Residential Detoxification Research Articles

Primary medical care and reductions in addiction severity: a prospective cohort study

To assess whether receipt of primary medical care can lead to improved outcomes for adults with addictions. We studied a prospective cohort of adults enrolled in a randomized trial to improve linkage with primary medical care. Subjects at a residential detoxification unit with alcohol, heroin or cocaine as a substance of choice, and no primary medical care were enrolled. Receipt of primary medical care was assessed over 2 years. Outcomes included (1) alcohol severity, (2) drug severity and (3) any substance use. For the 391 subjects, receipt of primary care (> or = 2 visits) was associated with a lower odds of drug use or alcohol intoxication (adjusted odds ratio (AOR) 0.45, 95% confidence interval (CI) 0.29-0.69, 2 d.f. chi(2)P = 0.002). For 248 subjects with alcohol as a substance of choice, alcohol severity was lower in those who received primary care [predicted mean Addiction Severity Index (ASI) alcohol scores for those reporting > or = 2, 1 and 0 visits, respectively, 0.30, 0.26 and 0.34, P = 0.04]. For 300 subjects with heroin or cocaine as a substance of choice, drug severity was lower in those who received primary care (predicted mean ASI drug scores for those reporting > or = 2, 1 and 0 visits, respectively, 0.13, 0.15 and 0.16, P = 0.01). Receipt of primary medical care is associated with improved addiction severity. These results support efforts to link patients with addictions to primary medical care services.

Linkage with primary medical care in a prospective cohort of adults with addictions in inpatient detoxification: room for improvement.

To identify patient characteristics and health care experiences associated with primary care linkage after alcohol or drug detoxification. Primary data collected over two years. Subjects were adults without primary medical care, in an urban residential detoxification program. A prospective cohort study in the context of a randomized trial of a linkage intervention, and an expansion of Medicaid benefits. Data were collected by interview assessment of predisposing, enabling, and illness variables. Linkage was defined as self-report of at least one visit with a primary care clinician during follow-up. Of 400 subjects, 63 percent linked with primary medical care. In a multivariable model adjusting for randomization assignment, predisposing, enabling, and illness variables, women, those with no recent incarceration, those with support for abstinence by family or friends, and those who had visited a medical clinic or physician recently were significantly more likely to link with primary care. Those with health insurance during follow-up were also more likely to link. Recent mental health or addictions treatment utilization and health status were not associated with linkage. A substantial proportion of adults with addictions do not link with primary medical care. These data suggest that efforts could be focused on those least likely to link, that contacts with mental health and addictions treatment providers are underutilized opportunities for these efforts, and that health policy changes such as expanding health insurance benefits may improve entry of substance-dependent patients into primary medical care.

Establishment of a Multidisciplinary Health Evaluation and Linkage to Primary Care (HELP) Clinic in a Detoxification Unit

We evaluated the feasibility of establishing a multidisciplinary Health Evaluation and Linkage to Primary care (HELP) clinic at an urban residential detoxification unit. Patients received a clinical evaluation and facilitated linkage to primary medical care including personalized referral, reminders, and appointment rescheduling. Of 235 adults reporting alcohol, cocaine or heroin as first or second drug of choice and without a primary care physician, 178 (76%) received a full HELP clinic evaluation, 35 (15%) some clinic components, and 7 (3%) only a primary care appointment. Of those with a full evaluation, 28% received pneumococcal vaccination, and most received health behavior counseling. Over the subsequent 2 years, 131 (60%) of the 220 patients whom had any contact with the HELP clinic had at least one primary care visit. A multidisciplinary health clinic to evaluate patients during detoxification is feasible and can link patients with substance dependence to primary medical care.

Screening for sexually transmitted infections in substance abuse treatment programs

Objectives: We evaluated the prevalence of the sexually transmitted infections (STIs) chlamydia and gonorrhea in clients at a methadone maintenance program and a residential detoxification program. Methods: We collected urine specimens for chlamydia and gonorrhea ligase chain reaction testing and assessed sexual, substance abuse and STI histories. Results: Of 700 subject assessments, 490 occurred among detoxification clients and 210 in methadone maintenance. Chlamydia trachomatis was detected in 5/700 (0.9, 95% CI=0.1–1.8%) and Neisseria gonorrhoeae in none. All chlamydia infected subjects were recruited from the detoxification program. Subjects reported high risk sexual behavior: 17% reported commercial sex exchange, and 22% reported inconsistent condom use with multiple sexual partners during the prior 2 months. Conclusion: Based on prevalence in Boston, MA, universal screening for STI in substance abuse treatments programs is not warranted. However, routine screening for younger substance abusers and in communities with high prevalence should be considered.

Datapoints: Medicaid Managed Care and Substance Abuse Treatment

Conversion of Medicaid substance abuse treatment to managed care has raised concerns about access. However, several states have expanded Medicaid eligibility criteria at the same time. Proponents argue that increasing Medicaid enrollment will ease access to treatment for previously uninsured individuals. It is also possible, however, that Medicaid expansion represents cost shifting from state to federal payers. If so, there would likely be no net increase in publicly funded substance abuse treatment admissions after Medicaid expansion. Another concern is “cream skimming”—giving treatment preferentially to clients whose illness is less severe. Thus the average severity of illness of those treated would decrease after conversion to managed care. Data to test these hypotheses were obtained from a Medicaid demonstration project in Oregon. Data elements from the Oregon Client Process Monitoring System were combined to generate a severity index. In a prospective study, the severity measure was found to be highly correlated with clinicians’ ratings of clients according to the placement criteria of the American Society of Addiction Medicine and with Addiction Severity Index ratings obtained via client interviews. Figure 1 plots the number of adult clients admitted for the three years before substance abuse treatment was integrated into Medicaid managed care in 1995 and the five years afterward. Medicaid admissions started to increase before the integration of substance abuse treatment because eligibility was expanded in 1994 under a federal Section 1115 waiver. After a modest initial reduction in the number of uninsured clients, the total number of publicly funded clients increased dramatically, primarily as a result of expanded Medicaid eligibility. Figure 2 plots the average severity

Beneath the surface: collaboration in alcohol and other drug treatment. An analysis using Foucault’s three modes of objectification

This study investigated the perceptions of alcohol and other drug (AOD) clinicians and consumers regarding the concepts of collaboration and empowerment. Working collaboratively is seen as a cornerstone of empowerment, a concept used extensively over the last decade in an attempt to isolate power and control issues. It is generally assumed that health professionals strive to achieve collaboration, but little research has been undertaken. The study was carried out in a variety of AOD treatment facilities in a large regional city in Australia. Facilities included an inpatient detoxification unit, an outpatients' clinic, a methadone maintenance clinic, a residential detoxification and rehabilitation unit using a 12-step treatment model and a residential unit using cognitive behavioural therapy (CBT). The nonprobability sample consisted of 57 staff and consumers who were interviewed using a semi-structured format. Data were analysed thematically using a Foucauldian analysis of discourse. Findings suggest that clinicians may be unwittingly imposing their beliefs and prejudices on consumers and in fact disempowering the very people they want to empower. Collaboration is not happening. Foucault's theory of objectification illuminates the processes involved. There is much more happening than originally thought between consumers and staff when Foucault's three modes of objectification are used to examine this practice area. Analysing discourse enables us to see how health workers interact with consumers and the effect this may have on treatment objectives, outcomes and self-esteem. It also illuminates the work environment where the therapeutic encounter takes place. The need for further effort in empowering both consumers and staff and working collaboratively becomes evident.

Mortality 5 years after detoxification and counseling as indicated by psychometric tests

Residential detoxification of substance abusers, using medication to alleviate withdrawal symptoms, often fails to ensure further abstention and predict which clients have the greatest risk of morbidity after detoxification. Prolonging the detoxification period with a counseling period has been shown to enhance compliance to counseling. Sixty‐one (61) substance abusers (mean age: 31.3 years; 22 women) with a mean length of abuse of 16 years in 1993–1994 were tested using two psychometric tests and then followed up in 1999 according to mortality. Mean value on Antonovsky's Sense of Coherence (SOC) scale was 2.98 and on Hopkins Symptom Checklist (HSCL‐24) was 2.06, indicating postdetoxification coping problems and distress. Thirteen (13) abusers died during follow‐up. Cox regression of mortality showed increased risk in men, and also an increased risk of dying in the observation period with lower SOC scoe (p < .01), but not with increasing HSCL‐24 score: Logistic regression indicated a 3.6 times higher risk of dying in the observation period if the SOC score was 1 point lower (on a scale range from 1 to 5). An increased mortality in drug addicts leaving the facility with an SOC value below 3.00 after a 4‐week detoxification and counseling stay is thus strongly supported by the data. Antonovsky ‘s SOC scale thus seems to be a good indicator of future mortality.

Effectiveness of Inpatient Drug Detoxification: Links between Process and Outcome Variables

The Psychiatric University Hospital of Zürich offers a 2-week residential detoxification treatment program for patients abusing illegal drugs. 96 out of 160 patients were interviewed at three intervals: upon admission, on the 10th day of treatment, and about 1 month after leaving the clinic. Approximately 17% of the patients were completely abstinent 1 month after treatment. About 50% of the patients could give up the consumption of particular drugs. For around one third of the dependents, the drug consumption remained the same or had increased. The analysis of the predictors of drug consumption after treatment stresses the importance of the social integration of the dependents before detoxification as well as of characteristics of the treatment process (relapse, dropping out of treatment, and referral to a follow-up program).

Antibodies to hepatitis B virus and hepatitis C virus in residential detoxification clients in Jamaica

The role of non-injecting drug abuse in viral hepatitis has not been studied widely and is not well understood. A total of 301 substance abusers, residents of a detoxification/rehabilitation unit, were investigated for exposure to hepatitis B virus (HBV) and hepatitis C virus (HCV). Samples of serum were tested for anti-HCV and anti-HBc antibodies and HBsAg. All of the patients were non-injecting drug users (non-IDUs). The prevalence of anti-HCV was 1.7%; anti-HBc was found in 28.7% and HbsAg in 0.6% of patients. Anti-HCV positivity correlated with the presence of elevated aminotransferases (80%). Exposure to HBV correlated significantly with gender (p < 0.05); age (p < 0.05); and duration of substance abuse (p < 0.05). No significant correlations were found between HCV and/or HBV infection, the drug of abuse, HIV, HTLV-1 or syphilitic infection. Residential detoxification/rehabilitation provides an opportune moment to identify and treat HCV positive substance abusers in the attempt to avert the severe hepatic sequelae. Measures which exclude substance abusers from volunteer blood donation should be considered.

The value of acupuncture detoxification programs in a substance abuse treatment system.

Our purpose is to compare baseline characteristics and detoxification readmission rates of clients treated at outpatient acupuncture programs and at short-term residential programs, two options available to persons seeking substance abuse detoxification. This was a retrospective cohort study using data on clients discharged from publicly funded detoxification programs in Boston between January 1993 and September 1994. Multivariate models were used to examine the effect on 6-month detoxification readmission rates of treatment at residential detoxification programs (used by 6,907 clients) versus at outpatient acupuncture programs (used by 1,104 clients) after adjusting for baseline differences. Acupuncture clients were less likely to be readmitted for detoxification within 6 months (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.53-0.95). Similar results were found when the analysis was performed on a subsample of clients that were relatively similar in terms of baseline characteristics (OR 0.61, 95% CI 0.39-0.94). We determined that acupuncture detoxification programs are a useful component of a substance abuse treatment system.

Contingent reinforcement sustains post-detoxification abstinence from multiple drugs: A preliminary study with methadone patients

This study examined the efficacy of a urinalysis-based contingency management program for preventing relapse to abused drugs following a brief residential detoxification. Fourteen methadone maintenance patients who were chronic benzodiazepine users were enrolled in a 7-day inpatient benzodiazepine detoxification and randomly assigned to receive Contingency Management (N=7) or Standard Care (N=7) therapy upon return to outpatient methadone treatment. In the Contingency Management condition, a methadone take-home dose or a US $25 voucher (patient's choice) could be earned for each urine sample submitted on a Monday, Wednesday or Friday that was free of opiates, cocaine and benzodiazepines. Data analysis and interpretation focused on within-group post-hoc differences due to group differences on employment and legal status, potentially confounding baseline variables. Repeated measures analysis of variance showed that Contingency Management patients submitted significantly more drug-free urine samples during the intervention compared to pre-detoxification (p<0.01), whereas no significance changes were observed from pre- to post-detoxification in the Standard Care patients. Employment and legal status of patients may have facilitated response to contingency management procedures, but did not prevent relapse when contingency management procedures were withdrawn. Overall, these preliminary results suggest that abstinence-based contingency management is a promising strategy for preventing relapse to multiple drugs of abuse in a subset of methadone maintenance patients when abstinence has been initiated through brief inpatient treatment.

Residential detoxification for substance abusers with HIV/AIDS. Walden House Detoxification Program.

Substance abusers with HIV/AIDS have a complex array of problems that are not easily addressed in outpatient or long-term residential programs. A new but promising treatment modality is residential detoxification for substance abusers with HIV/AIDS, such as described by this paper. The purpose of the program is profiled, as well as its general components and the aspects that address the special needs of HIV clients. Data indicating the successes and limitations of the program are presented, along with recommendations for further addressing the needs of substance abuses with HIV/AIDS.

Evaluation of a linked service model of care for HIV-positive, homeless, and at-risk youths.

Two instruments were used to evaluate an agency's type and availability of services for HIV-positive and at-risk adolescents, and to assess opinions concerning healthcare referral patterns. These instruments were administered to representatives of 22 agencies from 10 categories of healthcare services. Nonmetric multidimensional scaling was used to model ratings of interagency knowledge, referral patterns, and general satisfaction with services. We found that no agencies offered youth services for inpatient adolescent-specific mental health treatment or short-term residential drug treatment; however, few offered long-term residential substance abuse detoxification services (5%), outpatient drug maintenance (5%), HIV-specific inpatient services (9%), intensive day treatment for substance abusers (9%), HIV home care (14%), HIV hospice care (14%), inpatient medical services (14%), short-term shelters (14%), long-term housing (18%), HIV-specific clinical trials (18%), and dental services (23%). Barriers to expanding care included lack of funding, transportation, and lack of awareness among youths about services. A multidimensional scaling analysis identified a tight service cluster of two community health centers and the largest public hospital serving poor communities of color, as well as a relatively tight cluster of three service agencies located on the Boston Common serving homeless youths. A third service cluster consisted of two university-affiliated medical centers and one community health center. In conclusion, we found that many critical services for HIV-positive youths are relatively scarce. Multidimensional scaling provides a visual presentation of the relationships of network sites. This evaluation of services indicates a need for increased, accessible youth-oriented HIV services and suggests that linkages across the three distinct clusters of service providers should be solidified. These methodologies can be used to develop a generic model describing the stages of linkage formation in HIV care service networks.

Completers from a detoxification unit: Some cost‐benefit considerations after using psychometric tests

Completion of residential treatment has been taken to imply an improvement in prognosis toward rehabilitation and a life without drug abuse. On a sample of 61 consecutive clients in a detoxification and counseling unit, Antonovsky's Sense of Coherence test (SOC) and Hopkins Symptom Checklist (HSCL) were administered to detoxified clients in the second week of a 4‐week residential stay in order to indicate noncompletion. Eighteen clients (29.5%) did not complete their stay, and 17 of them had abnormal scores on the SOC and 12 on the HSCL scale, respectively. No attempt was made to use the information from the tests to influence completion rate. Increased emphasis on revealing the preferences of the clients toward values in life based on test results purportedly reduces noncompletion. The benefit to public budgets of using such information to prevent defection was calculated for three areas of interest: imputed reduction of future residential detoxification, reduction of future treatment sessions, and increase in taxable income from rehabilitated drug addicts. The total benefit per client was NKR19 000 (£1900, $2920) and NKR69 000 per noncompleter. High‐cost detoxification units would also benefit from reduction of noncompletion.

The Smithfield Project: a comprehensive service for dependent drinkers

This paper describes the components of the Smithfield Project in Manchester, UK. The project provides a comprehensive service for people who experience severe problems with alcohol through combining health and social care interventions. The paper describes the three key elements of the scheme: a 22-bed direct access residential detoxification service, a day centre and two short-stay hostels. A profile of the client group and their use of the project is also provided.

A comparison of residential heroin detoxification patients and methadone maintenance patients

Interviews were conducted with 101 heroin dependent persons entering a residential drug-free detoxification unit in 1989. These self-report data were compared with those previously collected in 1985-6 from 457 methadone maintenance patients. The detoxification patients injected less frequently, used less heroin, had been physically dependent for a shorter period and were more likely to be single, unemployed and to have been charged with a criminal offence in the last 12 months. It is suggested that these findings may indicate that addicts who use more heroin are less likely to seek drug-free detoxification. The wider implication of the finding is that future surveys of injecting drug users should assume that there are significant differences between heroin users entering different modalities of treatment.

Community psychology, drug use, and AIDS

Intravenous drug users may hold the key to the future epidemic of AIDS in the United States. Although gay men have changed their social norms to lower the risk of AIDS, such change will be more difficult to bring about in drug users. Several intervention efforts have been developed and are being evaluated. The psychoeducational workshops developed by the authors have shown promise in random-assignment trials with drug abusers in residential treatment, methadone maintenance, and outpatient detoxification. By orientation and training, community psychologists are uniquely qualified to develop, evaluate, and disseminate AIDS prevention programs to change community norms among drug users.

Immune response to hepatitis B vaccine in drug addicts

Drug addicts are at high risk of hepatitis B infection and are therefore candidates for vaccination against hepatitis B. Since drug addicts may have an impaired immune response, and low compliance for therapy extending over several months, we evaluated a vaccination scheme according to the instruction of the manufacturer (HB- Vax 20 micrograms at zero, one and six months) in drug addicts using daily methadone (Group M), in drug addicts in residential detoxification programmes (Group D), and in treatment centre staff who were seronegative for hepatitis Bs (Group S). All 23 controls and 20 of 21 of Group D completed the vaccination programme, in contrast to 14 of 24 in Group M. Anti-HBs developed in 91 per cent of Group S and in all addicts tested at six months. Anti-HBs titres at seven months were higher than 100 RIA units in 55 per cent of Group S, in 94 per cent of Group D and in 44 per cent of Group M. We conclude that HB- Vax induces production of anti-HBs equally well in drug addicts and in controls: a shorter-duration vaccination schedule might be more appropriate for 'non-captive' drug addicts living outside therapeutic communities.