Lansdowne Clinic, 3 Whittingehame Gardens, Glasgow G12 0AA,
1 Alcohol Problems Treatment Unit, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow G12 0YN and
2 Community Alcohol Service, Goldenhill Resource Centre, 2 Stewart Drive, Clydebank G81 6AH, UK
Received 8 April 1999; in revised form 9 May 1999; accepted 24 May 1999
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ABSTRACT |
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INTRODUCTION |
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In a recent review, Fleeman (1997) concluded that home detoxification is only likely to be a suitable setting for those with mild to moderate withdrawal symptoms, strong social support, and no medical or psychiatric complications. This project seeks to complement and extend these boundaries by including a more representative sample of the type of patients who usually attend routine alcohol services, many of whom have poor social support, are severely dependent and have complex alcohol-related difficulties (Allan, 1991).
It is important to be clear that this research does not constitute a controlled trial of home vs day hospital detoxification, but aims to look at the following issues: (1) the type of patients selected for home detoxification compared to those who attend a hospital day unit; (2) the safety and efficacy of both detoxification procedures during the first 10 days of treatment; (3) client satisfaction with each service; (4) involvement in further treatment once detoxification has been completed; (5) outcome at 60 days.
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SUBJECTS AND METHODS |
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GPs were contacted by letter telling them about the home detoxification service and the criteria for referring patients. They were also reminded that the new service was an adjunct to the usual day patient or in-patient services, which were still available to them. Patients were seen on the day of referral, or the next day if this was not achievable. The GP carried out a physical examination and prescribed medication which was chlordiazepoxide. This was commenced in a dose range between 30 and 100 mg in a day depending on the patient's needs and tailed off over a 710-day period. During detoxification, the patient was visited by a specialist community psychiatric nurse (CPN) on a daily basis to monitor withdrawal symptoms using a standard scale (Gross et al., 1973) and to advise on use of medication. Patients were breathalysed daily and persistent failure to remain abstinent resulted in the termination of treatment. Support for patients and carers was considered very important and treatment planning was discussed at various points during detoxification.
For purposes of comparison, a consecutive series of 36 patients referred to the APTU were recruited. Similar inclusion and exclusion criteria applied, except the day hospital doctor took medical responsibility. Patients had the support of a key worker (who was usually a psychiatric nurse) and received a reducing dose of chlordiazepoxide on the same basis as the home group during withdrawal. Patients were breathalysed on a daily basis and failure to remain abstinent resulted in exclusion. Key workers helped to plan further treatment and were willing to see and advise carers and relatives. There were generally between six to 15 other patients detoxifying at the same time forming a peer group for patients.
Follow-up interviews took place at 10 and 60 days after the start of detoxification and were carried out by a research assistant not involved in the delivery of treatment. This consisted of a standardized interview, which examined past and recent alcohol use and also contact with treatment services (Allan, 1991). Patients also completed a number of self-report questionnaires; the Severity of Alcohol Dependence Questionnaire (SADQ) (Stockwell et al., 1983
), the Alcohol Problems Questionnaire (APQ) (Drummond, 1990
), a measure of social disruption (Smart, 1979
), and the Treatment Satisfaction Scale, which examined patient satisfaction with different aspects of the respective detoxification packages (Stockwell et al., 1990
). A maximum score of 8 indicated complete satisfaction. The criteria for successful completion of detoxification were as follows: the patient had become abstinent, there had been a major reduction in withdrawal symptoms, and that detoxification took place within the original treatment setting.
At 60 days, the following outcome categories were used: good indicated complete abstinence from alcohol or drinking less than 8 U/week and no return to alcohol-related problems reported by direct interview with the patient and confirmed by breathalyser and an independent source (a relative, or, if none available, referral agent or treatment staff). A UK unit is equivalent to a glass of wine, or a public bar measure of spirits, or 0.5 pint of beer. Each unit contains approximately 1 cl/7.9 g of absolute alcohol. Improved indicated that if drinking had occurred, this did not exceed 21 U/week, dependence was not reinstated and the APQ was zero. The final category was unimproved and contained patients drinking in excess of 21 U/week or who were once more physically dependent and reporting alcohol-related problems.
Repeated efforts were made to contact patients personally, but, in the event of failure to do this, outcome was examined by consulting referral agents, treatment staff, and carers who were in touch with particular patients. Because of a lack of rigour in this, a conservative approach was taken and patients were allocated in the following manner. Those reported to be abstinent were assigned to the improved category. Patients who were reported to have resumed drinking were allocated to the unimproved category.
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RESULTS |
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In the day hospital sample, detoxification took place over an 8-day period and 28 patients (78%) completed detoxification. This group had a higher mean score in terms of withdrawal symptoms of 13.2 (± 4.7 SD), but the difference did not reach statistical significance. No further data were available for withdrawal symptoms as data were not routinely kept by ward staff. Two patients had episodes of visual hallucinations and one had a withdrawal seizure, giving altogether a rate of 8% for complications. In neither group were patients involved in an episode of self-harm, nor was it necessary for them to be transferred to in-patient care.
Satisfaction with treatment
Treatment Satisfaction Scales were completed by 21 of the home detoxification group and 30 of the day hospital group at the 10-day follow-up interview, and by 19 and 20 patients respectively at the 60-day follow-up. Seven out of the nine scales achieved significant testretest reliability coefficients (Spearman's = 0.37 to 0.68, P < 0.03, n = 39). Only items shown to be reliable have been presented, and the data for the 10-day point are given in Table 4
. For the home detoxification group, key elements including individual support from the CPN, support for carers and help to stay in the home environment were rated highly, as were support from the GP and the drugs prescribed. Overall satisfaction with the service was high. The day hospital detoxification group rated key worker support and the ward environment most highly. Overall satisfaction with the service was also relatively high.
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Outcome at 60 days
Nineteen (65%) of home detoxification patients were successfully re-interviewed. Thirteen patients fulfilled criteria for a good outcome and the remaining six patients reported a return to problem drinking and were therefore allocated to the unimproved group. Of those not contacted directly, five were reported abstinent and without alcohol-related problems by referral agents and treatment staff, and were therefore allocated to the improved category. A further two patients were categorized as unimproved, and no information was available for the remaining three patients. Taking the group as a whole, 45% of patients were categorized as having had a good outcome (Table 5).
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The relationships between treatment and outcome were calculated by amalgamating the good and improved groups together providing a dichotomous outcome category of improved and not improved. Patients who had attended for treatment after the conclusion of detoxification had significantly superior outcomes (Fisher's Exact Test, P < 0.03; 2 x 2 contingency tables).
A direct comparison with the period immediately prior to detoxification for subjects successfully interviewed at follow-up showed significant changes using paired t-tests (Table 6). There were significant reductions in weekly alcohol consumption, maximum daily consumption, SADQ, and APQ scores for both the home and hospital groups.
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DISCUSSION |
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Approximately half of the patients in both groups became involved in further treatment and this was associated with improved outcome at 60 days. Achieving a more sustained period of abstinence was much more difficult, as the outcome at 60 days indicated. By this point, 45% of the home group and 31% of the day hospital group were showing a good outcome. When considering longer-term outcome, there is little value in direct comparisons with other studies, because of differing selection criteria, length of follow-up, type of treatment received, and measures of treatment outcome. However, the general indications are that, given the initial levels of treatment severity, outcome is similar to that reported for comparable studies (Stockwell et al., 1990; Bennie, 1998
).
In the past, researchers have adopted a conservative approach, particularly towards patients selected for out-patient detoxification, and, in particular, home detoxification. Patients typically have had histories of problem-free withdrawal, low levels of physical dependence and a carer willing to assist in detoxification. This in some ways has produced a paradoxical situation, as they require only minimal or even no help to detoxify. One of the original aims of this research was to examine the feasibility of treating a more severe group of drinkers than the target group described by Fleeman (1997), which is closer to current clinical practice (Stockwell et al., 1986). Our findings indicate that this has been achieved and that GPs were willing to refer more impaired and dependent drinkers. However, it should be noted that there are indications that the hospital sample contained a very severe group with very high rates of dependence, alcohol-related problems, and social instability.
Caution must be exercised in interpreting the results from this study, because of the small numbers involved. However, there is now a growing body of evidence from this and other work that a wider range of patients can be safely and effectively detoxified outside an in-patient setting (Fleeman, 1997). What is lacking is a set of empirically based guidelines to aid decision-making about matching patients to particular types of detoxification services. In the absence of this, an unsystematic stepped care or treatment tiering approach is in operation, which is governed as much by the availability of resources as rational treatment planning (Breslin et al., 1997
). An integrated service involving community links and hospital-based services may be a cost-effective and efficient way of dealing with a range of problems. Clearly there will still remain patients who will require in-patient care and who cannot be safely withdrawn from alcohol outside such a setting. The challenge is then to define the characteristics of these respective groups.
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ACKNOWLEDGEMENTS |
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FOOTNOTES |
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REFERENCES |
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Bennie, C. (1998) A comparison of home detoxification and minimal intervention strategies for problem drinkers. Alcohol and Alcoholism 33, 157163.[Abstract]
Breslin, C. F., Sobell, M. B., Sobell, L. C., Buchan, G. and Cunningham, J. A. (1997) Towards a stepped care approach to treating problem drinkers: the predictive utility of within-treatment variables and therapist prognostic ratings. Addiction 92, 14791489.[ISI][Medline]
Drummond, C. (1990) The relationship between alcohol dependence and alcohol-related problems in a clinical population. British Journal of Addiction 85, 357366.[ISI][Medline]
Fleeman, N. D. (1997) Alcohol home detoxification: a literature review. Alcohol and Alcoholism 32, 649656.[Abstract]
Gross, M. M., Lewis, E. and Nagarajan, M. (1973) An improved quantitative system for the acute alcoholic psychoses and related states (TSA and SSA). Advances in Experimental Medicine and Biology 35, 365376.
Metcalfe, P., Sobers, M. and Dewey, M. (1995) The Windsor Clinic alcohol withdrawal assessment scale (WCAWAS): investigation of factors associated with complicated withdrawals. Alcohol and Alcoholism 30, 367372.[Abstract]
Smart, R. G. (1979) Female and male alcoholics in treatment: characteristics at intake and recovery rates. British Journal of Addiction 74, 275281.[ISI]
Stockwell, T., Murphy, D. and Hodgson, R. (1983) The severity of alcohol dependence questionnaire: its use, reliability and validity. British Journal of Addiction 78, 145155.[ISI][Medline]
Stockwell, T., Bolt, E. and Hooper, J. (1986) Detoxification at home managed by general practitioners. British Medical Journal 292, 733735.[ISI][Medline]
Stockwell, T., Bolt, E., Milner, I., Pugh, P. and Young, I. (1990) Home detoxification for problem drinkers: acceptability to clients, relatives, general practitioners and outcome after 60 days. British Journal of Addiction 85, 6170.[ISI][Medline]
Stockwell, T., Bolt, L., Milner, I., Russell, G., Bolderston, H. and Pugh, P. (1991) Home detoxification from alcohol: its safety and efficacy in comparison with in-patient care. Alcohol and Alcoholism 26, 645650.[ISI][Medline]