The substance use treatment industry in the US varies enormously in quality. Some programs operate at the current standard of care; others are operating two decades behind the evidence; a small number are actively problematic. The difference is not always visible from the website.
The questions below are the ones that separate programs operating at the current standard from the rest. A well-run program will answer most of them cleanly in a 20-minute admissions call. A program that dodges them, runs together on them, or gives answers that contradict the evidence is a program to keep looking past.
Medications
This is the single most important cluster of questions, and the one that most efficiently sorts programs.
Do you prescribe or coordinate medications for opioid use disorder (buprenorphine, methadone, naltrexone)?
The correct answer is yes, in some form, either the program has in-house prescribing, or it has established referral relationships. "We do not use those medications" or "We think patients should do that on their own" are disqualifying answers for any patient with opioid use disorder.
Do you prescribe or coordinate medications for alcohol use disorder (naltrexone, acamprosate, gabapentin, disulfiram)?
Same standard. For patients with moderate-to-severe alcohol use disorder, medication is first-line care. Programs that do not offer or coordinate MAUD are operating below current guidelines.
If a patient is stable on buprenorphine or methadone, do you continue the medication throughout the program?
The correct answer is unambiguously yes. Programs that require patients to taper off MOUD as a condition of admission are operating against ASAM 4th Edition standards and against the evidence. This practice carries a specific, quantifiable risk: post-discharge overdose risk is substantially elevated after MOUD discontinuation. Any program with this requirement should be eliminated from consideration. See Medications for Opioid Use Disorder.
Clinical approach
What evidence-based therapies do you use?
The answer should reference recognizable approaches: CBT for SUD, motivational interviewing, contingency management, relapse prevention, DBT, ACT, EMDR, or similar. Bonus points for specificity (e.g., "We use the Kathleen Carroll CBT4CBT manual" or "Our trauma work is TF-CBT").
Deflections to watch for:
- "We meet each patient where they are." This is not an answer. It is a marketing phrase.
- "We use a holistic approach." Often means no specific evidence-based curriculum.
- "Our program is based on the 12 Steps." 12-step facilitation has an evidence base (Project MATCH), but if it is the only modality the program offers, the program is not operating at the current standard.
How do you handle patients with co-occurring mental health conditions?
Most patients with substance use disorders have co-occurring depression, anxiety, PTSD, bipolar disorder, or ADHD. The correct answer involves integrated treatment of both, psychiatric assessment, medication management, and therapy addressing both domains. Programs that treat substance use in isolation from mental health are leaving outcomes on the table and often causing harm.
What is the caseload of individual clinicians?
A reasonable individual therapy caseload is 25 to 35 active patients per clinician. Substantially higher suggests the program is understaffed and individual therapy is a token rather than a real component.
Clinical staff
Who will be my primary clinician, and what are their credentials?
Expected credentials include LPC, LCSW, LMHC, LCADC, CADC, or similar state-level licenses. For medication management: MD, DO, NP, or PA.
Do you have prescribing clinicians on staff?
If the program claims to offer medication management, a prescriber should be identifiable. If prescribing is outsourced, the outsourcing arrangement should be explicit.
Does the program have a medical director, and who is it?
A medical director with identifiable credentials (board certification in addiction medicine, addiction psychiatry, or a relevant specialty) is a marker of clinical seriousness.
Program structure
How many hours per week of programming, across how many days?
For PHP: 20 or more hours per week across 5 days.
For IOP: 9 to 19 hours per week across 3 days.
Programs that blur these boundaries (e.g., 15 hours per week across 5 days) may be up-coding or down-coding for billing. Ask directly.
What is the typical length of stay?
Good programs have clinical pathways, not fixed timelines. Answers like "28 days for everyone" or "90 days standard" suggest the program is driven by billing windows rather than clinical criteria. "Typical range is X to Y depending on clinical progress, measured against specific criteria" is a better answer.
What are the criteria for step-up or step-down?
The program should be able to articulate specific clinical markers, sustained periods without use, specific skills acquisition, stability on medication, resolution of acute crises, that trigger a change in level of care.
Family involvement
How are family members involved?
CRAFT, BCT, or structured family therapy models are the evidence-based standards. Programs that involve family only through a single "family weekend" are offering theater rather than treatment. Programs that exclude family entirely are operating against the evidence, particularly for adolescent and young adult populations.
What happens if a patient uses
What is your response when a patient has a return to use during the program?
The correct answer is some version of clinical response, reassessment, possible intensification of care, possible medication change, increased clinical contact. Discharge for a positive drug test is not the current standard of care and is a sign of a program operating on punitive rather than clinical logic.
Do you drug-test during the program, and how are results used?
Regular drug testing is a standard component. The purpose is clinical information, not surveillance. Results should inform the treatment plan, not trigger discharge.
Harm reduction and safety
Do you provide naloxone to patients at discharge?
Naloxone distribution at discharge is now a standard component of responsible substance use programs. Programs that do not are missing a specific, evidence-based element of care. Bonus points for the program providing multiple doses and ensuring family members have training.
What is your overdose education and prevention content?
The correct answer includes specific content on overdose recognition, naloxone use, fentanyl contamination, tolerance loss after treatment, and never-using-alone protocols.
Discharge and continuing care
What is the discharge plan, and when is it developed?
A good program begins discharge planning in the first week of treatment, not the last. The plan should include a specific next level of care, specific providers with specific appointments, medication continuity, and a plan for housing, work, and social supports.
Do you continue to follow patients after discharge?
Post-discharge follow-up is associated with better outcomes. Programs that hand patients off at the end of the admission with no further contact are underperforming the evidence.
Cost, insurance, and financial practices
What insurance do you accept?
Straightforward question. Straightforward answer. If the program is evasive about in-network status, be careful.
What is the out-of-pocket cost, and what does that cover?
Reputable programs can give a clear answer. Programs that quote cost only after extensive admissions contact, or that shift cost estimates upward after admission, are operating with misleading practices.
Do you work with patients who have Medicaid?
Many evidence-based programs accept Medicaid. Programs that do not, particularly those that market heavily to families in crisis with commercial insurance, are often charging above their clinical value.
Red flags to watch for
A few patterns that indicate a program to avoid:
- Aggressive sales tactics. High-pressure phone calls, "this bed is available only for the next hour," artificial scarcity.
- "Luxury" marketing with unclear clinical substance. High-end amenities do not correlate with outcomes. They correlate with cost.
- Unverifiable claims. "90% success rate" is meaningless without a definition of success and a source. "Industry-leading" is a marketing phrase.
- Required discontinuation of MOUD. Disqualifying, as discussed above.
- Requirement to sign contracts or financial commitments before a clinical assessment. The assessment should happen first.
- Religious content presented as mandatory. Programs that require specific religious participation (beyond the patient's personal choice) are not operating on a clinical model.
The bottom line
A 20-minute phone call with these questions will tell you more about a program than an hour of website reading or a facility tour. Evidence-based programs answer them cleanly. Weaker programs deflect or contradict themselves. If a program cannot give clear answers on medications, clinical approach, and handling of return to use, keep looking.
What to read next
What to read next
Most people with substance use disorders can be treated effectively without residential rehab. Outpatient care, medications, and harm reduction are real options backed by clinical evidence. You do not have to make a permanent decision today. The next step can be small.