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We Keep Paying. He Keeps Returning to Use. How Much Longer?

Kim has watched her son’s struggle with stimulants for years, and has paid for his treatment and housing along the way. Although he’s had repeated success with short-term Partial Hospitalization Programs (PHPs), he starts using again when he moves to a lower level of care. And the bills have added up. Kim wants to continue her support, but worries that she can’t sustain it. Fortunately, there are approaches that could break this cycle. Allies CEO Dominique Simon-Levine has some informed and encouraging suggestions.

Hi, my son has been in and out of recovery and various levels of care for a few years now. He has most recently tried living in a halfway house situation. He does well for a few weeks, has a slip and is out for a few days, and then he is allowed back in if he tests negative for substances. Only to slip again and be out on the street.

I have said no to hotels at this point. I feel it is less safe for him than the streets. I want to support his request to try again but each time, we have to pay two weeks rent and a deposit, which we lose each time he is let go. This is getting costly. I understand that slips happen but there have been several tries. We encouraged him to go to a PHP that takes his insurance where housing is included, and he does, but every time he comes out and goes to a lower level of care, the same cycle occurs.

How do I support his efforts but also stop the bleeding of funds for his housing? Is it appropriate to say we support him but he will have to find a house that will let him pay when he gets a job?

 

Thank you for writing, Kim. Halfway houses, also called recovery houses (or in the old language, sober homes), offer little in the way of structure and accountability. The individual’s days are free and unsupervised. There may be a house manager; some are self-run. With a safe roof overhead, a motivated person can make constructive use of those days in the community. Others, though, make less effort, feel less able or hopeful, or are less open to recovery. For these people, such free days lead to a wandering mind and body.

The milieu of these houses is so vitally important for every resident. When drug use and misbehavior occur, it disrupts and endangers everyone in the house. Asking someone to leave who has used, however, is not a clinically informed decision for that person. When asked to leave, the person is typically offered admission to detox. And that’s often it.

All recovery houses are not equal

Whether or not to kick someone out for drug use has been a source of debate for years. I was part of a team that evaluated state-funded recovery houses across Massachusetts in the early 2000s, and we asked ourselves this question often. Recurrence and relapse, after all, are part of addiction. But if a person isn’t asked to leave, how equipped is the house to address active use? And how can it guarantee the safety of the other residents, now living with someone who may not be done using?

In the best cases, I have seen homes run with hands-on social accountability and self-governance, like those built on the social model. A good home gives the person a head start by helping them find work to pay for the housing. A house that throws people out for using and keeps the deposit worries me, however. How does a deposit even work in a recovery home? This is the first I’ve ever heard of charging a deposit. People in need of a recovery home don’t typically have the necessary savings.

As the need and popularity for homes has grown, so has the cost, with some houses charging $5000 a month and up­—plus deposit, I gather. Recovery homes at these prices start to look like more structured, privately-funded programs. They often come with chefs, paid housing managers, and other bells and whistles.

What worries me today is that the drugs are making people sicker for longer during withdrawal than those I evaluated in the early 2000s. Your son uses methamphetamines, a drug which, fortunately, still has a low rate of use in the Northeast. But as your son demonstrates, it’s certainly here.

Recovery needs vary person by person—and drug by drug

The current treatment system is designed to step the person down, after 30 days, from a partial-hospitalization program (PHP) to a less intensive recovery home. Thirty days helps most people through the worst of the withdrawals. But not those using drugs like methamphetamines and synthetic opioids like Fentanyl that stay in the system for longer periods of time.

Here’s one way to look at it: after 30 days, your son is likely still in serious withdrawal—quite low in mood, lethargic, and in rough shape overall. Too rough to be hitting the ground running, as is expected of recovery home residents. Your son is 38. We’re likely talking about a long history of drug and alcohol use.

Treatment for methamphetamine is still in its infancy. What we do know is that individuals need to stay in structured care for a long time—nine months or longer—to give the mind and body time to return to health. That process is naturally slow. Of course this varies by individual, but this basic fact is one to keep in mind. It’s not that surprising that your son relapses shortly after admission to a recovery home.

The good news here is that your son does well in PHPs. With a program’s good guard rails to buffer him, he is able to stop using. That makes sense to me and makes me hopeful. At 38, I imagine he must be getting pretty tired of the drug use. Stimulants are brutal on the body.

My hunch is that after 30 days (the average length of stay in a PHP), your son isn’t ready to step down to a recovery home. He needs more time to gain his footing, and more energy before landing in a strange community with days that need to be filled.

Breaking the cycle through longer care

In the current system, he will need to move to a recovery home setting soon enough. But I wonder if next time around your son can be admitted first to an inpatient program (a higher level of care intensity than a PHP), then step down to PHP, and finally, to a recovery home. This would at least buy him those guard rails for an additional 30+ days before moving to a recovery home.

If you are able to adjust his treatment plan on the front end to get those extra 30 days or more with an inpatient rehab, then finding a quality recovery house that is paid for by wages may be open to him. When I read about the troubles with recovery home funding in Vermont, I’m concerned that your son has few choices when it comes to subsidized housing, but such housing does appear to exist. Here is a directory with live updates about wait lists and other details about houses in Vermont. Here also is an article that describes Medicaid-funded rehabs in Vermont. One more resource to check out is this list of recovery communities across Vermont.

When we work with a family, we talk to the recovery communities and coaches about houses in their area. They know the well-run houses and may know of new opportunities not found on websites.

Since your son has faltered and cycled through a PHP more than once, insurance should see that a one-off PHP is not a sufficient level of care for him. This should help you argue for getting the inpatient rehab covered.

Finally, there’s a psychological approach that is showing promise for stimulant use disorder. It’s called contingency management—you can search the Allies member site for more information. The premise of contingency management is that when given a choice, people with addiction often (and surprisingly) choose rewards such as gift cards, money, tokens that can be exchanged for prizes, etc., over their drug.

Specifically, research suggests that contingency management is likely to be a useful component of treatment strategies designed to address methamphetamine use disorders. Researchers have found that in the ability to choose rewards over one’s drug of choice that more abstinent time can be encouraged. Here’s one inpatient place in Vermont that I found that offers contingency management.

I hope you find something useful in all of this, Kim. You’re dealing with big challenges, and I can sense the struggle, but your son is fortunate to have you on his side. My best to you and your family.

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