Numerous sources use the terms inpatient treatment and residential treatment interchangeably; however, there is a subtle difference between the two forms of treatment when referring to treatment for mental health conditions, such as substance use disorders. Technically, professional sources like Drug Abuse and Treatment Rehabilitation: A Practical Planning and Implementation Guide differentiate the two.
- Inpatient treatment provides the most intensive level of treatment. Patients receive 24-hour care/supervision and are monitored around the clock for their own wellbeing. Inpatient treatment services are usually delivered to patients in clinics or hospitals who need to be stabilized for some acute situation or a range of problems. They are then moved to a different level of care once these issues stabilize. These programs are typically short-term.
- Residential treatment provides structure and monitoring in a facility that is not a clinic or hospital. Medical staff are typically not available onsite 24 hours a day but are on call. The facility is a living facility, but not a medical facility. Residential treatment typically lasts far longer than inpatient treatment.
The difference is subtle and often leads to the terms being used interchangeably; however, the designation will remain in effect for this article.
Typically, individuals with alcohol use disorders or other substance use disorders will enter an inpatient treatment unit if they:
- Have a strong need placed in an intensive physician-assisted withdrawal management program for severe or complicated withdrawal syndromes (often referred to as a medical detox program)
- Have some significant medical condition that needs close supervision and treatment in addition to the alcohol use disorder
- Have some significant co-occurring psychological/psychiatric disorder or issue that also requires around-the-clock monitoring initially
- Have a history of numerous failed attempts at recovery and relapses
- Have a combination of any of the above conditions
On an inpatient treatment unit, the individual is cared for at all levels, with services including housing, meal prep, therapy, medical treatment, etc. The individual may be allowed visitors, but these visitors must conform to the established visiting hours of the facility. Individuals in inpatient units cannot leave the unit unless they are accompanied by staff and leaving the unit is approved by their supervising physician or other supervising member of the staff on the unit. Typically, individuals leaving an inpatient unit are leaving for some form of testing, assessment, or other form of treatment, and they are immediately returned back to the facility.
Individuals in inpatient treatment units transition to lower levels of care, including residential treatment, partial hospitalization treatments, intensive outpatient treatment, or outpatient treatment once their condition has stabilized and they are approved for transfer by their supervising physician and/or case manager.
Withdrawal Management and Relapse Prevention on an Inpatient Unit
Individuals with moderate to severe alcohol use disorders are often at risk for the development of a complicated withdrawal syndrome that may occur once the individual is abstinent from alcohol. There is no reliable way to predict if an individual will develop a complicated withdrawal syndrome; however, individuals with a past history of complicated withdrawal or who are heavy alcohol users are strong candidates to have severe confusion associated with alcohol discontinuation, psychosis related to the discontinuation of alcohol (the development of hallucinations and/or delusions), and the development of seizures associated with stopping alcohol.
These individuals are at risk for harm due to their confusion, psychosis, and/or seizures (which can be potentially fatal). As a result, such individuals are best treated on an inpatient unit until their withdrawal symptoms have stabilized and the withdrawal process from alcohol is relatively complete. Other individuals who are experiencing mild alcohol withdrawal may also be best placed on an inpatient unit initially to stabilize if they have significant issues or conditions that will increase the probability that they will relapse.
The withdrawal management protocol for alcohol typically involves the use of a benzodiazepine, such as Ativan (lorazepam), Valium (diazepam), or Librium (chlordiazepoxide), on a tapering schedule. Benzodiazepines control the symptoms of withdrawal from alcohol, including the potential for seizures. Over time, the treating physician slowly tapers the dosage of the benzodiazepine, and the person can withdraw from alcohol without experiencing any potentially serious symptoms. Other medications may also be used depending on the needs of the patient, including antipsychotic medications, medications to deal with cravings, and medications to address minor nausea, headache, etc.
Once the individual’s withdrawal syndrome is considered to be managed, they transition to a lower level of care. The particular level of care to which an individual is transferred to depends on the specific case. Some individuals may be transferred to residential treatment and others to various forms of outpatient treatment, depending on the complexity of their situation.
Inpatient Care for Patients with Co-Occurring Conditions
Individuals with alcohol use disorders often have one or more comorbid (co-occurring) medical or psychiatric conditions that require intensive treatment. When the situation consists of an alcohol use disorder and some other co-occurring psychiatric condition, it is often referred to as a dual diagnosis or co-occurring disorders. Some of these individuals may be potentially suicidal and need close 24-hour supervision.
There is a broad range of conditions that might qualify an individual to be placed on an inpatient unit, such as:
- Cardiovascular issues
- Liver damage
- Hepatitis, HIV, some types of cancer, or other serious diseases
- Dementia or other serious neurological issues
- Psychiatric diagnoses, including a diagnosis of bipolar disorder, major depressive disorder, a psychotic disorder (e.g., schizophrenia), a personality disorder, and a co-occurring substance use disorder to another drug, etc.
Depending on the level of the individual’s alcohol use disorder, the person may also be at risk for complicated alcohol withdrawal, and this can result in potential serious complications during the initial stages of recovery. These individuals require close 24-hour care and supervision until the comorbid (co-occurring) condition and the alcohol use disorder can be stabilized. Failing to address one of the conditions often results in relapse. Depending on the issue, it can lead to significant metal and/or physical complications and may even prove to be fatal.
Individuals with insurance coverage often need the referring physician to demonstrate that inpatient treatment is a medical necessity in order for the insurance company to approve inpatient treatment. Medical necessity as related to the need for inpatient treatment basically refers to the notion that the treatment the individual will receive can only be properly administered in a medical facility where the person gets 24-hour supervision and care. If the individual’s condition can be treated equivalently as an outpatient at a lower level of care, the insurance company will often not approve payment for an inpatient stay.
The length of time an individual remains on the inpatient unit depends on the severity of their issue, their documented progress, what level of care they will be transitioned to after inpatient treatment for their alcohol abuse is completed, and specific goals agreed upon by both the treatment providers and the insurance company. Typically, individuals who are receiving inpatient treatment for withdrawal management associated with alcohol abuse remain in the facility until the withdrawal management program is completed as documented by the treating physician; then, they are transitioned onto a lower level of care. However, many insurance companies have algorithms that they refer to in order to approve inpatient treatment for a specific block of time. If the individual’s physician believes that the patient needs to remain in an inpatient unit after this period of time has expired, they must get approval by the insurance company for additional time.
Individuals with Histories of Unsuccessful Recovery Attempts or with Toxic Environments
Many people who attempt to recover from an alcohol use disorder have had prior unsuccessful attempts to do so. In some cases, individuals may also have certain living conditions that predispose them to relapse, and inpatient treatment may be the best way to ensure success in their initial recovery efforts. In many cases, these individuals might qualify for 24-hour medical supervision in order to ensure that they are successful during the early stages of their recovery. This would include the use of a physician-assisted withdrawal management program.
- Help them successfully negotiate the withdrawal process, which is a high-risk period for relapse
- Stabilize them and get them started on the road to abstinence
- Help in identifying any co-occurring psychological/psychiatric disorders that may be contributing to their difficulties in recovery
- Remove them from potential toxic environmental situations, such as an abusive family situation, being homeless, or living in a high-risk area where drug and alcohol use/abuse is commonplace
- Help them develop confidence and commitment to maintain their progress in recovery
- Help them get a foothold in recovery while arrangements are made to place them in a more stable environmental situation
For the majority of these individuals, once their condition is stabilized, they will be transferred to a lower level of care, most often a residential treatment program or a partial hospitalization treatment program where individuals attend treatment in a clinic or hospital during the day and then return to a living facility that is attached to, but not part of, the treatment center.
Some General Advantages of Inpatient Treatment
In addition to the specific advantages that inpatient treatment offers to specific individuals with unique types of issues, there are several other general advantages to inpatient treatment.
- Treatment in an inpatient unit is highly structured.
- Care in inpatient units is typically delivered by a multidisciplinary team of treatment providers to address different issues from different angles/viewpoints.
- Inpatient treatment stresses personal accountability for one’s behavior.
- Individuals with legal issues as a result of their alcohol use disorder are often able to satisfy many of the requirements of the court when they are initially treated as an inpatient. This may reduce sanctions placed on them for breaking the law.
- Individuals who are unsure or resistant to becoming abstinent from alcohol find that they can remain abstinent from alcohol with inpatient treatment, and this may foster future success in recovery.
- The completion of an inpatient treatment program can be a motivating factor for an individual to remain abstinent.
Some of the disadvantages of inpatient treatment are outlined below.
- Inpatient treatment programs disrupt one’s life. One cannot attend work, school, be with their family, etc.
- Individuals often have to disclose their alcohol abuse to others, such as employers, friends, other relatives, etc., when they go to an inpatient unit because they are isolated from others and because of the disruption in normal activities that inpatient admission produces.
- Inpatient treatment is costly. Even individuals with insurance will often have significant copays associated with admission to an inpatient unit.
- Inpatient treatment is only the beginning of recovery. Without commitment to a solid aftercare program once one is released from an inpatient unit, the individual is likely to relapse.
Inpatient treatment for alcohol use disorders is the preferred method of care for individuals who have specific issues that require around-the-clock monitoring and care. The goal of an inpatient treatment program is to stabilize the acute issues associated with alcohol use disorder and then to transition the person to a different level of treatment, such as a residential treatment unit, intensive outpatient treatment, or general outpatient treatment. The length of time that the individual remains in an inpatient unit depends on what conditions are being addressed. Inpatient treatment for alcohol abuse is only the initial step in a long-term program of recovery.