Outcome Assessment In Inpatient Detoxification Services
Outcome Assessment in Inpatient Detoxification Services
Jing Wang (2585273) PhD Candidate
Supervisors: Professor Frank Deane and Associate Professor Peter Kelly Abstract
Detoxification is the beginning phase of treatment for many individuals with alcohol and other drugs (AOD) problems. Definitions of what constitute positive outcomes from detoxification treatment are complex. It is widely recognised that safe withdrawal from AOD use and initiation of abstinence are important goals. Further, detoxification provides an opportunity to motivate or facilitate referrals of service users into further, longer term treatment following detoxification to maintain abstinence and prevent relapse. Abstinence-based treatment outcome has historically been the primary treatment outcome measure in AOD treatment including detoxification. However, ample evidence from non-detoxification studies has shown that a proportion of people entering outpatient AOD treatment choose controlled use as their treatment goal instead of abstinence.
Meaningful outcomes other than abstinence have also been identified by AOD treatment recipients and their family and friends. These broader outcomes include: health, relationship, social circumstance (e.g. stable housing) (Thurgood, Crosby, Raistrick, & Tober, 2014). This may indicate that people entering detoxification do so for a multitude of reasons, however, there is no research that assesses the frequency of different reasons for entering detoxification. Further, there are likely to be a range of predisposing factors (e.g. homelessness, mental illness) which influence the reasons that people choose to enter detoxification. Homelessness is associated with poorer outcome including not completing detoxification, failing to enrol in further treatment and early relapse following detoxification (Ford & Zarate, 2010), and readmission to detoxification (Callaghan, 2003). Relationships between general social support and friends’ support for abstinence, mental illness and AOD use have previously been identified (Awgu, Magura, & Coryn, 2016).
Aims: To describe the variety of reasons that participants enter detoxification, determine the extent to which these reasons are addressed during treatment, how they are related to satisfaction with treatment, and finally explore whether homelessness is related to the reasons that participants enter treatment, and return to detoxification (RTD).
Method: Study 1 is a narrative review to identify the different types of outcomes evaluated in inpatient detoxification. Study 2 involves a survey of over 1000 participants to explore a wide range of reasons for entering residential detoxification and the extent to which each of these reasons were addressed during treatment (Perceived helpfulness of detoxification). Study 3 will explore whether homeless AOD users, compared to housed counterparts, endorse different reasons for attending detoxification (i.e., different treatment needs), and obtained poorer treatment outcome in terms of readmission, a proxy for relapse.
Preliminary Results: Study 1: The review identified 13 studies and revealed a lack of consensus in what constitutes positive outcomes and systematic structural domains for considering detoxification outcomes. Such structure could be constructed in terms of outcomes regarding 1) detoxification process (e.g., minimise withdrawal symptoms, abstinence during withdrawal), 2) outcomes at discharge (e.g., detoxification completion, acceptance of referral to further treatment), and 3) outcomes at follow-up (e.g., attending follow-up treatment, client abstinence/reduction in use, psychosocial functioning).
Study 2: Results (N=708) showed that participants endorsed a range of reasons for entering detoxification with achieving abstinence mostly endorsed (97%), followed by physical (91%) and mental (88%) health reasons, and preparation for further treatment (86%). Perceived helpfulness of detoxification was high in relation to all reasons, with the highest being stop using (94%), preparation for further treatment (94%), and reduce tolerance (94%). Overall service satisfaction was high with 93% (n=590) very or mostly satisfied. Approximately 48% participants endorsed seeking help with accommodation as one of the reasons for entering detox (they likely either are homeless or experienced difficulties with maintaining stable housing). Approximately 12% returned to detoxification (RTD) within 10 months. Compared to non-returners, “returners”, at discharge from their first admission, felt they were helped more with “their efforts to stop using” and “physical health” more than accommodation.
1. Outcomes Assessment in Inpatient Detoxification Services
In order to provide detoxification services that address the varying treatment needs of clients, it is important to develop appropriate outcome assessment measures. Existing literature on outcome assessment in detoxification services has predominantly focused on the following outcomes:(a) “safe” withdrawal described as the prevention of severe withdrawal sequelae and minimisation of distress associated with withdrawal (DiPaula, Schwartz, Montoya, Barrett, & Tang, 2002; Ponizovsky, Grinshpoon, Margolis, Cohen, & Rosca, 2006); (b) successful completion of detoxification treatment (Ford & Zarate, 2010; Sofin, Danker-Hopfe, Gooren, & Neu, 2017), (c) abstinence during detoxification treatment (Sofin et al., 2017), (d) abstinence rates at follow up (Ford & Zarate, 2010), (e) engagement in continuing care (Ford & Zarate, 2010; McGovern & Caputo, 1983), (f) detoxification satisfaction (DiPaula et al., 2002) and (g) miscellaneous aspects of client functioning (e.g. rates of homelessness and employment, etc.) (Ford & Zarate, 2010; Foster, Peters, & Marshall, 2000). These studies on outcome assessments in inpatient detoxification settings include polydrug detoxification, alcohol detoxification and opiate detoxification studies.
1.1. Study 1
Study 1 involves a narrative review (e.g., Aschenbrener & Johnson, 2017) aimed at clarifying the types of outcome assessments used in inpatient detoxification services and their relative strengths and weaknesses. This review will inform the development of Study 2.
Table 1 summarises the 13 studies included in the review of outcomes for consumers in inpatient detoxification programmes. The sample size ranged between 117 to 877. The length of those detoxification programmes varied from 3 (Carroll, Triplett, & Mondimore, 2009) to 30 days (Callaghan, 2003). All programmes consisted of pharmacotherapy; and the majority contained a psychotherapy component (Sofin et al., 2017; Franken & Hendriks, 1999; Carroll et al., 2009; McCusker, Bigelow, Luippold, Zorn, & Lewis, 1995; McGovern et al., 1983) designed to motivate detoxification inpatients to engage in further treatment following detoxification and provide proper referral to facilitate such engagement. Three studies incorporated relapse prevention (Sofin et al., 2017; Callaghan et al., 2003; Ponizovsky et al., 2006) and a Canadian study (Callaghan et al., 2003) included provision of referral for housing.
In terms of outcome assessment, studies differed in their definition of successful detoxification, and accordingly employed different measures to assess detoxification outcome. Just over half (7 of 13) of studies reported rates of detoxification completion as an outcome measure (Callaghan, 2003; Ford & Zarate, 2010; McCusker et al., 1995; Sofin et al., 2017), and rates varied from 50% (Ponizovsky et al., 2006) to 100% (DiPaula et al., 2002).
Detoxification treatment success was defined as transfer from detoxification to further treatment in 4 studies. Specifically, a study in Netherlands defined treatment success as transfer to inpatient rehabilitation treatment and recorded the transfer rate as 46% (81 of 175, Franken & Hendriks, 1999). Two US studies defined successful transfer as engagement in residential, outpatient drug-free, and methadone maintenance programme within 30 days leaving detoxification and reported the transfer rate as 21% (McCusker et al., 1995) and 71% (Ford & Zarate, 2010) respectively. The higher transfer rate could be partially due to clients signing a contact agreeing to a) following through with post-detoxification treatment, 2) paying the cost of detoxification if they did not (the specific cost was not reported). Another US study (Carroll et al., 2009) defined treatment success as transfer to a broader range of further treatment options including residential, recovery houses, outpatient and methadone maintenance programme, and reported a transfer rate of 82.9% (102/123).
Additionally, Ford and Zarate (2010) reported outcomes in terms of the length of stay in follow-up treatment (average 116 days) and completion of treatment/having made satisfactory progress in follow-up treatment (44%). Such outcomes are not entirely related to detoxification, but also include the effects of subsequent treatment. This is often the case in studies that utilised measures of client functioning.
Client functioning including abstinence rates/reduction in consumption at follow-up and associated changes in psychosocial functioning was reported in 3 studies, but assessments occurred well after the detoxification period. Ford and Zarate (2010) reported length of continuous sobriety following detoxification, percentage of clients remaining sober at various time intervals as well as the total number of sober days over the year following detox. They reported that the average number of days sober in the year after detoxification was 206 compared to 60 in the year before detoxification. They concluded that inpatient detox, especially when combined with follow-up treatment, substantially improved client outcomes in a wide range of areas, but receipt of additional treatment meant that the specific outcomes of detoxification could not be untangled from other services.
Withdrawal symptoms as an outcome measure was employed in one study which compared detox with buprenorphine vs clonidine for opiate detox (Ponizovsky et al. 2006). Withdrawal symptoms were assessed using the Clinical Global Impression Scale, Distress Scale for Adverse Symptoms, and an interview question. The buprenorphine group had higher well-being, perceived social support and feelings of self-efficacy compared to clonidine group. Two studies using the Clinical Institute Narcotic Assessment (DiPaula et al., 2002) and the Clinical Institute Withdrawal Assessment for Alcohol (Sofin et al., 2017) to assess the severity of withdrawal symptoms did not report specific outcomes from these measures.
Detoxification outcome was assessed by the rate of readmission to detoxification in 2 studies (Ford & Zarate, 2010; Callaghan, 2003). Readmission rate was reported to be 34.7% within 12 months in a Canadian study. One of the biggest predictors of relapse and readmission to detoxification services was residential instability (Callaghan, 2003). In an US sample, homelessness predicted detoxification completion, enrolment in follow-up treatment, and readmission to detoxification (Ford & Zarate 2010).
Finally, detoxification satisfaction was evaluated as an outcome by 1 study using a 3-question interview, and 90% participants were satisfied with the treatment (DiPaula et al., 2002).
In summary, previous studies have assessed outcomes including abstinence during the detoxification and abstinence at follow up, safe withdrawal, detoxification completion, engagement in further treatment, length of stay in detoxification and in follow up treatment, clients’ detoxification satisfaction, and better psychosocial functioning at follow up.
1.2. What is Missing in Research on Outcome Assessment in Inpatient Detoxification?
Review of past studies revealed a number of issues. Firstly, there was a lack of consensus in what constitutes positive outcomes. Secondly, some subsequent outcomes obtained from treatment following detoxification were treated as part of detoxification outcome. Finally, there is a lack of systematic structure for considering detoxification outcomes. Such structure could be constructed in terms of outcomes regarding, 1) the detoxification process (e.g., minimise withdrawal symptoms, abstinence during withdrawal), 2) outcome at discharge (e.g., detoxification completion, acceptance of referral to further treatment), and 3) outcome at follow-up (e.g., receiving further treatment, abstinence/reduction in use, psychosocial functioning).
Current detoxification outcomes focus on goals defined by service providers and do not sufficiently take into account service users’ perspectives of recovery. A conceptual model of recovery was constructed using the views of those recovering from addiction, treatment providers and researchers identified 7 indicators of outcome: physical, biomarker, psychological, psychiatric, chemical dependence and family, social and spiritual (Dodge, Krantz, & Kenny, 2010). AOD users’ wellbeing is defined by a number of constructs, and outcome is, therefore, a compilation of related but independent measures (Raistrick, Tober, Sweetman, Unsworth, Crosby, & Evans, 2014). Past detoxification studies examined biomarker and chemical dependence as outcome indicators. However, physical, psychological, family, social and spiritual indicators of outcome were not examined in previous inpatient detoxification studies.
Although most AOD users identify abstinence as their only goal of seeking treatment, there are consumers who seek treatment for the purpose of harm reduction. Of AOD users from 33 treatment agencies, 56.6% chose “abstinence” as their only goal of receiving treatment, whereas 7.1% identified “reduced drug use” as their goal and 7.4% “stabilization” only (McKeganey, Morris, Neale, & Robertson, 2004). We could locate no studies which reported initial goal of detoxification that might include controlled use rather than abstinence.
Even when the intention of detoxification is to achieve abstinence, many do not sustain this goal following detoxification. Almost one-third of the 116 opiate detoxification recipients returned to daily and nearly daily use at 6-month follow-up (Chutuape, Jasinski, Fingerhood, & Stitzer, 2001). Further, some AOD users report wishing to stop one substance but not all the substances they use, whereas others want to control their use of one or more substances rather than stop using all substances (Neale, Nettleton, & Pickering, 2011). In research on detoxification services the assessment of outcomes usually does not include such options.
A recent study investigated views of AOD service users and their family and friends on what constitutes a good outcome for AOD treatment (Thurgood et al., 2014). According to a wide range of survey participants, improved social circumstances (e.g. stable housing), abstinence, health, activities, relationship, self-awareness (e.g. confidence) and wellbeing of family and friends were identified as desirable outcomes. For those recovering from AOD problems, abstinence may be their ideal or ultimate goal, but reduced use with improved psychosocial functioning across several life domains are also clinically and personally meaningful outcomes. Expanding the scope of help provided in detoxification services beyond achieving abstinence or as a pathway to further treatment is much needed because transfer rates from detoxification to follow-up treatment varies from 21% to 82.9% (Ford & Zarate, 2010; Franken & Hendriks, 1999; Carroll et al., 2009; McCusker et al., 1995). For those who do not enter further treatment following detoxification, the detoxification service is likely their only opportunity to obtain help with a wider range of recovery outcomes.
1.3. Controlled Use as a Treatment Goal in Outpatient (Non-detoxification) Substance Abuse Treatment
Controlled use as a treatment goal choice has been studied extensively in the treatment of alcohol dependence in outpatient non-detoxification settings (Adamson, Heather, Morton, & Raistrick, 2010; Dunn & Strain, 2013; Booth, Dale, Salde, Dewey, 1992; Al-Otaiba Worden, McCrady, & Epstein, 2008; Hodgins, Leigh, Milne, & Gerrish, 1997; Meyer, Wapp, Strik, & Moggi, 2014). Drinkers seem to select the goal that best suited their needs and circumstances, and both abstinent and controlled drinking goal groups reported positive outcomes in consumption and psychosocial functioning (e.g. Dunn & Strain, 2013). In the treatment of cannabis use, those who chose abstinence-based goals were more likely to have abstinence outcomes, whereas those choosing moderation goals were more likely to engage in moderate use at the end of treatment (Lozano, Stephens, & Roffman, 2006).
Younger drinkers with less severe alcohol dependence tended to more frequently choose controlled drinking as a goal (Booth, Dale, & Ansari, 1984; Andamson & Sellman, 2001). Therefore, the inclusion of a controlled drinking goal into the range of possible outcomes advocated by services might be appealing to younger drinkers. Those who choose non-abstinence goals have the worst outcome (i.e. abstinence) when they are strongly advised to abstain (Booth et al., 1984).
Two studies reported the association between treatment outcome and goal selection at discharge from outpatient treatment and have noted the shift of goal choice over the course of treatment (Hodgins et al. 1997; Meyer et al., 2014). Hodgins and colleagues (1997) found that 89% of those who initially chose abstinence retained this goal. In comparison, 51% of those choosing moderation retained this goal after treatment. That is, approximately half of the individuals did not choose abstinence as a goal after having received 4 sessions of treatment over 4 weeks (Hodgins et al. 1997).
2. Study 2: Rationale and Significance
The review revealed that previous studies in inpatient detoxification treatment have largely focused on abstinence-oriented treatment outcomes. This expectation is driven by most inpatient detox programs requiring cessation of all alcohol and illicit drugs. This explicit expectation at times becomes an implicit expectation that abstinence should be the goal of subsequent treatment, however, our review indicates that this implicit expectation is borne out in other outpatient treatment settings following detoxification.
Two major concerns have been identified above; a) not all AOD service users endorse the treatment goal of abstinence as advocated by service providers (especially detoxification); and; b) outcome measures typically do not incorporate service users’ perspectives which, in addition to abstinence-oriented outcomes, extend to other areas of psychosocial functioning such as stable housing, employment, relationships, etc.
To our knowledge, previous inpatient detoxification studies have not examined clients’ individual reasons and goals as reported when entering detoxification treatment. Past findings show that drinking goal preference was associated with several clinically important findings, including reduction in consumption, alcohol-related problems, and improvement in psychosocial functioning.
Therefore, Study 2 aims to explore a range of reasons and goals that detoxification clients have at their entry to detoxification service and again at discharge. This will inform better understanding about clients’ personal goals and reasons for entering detoxification, allowing for more targeted motivational enhancement, a tailored approach to treatment that addresses the varying and unique treatment needs of each individual entering detoxification, identification of optimal treatment following discharge from detoxification, and providing other support (e.g. accessing stable housing).
Finally, it is important to gain insight into clients’ satisfaction of detoxification service, which helps improve service quality to enhance client care as well as reduce unsatisfactory treatment experience, and improve treatment outcome (Kelly, Kyngdon, Ingram, Deane, Baker, & Osborne, 2018). We only identified one study (DiPaula et al., 2002) that investigated clients’ satisfaction of detoxification services. This was assessed by 3 questions specifically evaluating satisfaction with buprenorphine detoxification for heroin, which has limited generalisability of study findings to other inpatient detoxification treatment. In abstinence-based residential AOD treatment services other than detoxification, it has been found that more satisfied clients were more likely to attend outpatient aftercare (Arbour Hambley, & Ho, 2011). This is a desirable outcome because one of the main aims of detoxification is to encourage people to seek further treatment, which reduces the risk of relapse and readmission to detoxification. Further the higher overall ratings of satisfaction with treatment was associated with increased likelihood to return to treatment if needed (Donovan, Kadden, DiClemente, & Carroll, 2002). So if satisfaction is related to seeking further treatment or returning to treatment if needed, then it is an important initial outcome to consider. Thus we will also explore the relationship between satisfaction with services and the extent that participants felt they were helped for the reasons they entered detoxification.
Study 2 will trial a standard set of measures in inpatient detoxification services that aim to capture the individual goals and reasons (e.g. abstinence versus controlled use; help with accommodation, etc.) that participants have when entering detoxification and at the discharge from the service. To date, there is no study examining goals and reasons for entering detoxification. The following research questions and hypotheses are posed for study 2.
1. What proportion of participants entering detoxification have treatment goals other than abstinence? Do participants’ goals regarding abstinence/reduction in use change pre- (at intake) and post-detoxification (at discharge)?
2. Other than goals of abstinence or reduction in consumption, what are some other reasons for which participants enter detoxification?
3. What proportion of participants find detoxification beneficial in terms of addressing the different reasons for entering detoxification?
4. How satisfied do clients feel about detoxification services?
It is hypothesised that there will be positive relationship between treatment satisfaction and the extent that participants felt they were helped for the various reasons that they entered treatment.
The sample consisted of clients attending one of the Australian Salvation Army detoxification services located in Sydney, New South Wales (10 beds) or Brisbane, Queensland (12 beds), and the Gold Coast, Queensland (11 beds). These services are categories as Medium Level 1 detoxification facilities. Clients attending these services were provided with non- to low-medicated detoxification programs. Individuals at risk of severe medical or psychiatric complications were not admitted. The standard duration of the detoxification program is 7 days, although this varies on an individual basis depending on the level of care needed. Data were collected on clients entering detoxification services from April 2017 to January 2018, during which time 708 out of 1349 clients (52.48%) agreed to participate in the study. Those who were considered unsuitable to participate (e.g. exhibited high level of distress symptoms or aggression; not considered medically stabilised by staff, or those who were discharged before stabilisation) were not approached to participate in the study. This likely explains the relatively low participation rate.
A 16-item survey was developed based on prior research on goals and reasons for entering detox service. There are 3 goal choices of abstinence, controlled use and no change in use following detoxification, and 14 specific reasons (e.g. accommodation, legal, mental health, physical health, preparation for further treatment, etc.) and other (asked to specify). Items are scored on a Likert scale from 1 (strongly disagree) to 4 (strongly agree) with different descriptors for each response point.
Same measure was repeated at discharge to assess goals following detoxification using same item of goal choices, and 15 items of reasons to assess perceived help received. Items are scored on a Likert scale from 1 (Not at all) to 4 (very much) with different descriptors for each response point, and 0 (Does not apply to me).
A single item measure of influences for entering detoxification was based on an item from the Help Seeking Influences Question (Cusack, Deane, Wilson, & Ciarrochi, 2004) and is scored on a Likert scale from 1 (totally for others) to 7 (totally for myself) with different descriptors for each response point.
Addiction Severity Index (ASI-5; McLellan, Kushner, Metzger, Peters, Smith, Grissom, Pettinati, & Argeriou, 1992) is a semi-structured interview commonly used as a component of comprehensive assessment in AOD treatment programs. The AOD severity composites were used in this study.
Satisfaction measure consists of 16 items developed for the current study with 1 item assessing the overall satisfaction with the detoxification service received and 15 items assessing various aspects of the service, e.g. assessment process, accommodation, meals, case management support, recreational and social activities, spiritual support, medical treatment, transport, management of physical withdrawal symptoms, physical health, discharge planning, and preparation for future support, etc. The single item global satisfaction item correlates with the Client Satisfaction Questionnaire (CSQ-8). The 15 specific satisfaction items have internal reliability with a Cronbach’s alpha of .96 (n=548).
Salvation Army Management Information System (SAMIS) data will be accessed for other background, demographic and clinical data.