Therapies Offered at Residential Addiction Treatment Programs in the United States

Residential treatment programs are a common, costly setting for treating opioid use disorder¹ and are frequently promoted in policy proposals to improve access to care.² However, concerns have been raised about the quality of care and low use of evidence-based opioid agonist treatment (OAT) in these settings.³ Most data available on programs come from self-reported surveys⁴ that may not reflect patient experience, so we simulated patient calls to audit treatments offered by programs nationally.

We surveyed a random sample of residential treatment programs in the United States identified from publicly available federal directories and listings of search engine advertisements. From a sampling frame of 1436 facilities, we randomly selected an equal proportion of for-profit and nonprofit (including public) programs. To reach our target number of respondents, 3 trained research assistants called 613 programs with a standardized script from June 27 to September 20, 2019. Callers posed as 27-year-old individuals who use heroin and lack insurance. They spoke with the first available person who managed prospective admissions. Callers inquired about whether they could receive OAT, specifically mentioning “Suboxone” (buprenorphine-naloxone). We systematically collected information on availability of OAT and non-OAT treatments. We also recorded whether any anti-OAT messaging (eg, “substituting one addiction for another”) was used. We stratified outcomes by facility profit status, accreditation, and state licensure. We estimated logistic regression models controlling for facility characteristics to assess independent factors associated with OAT-related outcomes. P values were estimated using 2-sided Wilcoxon rank sum tests or χ² tests. Analyses were performed in Stata version 14 (StataCorp). The Harvard University institutional review board determined that the analysis was not human subjects research.

From the 613 programs contacted, 160 were excluded as out of sample (4 most common reasons: outpatient-only program [67]; served special populations [55]; accepted only insured patients [19]; and nonworking phone [16]). We completed contact with 368 of 453 in-sample programs (81% response rate), or 26% of nonfederal programs nationally. Nonrespondents were more likely than respondents to be nonprofit (61% vs 27%, respectively).

Nationally, 107 programs (29%) offered OAT with the option to continue maintenance (Table 1). An additional 114 (31%) offered OAT only for short-term detoxification, while 143 programs (39%) did not offer OAT or were unclear about whether OAT was available. Seventy-eight programs (21%) actively discouraged callers from using OAT.

The availability of OAT with maintenance treatment was not significantly different at nonprofit and for-profit programs (31% in nonprofit vs 29% in for-profit; adjusted difference, 4.8%; 95% CI, −7.3% to 16.8%), while publicly operated programs were significantly more likely to not offer or be unclear about OAT availability (77% in public vs 27% in for-profit; adjusted difference, 30.7%; 95% CI, 9.6%-51.8%). Programs’ accreditation or state licensure had no significant association with OAT availability for maintenance treatment or anti-OAT messaging.

Almost all programs (335 [92%]) offered some form of 12-step program (Table 2). Overall, 38 non-OAT treatment modes were offered by 5 or more facilities, such as cognitive behavior therapy (106 [29%]) or animal therapy (34 [9%]). Programs without clear OAT availability offered fewer non-OAT treatments (median, 2 [interquartile range, 1-4]) than those offering OAT for maintenance therapy (median, 4 [interquartile range, 2-6]; P < .001).

In this national survey of residential programs for opioid use disorder, 29% of programs offered OAT as maintenance therapy, the standard of care for opioid use disorder, while many actively discouraged use of OAT to callers. Thirty-one percent of programs offered OAT only for detoxification, which has worse outcomes compared with OAT maintenance.⁵

The presence of licensure or accreditation did not ensure availability of OAT or low use of anti-OAT language. Therefore, these “seals of approval” do not appear to guide consumers to programs consistently offering the most effective treatment for opioid use disorder or direct them away from those discouraging its use.

This study has limitations. Differences between nonrespondents and respondents could bias results. Because callers spoke only with the first available person, facilities’ true breadth of treatments may not have been captured. Also, callers had a fixed script representing an uninsured, cash-paying individual, so results may not generalize to other populations.

Overall, these findings raise concerns about the quality of care offered by residential programs.

Corresponding Author: Michael L. Barnett, MD, MS, Department of Health Care Policy and Management, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Kresge 411, Boston, MA 02115 (mbarnett@hsph.harvard.edu).

Accepted for Publication: May 11, 2020.

Author Contributions: Ms Beetham and Dr Barnett had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Beetham, Saloner, Wakeman, Frank, Barnett.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Saloner, Wakeman, Frank, Barnett.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Saloner, Gaye, Barnett.

Administrative, technical, or material support: Gaye, Frank, Barnett.

Supervision: Beetham, Frank, Barnett.

Conflict of Interest Disclosures: Dr Wakeman reported receipt of personal fees from Optum Labs. Dr Barnett reported being retained as an expert witness by plaintiffs in lawsuits against opioid manufacturers. No other disclosures were reported.