Is the 28-Day Rehab Stay Obsolete?

When you hear why the traditional 28-day rehab stay came into being, the clinical rationale for it becomes instantly suspect.

Here’s the story: In the middle of the last century, when servicemen in the U.S. Air Force needed treatment for suspected alcoholism, 28 days was the longest they could be away from their unit without requiring an official transfer. When those 28 days were over, back they’d go to their posts.

Absent good data at the time that proved otherwise, 28 days became the standard length of drug and alcohol rehab for military personnel and civilians alike. That standard has existed to this day.

Not exactly the stuff great treatment protocols are made of.

A different timeframe emerges.

Thanks to decades of patient data and real-world experience, we can now say with confidence that longer is better when it comes to treatment stay. Twenty-eight days? In most instances, that’s hopelessly inadequate.

A definitive 2018 National Institute on Drug Abuse (NIDA) report puts it this way: “Individuals progress through drug addiction treatment at various rates, so there is no predetermined length of treatment. However, research has shown unequivocally that good outcomes are contingent on adequate treatment length.”

“Generally,” continues the NIDA report, “for residential or outpatient treatment, participation for less than 90 days is of limited effectiveness, and treatment lasting significantly longer is recommended for maintaining positive outcomes.”

Those italics are mine, as that’s the key message. To be clear, the 90 days doesn’t all need to be spent in residential care, i.e., rehab. But in my opinion, most of it should be, based on what I know after decades in the addiction treatment field.

If I ruled the (addiction treatment) world

What timeframe standard would I recommend if it was my call? I would go with that 90-day total, with the first 60 in rehab and the final 30 in outpatient therapy.

Again, though, that would be my recommended standard. Some people would do fine with less time, while others might need considerably more.

The justification for 90 days

Here’s what we know about the time it takes for people to get better in treatment:

Your brain needs to recover.

Chronic drug or alcohol use actually changes the chemistry and structure of the brain. Once you stop using, it can take weeks, months, even a year or more for your brain to return to normal. Until it does, you’re at a far higher risk of relapse—thus, an intensive, multi-pronged treatment program is critical during this period of early recovery.

Therapy takes time to take hold.

It can take months to uncover and untangle the triggers, the family dynamics that play into the disease of addiction, and other underlying behavioral issues. Once you identify all these things, you then have to learn coping strategies for dealing with them. Behavior change is a slow process. Very rarely is it a 28-day process.

Other conditions must be dealt with as well.

Many, if not most, people who enter addiction treatment are also battling other mental illnesses, such as depression, anxiety disorder, and trauma. These conditions affect your addiction and are affected by it. Leaving treatment without dealing with these co-occurring disorders is a recipe for failure and makes a relapse far more likely.

Depression is a good example of a co-occurring condition you need to get a handle on in treatment. But depression medication alone—never mind the therapy you also need for this illness—often takes six to eight weeks just to reach a therapeutic level. Along the way, your response to the medication needs to be monitored to determine if that medication is the right option and at the right dosage. Monitoring takes time.

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Lifestyle habits often need a lot of work.

People frequently come into addiction treatment with very poor nutrition, little to no physical activity, bad sleep habits, hygiene issues, and so on. As with co-occurring conditions, poor lifestyle habits can both exacerbate your addiction and be exacerbated by it. People often need to make serious lifestyle changes for recovery to have a decent chance, and you guessed it, that takes a while, and it requires supervision.

An important caveat: Shorter stays can work for some people.

Some addiction treatment centers offer patients rehab stays that last less than 28 days. My center is one of them; we offer a 14-day option to people who meet the program criteria.

These programs often get good results with people who have established long-duration recoveries who then experience short, mild relapses. Patients normally undergo a several-day detox; they get full medication and mental health reviews, intensive behavioral therapy, and a comprehensive aftercare plan to take with them. The point being, these programs may be short in duration, but the successful ones offer highly concentrated treatment.

Short-stay programs are sometimes used by people who believe they simply can’t stay longer for whatever reason—maybe because of job or family responsibilities or financial limitations. The way I see it, the shorter option may not be optimal for this group, but it’s better than nothing, and it works for some.

A successful, longer-term timeframe already exists.

Many doctors, nurses, pilots, train engineers, and others in safety-sensitive positions are required to undergo 90 days of treatment for alcohol or drug addiction. Those 90 days are usually tailored to whatever works best for each patient—for example, 45 days of rehab followed by 45 days of outpatient care—but 90 days is the required standard. And guess what? It works.

Case in point: In a well-publicized research study published in 2009, a large group of physicians was tracked during treatment that began with 90 days of residential or intensive outpatient care. That was followed by 3 to 12 months of less intensive outpatient treatment. The physicians were also monitored via drug or alcohol testing for 5 years. Remarkably, in those 5 years, 78 percent of study participants had no positive tests for either alcohol or drugs.

Compare that to the standard relapse rate of 50 percent for the general population!

Which leads to this question: If a longer-term treatment works, and it’s the standard for people in safety-sensitive jobs, why isn’t it the standard for everyone else?

Final advice for getting the amount of treatment you need

If you or a loved one needs addiction treatment, and you aren’t able or willing to stay beyond the standard 28 days in rehab, you have options. I urge you to consider them.

These include partial hospitalization programs (PHPs), outpatient therapy, primary care doctor visits, group and individual therapy, AA, NA, or SMART Recovery meetings, and more. Combining several of these together can create a powerful, long-term recovery framework. The idea being that treatment doesn’t have to end just because you leave a 28-day program.

And in fact, most treatment centers are great about helping patients step down to those care alternatives once they leave rehab. If that aftercare guidance is inadequate (which it can be), be prepared to advocate for yourself or your loved one, and be determined to take advantage of available recovery resources.