Detoxification Services Research Articles

Meeting the needs of women who use drugs and alcohol in North-east India – a challenge for HIV prevention services

BackgroundThe North-east Indian states of Manipur and Nagaland consistently report relatively high HIV prevalence. The targeted HIV prevention interventions in these two states are mostly delivered by non-government organizations (NGOs), and prevention of HIV transmission by injecting drug use is their main focus. Most injecting drug users (IDUs) are male, and the services are primarily tailored to meet their needs, which are not necessarily the same as those for women. This qualitative study describes the health service needs of women who use drugs and alcohol in Manipur and Nagaland, with the goal of identifying strategies and activities that can be implemented by NGOs wanting to improve their reach among vulnerable women.MethodsIn 2009-10, semi-structured in-depth interviews were conducted with 27 key informants and nine focus group discussions (FGDs) with women who use drugs and alcohol, and two FGDs with male IDUs. The thematic areas covered included: the context of female drug and alcohol use; drug and alcohol use patterns; HIV risk behaviours; barriers and facilitators of service use; perceived health needs; and expressed health service needs. The data were recorded, transcribed, translated and thematically analysed.ResultsThe most problematic substance for women from Nagaland was alcohol, and for women from Manipur it was heroin. The most commonly identified health problems were primarily related to the women’s drug and alcohol use, reproductive health and mental health. Other problems of major concern included social exclusion, violence, children’s welfare, and financial difficulties. The expressed service needs of these women were women-only integrated health services, women-only detoxification and rehabilitation services, mental health services, desensitization of mainstream health workers, free access to medicines, assistance to meet basic needs, and a safe place for engaging in sex work.ConclusionThe expressed health and other service needs of women who use drugs and alcohol in Manipur and Nagaland do not match the services currently provided by HIV prevention NGOs, and this may, in part, account for the relatively poor uptake of these services by women. Strategies and activities that can be implemented by NGOs to strengthen their reach to vulnerable women are identified. However, many of these women’s needs are beyond the scope of services typically offered by HIV prevention NGOs, and require a coordinated multi-sectoral response.

Intrusive memories of trauma in PTSD and addiction

Aims and methodTo study intrusive phenomena relating to traumatic experiences in a community sample seeking treatment for substance use disorder and an in-patient sample from an addiction in-patient detoxification service in London. Perceived effect of drugs and drug use on traumatic intrusion and memory experiences was also analysed. The study was conducted using a semi-structured patient interview comprising a series of questionnaires.ResultsThe most frequently identified traumatic memories were those of traumatic bereavements. Substance use appears to have had the effect of dampening the memories for those with post-traumatic stress disorder (PTSD), and significantly more individuals reported that their memories were less vivid and less distressing before they ceased substance use.Clinical implicationsThe findings suggest that continued substance use could in part be motivated by its capacity to dampen distressing memories within the PTSD group. This should be addressed within a treatment plan of comorbid PTSD.

Evaluating the impact of community‐based treatment options on methamphetamine use: findings from the Methamphetamine Treatment Evaluation Study (MATES)

To evaluate the impact of community-based drug treatment on methamphetamine use using inverse probability of treatment-weighted (IPTW) estimators to derive treatment effects. A longitudinal prospective cohort study with follow-ups at 3 months, 1 year and 3 years. Treatment effects were derived by comparing groups at follow-up. IPTW estimators were used to adjust for pre-treatment differences between groups. Sydney and Brisbane, Australia. Participants were methamphetamine users entering community-based detoxification (n = 112) or residential rehabilitation (n = 248) services and a quasi-control group of methamphetamine users (n = 101) recruited from the community. Frequency of methamphetamine use between interviews (no use, less than weekly, 1-2 days per week, 3+ days per week), continuous abstinence from methamphetamine use, past month methamphetamine use and methamphetamine dependence. Detoxification did not reduce methamphetamine use at any follow-up relative to the quasi-control group. Relative to quasi-control and detoxification groups combined, residential rehabilitation produced large reductions in the frequency of methamphetamine use at 3 months [odds ratio (OR) = 0.23, 95% confidence interval (CI) 0.15-0.36, P < 0.001), with a marked attenuation of this effect at 1 year (OR 0.62, 95% CI 0.40-0.97, P = 0.038) and 3 years (OR = 0.71, 95% CI 0.42-1.19, P = 0.189). The greatest impact was for abstinence: for every 100 residential rehabilitation clients there was a gain of 33 being continuously abstinent at 3 months, with this falling to 14 at 1 year and 6 at 3 years. Community-based residential rehabilitation may produce a time-limited decrease in methamphetamine use, while detoxification alone does not appear to do so.

Estimating the prevalence of illicit opioid use in New York City using multiple data sources

BackgroundDespite concerns about its health and social consequences, little is known about the prevalence of illicit opioid use in New York City. Individuals who misuse heroin and prescription opioids are known to bear a disproportionate burden of morbidity and mortality. Service providers and public health authorities are challenged to provide appropriate interventions in the absence of basic knowledge about the size and characteristics of this population. While illicit drug users are underrepresented in population-based surveys, they may be identified in multiple administrative data sources.MethodsWe analyzed large datasets tracking hospital inpatient and emergency room admissions as well as drug treatment and detoxification services utilization. These were applied in combination with findings from a large general population survey and administrative records tracking prescriptions, drug overdose deaths, and correctional health services, to estimate the prevalence of heroin and non-medical prescription opioid use among New York City residents in 2006. These data were further applied to a descriptive analysis of opioid users entering drug treatment and hospital-based medical care.ResultsThese data sources identified 126,681 cases of opioid use among New York City residents in 2006. After applying adjustment scenarios to account for potential overlap between data sources, we estimated over 92,000 individual opioid users. By contrast, just 21,600 opioid users initiated drug treatment in 2006. Opioid users represented 4 % of all individuals hospitalized, and over 44,000 hospitalizations during the calendar year.ConclusionsOur findings suggest that innovative approaches are needed to provide adequate services to this sizeable population of opioid users. Given the observed high rates of hospital services utilization, greater integration of drug services into medical settings could be one component of an effective approach to expanding both the scope and reach of health interventions for this population.

A Proposal for Comprehensive and Specific Essential Mental Health and Substance Use Disorder Benefits

This Article analyzes the initial efforts of the Federal Department of Health and Human Services (HHS) to implement the essential mental health and substance use disorder services benefit required by section 1302(b)(1)(E) of the Affordable Care Act (ACA) and proposes the adoption of a comprehensive and specific essential mental health and substance use disorder benefit set. At a minimum, the benefit set should cover medically necessary and evidence-based inpatient and outpatient mental healthcare services, inpatient substance abuse detoxification services, inpatient and outpatient substance abuse rehabilitation services, emergency mental healthcare services, prescription drugs for mental health conditions, participation in psychiatric disease management programs, and community-based mental healthcare services.This Article builds on three previous articles that have proposed reforms of federal and state mental health parity laws and mandatory mental health and substance use disorder benefit laws.

A experiência de cuidar da mulher alcoolista na família

Este estudo tem como objetivo investigar as práticas de cuidados desenvolvidas pela família à mulher alcoolista e conhecer a percepção desta em relação aos cuidados que recebe. Trata-se de um estudo de caso, desenvolvido com uma abordagem qualitativa, cujos dados foram coletados através de entrevistas semi-estruturadas, realizadas em 2008, no domicílio de uma família de classe média, residente em um município no extremo sul do Brasil e, posteriormente, submetidos à análise de conteúdo. Os resultados mostram que os cuidados desenvolvidos pela família são centrados nas necessidades de alimentação, higiene, sono, repouso, encaminhamento aos serviços especializados para a desintoxicação e que a mulher alcoolista interpreta esses esforços como sendo ações de controle sobre sua vida e punição pela sua condição de dependência. Destaca-se que a maneira da família cuidar modifica-se no mesmo compasso em que o alcoolismo evolui.

Physicians in the substance abuse treatment workforce: Understanding their employment within publicly funded treatment organizations

The employment of physicians by substance abuse treatment organizations is understudied, despite physicians' importance in implementing pharmacotherapy and integrating treatment into the broader system of medical care. Drawing on data collected from 249 publicly funded treatment organizations, this study examined organizational and environmental factors associated with the employment of physicians in these settings. A negative binomial regression model indicated that greater numbers of physicians were employed when organizations offered detoxification services, were embedded in health care settings, and were larger in size. Funding barriers, including the costs of physicians and inadequate reimbursement by funders, were negatively associated with physician employment. Programs unaware that they could use state contract funding to pay for medical staff employed fewer numbers of physicians than programs aware of this type of state policy. Attempts to increase physician employment in substance abuse treatment may require attention to both organizational and environmental factors rather than simply trying to attract individuals to the field. Increasing physician employment may be challenging in the current economic climate.

A model for retention and continuity of care and treatment for opioid dependent injection drug users in the Russian Federation

Health and Development Foundation has worked collaboratively with the Government of the Russian Federation to develop and implement a model program of retention and continuity of care for opioid dependence and HIV infection. The model utilizes the Narcology Detoxification Service, State AIDS Centers, Non Government Organization (NGO) managed narcology treatment and rehabilitation centers, NGO outreach programs and the community. The model program was developed and implemented as a pilot demonstration project to provide essential health services to injection drug users and retain them in care. The interventions developed and implemented comprised HIV Testing and Counseling, HIV/AIDS Narcology Post-Graduate Curriculum, Peer Support Groups (Buffer groups), Narcological Follow-up Phone Monitoring, Women’s Narcological Services and Short Messaging Services for Injection Drug Users. These services and interventions promoted the integration and utilization of HIV/AIDS health services and narcological services to form an evidence-based health service delivery model providing essential services to people who inject drugs and people living with HIV/AIDS in the Russian Federation.

Experiences of home detoxification for alcohol dependency

To identify the experiences of service users, family members and staff involved with a community alcohol service that provided home detoxification and psychosocial support. Semi-structured interviews were conducted with service users, family members and staff (n=35). Comment sheets were sent to all service users and 22 were returned. Data were analysed using thematic analysis. Participants were positive about the detoxification service and particularly valued the therapeutic relationship with nursing staff. Service users also valued the availability of psychosocial services. Contradictory views from service users and staff were identified regarding some aspects of the service. Service users were very satisfied with the community alcohol service and valued the support offered by nurses.

Factors Associated with Frequent Utilization of Crisis Substance Use Detoxification Services

ABSTRACT Previous research suggests that some substance users have multiple crisis detoxification visits and never access rehabilitation care. This care-seeking pattern leads to poorer outcomes and higher costs. The authors aimed to identify predictors of repeat detoxification visits by analyzing state-level data routinely collected at the time of substances use services admission. Repeat detoxification clients were more likely to be homeless, city-dwelling fee-for-service Medicaid recipients. Repeat detoxification clients were less likely than those with one admission to enter rehabilitation within 3 days. Treatment providers should aim for rapid transfer to rehabilitation and consider expanding detoxification intake data to improve risk stratification.

Impact of a Housing First Program on Health Utilization Outcomes Among Chronically Homeless Persons

The authors examined the impact of a Housing First program on the use of specific health services, detoxification services, and criminal activity of long-term homeless individuals. The study sample consisted of eligible members of the inception cohort (18 enrollees) in the Single Adults Residential Assistance program (SARA) in Minneapolis, Minnesota. Analyses examined participant housing stability after enrollment in SARA and compared the use of a county medical center, detoxification programs, and criminal activity in the 2 years before and after enrollment in SARA. Only 1 of the 18 enrollees studied experienced homelessness during the 2-year follow-up after enrollment in SARA. There was a significant reduction in the amount of criminal activity in the 2-year period after SARA enrollment. The direction of association observed for other service uses remained consistent with expectations in existing literature, but were not statistically significant. Supportive housing for chronically homeless individuals may be successful at decreasing homelessness among this fragile population and may help reduce criminal activity.

The perceived challenges facing alcohol treatment services in England: A qualitative study of service providers

Background: Although there is currently a high level of need for alcohol treatment in the United Kingdom, there has been a lack of research into alcohol treatment to date. This study reports on what the current challenges to alcohol treatment services in England are, what resources might help to improve services, and which groups are poorly served by alcohol treatment services, as perceived by service providers.Methods: Qualitative data was obtained in three open-ended questions from a sample of 207 alcohol treatment agencies that responded to the national alcohol needs assessment postal survey.Results: Lack of funding, a general lack of resources to provide services, inadequate access to detoxification and rehabilitation services, and a lack of trained staff to deliver services were key challenges presented. More staff, improved access to detoxification and rehabilitation services, better premises, more funding allocation, improved links with other services, and better resources in general to provide services were the key factors reported to improve services. Clients with complex needs (e.g., dual diagnosis, brain damage), women with children, homeless people, and ethnic minorities were perceived to be poorly served by alcohol treatment services.Conclusions: Alcohol treatment services in England face many challenges which should be incorporated into future alcohol treatment service development.

Closing the Gaps: The Impact of Inpatient Detoxification and Continuity of Care on Client Outcomes

Inpatient detoxification is a critical element of the continuum of care for chemically dependent individuals, especially for those unable to establish sobriety on an outpatient basis. This study evaluated the impact of one such detoxification program on client outcomes during the year after detoxification. The program was a public/private partnership between Ventura County, California, and Tarzana Treatment Center in Los Angeles. Before admission, applicants agreed to enroll in treatment after detoxification. Clients were contacted at one month post-admission and quarterly thereafter for one year to collect data, corroborated by county records, on treatment and outcome variables. The sample included 117 consecutive admissions between July 2007 and June 2009. Detoxification completion rates and follow-up treatment enrollment rates were substantial: 85% of the sample completed detoxification; 71% enrolled in treatment afterward. Client outcomes were positive, particularly for those enrolled in followup treatment: compared to clients not completing detoxification, and to client functioning in the year before admission, sobriety and employment rates increased, and rates of homelessness, arrests and days incarcerated decreased. The study concludes that public investment in inpatient detoxification services and aftercare is an effective means to decrease both individual and societal costs of addiction.

158: Social Worker Intervention for Detoxification Referral and Rate of Recurrence of Acute Alcohol- Intoxicated Patients Presenting to the Emergency Department

Recurrent emergency department (ED) visits for acute alcohol intoxication are common requiring utilization of various resources. In the ED at our institution, social worker intervention (SWI) provides referral for outpatient detoxification (detox) services. This study was conducted to determine the rate of recurrence of acute alcohol intoxicated (AAI) patient visits presenting to the emergency department and to evaluate the success of SWI for an outpatient detox program referral and treatment. We used an observational retrospective cohort design in the setting of an inner city teaching hospital to study AAI patients visiting the ED from June 2008 to May 2009. Patients were included if they were over 18 years, had Medicaid insurance, a primary ED diagnosis related to AAI and were not hospitalized. We reviewed the records to determine the following: age, sex, total number of alcohol related visits, if the patient received a SWI and whether or not the patient went to a detox program. For purposes of this study, 2 or more ED visits for an AAI was considered a recurrence and 4 or more visits to the ED for AAI was considered chronic recurrence. A total of 40 patients were identified. The mean age of the population studied was 46.35 years (95%CI 43.51 - 49.19). 30/40 (75%) were male and 10/40 (25%) were female. There was a total number of 265 ED visits. The mean number of visits was 6.98 (95%CI 3.72 - 10.23). Recurrent visits of 2 or more was seen in 28/40 (70%) patients. Chronic recurrence of 4 or more visits was seen in 16/40 (40%) patients. SWI was received on 201/265 visits (75.8%) and on the rest of the visits 64/265 (24.2%) the patient either refused SWI or left before SWI. On the majority of visits 240/265 (90.6%) patients did not go to detox treatment. Detox was obtained on 21/265 (7.9%) visits and unknown in 4/265 (1.5%) visits. A multilinear regression analysis was used to compare those visits where detox was obtained and SWI and no correlation was found. (p = 0.47) In addition, there was no correlation found when comparing went to detox with respect to age (p = 0.58), sex (p = 0.63) and total number of AAI patient ED visits (p = 0.76). The mean number of visits of AAI patients was just about 7 per year. In addition, recurrence is an issue with 2 or more ED visits for AAI being seen in 70% of patients and chronic recurrence being indicated in 40% of patients who had 4 or more ED visits for AAI. More importantly, in this study, since no correlation was shown between SWI and detox, SWI alone was not effective for ensuring that AAI patients receive outpatient detox treatment. This warrants continued further investigation on ways to better utilize ED resources as well as social services for these AAI patients to facilitate improved compliance with going to an outpatient detox program.

Maze and minefield — a grounded theory of opiate self‐detoxification in rural Ireland

Opiate use is no longer confined to the greater urban context in Ireland, with scant detoxification services present in rural areas (Carew et al, 2009; National Advisory Committee on Drugs, 2008). This exploratory research aimed to yield an illustrative account of opiate users' experiences of self‐detoxification by adopting a grounded theory approach (Glaser & Strauss, 1967). Data emerging from 21 in‐depth interviews (n=12 heroin users, n=9 drug service providers: statutory, community and voluntary) were analysed using the constant comparative method. The study generated a substantive theory of self‐detoxification as a subjective process of seeking heroin abstinence. Self‐detoxification emerged as a frequent and reactive or proactive process in collaboration with others (heroin users, family and drug service providers). The study has implications for drug service delivery in rural Ireland in terms of increasing information provision and access to opiate detoxification through the development of low threshold services and community‐based detoxification.

P01-164 - Volatile inhalant dependence and intoxication among a sample of Egyptian street children

One hundred Subject attending drop out units for street children were investigated using: (1) Short interview sheet for street children,(2) Inhalant Dependence and Intoxication Checklist for Street children,(3) Inhalant Dependence and Intoxication diagnostic criteria DSM IV (Diagnostic and Statistical Manual for Mental Disorders-4th edition) (4) urine screen for hippuric acid. The study aims at identification of common manifestations of volatile inhalants (glue, fuel, and thinner) dependence and intoxication among a sample of Egyptian street children. Research subjects were using volatile inhalants (100%) with variable amounts and sometimes in combination with other substances such as: Nicotine and Hashish (25%) and oral drugs (cough sedatives) (15%). According to DSM IV criteria, inhalant dependence and intoxication were reported among all research subjects. Dizziness, in-coordination, lethargy, slurred speech, tremors, blurred vision and euphoria were the commonly reported signs of intoxication. Street children diagnosed as intoxicated were vulnerable to many disadvantages. They are using inhalants despite their knowledge of its harmful effects on physical and psychological wellbeing. There is a great need to develop integrated rehabilitation medical services directed towards such vulnerable individuals especially detection, detoxification and mental health services.

Buprenorphine adoption in the National Drug Abuse Treatment Clinical Trials Network

The National Drug Abuse Treatment Clinical Trials Network (CTN), a collaborative federal research initiative that brings together universities and community-based treatment programs (CTPs), has conducted multiple clinical trials of buprenorphine for opioid dependence. Part of the CTN's mission is to promote the adoption of evidence-based treatment technologies. Drawing on a data collected during face-to-face interviews with administrators from a panel of 206 CTPs, this research examines the adoption of buprenorphine over a 2-year period. These data indicated that the adoption of buprenorphine doubled between the baseline and 24-month follow-up interviews. Involvement in a buprenorphine protocol continued to be a strong predictor of adoption at the 2-year follow-up, although adoption of buprenorphine tripled among those CTPs without buprenorphine-specific protocol experience. For-profit CTPs and those offering inpatient detoxification services were more likely to adopt buprenorphine over time. A small percentage of programs discontinued using buprenorphine. These findings point to the dynamic nature of service delivery in community-based addiction treatment and the continued need for longitudinal studies of organizational change.

Organizational-level correlates of the provision of detoxification services and medication-based treatments for substance abuse in correctional institutions

In recent years, there has been an increased examination of organizational-level innovation adoption in substance abuse treatment organizations. However, the majority of these studies have focused on community-based treatment centers. One understudied area of the substance abuse treatment system is correctional institutions. This study uses the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative's National Criminal Justice Treatment Practices (NCJTP) survey to examine the adoption of detoxification services and pharmacotherapies for the treatment of substance abuse across a nationally representative sample of correctional institutions ( n = 198). There were significant differences between jails and prisons in the percentage of organizations offering detoxification services and medications. Specifically, detoxification services were offered by 5% of prisons and 34% of jails; and, medications were offered by 6% of prisons and 32% of jails. Binary logistic regression models were used to examine the associations between these services and organizational characteristics, including context, resources, previously introduced practices, culture, and systems integration. Variables measuring organizational context and previously introduced practices were significant correlates of the provision of both detoxification services and medications. Multivariate results indicated that the differences between jails and prisons remained significant after controlling for other organizational factors. Although the adoption of detoxification services and pharmacotherapies may be a controversial topic for correctional institutions, these services have the potential to improve offender well-being and reduce public health risks associated with substance abuse.

Harm Reduction: Keeping the Public’s Health in Sight

The article by Harvard et al. (in this issue of the Journal) on the distribution of harm reduction products in British Columbia provides an opportunity to revisit the recent controversy surrounding Insite, the Vancouver safe injection facility. Started in 2003, Insite is North America’s first legal supervised injection site. Funded by the BC Ministry of Health and operated by Vancouver Coastal Health in partnership with Portland Hotel Society Community services, Insite is one of this country’s important public health successes. Each year, over a quarter of a million visits are registered by over 10,000 individuals for clean and medically supervised drug injection. Insite targets marginalized populations and decreases needle sharing, prevents mortality from overdose, decreases harmful drug-related behaviours and offers both primary health care and addiction counseling and treatment to its clients. In particular, because HIV and hepatitis C infections are endemic among IV drug users (18% and 87%, respectively, of Insite clients), decreasing the risk of transmission is a public health no-brainer. However, the public’s health is at risk of being overtaken by opposition to Insite voiced at the Canadian Medical Association meeting in Montreal last August by the then federal Minister of Health. Although the BC Supreme Court recently extended Insite’s exception to the Controlled Drugs and Substances Act, this decision is being appealed by the federal government which has stated that it would like to see Insite closed. There is strong and consistent evidence that harm reduction strategies have substantial benefits for the health of high-risk, marginalized and hard-to-reach populations. In particular, several independent scientific evaluations by the BC Centre for Excellence in HIV/AIDS have shown not only that Insite has had an important public health impact since its opening, but also that the feared potential increase in crime rates, drug abuse and drug dealing in the community failed to materialize. 1 Quite to the contrary, there was a 30% increase in detoxification service use among Insite clients and no change in drug-related crimes was reported by the police after introduction of the facility. Decision makers sometimes assert that research results are not informative enough to support policy making. In this case, there are ample research results, as well as local community endorsement, in support of a clear-cut, evidence-based policy. Public health must speak loudly and of one voice in support of Insite and for extending this effective intervention model to other high-risk areas in Canada.

Substance Abuse Treatment Outcomes: A Comparison of Medicaid- and Non-Medicaid-Funded Adolescents

ABSTRACT The state of Missouri provides detoxification, residential and outpatient services to substance abusing adolescents through its Comprehensive Substance Abuse Treatment and Rehabilitation (CSTAR) program. This analysis compares Medicaid-funded and non-Medicaid-funded youth in CSTAR at treatment admission, during treatment, and at treatment discharge. Medicaid-funded youth demonstrated a higher risk at pretreatment for substance use and delinquency. Consistent with this higher risk status, they remained in treatment longer and had higher service costs. Both groups demonstrated similar treatment completion rates and abstinence levels at discharge. The findings suggest that longer treatment for the Medicaid group mitigated issues relating to poverty, criminal behavior, and family cohesiveness.