Twenty-eight days is no longer a magic number when it comes to substance-abuse treatment. These days, you can stay only if you can pay.
In the movie 28 Days, Sandra Bullock plays a party girl whose good times come crashing to an end when too many binges force her into alcohol rehabilitation.
Her character goes to Serenity Glen, where recovering alcoholics hold hands, sing songs and confront one another in therapy sessions during their 28-day retreat from the world.
They strive to sever their dependence on booze and drugs. Family rifts are healed, characters move easily to better lives.
Real life, of course, is something else.
In the era of managed care, 28-day inpatient drug and alcohol treatment has gone the way of doctors' house calls and five-day maternity stays.
Dozens of inpatient alcohol- and drug-rehabilitation centers have closed nationwide in recent years, and those that remain have dramatically shifted their focus to alternative therapies and treatments. The Betty Ford-type rehabilitation retreats still exist for those who can pay thousands of dollars out of pocket, but even these centers have been forced to change philosophy.
"There was nothing magical about 28 days," said Ken Talge, president of the Alcohol and Drug Recovery Centers, a private nonprofit group of treatment centers.
"About 15 years ago, alcoholism began to be treated more medically, which resulted in the opening of a lot of for-profit centers which insurance providers would pay for," Talge said.
With the inception of managed care, he said, "these centers started closing down dramatically. First it was 21 days, then 15 days. Now you're very lucky if you can get seven days of inpatient treatment. Only the sickest of the sick can get that."
The 28-day treatment has instead been replaced by a more individual approach on an outpatient basis.
"It's a two-edged sword," Talge said. "There are pluses and minuses. Some people thrive; others just go out and relapse."
Chris Leary, president of New Directions, a treatment center in Enfield, Conn., said that, typically, addicts may undergo a few days of inpatient detoxification until they are medically stable and then move on to a structured outpatient program that includes counseling.
Leary has found that the new protocol, while it works well for many, has not been as good for some, especially women.
In the real world, Bullock's party girl would go home every night to her champagne-swilling boyfriend, who had no intention of ever giving up the party life.
"Women are more relational; they need other women to give them the kind of support they need," Leary said. "Female alcoholics are viewed differently by society than males." Women can benefit from a program that is more structured, he said.
Pamela Greenberg, president of American Managed Behavioral Healthcare Association, which represents substance-abuse insurers, said the old 28-day model often meant that everyone got 28 days, whether they needed it or not.
"There was never any medical basis for that number," Greenberg said. "People are now getting what is appropriate for them, more tailored for the individual. Some people might get seven days, others might get 32."
Greenberg added that new approaches are also being tried in different settings. "There is a continued search for treatment alternatives to broaden the array of choices out there," she said.
Substance-abuse treatment lags behind other medical services, Leary said.
"There is a stigma, especially when you need to go to state agencies for funding," he said. "It's not a cause that people want to get behind. These are clients that no one has empathy for. It's still something that is viewed as a moral disorder, rather than a legitimate medical problem."