There are no systematic reviews or meta-analyses considering the impacts of bed-based programs (also called residential or inpatient treatment) or supportive recovery treatment programs for individuals with opioid use disorder. The overall dearth of evidence does not mean that bed-based treatment is ineffective, but rather that the intervention has been under-studied, thus requiring review of individual studies. There are also no large clinical trials comparing bed-based treatment to other interventions, and few rigorous evaluations that identify specific characteristics of effective bed-based treatment programs or patient characteristics that may predict appropriateness of bed-based treatment referral. 

Observational cohort studies in the UK have found that relapse is relatively common among clients discharged from bed-based treatment for opioid use disorder. For example, a 2010 study examining the outcomes of a six-week bed-based treatment program in Ireland that included methadone-based withdrawal management, psychosocial therapy (i.e., group, individual, and/or family therapy) and an aftercare component found that 80% of participants reported relapse within one month, with 59% relapsing within one week of discharge. Younger age, not completing the full six weeks of treatment, greater heroin use prior to treatment, history of injecting, and not enrolling in aftercare were associated with a shorter time to relapse. Similarly, in the 2000 National Treatment Outcome Research Study (NTORS), approximately 57% of clients reported heroin use within 30 days of discharge, with 31% relapsing to regular levels of heroin use at 1-year follow-up. However, for the full cohort of individuals who attended bed-based treatment for alcohol or substance use disorders, the NTORS study did find that, at 4–5 years follow-up, injecting rates dropped from 61% at intake to 29% at follow-up, while abstinence from heroin use increased from 23% to 49% across the same period.347 Overall, individuals who completed bed-based treatment also demonstrated improvements in terms of safer injection practices, psychological and physical health, and reductions in criminal behaviour at 4–5 years follow-up.348 

Studies of bed-based treatment in the United States also present varied results. One 2004 longitudinal study of abstinence-based treatment programs found similar rates of retention, completion, and patient satisfaction among individuals in outpatient and bed-based treatment programs.349 A 2013 study found that a four-week bed-based treatment program significantly decreased several maladaptive cognitive and behavioural patterns that may contribute to ongoing substance use problems in adults with opioid use disorder.350 A 2014 randomized clinical trial found that a combination of community reinforcement and family training in addition to bed-based withdrawal management using buprenorphine, particularly when involving the adult patient’s parents, was positively and significantly associated with improved retention in treatment and reductions in opioid and other drug use.351 Therefore, patients may benefit from bed-based treatment that involves fostering family and other social connections.

Although the 2002 outcomes of the NTORS cohort study found that bed-based treatment was associated with reduced rates of non-fatal overdose at one-year follow up (7%) compared to pre-treatment rates (22%),352 providers should be aware of risks associated with loss of tolerance for patients who attend residential treatment programs when not receiving OAT. For instance, a retrospective study of Massachusetts admissions data from 2013–2015 found twice as many individuals experienced an opioid overdose in the first two weeks following discharge from bed-based treatment compared to the following two-week time period.353 Similarly, a 2016 national cohort study in England found that risk of fatal overdose was twice as high for patients who completed psychosocial treatment only (outpatient or bed-based treatment) compared to patients who had received OAT. 

There is growing advocacy for the provision of OAT in supportive recovery services. 215–217,222–224 However, there have been barriers to integrating OAT and recovery-oriented services, as these approaches have evolved from distinct communities of practice, siloed service delivery systems, and—in some cases—divergent belief systems.216 In the past, many clients receiving OAT were excluded from recovery-oriented services and programs, including supportive recovery residences, as they were not considered to be in “true recovery.”217 Patients benefit when OAT clinics and recovery programs work collaboratively. 

Studies indicate that a minority of bed-based treatment facilities offer OAT. A retrospective cohort study of 36 publicly funded bed-based treatment facilities in Ontario from 2013–2016 determined that, while a slight majority (55.6%) of facilities allow patients to be on OAT during bed-based treatment, 75.5% of those facilities do not prescribe or dispense on-site, 8.5% only prescribe on-site, 13% only dispense on-site, and only 3% both prescribe and dispense on-site354 Similarly, a 2020 cross-sectional study of bed-based treatment facilities in the United States found that only 33.3% of facilities offered buprenorphine and 2.1% offered methadone. Overall, 60% of facilities provided no form of medication for opioid use disorder (including extended-release naltrexone), and only 1.3% of facilities provided buprenorphine, methadone, and extended-release naltrexone.

There is limited evidence regarding the effects of OAT and other medications for opioid use disorder on patient outcomes in bed-based treatment facilities. A cohort study analyzing the mortality risks of patients who completed withdrawal management between 2012 and 2014 found that patients who participated in subsequent bed-based treatment had reduced all-cause mortality compared to those who received no further treatment (adjusted hazard ratio [AHR]=0.63, 95% CI: 0.47–0.84).355 When bed based-treatment was combined with medication for opioid use disorder (buprenorphine, buprenorphine/naloxone, methadone, or naltrexone), all-cause mortality was further reduced (AHR=0.11, 95% CI: 0.03–0.43). Similarly, opioid-related mortality was reduced in patients who received subsequent bed-based treatment (AHR:0.69; 95% CI:0.50–0.94) and bed-based treatment combined with medication for opioid use disorder (AHR:0.14; 95% CI:0.03–0.55).355 In a 2020 cohort study examining the feasibility and effectiveness of incorporating medication for opioid use disorder into bed-based and day treatment programs based on the 12-step program, a majority (71%) of participants opted to receive some form of medication. Treatment adherence between medication groups did not differ significantly one-month post-treatment, with 87% of buprenorphine/naloxone participants, 80% of extended-release naltrexone participants, and 65% of oral naltrexone participants reporting adherence (p=0.39). Among participants who completed follow up at 6-months post-treatment, 72% of buprenorphine/naloxone patients, 53% of extended-release naltrexone patients, and 29% of oral naltrexone patients reported adherence. Buprenorphine/naloxone patients were significantly more likely to report medication adherence than oral naltrexone patients (p<0.01).356