AIDS/Drugs Service, Cherry Orchard Hospital, Dublin 10
Department of Public Health and Primary Care, Trinity College, Dublin
St Patricks Hospital, Dublin 8
AIDS/Drugs Service, Cherry Orchard Hospital, Dublin 10
Baggot Street Clinic, Dublin 4
AIDS/Drugs Service, Cherry Orchard Hospital, Dublin 10, Ireland
Correspondence: Dr Bobby P. Smyth, Department of Public Health and Primary Care, Adelaide and Meath Hospital, Tallaght, Dublin 24, Ireland. E-mail: bobby.smyth{at}swahb.ie
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ABSTRACT |
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Aims To measure the outcome 23 years after in-patient treatment.
Method Opiate-dependent patients admitted with a goal of abstinence were followed-up. A structured interview examined drug use and treatment in the preceding month.
Results Five patients had died and 109 (76%) of the remaining 144 were interviewed. Fifty per cent (54 patients) reported recent opiate misuse and 57% (62) were on methadone maintenance. Twenty-three per cent (25 patients) were abstinent (i.e. neither using opiates nor on methadone maintenance). Abstinence was significantly associated with completion of the 6-week in-patienttreatment programme and attendance at out-patient after-care, and negatively associated with a family history of substance misuse.
Conclusions Abstinence remains an attainable goal. As the principal influence on outcome was treatment adherence, inpatient services should seek to enhance rates of programme completion. After-care should be provided to patients. We caution against use of pre-treatment patient characteristics as criteria for prioritising access to in-patient treatment.
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INTRODUCTION |
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METHOD |
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Cuan Dara opened in 1995, operating as a specialist in-patient drug dependency unit focusing primarily on detoxification. Prior to admission, all patients were expected to have commenced therapeutic work with an addiction counsellor in a community-based treatment service. In addition, all patients underwent a psychiatric assessment to determine psychiatric comorbidity and motivation to detoxify. The standard treatment programme lasted 6 weeks. This included a 10-day methadone detoxification and a benzodiazepine detoxification if indicated. Throughout treatment patients were involved in individual therapy and group therapy. This 6-week admission period is longer than in NTORS (Gossop et al, 1998). Patients were encouraged to access one of two forms of after-care following discharge. They could re-attend their local addiction counsellor or they could access an after-care programme in Cuan Dara one evening each week.
Patients
Consecutive admissions to the unit from July 1995 to December 1996 were
included if they met the following criteria: primary diagnosis was opiate
dependence syndrome, using ICD10 criteria
(World Health Organization,
1992) and they were admitted with the goal of ceasing use of all
opiates, both illicit and prescribed. Baseline information was obtained from
the semi-structured interview conducted by a psychiatrist on the day of their
admission.
Follow-up interview
The core instrument used for data collection during follow-up was the
Maudsley Addiction Profile (Marsden et
al, 1998). This yields information on the 30 days prior to
interview. Eight experienced addiction outreach workers conducted the
interviews. Their expertise ensured that they had the skills and knowledge to
locate patients both via treatment services and through drug users peer
networks. Follow-up interviews took place between July 1998 and March 1999. It
was anticipated that the range in time gaps from discharge to follow-up
interview would be wide. This was a consequence of the patients being admitted
over an 18-month period and followed-up in an opportunistic manner over a
10-month period. Patients who agreed to participate were paid Ir£10
(12.50). Following interview, those who described ongoing drug use
problems were given advice and directed towards appropriate treatment
services.
Statistical analysis
The main outcome variable in this study was attainment of abstinence from
opiates during the month prior to follow-up. Abstinence implied that patients
were neither misusing opiates nor being prescribed methadone. The main
predictor variables were those indicating treatment adherence: completion of
detoxification; completion of the 6-week in-patient programme; and attendance
at after-care for at least 6 months. We also explored the possibility that
pre-treatment patient characteristics might predict abstinence at follow-up.
Patients followed-up were compared with those lost to follow-up in order to
rule out any systematic bias in the follow-up group.
Categorical variables were compared using Pearsons 2
test or Fishers exact test, as appropriate. Odds ratios (ORs) and their
95% confidence intervals (95% CIs) are reported to indicate the direction and
strength of associations. A multivariate analysis was conducted to identify
variables that were independently associated with opiate abstinence. All
variables were eligible for entry into the final regression equation. The
selection method involved using both the forward and backward stepwise
selection techniques, using the likelihood ratio test. The P value
for entry was set at 0.05 and that for removal at 0.10. Variables entered into
the final regression equation were examined for evidence of interaction.
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RESULTS |
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Five patients were known to have died prior to follow-up. One hundred and nine (76%) of the remaining patients were interviewed. We examined the baseline socio-demographic, drug misuse and treatment adherence characteristics of all patients and found no significant differences between those followed-up and those lost to follow-up. The period from discharge to follow-up ranged from 18 to 42 months, with a median of 29 months. Face-to-face interviews were conducted with all patients apart from five who completed telephone interviews. No patients were in residential treatment at follow-up.
At follow-up, 45 (41%) reported heroin use and 20 (18%) reported methadone misuse. Overall, 54 (50%) reported misuse of at least one opiate. Sixteen (15%) were using heroin daily. Among the 86 patients who completed the methadone detoxification, 46 (53%) reported no recent opiate misuse. Sixty-two (57%) were on methadone maintenance treatment at follow-up.
Table 2 indicates the factors associated with the main outcome variable, recent abstinence from all opiate use, both illicit and prescribed. Twenty-three per cent reported opiate abstinence. Only those characteristics that were at least weakly associated with this outcome (OR greater than 2 or less than 0.5) are reported. On univariate analysis, abstinence was significantly associated with completion of the in-patient treatment programme, attendance at after-care treatment for at least 6 months following discharge, no previous drug injecting and absence of a family history of substance misuse. Abstinence was not associated with other socio-demographic characteristics, nor was it associated with past psychiatric history, previous addiction treatment, duration of opiate use or quantity of heroin use at baseline. The time interval from discharge to follow-up was not associated with outcome.
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On the multivariate analysis, abstinence was significantly associated with completion of the in-patient treatment programme (OR=4.1, 95% CI 1.411.9), persistence with after-care (OR=7.6, 95% CI 2.325.3) and absence of a family history of substance misuse (OR=3.3, 95% CI 1.19.9).
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DISCUSSION |
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Follow-up
The follow-up rate achieved in this study is equivalent to that in similar
studies (Hubbard et al,
1997; Gossop et al,
1999). Nevertheless, loss to follow-up is a concern, as those
patients who are difficult to locate may be more likely to be using opiates.
The absence of any significant difference between the baseline and treatment
adherence characteristics of those followed-up compared with those not located
suggests selection bias was not prominent.
The period from discharge to follow-up varied substantially in this study owing to methodological issues already discussed. We found no association between duration of follow-up and abstinence. The NTORS demonstrated that the treatment gains obtained at 1 year remained relatively static at years 2 and 5 (Gossop et al, 2003). Although individual patients may alternate between relapse and abstinence during subsequent years, the proportions of patients moving in each direction tend to cancel each other out beyond the first year after treatment.
Mortality
The five deaths that occurred in this young cohort are consistent with
international mortality rates of 12 per 100 person-years
(Oppenheimer et al,
1994; Gossop et al,
2002). It should be noted that one of the risks associated with
abstinence-orientated treatments is accidental overdose following relapse due
to the reduction in opiate tolerance
(Strang et al,
2003).
Methadone maintenance treatment
Over half of the cohort was on methadone maintenance treatment at
follow-up. This indicates that many patients relapsed following discharge and
subsequently reaccessed treatment. In Switzerland, Broers et al
(2000) found that 35% of those
admitted for in-patient opiate detoxification were on methadone maintenance
when followed-up after 6 months. Other studies have demonstrated that early
relapse is a frequent outcome following in-patient treatment
(Chutuape et al,
2001). The fact that opiate dependence frequently follows a
chronic relapsing course highlights the need for an accessible and
comprehensive range of therapeutic interventions for this patient group.
Drug misuse outcomes
The NTORS demonstrated a significant decline in heroin misuse among
patients offered residential treatment, from 74% at admission to 49% at 1-year
follow-up (Gossop et al,
1999). Chutuape et al
(2001) and Broers et
al (2000) found that about
30% of patients reported abstinence from heroin 6 months after a brief
inpatient opiate detoxification. We found that although 89% of the patients
were admitted with a primary problem of heroin dependence, only 41% reported
recent heroin misuse at follow-up and only 15% report daily heroin use.
Although baseline and follow-up data were obtained using different
methodologies, our findings support the view that in-patient treatment is
effective in reducing heroin misuse. Among those who completed at least the
methadone detoxification phase of treatment, 53% denied any opiate misuse at
follow-up. Gossop et al
(1989) found an almost
identical proportion in their 6-month follow-up study.
The reduction in misuse of heroin cannot be entirely attributed to in-patient treatment. Many patients were on methadone maintenance at follow-up and this will also have contributed to the reduced rates of use. While reliance on self-report of substance misuse at follow-up may be considered a weakness of this study design, similar studies have found that self-report correlates highly with results of urine testing (Gossop et al, 1997; Darke, 1998).
Achievement of abstinence
At follow-up, 23% of participants had achieved their initial treatment goal
of abstinence from opiates without the assistance of methadone maintenance.
Most studies examining outcome following in-patient treatment report
proportions using heroin before and after treatment, without making it clear
that those who are abstaining from heroin at follow-up are not receiving
methadone maintenance treatment (Gossop et al,
1989,
1999;
Broers et al, 2000;
Chutuape et al, 2001).
In seeking to clarify this important issue, we found that almost one in four
were genuinely abstinent after an average of 2.5 years. This should be a
source of optimism to patients, to commissioners of addiction services and to
those who deliver similar services. It should be noted, however, that
abstinence during the month prior to follow-up interview does not imply
abstinence throughout the follow-up period.
In this era of harm reduction, abstinence has become a secondary goal of treatment services. Dublin has embraced the principles of harm reduction, and a well-developed treatment infrastructure existed at the time of this study (Farrell et al, 1999). This included relatively easy access to methadone maintenance treatment. Reservations have long been expressed that improved access to methadone maintenance might reduce the possibility of drug misusers attaining abstinence (Bratter & Pennacchia, 1978; Gerlach & Schneider, 1991). This study indicates that abstinence remains an attainable goal and confirms our first hypothesis.
Abstinent patients were more likely to have completed the in-patient treatment programme and more likely to have attended after-care treatment for at least 6 months. The DATOS failed to demonstrate that better outcome was predicted by a longer stay in short-term in-patient treatment programmes such as that delivered in this study (Hubbard et al, 1997). This may be due to differences in treatment delivery in the USA and substantial differences in the patient population: the vast majority of patients in DATOS presented with cocaine dependence. There is much other research consistent with our findings that significant improvement in outcome is associated with better treatment adherence and with transfer to long-term out-patient after-care following in-patient addiction treatment (van de Velde et al, 1998; Gossop et al, 1999; Chutuape et al, 2001; Ghodse et al, 2002). In-patient treatment is an expensive and limited resource. In order to maximise the health gain that such services can deliver we need to identify more effectively those patients who are most likely to persist with treatment. There is also a need to improve our understanding of the factors within different in-patient and after-care programmes that facilitate patient attendance. Finally, there is a need to develop imaginative measures that can actively enhance treatment adherence at all stages of the treatment process (Horwitz & Horwitz, 1993; Giuffrida & Torgenson, 1997).
The finding that a family history of substance misuse was associated with a significant reduction in the likelihood of abstinence was unexpected. There are a number of possible explanations for this. Environmental explanations seem most plausible. Two-thirds of those who reported a family history of substance misuse identified a sibling who was misusing opiates. Returning home to an environment with an opiate-using sibling may have made heroin access easier and promoted relapse (Maisto et al, 2001). There is also a possible contribution of genetic influences. However, it may simply represent a chance finding as a result of a type 2 statistical error in view of the large number of statistical tests conducted in this study.
In common with many other addiction treatment studies, we found that patient pre-admission characteristics account for a very small proportion of the variance in outcome. Consequently, there is minimal evidence to support their use in prioritising access to in-patient treatment.
This study suggests that in-patient treatment can be effective for opiate-dependent patients, particularly when the patient completes treatment and proceeds to access after-care. In addition, evidence from the USA indicates that it can also be a cost-effective option compared with out-patient treatments (French et al, 2000). In-patient addiction services must strive to develop strategies to improve rates of programme completion. Commissioners of addiction services should ensure after-care is available and drug dependency units should actively facilitate patient transfer to such services following discharge.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
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Broers, B., Giner, F., Dumont, P., et al (2000) Inpatient opiate detoxification in Geneva: follow-up at 1 and 6 months. Drug and Alcohol Dependence, 58, 85 92.[CrossRef][Medline]
Butler, S. (2002) The making of the methadone protocol: the Irish system? Drugs: Education, Prevention and Policy, 9, 311 324.[CrossRef]
Chutuape, M. A., Jasinski, D. R., Fingerhood, M. I., et al (2001) One-, three-, and six-month outcomes after brief inpatient opioid detoxification. American Journal of Drug and Alcohol Abuse, 27, 19 44.[CrossRef][Medline]
Darke, S. (1998) Self-report among injecting drug users: a review. Drug and Alcohol Dependence, 51, 253 263.[CrossRef][Medline]
Farrell, M., Howes, S., Verster, A., et al (1999) Reviewing Current Practice in Drug Substitution Treatment in Europe. Project no. CT.98DR 10. Lisbon: European Monitoring Centre for Drugs and Alcohol Addiction.
French, M. T., Salome, H. J., Krupski, A., et al
(2000) Benefitcost analysis of residential and
outpatient addiction treatment in the State of Washington.
Evaluation Review, 24, 609
634.
Gerlach, R. & Schneider, W. (1991) Abstinence and acceptance? The problematic relationship between the German abstinence paradigm, low-threshold orientated drug work, and methadone. Drug and Alcohol Review, 10, 417 421.
Ghodse, A. H., London, M., Bewley, T. H., et al (1987) In-patient treatment for drug abuse. British Journal of Psychiatry, 151, 72 75.[Abstract]
Ghodse, A. H., Reynolds, M., Baldacchino, A. M., et al (2002) Treating an opiate-dependent opiate-dependent inpatient population: a one-year follow-up study of treatment completers and noncompleters. Addictive Behaviors, 27, 765 778.[CrossRef][Medline]
Giuffrida, A. & Torgenson, D. J. (1997)
Should we pay the patient? Review of financial incentives to enhance patient
compliance. BMJ, 315, 703
707.
Gossop, M., Johns, A. & Green, L. (1986) Opiate withdrawal: inpatient versus outpatient programmes and preferred versus random assignment to treatment. BMJ, 293, 103 104.[Medline]
Gossop, M., Green, L., Phillips, G., et al (1989) Lapse, relapse and survival among opiate addicts after treatment. A prospective follow-up study. British Journal of Psychiatry, 154, 348 353.[Abstract]
Gossop, M., Marsden, J., Stewart, D., et al (1997) The National Treatment Outcome Research Study in the United Kingdom: six month follow-up outcomes. Psychology of Addictive Behaviors, 11, 324 337.[CrossRef]
Gossop, M., Marsden, J., Stewart, D., et al (1998) Substance use, health and social problems of service users at 54 drug treatment agencies. Intake data from the National Treatment Outcome Research Study. British Journal of Psychiatry, 173, 166 171.[Abstract]
Gossop, M., Marsden, J., Stewart, D., et al (1999) Treatment retention and 1 year outcomes for residential programmes in England. Drug and Alcohol Dependence, 57, 89 98.[CrossRef][Medline]
Gossop, M., Stewart, D., Treacy, S., et al (2002) A prospective study of mortality among drug misusers during a 4-year period after seeking treatment. Addiction, 97, 39 47.[CrossRef][Medline]
Gossop, M., Marsden, J., Stewart, D., et al (2003) The National Treatment Outcome Research Study (NTORS): 45 year follow-up results. Addiction, 98, 291 303.[CrossRef][Medline]
Horwitz, R. I. & Horwitz, S. M. (1993) Adherence to treatment and health outcomes. Archives of Internal Medicine, 153, 1863 1868.[Abstract]
Hubbard, R. L., Craddock, S. G., Flynn, P. M., et al (1997) Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors, 11, 261 278.[CrossRef]
Maisto, S., Pollock, N., Lynch, K., et al (2001) Course of functioning in adolescents 1 year after alcohol and other drug treatment. Psychology of Addictive Behaviours, 15, 68 76.
Marsden, J., Gossop, M., Stewart, D., et al (1998) The Maudsley Addiction Profile (MAP): a brief instrument for assessing treatment outcome. Addiction, 93, 1857 1868.[CrossRef][Medline]
Oppenheimer, E., Tobutt, C., Taylor, C., et al (1994) Death and survival in a cohort of heroin addicts from London clinics: a 22-year follow-up. Addiction, 89, 1299 1308.[Medline]
Polkinghorne, J., Farrell, M., Fry, M., et al (1996) The Task Force to Review Services for Drug Misusers: Report of an Independent Review of Drug Treatment Services in England. London: Department of Health.
Smyth, B. P., OBrien, M. & Barry, J. (2000) Trends in treated opiate misuse in Dublin: the emergence of chasing the dragon. Addiction, 95, 1217 1223.[CrossRef][Medline]
Strang, J., McCambridge, J., Best, D., et al
(2003) Loss of tolerance and overdose mortality after
inpatient opiate detoxification: follow up study. British Medical
Journal, 326, 959
960.
van de Velde, J. C., Schaap, G. E. & Land, H. (1998) Follow-up at a Dutch addiction hospital and the effectiveness of therapeutic community treatment. Substance Use and Misuse, 33, 1611 1627.
World Health Organization (1992) Classification of Mental and Behavioural Disorders. Geneva: WHO.
Received for publication March 3, 2003. Revision received February 2, 2004. Accepted for publication February 14, 2004.
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