1 Centre for Psychology, University of Wales Institute Cardiff, Llandaf campus, Western Avenue, Cardiff, 2 Inter-professional studies, University of Wales Institute, Cardiff, Wales, 3 Alcohol Education Research Council, London, UK and 4 School of Health Sciences, University of Wales, Swansea, Wales
* Author to whom correspondence should be addressed at: Centre for Psychology, University of Wales Institute Cardiff, Llandaf campus, Western Avenue, Cardiff. Tel.: 02920 416000 Fax: 02920 416985; E-mail: talwyn{at}uwic.ac.uk
(Received 23 February 2004; first review notified 23 March 2004; in revised form 1 July 2004; accepted 2 July 2004)
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ABSTRACT |
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INTRODUCTION |
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There is strong evidence to support the safety and effectiveness of both outpatient and home detoxification (Fleeman, 1997). There are also a number of other advantages such as reducing the stigma often attached to inpatient care, encouraging family involvement and support, and reducing the waiting list. Bartu and Saunders (1994)
proposed that detoxification in the home is far more realistic in relation to alcohol, as patients are not isolated from drinking cues and drink triggers.
The aims of the current study are to develop and test the feasibility of a psychological intervention for use as an adjunct to a home detoxification programme; to assess the impact of this by completing follow-up interviews at 3 months and 12 months post treatment to assess consumption levels, dependence, alcohol-related problems, social satisfaction and health; and to assess the cost effectiveness of this intervention in comparison with other treatment approaches for detoxification.
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METHODS |
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Recruitment of participants
Participants were recruited by intake assessment medical staff from consecutive referrals to home detoxification services in four participating areas. These four areas had an existing similar home detoxification service in place. The four centres were: Bro Taf Community Addiction Unit, Cardiff; Sandwell Community Alcohol Team, Birmingham; Clwyd Community Addictions Unit; and Gwynedd Community Addictions Unit. Referrals to these home detoxification services came from general practitioners, self-referral, social services and voluntary agencies such as local community alcohol teams.
Inclusion/exclusion criteria
All referred patients, who met the clinical criteria for home detoxification, were included in the trial. Exclusion criteria were identical to those for existing home detoxification services: previous history of withdrawal fits; epilepsy; very severe physical or psychological disorders; no stable address.
Initial screening assessment
All patients referred to the community units were assessed by the clinical staff for their suitability for home detoxification, based on the above criteria and were asked whether they would agree to participate in the trial.
Informed consent
Informed consent was obtained by the researcher prior to initial assessment.
Research assessment
Either the research staff or the participating Community Psychiatric Nurses (CPNs) administered the research assessment. This assessment was carried out 25 days prior to treatment. The assessment battery took 75 min to complete and was administered on a one-to-one basis in patients' homes or treatment centres, at their own convenience. Some of the questionnaires were interviewer led and others were self-completed. In order to avoid data contamination, the presence of a significant other was discouraged.
Randomization
On completion of the initial research assessment participants were randomly allocated to one of the two treatment conditions, using a random number table. This was implemented by the project administrator who had no knowledge of, or access to any individual patient information.
Assessment measures
The following measures were chosen in order to reflect the research aims and objectives. (i) Form 90 family of instruments (Miller, 1996); this measure records information on days abstinent, drinks per drinking day (in units, 1 unit = 8 g ethanol), total consumption during the previous 3 months (in units) and other drug use. (ii) Severity of Alcohol Dependence Questionnaire (SADQ) (Stockwell et al., 1979
); used to assess the severity of the alcohol dependence syndrome. (iii) Alcohol Problems Questionnaire (APQ) (Drummond, 1990
); in order to quantify information on alcohol related problems. (iv) Social Satisfaction Scale (Tober, 2000
); to assess levels of dissatisfaction with specific aspects of living. (v) Self Esteem questionnaire (Rosenberg, 1965
); a measure commonly used to assess self esteem.
Treatments
Participants in both groups were detoxified using appropriate medication for detoxification which was consistent for all participants. This was dispensed on a daily basis with the dose gradually being reduced over a period of 58 days. Participants' GPs took medical responsibility for the prescribing of the detoxification medication.
Control: treatment as usual (five home visits over a 58 day period)
Treatment as usual involved five home visits of 30 min duration by the CPN for administration of the appropriate dose of medication for detoxification. The other aspect of these sessions included developing rapport and providing simple advice, especially regarding withdrawal symptoms and physical discomfort.
The psychological intervention (five home visits over a 58 day period)
As well as the administration of the appropriate dose of medication for detoxification, the psychological component was a relatively brief intervention consisting of three main approaches within one 30 min session on each of five home visits. Sessions were scheduled as follows.
Session 1: motivation. The first session focused on motivation and building rapport with the client. Motivation to change was briefly considered by exploring the benefits of change. Reasons for stopping or reducing drinking were discussed with the aim of gently motivating change. This was carried out with empathy, and confrontation was avoided.
Sessions 2 and 3: coping skills. The emphasis in these sessions was upon developing a simple cognitive coping strategy that involved accepting discomfort and bringing to mind reasons to change. These sessions focused on the desensitization of alcohol cues or triggers that may lead to relapse, drink refusal skills and dealing with thoughts about alcohol. The client was encouraged to learn and develop appropriate and relevant coping skills. To help clients with this, a three step coping strategy technique was developed, which they were encouraged to practise regularly, especially when experiencing craving.
Sessions 4 and 5: social support. Therapists were encouraged to be as creative as possible in helping the client to access effective support provided by partners, friends or other family members. Positive social support for abstinence (or sensible drinking in a few cases) was the main focus of these sessions. Increasing social activities could involve local groups, or taking up hobbies or activities that encourage social interaction, which may enable the development of new social networks.
The integrity by which the two forms of treatment were implemented by the therapists was addressed by (i) supervision and training of the therapists: this involved the initial training plus one further visit to the participating centres by the research team in order to resolve any problems or difficulties experienced. (ii) Monitoring through ongoing telephone contact with therapists: the research team maintained regular telephone contact with the participating centres, and CPNs involved were provided with a mobile 'helpline' number. (iii) All therapists were supplied with a treatment manual (available from the first author).
Therapists
The control treatment was conducted by CPNs; each CPN carried out both the control and psychological treatments with the exception of one agency. In this agency the psychological treatment was conducted by one of the research psychologists. Therapists all had at least 2 years experience in the alcohol field. All the CPNs were trained in the mental health field and were F grade or above.
Follow-up
Follow-up interviews with participants were carried out at 3 months and 12 months post treatment. See Fig. 1 for the research process flow chart.
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For some measures the repeated measures analysis was not possible. This was because the data were nominal or ordinal and therefore alternative non-parametric statistical tests were utilized.
The aim was to test for a medium effect size (d = 0.6) with an alpha of 0.05 and power of 0.90.
Ethical approval
Local research ethical committees approved the trial.
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RESULTS |
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Group 1 (n = 45) received the simple home detoxification (the control group); group 2 (n = 46) received the home detoxification treatment programme plus the psychological intervention (the treatment group).
Baseline alcohol related measures
Alcohol consumption. Of the whole sample (n = 91), 81 (89%) were assessed as steady drinkers, that is, individuals whose drinking was regular and consistent over the 90 day period prior to baseline assessment (i.e. drinking daily or on most days for the majority of the period). Ten were assessed as binge drinkers, where drinking was episodic with no regular steady pattern. Nevertheless, they had consumed alcohol consistently at high enough levels to suffer from withdrawal symptoms and therefore were considered suitable for detoxification. They were evenly distributed between the two treatment groups.
Consumption measures for steady pattern drinkers. For this group the mean score for total number of days abstinent in the past 90 days was two (SD = 3.83). Fifty-four of the 81 (67%) in this category group had no abstinent days in the period prior to assessment and treatment, which demonstrates the dependent nature of the sample. The mean for the units consumed per drinking day was 27.4 (SD = 10.55) with the median being 27.
Consumption measures for binge drinkers. For this group the mean number of days abstinent in the past 90 days was 39 (SD = 12.19). The mean score for the units consumed per drinking day (drinks per drinking day) was 27.0 (SD = 10.50). Although this group are classified as binge drinkers, the figures demonstrate that the amount they consume per day when drinking is similar to that of steady drinkers.
Severity of alcohol dependence. The mean SADQ score was 30.94 (SD = 12.40) with a range of 5 to 56 (the maximum score possible is 60). A cut off score of 30 suggests severe dependence. Out of the 91 participants, 72 (79%) scored >30.
Base line differences
Independent t-tests showed no significant differences between the groups on any pre-treatment variable.
Follow-up and attrition
Of the 91 participants in the trial, 85 (92%) were successfully followed up at 3 months and 78 (86%) were successfully interviewed at the 12 month follow-up point. Less than 25% of these were not blind. This was due to geographical constraints.
Treatment outcome
Drinks per drinking day. For this measure there was a significant interaction effect for occasion x group (P = 0.007). This was further explored by examining treatment interactions from base line to 3 months and from base line to 12 months. Changes at both 3 months and 12 months were significantly greater for the psychological treatment group than for the control group (baseline to 90 days post treatment, P = 0.012; and from baseline to 12 months post treatment, P = 0.005). This indicates that the treatment group drank significantly fewer units per drinking day than the control group at both the follow-up occasions (see Fig. 2).
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Time to first drink following treatment. For the treatment group this was 114 days compared to 52 days for the control group (P = 0.011).
Alcohol related problems. This was assessed at two time points: baseline and at 12 months post treatment. The repeated measures show an interaction effect for occasion x group (P = 0.048). This interaction indicates that the reduction in problems at the 12 month follow-up was significantly greater for the psychological treatment group than for the control group.
Social satisfaction. This was assessed over three time points: baseline, 3 and 12 month follow-up post-treatment. There was a significant interaction effect for occasion x group (P = 0.020).
Self-esteem. Repeated measures analyses showed a nearly significant interaction effect for occasion x group (0.061), which would be significant on a one tailed test.
Abstinence or moderate drinking at 3 month and 12 month follow-up. Table 1 illustrates that at the 3 month follow-up, 25 of the 43 participants in the treatment group were abstinent or drinking <3 units a day, compared with 10 of the 42 in the control group. These results show a significant treatment effect (-square 10.34, P = 0.01).
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Missing data
There was no difference at either the 3 month follow-up point in the proportion successfully followed (control group n = 42; psychological intervention group n = 43), nor at the 12 month follow-up point (control group n = 40; psychological intervention group n = 38). However, as a check on the effect of differential drop-out, the analyses displayed in Tables 1 and 2 were repeated with the assumption that all the participants with missing data did badly at 12 month follow-up. This made no difference to the main findings.
Cost analysis
The cost of providing both control and treatment detoxification programmes is relatively inexpensive compared to other detoxification programmes (see Table 3). Both detoxification programmes in this study amounted to five visits (over a 58 day period) of 30 min duration. The costs of implementing the psychological intervention were relatively small. As there was already an existing home detoxification service providing a simple medical detoxification, the only additional costs were the training of the CPNs on how to implement the intervention. The hourly rate for a home visit by a CPN is £77 (Netten et al., 2001). The cost per participant amounts to £175, plus the costs of the medication used in the detoxification (for both groups), which was only a few pence (BNF, 2001
).
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The Number Needed to Treat (NNT) to produce one extra non-hazardous drinker is therefore 3.13 (100/31.97). This means that just over three patients have to receive the psychological intervention in order for one extra to be in remission.
It is therefore reasonable to assume that the psychological programme, as part of a home detoxification service, results in cost savings to the NHS and may well generate additional benefits in terms of a larger number of days abstinent and reduced alcohol related problems than the home detoxification programme on its own.
Therapist profession and outcome
One of the unavoidable methodological idiosyncrasies of this trial resulted from constraints on nurse time in one district. Two research psychologists carried out the psychological intervention in this district. They gave this intervention to 18 clients. In the other four districts, Community Psychiatric Nurses gave the psychological intervention to 28 clients. In a repeated measures analysis of variance the interaction (occasions x treatment x profession) did not approach significance (F = 0.343; df = 2; P = 0.71). An inspection of the data confirmed that there were no signs of differences in treatment outcomes when given by psychologists or by CPNs.
Differences in outcome between participating centres
A repeated measures analysis was performed to assess outcome x group x centre. The results showed that centre made no significant differences to treatment outcome.
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DISCUSSION |
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Clinical implications
Teams of CPNs working in three of the four areas, and a psychologist working in the other, led to an opportunity to investigate whether there were any differences in treatment outcome between the four centres. The results show that there were no differences. Thus, the results could be generalized to other home detoxification services that have the same clinical criteria and detoxification treatment process. This was a pragmatic study and the results appear to demonstrate that the nurses involved have been able to incorporate the psychological intervention very effectively into their existing treatment approach.
Critical appraisal of the current study
A number of limitations of this study need to be addressed.
(i) There is no objective confirmation of subjective outcome measures (for example, collateral information or liver function tests); a lack of funding precluded this. However, a great deal of research indicates that subjective measures are accurate and valid (Sobell et al., 1980). The Project MATCH Team (Babor et al., 2001), compared self reported consumption to biochemical measures and concluded that self-report measures were accurate enough to warrant routine use. Furthermore, any lack of reliability in self reported measures would be unlikely to account for between group differences in the current study.
(ii) In the current study the implementation of the psychological intervention was not audited with the use of audio or video tapes. However, poor implementation would not explain why the psychological intervention produced a differential treatment effect.
(iii) Due to economical and geographical constraints, some of the assessors at follow-up were not blind to treatment groups. However significant interaction effects were obtained for patient self-completion measures (social satisfaction and alcohol-related problems). Furthermore, therapists and clients would not have had a vested interest in faking good in favour of the psychological intervention. If at all, therapists would have been expected to be biased in favour of the detoxification process that they were used to.
(iv) This was a pragmatic trial and the use of psychologists to implement the therapy in one participating district added to the complexity. However, there were no differences between outcomes for psychologists and CPNs. In fact, what appeared to be a methodological problem turned out to be a strength, since it demonstrated that this manual-driven intervention does not appear to require a particular professional training.
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CONCLUSIONS |
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ACKNOWLEDGEMENTS |
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REFERENCES |
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Babor, T. F., Steinberg, K., Anton, R. and Del Boca, F. (2000) Talk is cheap: measuring drinking outcomes in clinical trials. Journal of Studies on Alcohol 61, 5563.[ISI][Medline]
Bartu, A. and Saunders, W. (1994) Domiciliary detoxification: a cost effective alternative to inpatient treatment. The Australian Journal of Advanced Nursing 11, 1218.[Medline]
Bien, T., Miller, W. and Tonigan, S. (1993) Brief Interventions for Alcohol Problems: A Review. Addiction 88, 315336.[ISI][Medline]
British National Formulary (2001) British Medical Association & Royal Pharmaceutical Society of Great Britain.
Cooper, D. B. (1995) Alcohol home detoxification: A way forward. British Journal of Nursing 4, 13151318.[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]
Feldman, D. J., Pattison, E. M., Sobell, L., Graham, T. and Sobell, M. B. (1975) Outpatient alcohol Detoxification: Initial findings on 564 patients. American Journal of Psychiatry 132, 407412.[Abstract]
Fleeman, N. D. (1997) Alcohol home detoxification. A literature review. Alcohol and Alcoholism 32, 649656.[Abstract]
Klijnsma, M. P. (1995) Outpatient alcohol detoxification outcome after two months. Alcohol and Alcoholism 30, 669673.[Abstract]
Kraus, M. L., Segal, S. R., Sanguineti, V., Johnston, M. and Genova, C. (1986) Ambulatory alcohol detoxification: An alternative. Connecticut Medicine 50, 717720.[Medline]
Miller, W. R. (1996) Form 90: a structured assessment interview for drinking and related behaviours (Project MATCH monograph series volume 5). National Institute on Alcohol Abuse and Alcoholism, Rockville MD.
Netten, A., Rees, T. and Harrison, G. (2001) Unit Costs of Health and Social Care University of Kent, PSSRU.
Rosenberg, M. (1965) Society and the adolescent self image. Princeton University Press, Princeton.
Sobell, M. B., Maisto, S. A., Sobell, L. D., Cooper, A. M., Cooper, T. C. and Saunders, B. (1980) Developing a prototype for evaluating alcohol treatment effectiveness. In Evaluating alcohol and drug abuse treatment effectiveness, Sobell, M. B., Sobell, L. D. and Ward, E. eds, pp. 129150. Pergamon Press, New York, NY.
Stockwell, T., Hodgson, R. J., Edwards,G., Taylor, C. and Rankin, H. (1979) The development of a questionnaire to measure the severity of alcohol dependence. British Journal of Addiction 74, 7987.[ISI]
Stockwell, T., Bolt, L., Milner, I., Bolderston, J. and Pugh, P. (1991) Home Detoxification from Alcohol: its safety and efficacy in comparison with inpatient care. Alcohol and Alcoholism 26, 645650.[ISI][Medline]
Tober, G. W. (2000) The nature and measurement of change in substance dependence. Unpublished PhD thesis. University of Leeds, UK.
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