Opiate detoxification in an inpatient setting

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1 Opiate detoxification in an inpatient setting Dr Ed Day June 2005 >> Research briefing: 9

2 Key findings Outcomes Studies on inpatient opiate detoxification and its outcomes are relatively rare. In general, they report higher rates of successful completion of treatment than outpatient-focused studies. Client group served There is a reasonable level of clinical consensus regarding the types of clients that may benefit from inpatient treatment, for example people who are socially unstable, have severe drug or polydrug use, have co-existing medical and psychological problems or have a history of unsuccessful detoxifications in the community. However, clients with less severe problems may also benefit from inpatient treatment. Cost-effectiveness There is evidence that inpatient treatment leads to good outcomes overall and is possibly slightly more cost-effective. Detoxification is more expensive in inpatient settings, but such cost calculations should be informed by, and adjusted for, evidence of actual effectiveness in populations with different severities and outcomes. There is little specific research on the relative cost-effectiveness of treating more unstable patients with this intervention, but in clinical practice this form of treatment may be determined by individual client needs. Treatment setting Specialist drug and alcohol facilities may be more effective than non-specialist facilities for drug detoxification (for example, general psychiatric wards). Enhancing good outcomes Better treatment outcomes are seen where there is: an adequate length of time spent in treatment effective linking of detoxification to aftercare services, including residential rehabilitation. Factors associated with good outcomes suggest that detailed assessment and care planning, including a consideration of goals of treatment and aftercare provision, may help to maximise the efficiency of inpatient bed usage. Range of services The full potential of inpatient treatment is not limited to opiate detoxification. Current inpatient interventions include detoxification for a range of substances, dose titration, stabilisation of prescribed medication and assessment of physical and psychological functioning, as well as entry to residential rehabilitation. 2

3 Introduction The term inpatient treatment covers a range of services in many different settings. This may involve detoxification, rehabilitation, a combination of both, or one followed by the other. 1, 2 The full range of potential inpatient treatment includes inpatient assessment, dose titration and stabilisation. This review will focus on the use of inpatient services for opiate detoxification (excluding ultra-rapid detoxification under anaesthesia), but reference will be made to their uses in rehabilitation. Such services involve medically supervised prescribing with 24-hour medical or nursing cover, in addition to a variable level of psychological and other support. Because of its high cost, there has been a tendency to view inpatient treatment as expensive and unnecessary in all but the most complicated cases. 3 The number and variety of different inpatient services in England 2, 4 6 is not clear, but they appear to have diminished over time. There are both standalone specialist hospital units dedicated to the treatment of clients with drug or alcohol problems and services located within psychiatric or acute medical wards. In addition, many of the existing residential programmes in the non-statutory sector combine detoxification and residential rehabilitation (this briefing will not review the literature on the latter). Who should (and does) get admitted? There are a number of possible benefits from inpatient admission. 1, 7, 8 A hospital setting permits a high level of medical supervision and safety for individuals who may require intensive physical and psychiatric monitoring. The greater intensity of treatment may also help patients who do not respond to lesser measures. Inpatient treatment can help interrupt a cycle of drug use even in the absence of medically dangerous withdrawal symptoms. For some, the safety of an inpatient environment and a period of respite can help in their attempts to make important life decisions. Withdrawal can often be completed far more quickly in an inpatient environment, but if the programme is a comprehensive one, attention should also be paid to family, vocational, medical and psychiatric issues. However, the protectiveness of an inpatient unit may also be one of its main disadvantages, as a major determinant of craving is drug availability. Moreover, inpatients are unable to work, care for their families, study or conduct their normal daily activities. The stigmatisation of some inpatient service settings may also be a deterrent, particularly where beds are located within general 9, 10 psychiatric wards. Although there is a limited research evidence base for the role of inpatient detoxification services, there is a reasonable level of clinical consensus about the types of client who benefit from being admitted. 1, 8, 11, 12 Inpatient treatment may be of benefit to people who are socially unstable, more severely dependent, have co-existing medical or psychological problems or who have failed to complete more than one community-based detoxification. 1, 12, 13 Inpatient detoxification, in units offering intensive medical support, is also commonly used because of the reduced risk of the potentially serious medical consequences of withdrawal. Similarly, complicated detoxification regimes such as those required for patients dependent on two or more substances are also much easier to administer in a hospital setting. There is evidence that inpatient units facilitate clients who use multiple substances to achieve reductions in 14, 15 substance use. The National Treatment Outcome Research Study (NTORS) included a residential sample including 23 treatment programmes, eight of which were inpatient services and 15 were residential rehabilitation agencies. In total, 408 clients were recruited on entry to residential treatment, with 122 from inpatient units. 15 When compared to the study average, the inpatient sample had some of the longest heroin careers, lowest rates of employment and highest levels of psychiatric and physical health problems. The group was also more likely to have used cocaine than the community treatment cohort and had higher average levels of alcohol consumption. 5 A majority of clients achieved widespread improvements across a range of outcome behaviours and these were maintained at two years. What services can inpatient treatment provide? Medically-supported inpatient settings can be used for a range of tasks: Assessing the level of dependence Stabilising drug use, particularly when there is dependence on more than one substance Stabilising and/or subsequent detoxification of opioids, barbiturates, benzodiazepines or other sedative hypnotics Managing drug problems complicated by alcohol dependence Assessing and managing drug dependence and pregnancy Treating the secondary complications of drug use Assessing mental state Providing a period of respite from drug use and the ensuing psychosocial problems, particularly when there is limited social support available in the community. Furthermore, detoxification is often only the first step in the treatment process and inpatient settings may convey some 16, 17 advantages in enhancing entry to aftercare. 3

4 How effective is detoxification in inpatient services? Comparison of inpatient and outpatient settings Studies on inpatient detoxification and its outcomes are relatively rare. In general, a higher proportion of patients finish the treatment successfully in an inpatient environment (36 81 per cent) 9, 10, 13, compared with an outpatient setting (17 60 per cent) More research is needed to investigate the impact of new medical treatments now available in community settings, such as lofexidine and buprenorphine. Two randomised controlled trials have been reported with opioid dependent clients. Gossop et al 40 reported that 81 per cent completed a 21-day methadone reduction detoxification in an inpatient unit in London, compared with 17 per cent completing a six-week methadone reduction programme as an outpatient. 20 Wilson et al 9 found seven out of ten (70 per cent) of their inpatient detoxification group were opioid-free on discharge, compared with 11 out of 30 (37 per cent) of the outpatient group. 9 However, both studies included very small numbers of clients and utilised different medical treatment regimes in each setting. Non-randomised studies comparing inpatients and outpatients typically show that the former have more severe substance use histories and a greater prevalence of medical, psychosocial and vocational difficulties, including less social stability, increased unemployment and a greater prevalence of medical and psychiatric disorders. 1 However, this data reflects referral patterns and individual care needs rather than which populations fare best in each setting. Inpatient detoxification is considered to be most useful for those individuals who have too many adverse prognostic features to be successful at detoxification as an outpatient. In practice, not only are such individuals also the least likely to complete detoxification as an inpatient, but they are often especially unable to tolerate the constraints of a hospital setting. This has been described as the severity paradox, in which success is least likely in those who are particularly considered to require the approach. 30 Nevertheless, inpatient treatment for clients with complex problems is usually indicated because of clinical or other needs. Moreover, if clients with high healthcare costs and economic costs benefit from such intensive treatment, there is still a clear justification for providing inpatient services for that group, irrespective of how they compare to stable patients. Predictors of detoxification completion A number of studies have examined predictors of outcome for inpatient detoxification, but the research is very heterogeneous and it is difficult to draw firm and consistent conclusions. Retrospective reviews of specialist services are limited by methodological problems and it is doubtful that findings from varied settings, such as detoxification units and therapeutic communities, are comparable. Many studies include samples containing both alcohol and drug dependent clients, which limits the potential to make generalisations from the results. Furthermore, even studies that produce statistically significant results can yield findings that are of limited practical use in the clinical treatment situation. 31 Many studies have sought to identify those factors associated with leaving treatment before completion. Across all treatment settings, no consistent association has been found between dropout rates and age, sex, prior history of criminal activity or socio-economic factors. 32 Likewise, a history of previous treatment for substance misuse does not identify patients more likely to drop out, though a greater degree of drug or alcohol use upon entering treatment has been shown to be correlated with higher dropout rates. A range of predictors of inpatient detoxification completion have been identified. These include having lower levels of anxiety and depression on admission, 33 better family functioning, 34 greater lifestyle stability and more positive beliefs about self, 35 greater social integration before detoxification, 14, 25 less severe drug and medical problems 36 18, 22, 25 and reduced crack or cocaine use. Involvement with the criminal justice system appears to have a variable impact, with one study suggesting that being on probation or having a history of imprisonment was predictive of detoxification completion, 21 whereas another found that legal problems were associated with inpatient treatment failure. 18 An interesting study in Germany took advantage of changes in the national drug treatment system to show that regular contact with a counsellor and plans for abstinence-based follow-up treatment were significant predictors of completion. 21 Cost and cost-effectiveness The cost of providing inpatient services is clearly an important issue. In simple terms, detoxification in an inpatient setting appears to be much more expensive. Gossop and Strang, analysing the results of the London study mentioned above, 20 calculated that a three-week inpatient detoxification programme costs nine times more than an eight-week outpatient programme. However, when adjustments are made for different extents of successful outcomes, the costs of inpatient and outpatient treatment are almost identical, with a slight advantage to inpatient treatment in some cases. 37 A discussion of treatment costs is misleading if not informed by (and adjusted for) evidence of effectiveness. Rapid and successful exit from treatment is an issue to be taken into account. 4

5 Key success factors Effectiveness of specialist and general settings The use of non-specialist facilities for opioid and other drug detoxification is widespread in many areas of England, 6 but there is some evidence that it is not the most effective use of resources. Strang et al randomised heroin addicts to either a specialist inpatient drug dependence unit (DDU) or a general (non-drug specialist) psychiatric ward. 10 Of the 69 clients admitted to the DDU, 52 (75 per cent) remained in treatment until at least their first drug-free day, compared with only 13 (43 per cent) of the 30 clients admitted to the general ward. The specialist setting was associated with greater acceptance of randomisation, entry into treatment, completion of detoxification in hospital and a greater likelihood of opioid-free status at both two and seven-month follow-up. Length of stay The extent of the association between length of stay and inpatient treatment outcome is not clear. 1 Large-scale outcome studies have shown that drug-dependent patients, who received less than 90 days of treatment in either inpatient or outpatient programmes, did less well than those receiving more than 90 days. 38 NTORS calculated the odds of opioid use at one year for three periods of treatment 10, 28 and 60 days. In the inpatient and short-stay rehabilitation programmes, a period of 28 days was associated with the greatest chance of abstinence 16 and this was strongly related to the likelihood of overall improvement. The odds of abstinence from all of the target drugs at follow-up were about five times greater for those clients who remained in treatment for this length of time. Linking detoxification with aftercare Long-term drug treatment offers the most promising route to reduction in drug dependence and some dependent individuals begin their contact with the treatment system via detoxification. Even admissions as short as three days have been shown to have considerable benefits up to six months later. 39 Nevertheless, detoxification can also be problematic when not integrated into a comprehensive treatment system. The risk of accidental overdose with opioids is increased immediately after a period of detoxification. 40 It is important to consider the process not as a treatment in its own right, but rather as the first (and often necessary) step on a path to recovery. With this in mind, the link to a comprehensive aftercare package is important post-detoxification. Research at one inpatient unit has shown significantly better treatment outcomes among those who completed detoxification and went on to spend at least six weeks in a recovery and/or residential rehabilitation unit. In contrast, there were no significant differences between non-completers and completers who had no aftercare on the majority of measures of drug use during follow-up. 17 Studies examining predictive factors for entry into long-term treatment after detoxification have emphasised the importance of completion of treatment. 41 In one inpatient sample of clients treated for either alcohol or drug misuse problems, the severities of medical and drug problems were the strongest negative predictors for long-term treatment uptake. 36 Attempts have been made to evaluate psychological interventions to increase the uptake of aftercare after inpatient treatment. 42, 43 There is some evidence that participants who believed that long-term treatment would help them, would lead them to have more pleasure and fewer problems and reduce their health and money problems, were significantly more likely to utilise long-term treatment. A stated desire to participate in an abstinence-based treatment programme has been shown to be a significant predictor of completing an inpatient detoxification. 21 Conclusion Studies on inpatient detoxification and its outcomes are relatively rare, but the following broad conclusions can be drawn: The rates of successful completion of opiate detoxification are generally higher in studies carried out in inpatient settings, than those in outpatient settings. There is a degree of consensus about the type of client who may benefit from inpatient treatment, including those with complex needs and those in situations where residential treatment is required for medical or social reasons. Inpatient treatment can also be beneficial for more stable patients and although it is more expensive than communitybased-treatment options, the higher costs are at least partially offset by improved detoxification completion rates in the inpatient setting. Detoxification and other interventions in an inpatient setting can therefore be cost-effective. The factors that influence the likelihood of treatment success and improved outcomes include length of stay, the linking of detoxification with rehabilitation and aftercare, and the provision of treatment in specialist facilities. Models of care and Clinical guidelines for the management of drug misuse recommend that any intervention should be 3, 11 matched to the level of severity and complexity of drug misuse. Therefore, on the basis of both currently available evidence and extensive clinical experience in this area, inpatient services should form an important part of the complete treatment spectrum. However, further research would be useful to clarify the key therapeutic elements. This paper has focused on opiate detoxification and not on the wider role of the inpatient unit within the full spectrum of treatment for drug dependence. Future reviews should look at the role of inpatient detoxification for crack or benzodiazepine dependence. They should also look at the role of inpatient units in stabilisation, dose titration and assessment of prescribing of injectable medication. 5

6 References 1. Weiss, RD (1999) Inpatient treatment. In Galanter, M, Kleber, HD (eds) Textbook of substance abuse treatment. 2nd edn, Washington DC: The American Psychiatric Press. 2. National Treatment Agency for Substance Misuse (2003) Briefing on tier 4 services, London: National Treatment Agency for Substance Misuse. 3. Department of Health (1999) Drug misuse and dependence guidelines on clinical management, London: Department of Health. 4. MacGregor, S, Smith, L, Flory, P (1994) The English drugs treatment services, London: Social Policy Research Centre. 5. Department of Health (1996) Task force to review services for drug misusers: report of an independent review of drug treatment services in England, London: Department of Health. 6. Cyster, R, Brereton, R (draft, 2002) In-patient and residential detoxification and rehabilitation services in Yorkshire and Humberside, Resource & Service Development Centre. 7. Kleber, HD (1999) Opioids: detoxification. In Kleber, HD, Galanter, M, (eds) Textbook of substance abuse treatment, Washington: American Psychiatric Press: Mattick, RP, Hall, W (1996) Are detoxification programmes effective? The Lancet; 347: Wilson, BK, Elms, RR, Thomson, CP (1975) Outpatient vs hospital methadone detoxification: an experimental comparison. The International Journal of the Addictions; 10(1): Strang, J, Marks, I, Dawe, S, Powell, J, Gossop, M, Richards, D et al (1997) Type of hospital setting and treatment outcome with heroin addicts. British Journal of Psychiatry; 171: National Treatment Agency for Substance Misuse (2002) Models of care for the treatment of drug misusers, London: National Treatment Agency for Substance Misuse. 12. Ghodse, AH (2002) Drugs and addictive behaviour. A guide to treatment. 3rd edn, Cambridge: Cambridge University Press. 13. San, L, Cami, J, Peri, JM, Mata, R, Porta, M (1989) Success and failure at inpatient heroin detoxification, British Journal of Addiction; 84: Hattenschwiler, J, Ruesch, P, Hell, D (2000) Effectiveness of inpatient drug detoxification: links between process and outcome variables, European Addiction Research; 6: Gossop, M, Marsden, J, Stewart, D (1998) NTORS at 1 year. The National Treatment Outcome Research Study: changes in substance use, health and criminal behaviours at 1 year after intake. London: Department of Health. 16. Gossop, M, Marsden, J, Stewart, D, Rolfe, A (1999) Treatment retention and 1 year outcomes for residential programmes in England. Drug and Alcohol Dependence; 57: Ghodse, AH, Reynolds, M, Baldacchino, AM, Dunmore, E, Byrne, S, Oyefeso, A, et al (2002) Treating an opiatedependent inpatient population: a one-year follow-up study of treatment completers and non-completers, Addictive Behaviors; 27: Broers, B, Giner, F, Dumont, P, Mino, A (2000) Inpatient detoxification in Geneva: follow-up at 1 and 6 months, Drug and Alcohol Dependence; 58: Craig, RJ (1984) Personality dimensions related to premature termination from an inpatient drug abuse treatment program, Journal of Clinical Psychology; 40(1): Gossop, M, Johns, A, Green, L (1986) Opiate withdrawal: inpatient versus outpatient programmes and preferred versus random assignment to treatment, British Medical Journal; 293: Backmund, M, Meyer, K, Eichenlaub, D, Schutz, CG (2001) Predictors for completing an inpatient detoxification program among intravenous heroin users, methadone substituted and codeine substituted patients, Drug and Alcohol Dependence; 64: De Los Cobos, JP, Trujols, J, Ribalta, E, Casas, M (1997) Cocaine use immediately prior to entry in an inpatient heroin detoxification unit as a predictor of discharges against medical advice, American Journal of Drug and Alcohol Abuse; 23(2): Ghodse, AH, Dunmore, E, Sedgwick, PM, Howse, K, Gauntlett, N, Clancy, C (1997) Changing pattern of drug use in individuals with severe drug dependence following inpatient treatment, International Journal of Psychiatry in Clinical Practice; 1: Ghodse, AH, London, M, Bewley, TH, Bhat, AV (1987) Inpatient treatment for drug abuse, British Journal of Psychiatry; 151: Westreich, L, Heitner, C, Cooper, M, Galanter, M, Guedji, P (1997) Perceived social support and treatment retention on an inpatient addiction treatment unit, The American Journal on Addictions; b6(2):

7 26. Kleber, HD, Riordan, CE, Rounsaville, B, Kosten, T, Charney, D, Gaspari, J, et al (1985) Clonidine in outpatient detoxification from methadone maintenance, Archives of General Psychiatry; 42: Carnwath, T, Hardman, J (1998) Randomised double-blind comparison of lofexidine and clonidine in outpatient treatment of opiate withdrawal, Drug and Alcohol Dependence; 50: Akhurst, JS (1999) The use of lofexidine by drug dependency units in the United Kingdom, European Addiction Research; 5 (1): Day, E, Fisher, K, Jacqueline, W, Al-Gommer, O, McCormick, T (2003) The role of detoxification using methadone reduction in a drug treatment service, Journal of Substance Use; 8 (4): Seivewright, N (2000) Community treatment of drug misuse: more than methadone, Cambridge: Cambridge University Press. 31. Friedman, AS, Terras, A, Ali, A (1998) Differences in characteristics of adolescent drug abuse clients that predict to improvement: for inpatient treatment versus outpatient treatment, Journal of Child & Adolescent Substance Abuse; 7 (3): Stark, MJ (1992) Dropping out of substance abuse treatment: a clinically oriented review, Clinical Psychology Review; 12: Araujo, L, Goldberg, P, Eyma, J, Madhusoodanan, S, Buff, DD, Shamim, K et al (1996) The effect of anxiety and depression on completion/withdrawal status in patients admitted to substance abuse detoxification program, Journal of Substance Abuse Treatment; 13 (1): Murphy, PN, Bentall, RP (1999) Research note: opiate withdrawal outcome: the predictive ability of admission measures from the family assessment advice (FAD), Substance Use & Misuse; 34 (2): Murphy, PN, Bentall, RP (1997) Opiate withdrawal outcome: the predictive ability of admission measures of motivation, self-efficacy and lifestyle stability, Substance Use & Misuse; 32 (11): Franken, IHA, Hendriks, VM (1999) Predicting outcome of inpatient detoxification of substance abusers, Psychiatric Services; 50 (6): Gossop, M, Strang, J (2000) Price, cost and value of opiate detoxification treatments. Reanalysis of data from two randomised trials, British Journal of Psychiatry; 177: Simpson, DD (1979) The relation of time spent in drug abuse treatment to post-treatment outcome, American Journal of Psychiatry; 136 (11): Chutuape, MA, Jasinski, DR, Fingerhood, MI (2001) One-, three-, and six-month outcomes after brief inpatient opioid detoxification, American Journal of Drug and Alcohol Abuse; 27(1): Strang, J, McCambridge, J, Best, D, Beswick, T, Bearn, J, Rees, S, et al (2003) Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study, British Medical Journal; 326(7396): McCusker, J, Bigelow, C, Luippold, R, Zorn, M, Lewis, BF (1995) Outcomes of a 21-day drug detoxification program: retention, transfer to further treatment, and HIV risk reduction, American Journal of Drug and Alcohol Abuse; 21(1): Lash, SJ (1998) Increasing participation in substance abuse aftercare treatment, American Journal of Drug and Alcohol Abuse; 24(1): Millery, M, Kleinman, BP, Polissar, NL, Millman, RB, Scimeca, M (2002) Detoxification as a gateway to long-term treatment: assessing two interventions, Journal of Substance Abuse Treatment; 23:

8 Reader information Document This summary aims to review the factors purpose influencing the successful completion of opiate detoxification in an inpatient setting. Title Opiate detoxification in an inpatient setting Author Dr Ed Day Publication date June 2005 Contact details National Treatment Agency for Substance Misuse Until 16 July 2005: 5th floor, Hannibal House, Elephant and Castle, London SE1 6TE. Tel Fax From 18 July 2005: 8th floor, Hercules House, Hercules Road, London SE1 7DU. Tel Fax Target audience Primarily providers and commissioners of Gateway/ROCR The NTA is a self-regulating agency in relation drug treatment services in England, and approval to the Department of Health Gateway service users and carers. Circulation list Description Managers and commissioners of treatment services Co-ordinators and chairs of local partnership (e.g. drug action teams and crime and disorder reduction partnerships) Service user and carer groups Directors of public health, social services, police and probation services Special health authorities Medical directors of primary care trusts and mental health trusts Managers of prison healthcare Regional government department leads on drugs Central government department leads on drugs Royal College of Psychiatrists British Psychological Society/substance misuse faculty This review discusses the major variables affecting the success of an inpatient opiate detoxification programme, including treatment settings, length of stay and the range of client groups treated. Gateway/ROCR The NTA is a self-regulating agency in relation approval to the Department of Health Gateway Research briefings These briefings commissioned by the NTA are summaries of the research evidence on a particular topic to help inform providers and commissioners of services. They are not NTA guidance but are aimed at helping providers and commissioners reflect on local service provision. National Treatment Agency, London, 2005 The text in this document may be reproduced free of charge in any format or media without requiring specific permission. This is subject to the material not being used in a derogatory manner or in a misleading context. The source of the material must be acknowledged as the National Treatment Agency. The title of the document must be included when being reproduced as part of another publication or service. Publications All NTA publications can be downloaded from To order additional copies of this report, complete the online order form at or or telephone and quote product code: RB9 Product code: RB9 8

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