Louis Casanova is playing cards with a friend on the back deck of a recovery house in Philadelphia’s northern suburbs.
He’s warm and open as he talks about his past few years. He started using drugs like Xanax and Valium during his freshman year of high school, and at age 18, Casanova turned to heroin. About two years later, the rehab shuffle began.
“I relapsed and then I was just getting high. And then I went to treatment again in February of 2015,” said Casanova. “Then I relapsed again and went back to treatment.”
Now 23, Casanova has suffered and caused suffering with his addiction. His criminal record is long, and he has hurt people close to him. By his own count, he has been through eight stays in inpatient rehabs.
“I did 30 days, and after that I came here,” he concludes, talking about his latest visit. Earlier stints ranged from about 18 to 45 days.
A month’s stay is typical for people who go to an inpatient facility to treat drug or alcohol addiction.
But why?
“As far as I know, there’s nothing magical about 28 days,” said Kimberly Johnson, director of the Center for Substance Abuse Treatment at SAMHSA, the federal agency that studies treatment services.
Anne Fletcher, author of the book Inside Rehab, agreed.
“It certainly is not scientifically based,” she said. “I live in Minnesota where the model was developed and a lot of treatment across the country really stemmed from that.”
Fletcher said the late Daniel Anderson was one of the primary architects of the “Minnesota model,” which became the prevailing treatment protocol for addiction specialists. At a state hospital in Minnesota in the 1950s, Anderson saw alcoholics living in locked wards, leaving only to be put to work on a farm.
To find a path for them to get sober and leave the hospital, he came up with the 28-day model. Later Anderson became the president of what is now the Hazelden Betty Ford Foundation.
Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers, has studied the model’s history. He says the month-long standard comes from the notion that when “someone is suffering from addiction — and in the days that this began, we’re pretty much talking about alcoholism — it made sense to people that it took about four weeks to stabilize somebody.”
Later, Ventrell said, “it became the norm because the insurance industry was willing to pay for that period of time.”
The model is being used to treat opioid addiction, even though recovering from addiction to those powerful drugs may be quite different from recovery from alcoholism.
Ventrell acknowledged there isn’t enough research about the most effective length for an inpatient stay for opioid addiction.
“Treatment centers have to step up and say, ‘Just like cancer or heart disease, we’re going to measure our outcomes and show them to you,’” he said.
The federal government estimates spending on treatment for all substance abuse will hit a high of $42 billion by 2020. Some people pay tens of thousands of dollars out-of-pocket, desperately hoping inpatient treatment will work.
After a string of inpatient rehabilitation stays, Louis Casanova, who lives near Philadelphia, says he is still trying to break his addiction. (Ben Allen/WITF)
But there’s increasing evidence that medication-assisted treatment with the methadone or Suboxone can help those addicted by relieving symptoms of withdrawal and reducing cravings. It is especially effective when paired with strong outpatient counseling and other support.
Fletcher said it’s important for treatment to move away from the default month-long model.
That may be enough for some people, she said, but it “isn’t the case for most people. It’s like any other chronic disorder, it waxes and wanes.”
For his part, Casanova said he preferred longer stays because it gave him more time to learn from other patients in a supportive environment.
After a recent relapse, he had to serve some jail time. But he’s back in the recovery house, and hoping to soon make the leap to the next stage — a house with more independence.
This story is part of a partnership that includes WITF’s Transforming Health, NPR and Kaiser Health News.