The Cleveland Clinic Alcohol Rehabilitation Program: a treatment outcome study

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1 The Cleveland Clini Alohol Rehabilitation Program: a treatment outome study A preliminary report 1 Gregory B. Collins, M.D. Joseph W. Janesz, M.Ed. Jan Byerly-Thrope, M.A. Sarah B. Forsythe Matthew J. Messina After the first 18 months of operation of the Cleveland Clini Alohol Rehabilitation Program, a treatment outome study was performed to determine demographi harateristis of the patient population and effetiveness of treatment. verall, 65.1% of alohol abusers and 78.4% of drug abusers ahieved favorable outomes. Treatment modalities that orrelated with positive outomes inluded inpatient rehabilitation, outpatient psyhotherapy, urrent ativity in Aloholis Anonymous, and taking disulfiram. The multimodality treatment approah was shown to be highly benefiial in helping people ahieve stable avoidane of drugs or alohol. Index term: Aloholism, rehabilitation Cleve Clin Q 52: , Summer Alohol Rehabilitation Program (G.B.C., J.W.J., J.B-T., M.J.M.) and the Department of Biostatistis (S.B.F.), The Cleveland Clini Foundation. Submitted for publiation June 1984; aepted Feb lp /85/02/0245/07/$2.75/0 Copyright ( dation 1985, The Cleveland Clini Foun- In August 1980, the Department of Psyhiatry at The Cleveland Clini Foundation developed an Alohol Rehabilitation Program (ARP) to provide outpatient and onsultation-liaison servies to patients with alohol and drugdependeny problems. No inpatient failities for detoxifiation or rehabilitation were available. Servies provided in the ARP inluded omprehensive hemial-dependeny evaluations, outpatient psyhotherapy aimed at abstinene from drugs and alohol, referral to Aloholis Anonymous (AA) or Narotis Anonymous, family therapy, and disulfiram (Antabuse) for seleted patients. Many patients were referred to other institutions for inpatient detoxifiation and rehabilitation. Upon return to outpatient status, the 245

2 246 Cleveland Clini Quarterly Vol. 52, No. 2 MISSING DATA 11.6% \ n=27 VERY PR PR 2.8% LIGHT USAGE 17.7% n=41 Fig. 1. Post-treatment use of alohol in 232 patients. n=57 Fig. 3. Post-treatment job performane in 232 patients. MISSING DATA 10.8% Fig. 2. Post-treatment use of drugs other than alohol in 232 patients. patients were followed in the ARP on a weekly or bi-weekly basis. After 18 months of operation of the ARP, a treatment-outome study was performed to determine harateristis of the patient population and the effiay of treatment modalities used in the ARP. Method In February 1982, after 18 months of ARP operation, an attempt was made to ontat all patients seen by the program sine its ineption. Inpatients and onsultation-liaison patients were exluded from the study. The information was obtained with the aid of a questionnaire during offie visits to the ARP, by telephone, or by hart review. Most information was obtained from pa- tients diretly, with a large majority of these responses orroborated by spouses, employers, or AA members. The questionnaire foused on demographi desriptive data, alohol and drug use, treatment modalities, employment status and performane, and global ratings of improvement. Statistial analysis and omputation of data were provided by the Department of Biostatistis at the Cleveland Clini. Results During 18 months between August 1980 and February 1982, 232 outpatients sought treatment at the ARP for hemial-dependeny. f these, 160 (69.0%) were male and 71 (30.6%) were female, (47.8%) were married, 30 (12.9%) were Cleveland Clini employees, 124 (53.4%) were employed full time outside the Cleveland Clini, 60 (25.9%) were ollege graduates or had postgraduate training, 56 (24.1%) had some ollege training, 56 (24.1 %) were high shool graduates only, and 36 (15.5%) had not ompleted high shool. The most ommonly used hemial was alohol (62.9%), although ombined alohol and drug use aounted for 18.1%, and naroti analgesi use represented 5.2%. ther drugs inluded tranquilizers, marijuana, oaine, stimulants, halluinogens, and inhalants. f referrals, 57.5% ame from medial or psyhiatri servies within the Cleveland Clini. Mean age of patients was 39.6 years (range, 14

3 Summer 1985 Cleveland Clini Alohol Rehabilitation Program (n=96) (n=107) F B YES M N Fig. 4. Any attendane in Aloholis Anonymous. Fig. 5. Patients urrently attending self-help meetings. to 69 years). Mean length of time of treatment was eight months. Post-treatment data for alohol and drug use of patients treated by the ARP are presented in Figures 1 and 2. The designation of "total abstinene" was given if a patient had not onsumed any alohol or drugs sine the time of entering treatment. This stringent outome riterion was met by 47.4% of aloholis, and 70.3% of drug abusers. The designation "abstinene plus light usage" inludes both totally abstinent patients and patients who had light, nonproblemati use on three or fewer oasions. This broader ategory is still onsidered positive, and inluded 65.1% of aloholis and 78.4% of drug abusers. The designation of "heavy-abusive usage" inludes heavy drinking episodes or overall heavy use of alohol or drugs, whih was reported in 23.3% of aloholis and 10.8% of drug abusers. "Missing data" inludes all patients who ould not be ontated for the ARP follow-up interview. Figure 3 displays reported job performane after treatment. f 141 appliable responses, 105 (74.5%) reported "very good" or "good" posttreatment job performane, whereas 15 (10.6%) reported "poor" or "very poor" job performane. All 232 patients reeived omprehensive evaluations and reommendations for treatment. Initially, 53 (22.8%) were admitted to the Cleveland Clini, 183 (78.9%) were referred to inpatient rehabilitation units or enters, and 103 of the 183 (56.3%) were admitted. f those admitted, 82% reported improvement as opposed to 62% improvement in those who refused admission. Although all patients were referred to AA, only 119 (51.3%) had some ontat with AA. Figure 4 illustrates hemial avoidane in patients who had been or were urrently in AA. In the 119 patients reporting any AA attendane, 99 (83.2%) were in the abstinent-light usage ategories, as opposed to 49 (67%) with no AA attendane. f 96 patients reporting urrent attendane at self-help groups, 87 (91%) reported abstinene or light usage, as opposed to 62 (58%) of 107 patients not urrently attending AA sessions (Fig. 5). Chemial avoidane also was orrelated with more frequent AA meeting attendane (78/86 or.7% "abstinene or light usage" for two or more AA meetings per week versus 7/9 or 78% for one meeting per week) (Fig. 6), and with having an AA "sponsor" (79/93 or 85% abstinene or light usage with sponsor versus 69/ 108 or 63.9% without sponsor) (Fig. 7). f those who reeived outpatient therapy, 80% reported

4 248 Cleveland Clini Quarterly Vol. 52, No (n= (n=9) g u F l i g h t usage 25 NE TW R MRE 0 Fig. 6. Number of self-help meetings per week. Number of patients with a sponsor in Aloholis Anon- Fig. 7. ymous. improvement. Disulfiram was used by only 7 patients, but (86%) of that group reported signifiant improvement. Spouse involvement in therapy or involvement in Al-Anon did not orrelate with improved outome. The order or sequene of treatment modalities was not evaluated. Generally, patients who reported using several of the reommended treatment modalities reported better hemial avoidane than those who used fewer modalities (Fig. 8). The treatment modalities reommended inluded evaluation, inpatient treatment, outpatient ounseling with the ARP, AA, disulfiram, family therapy, Narotis Anonymous, and Al-Anon. Surprisingly, 31 of 45 patients or 68.9% with minimal treatment (evaluation only and AA) did well. f 31 who eleted "evaluation only," 14 (45.2%) showed improvement. The ARP has had good suess regardless of marital status, although single and separated patients did not respond as well as others (Fig. 9). The ARP also has had good suess regardless of employment status, with the exeption of disabled patients. Espeially favorable results were ahieved among full-time Cleveland Clini employees (79.3%) and housewives (91.7%) (Fig. 10). The suess rate for all age groups was good exept for redued rates among the 21- to 30- year-old group (Fig. 11). Soial lass was determined by the method of Hollinshead and Redlih 1 aording to oupation and eduational level. Figures 12 and 13 show post-treatment alohol and drug use by soial lass. Class 5 (lowest) had the poorest outome for alohol abusers, and lasses 4 and 5 (lowest two lasses) had the poorest outome for drug abusers. Figure 14 demonstrates a strong orrelation between post-treatment drinking pattern and self-reported degree of improvement of the patient. Ninety-four perent of patients who reported being "muh better," and 86% who reported being "better" were in the "abstinene or light usage" group, while only 47% who reported being the "same," and 17% who reported being "worse" were in the "abstinene or light usage" group. Figure 15 shows a orrelation between selfreport of overall improvement and the number of treatment modalities used. The use of more

5 Summer 1985 Cleveland Clini Alohol Rehabilitation Program 249 (n = 8) (n=41) (n=48l (n=40) 80 (n=47) (n=31) 70 (n=43) 60 a«50 = 60 u. SS or more H H Fig. 8. Number of treatment modalities used by patients. Fig. 9. Marital status of patients. treatment modalities appears to be orrelated with linial improvement. In orrelating the length of time in treatment with linial improvement, it appears that during the first three months of treatment, all patients reported improvement. Beyond three months, the degree of improvement bore no orrelation to the length of time in treatment. Disussion After 18 months of operation, the Cleveland Clini ARP undertook this follow-up study despite several previously reported methodologial problems ommon to aloholism treatment studies. Voris 2 noted the onfounding fators of unertain suess riteria, questionable validity of self-report, and inability to loate subjets for follow-up. In the Cleveland Clini study, treatment "suess" was asertained through both "hard" measurements of outome, suh as abstinene or frequeny of use, and "soft" measurements suh as ratings of job performane and overall improvement. The unique stability of the Cleveland Clini patient population made it possible for outome data to be obtained on 89% of patients, with a high degree of orroboration and ross-validation. ur findings indiate that the ARP appears to be benefiial to most patients. Even when onsidering those patients with missing data as treatment failures, the ARP shows a favorable suess rate. If absolute abstinene is the riterion for suess, the ARP an report 47.4% of patients as Fig. 10. (n=16) (n-37) (n=8) ^ < f / / / / Employment status of patients. UNDER Q g 0 Fig. 11. Age at entry into the Cleveland Clini Alohol Rehabilitation Program.

6 250 Cleveland Clini Quarterly Vol. 52, No (n=77) (n=52) IW\\J 60 V (lowest) I Ü IV III II I HINGSHEAD& REDLICH SCALE (highest) tìsj 2 (n=23) Fig. 12. Post-treatment drinking pattern by soial lass. 10 g] (n=4) 0 totally abstinent from alohol and 70.3% of patients as abstinent from drugs. If light, rare, nonproblemati use is inluded with abstinene as the riterion for suess, 65.1% of alohol abusers and 78.4% of drug abusers had a favorable outome. In a review of the literature, Emrik/' 4 reported an overall abstinene rate of 33% after 12 months. Neubuerger et al 5 reported 52% abstinent after one year of 1,245 patients treated. Armor et al 6 indiated that only 10% to 24% of treated alohol abusers reported at least six months of alohol abstinene 18 months after finishing treatment. In omparison, the ARP of the Cleveland Clini appears to be working favorably. Subjetively, 71.7% of the patients treated in the ARP reported being "better" or "muh better," and 74.5% of those employed reported "good" or "very good" job performane Fig. 13. HINGSHEAD & REDLICH SCALE (n=28) Use of drugs other than alohol by soial lass. ^ gj Fig. 14. MUCH BETTER SAME WRSE MUCH BETTER WRSE Self-reported degree of overall improvement. sine treatment. Self-report of overall improvement was highly orrelated with hemial abstinene or avoidane. Sine patients were not randomly assigned to different treatment modalities in this study, omparisons between treatments are not possible. Nonetheless, positive outomes were assoiated with ative partiipation in treatment. Patients who used five or more treatment modalities had LU 1-1- UJ m LU CC 1- h- u LU z m 1- X 60 u 3 Q_ S LU 50 CC C o Fig. 15. (n=31) (n=. im, NE (n=41 ) (n=41) 'MVA TW THREE FUR FIVE TREATMENT MDALITIES R MRE Number of treatment modalities used by patients.

7 Summer 1985 Cleveland Clini Alohol Rehabilitation Program % positive outomes. Either more treatment is better or better-motivated (and more ative) patients have better outomes. Treatments that orrelated with positive outomes inluded inpatient rehabilitation, outpatient therapy, urrent ativity in AA, having an AA sponsor, and taking disulfiram. utpatient afterare ounseling was assoiated with improvement in 80.4%, whih supports the finding of Walker et al, 7 who reported 70.2% abstinene with afterare versus 23.4% without suh support. Dramati results were ahieved in patients who attended AA and other self-help programs. The value of self-help programs has been previously reported by Alford, 8 and Giannetti. verall, this outome study demonstrates that the Cleveland Clini ARP, with its multimodality approah, is highly effetive in helping people ahieve stable avoidane of drugs or alohol. Gregory B. Collins, M.D. Head, Setion of Drug and Alohol Rehabilitation The Cleveland Clini Foundation 9500 Eulid Ave. Cleveland H Referenes 1. Hollinshead AB, Redlih FC. Soial Class A Mental Illness: A Community Study. New York, Wiley, Voris SW. Alohol treatment outome evaluation: an overview of methodologial issues. Am J Drug Alohol Abuse ; 8: Emrik CD. A review of psyhologially oriented treatment of aloholism. I. The use and interrelationships of outome riteria and drinking behavior following treatment. J Stud Alohol 1974; 35: Emrik CD. A review of psyhologially oriented treatment of aloholism. II. The relative effetiveness of different treatment approahes and the effetiveness of treatment versus no treatment. J Stud Alohol 1975; 36: Neubuerger W, Miller SI, Shmitz RE, Matarazzo JD, Pratt H. Repliable abstinene rates in an aloholism treatment program. JAMA 1982; 248: Armor DJ, Polih JM, Stambul HB. Aloholism and Treatment. Santa Monia, California, Rand Corporation, Walker RD, Donovan DM, Kivlahan DR, 'Leary MR. Length of stay, neuropsyhologial performane, and afterare: influenes on alohol treatment outome. J Consult Clin Psyhol 1983; 51: Alford GS. Aloholis Anonymous: an empirial outome study. Addit Behav 1980; 5: Giannetti VJ. Aloholis Anonymous and the reovering aloholi: an exploratory study. Am J Drug Alohol Abuse 1981; 8:

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