly used FDA approved medications are buprenorphine/naloxone, methadone, naltrexone/depot naltrexone, and Acamprosate (link is external). This is known as “Medication Assisted Treatment” or “MAT”. It is a red flag if the program is against MAT. At no time should your loved one be forced to end MAT, including when they first enter the program if they have already started MAT.
A further indicator of quality treatment is having reliable, valid measurement systems in place to track patients’ response to treatment. Similar to regular assessment of blood pressure at each point of care in the treatment of hypertension, addiction treatment programs should collect “addiction and mental health vital signs” in order to monitor the effectiveness or ineffectiveness of the individualized treatment plan and adjust it accordingly when needed. Without any kind of standardized metrics it is difficult to document and demonstrate patients’ progress.
These can include, but not be limited to, scores on validated tests which show if a client is improving or getting worse, obtaining employment, not detecting any drugs when given a urine analysis (UA) test, your loved one’s compliance with court and paying fines, any new arrests while in treatment, and obtaining housing.
Accreditation from external regulatory organizations such as the Joint Commission on Accreditation of Healthcare organizations (JCAHO; aka “the Joint Commission”), the Commission on Accreditation of Rehabilitation Facilities (CARF), and the Council on Accreditation (COA); and programs which are licensed by the state tend to have higher quality care as they must contain minimal levels of evidence-based care.
While this external accreditation is not a requirement to become a provider of substance use treatment, it does mean that the provider is under additional scrutiny to comply with specific industry standards.