Who makes the rules — and more importantly, who do they serve?

In 2017, Paul Reithlinghshoefer, a heroin user, was admitted to Adventist Behavioral Health Hospital in Rockville, Maryland.

He left the program a week early and told his mom he had gotten kicked out for smoking a cigarette (the hospital is a smoke- and tobacco-free environment).

Less than a month after his expulsion, Paul died of a fentanyl overdose.

The hospital hasn’t commented on the reason for Reithlinghshoefer’s expulsion, though they deny that it was for smoking a cigarette.

It’s made me ponder the question (and not for the first time, either): How do we decide, exactly, what is and isn’t permissible in rehab?

Regardless of if Reithlinghshoefer was kicked out over a cigarette or not, the question of what should be allowed in inpatient centers is a thorny one — and not as consistent as you might assume. 

I’ve heard of some rehabs that prohibit coffee and other caffeinated beverages (!) or nicotine. The rehab I was fortunate to attend allowed both of those things but was quite strict about medication.

Anti-anxiety drugs (like Xanax) and stimulants (like Adderall) were absolutely forbidden, even if the patient had a doctor’s prescription for the drug.

It’s not hard to guess why: There are people whose use of those drugs is an integral part of their substance use disorder.

If you go to rehab because you misuse Xanax and the facility lets you take Xanax because you have a prescription for the drug, it might seem like you’re defeating the purpose of being in treatment.

But before we can figure out if something like Xanax or a cigarette does, in fact, defeat ‘the purpose’ of being in treatment, we have to figure out what that purpose is.

My experience of rehab was a powerful one, and while I wouldn’t trade that for anything, the excellent care I was offered — the classes, support groups, knowledgeable staff, many of whom were in recovery themselves — wasn’t actually the most important part.

For me, the most valuable part of rehab was the simplest: for 28 days, I couldn’t get drunk. 

I had been using alcohol in a way that was guaranteed to kill me (and nearly did), and for 28 days, that was something I simply couldn’t do.

It was triaged medical care, really — akin to walking into an emergency room bleeding out my eyes. The first, most important task was stopping the bleeding. Without getting that under control, doctors couldn’t diagnose the problem or help me heal.

In those 28 alcohol-free days, I learned new habits and routines. I talked to other patients who were struggling with their own substance issues.

I went to classes to learn about what happened in my brain when I used alcohol, and how it explained why, despite my best efforts, I couldn’t use alcohol responsibly, the way my friends could.

But none of that would have been possible if, first and foremost, we hadn’t stopped the bleeding. 

Which brings me back to the purpose of rehab for substance use disorders. If we think of rehab as being akin to emergency triage, we might imagine the purpose of rehab to be something like this:

  1. Get and keep the patient out of immediate danger.
  2. Treat the addiction(s) that are most harmful/dangerous.
  3. Address any secondary or possible substance use issues that aren’t as immediately dangerous (i.e. smoking) if the patient wants to.

In this last category, I would include the use of prescribed medications that have addictive potential but to which the patient isn’t misusing. 

In other words, if a person wants to try to stop taking Xanax because of the addictive potential — great. But if they haven’t been misusing it, that part of the treatment is optional.

These guidelines might seem fairly obvious, but with rehab facilities not seeming aligned on even these basic ideas, it begs the question: Is the rigidity and inflexibility of many rehab centers truly helpful for a patient’s recovery?

What’s the point of forcing someone with ADHD off their medication, for example, when their addiction is to alcohol — especially when we consider the links between untreated ADHD and addiction?

And what, exactly, is the point of kicking a person addicted to opioids out of rehab for smoking a cigarette?

Stories like Paul’s open up a larger question of whether or not the goals of rehab centers are actually supported by the policies put in place.

If the goal of rehab is to foster the safest and most productive environment for treatment, can we honestly say that banning cigarettes, coffee, or necessary prescription medications supports that aim?

This isn’t a radical idea by any means — some rehabs are already revisiting their own policies, though too many aren’t. And unfortunately, it comes at the patient’s expense.

While we can’t say for sure that Reithlinghshoefer was kicked out of treatment over a cigarette — or if his relapse could’ve been prevented had he been able to complete treatment — I don’t necessarily think those are the right questions to begin with. 

The better question is: What’s the ultimate purpose of rehab, and in Paul’s case, did they make every effort to fulfill it?

Unfortunately, I think we can safely say the answer to that is no.

Katie MacBride is a freelance writer and the associate editor for Anxy Magazine. You can find her work in Rolling Stone and the Daily Beast, among other outlets. She spent most of last year working on a documentary about the pediatric use of medical cannabis. She currently spends far too much time on Twitter, where you can follow her at @msmacb.