A feasibility study to establish a new model for inpatient detoxification at the Independence Initiative

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1 A feasibility study to establish a new model for inpatient detoxification at the Independence Initiative Dr Michelle Wareing Researcher in Substance Misuse Dr Harry Sumnall Senior Research Fellow February 2006 Centre For Public Health, Faculty of Health and Applied Social Sciences Liverpool John Moores University Castle House, North Street Liverpool L3 2AY 1

2 Executive Summary Introduction A feasibility study for a one-to-one detoxification service was carried out by the Centre for Public Health, Liverpool John Moores University. The study was conducted in order to ascertain the feasibility of establishing a new model of one-toone inpatient detoxification at the Independence Initiative, located in Bootle, Merseyside. This study was not a cost analysis of a one-to-one detoxification service but examined feasibility based on potential demand. This was completed in order to establish perceptions in relation to the establishing of an alternative model of detoxification. Methodology A series of semi-structure interviews were conducted with clients from the Independence Initiative, clients from community drug teams and with D(A)AT commissioners in order to investigate the feasibility of establishing a one-to-one detoxification model. In all, a total of 35 clients were recruited to participate in the study, 20 individuals were from the Independence Initiative (3 female and 17 male, mean age 39.1), and a cross section of 15 recovering drug users community drug teams (4 female and 11 male, mean age 35.1). Clients were asked to respond to various questions relating to sociodemographics, current drug use, and experiences of detoxification, aftercare provision, and one-to-one models of detoxification. Four D(A)AT commissioners participated in the study and were asked to respond to several questions describing their current detoxification interventions, and to describe their beliefs about the feasibility of establishing a one-to-one model of detoxification. 2

3 Findings The overwhelming majority of clients from the Independence Initiative were interested in the prospect of a one-to-one detoxification service being established and cited the main benefit of this type of approach as the lack of interaction with other drug users. However, the disadvantages of this particular type of detoxification were also addressed and other clients claimed that they might feel lonely without contact with friends and families, and paradoxically, other drug users. The most important elements of establishing a one-to-one detoxification service from the clients perspective was a safe environment which they could detoxification within; friendly, sensitive, and helpful staff, and activities (e.g. recreation, skills) to keep them occupied. Clients from the community drug teams gave almost identical responses to the questions about one-to-one detoxification service, indicating that this type of approach would be popular with a wide variety of clients, not just those already in contact with the Independence Initiative. D(A)AT commissioner s responses to the establishment of a one-to-one model of detoxification were mixed. Half the D(A)ATs questioned said they would be willing to commission such a service and the other half were unsure. The main issue raised by commissioners was that client isolation may be a problem and that they would also need more evidence that this particular type of detoxification would be (cost) effective. In order to provide support to the commissioning of a one-to-one service, D(A)ATs would require that this particular model was first piloted and a suitable stable aftercare system put in place. Again, half of commissioners questioned could foresee barriers to this type of detoxification service, in that, cost may be an issue and that clients may need some type of peer/client support. However, if proven a (cost) 3

4 effective intervention, the feasibly of commissioning this particular type of detoxification can not be ruled out as D(A)ATs did not identify any impassable barriers to a one-to-one service Recommendations Set out below is a list of recommendations prior to the establishment of a one-to-one detoxification service. It is recommended that a full cost analysis based on the accommodation available and development of such a property to house one-to-one detoxification clients be undertaken. It is also recommended that a full cost analysis be completed in order to determine household running costs (e.g. food, electricity, gas, etc) and staffing levels including clinical staff, as well as the extent of multi-disciplinary input. Set out below is a list of recommendations based on the finding from this feasibility study. It is recommended that a comprehensive assessment be undertaken of potential clients in order to judge their appropriateness of entering into a one-to-one detoxification service. It is recommended that clients who do engage in this particular type of detoxification model understand, and be familiar with, the expectations of a one-to-one detoxification service. It is also recommended that clients should be allowed communication and contact with their family or partner/spouse. Caution will be required as family members/spouses may also be substance users. It is not recommended that 4

5 there is contact with other clients and known drug users. Communication opportunities will reduce feelings of isolation and loneliness. A number of diversionary and skills related activities should also be put in place in order to for clients to be able to occupy themselves. This may also help with problems of loneliness and isolation. Both clients and D(A)AT commissioners raised the issue of employing helpful and caring staff. Therefore, staff members should be aware of the uniqueness of the one-to-one model and likely client needs, and have sufficient knowledge and ability in order to be able address their needs in a professional manner. 5

6 Contents Page number 1.0 Introduction The Independence Initiative Detoxification and Treatment Approaches Naltrexone Ultra Rapid Detoxification (URD) Residential Rehabilitation and Community Detoxification Models of Care Waiting Times for Detoxification Provisions in the United Kingdom Aftercare, ICT and Basic Skills Provision Summary and Aim of the Current Study Research Methodology Results Independence Initiative Current and Previous Drug Use Cannabis Cocaine Crack Cocaine Heroin 33 6

7 2.1.5 Methadone Alcohol Previous Detoxification Experiences In-Patient Detoxification Community Detoxification Prison Detoxification Unsupported Detoxification Relapse Prevention Aftercare Activities One to One Detoxification Results Community Drug Team Clients Drug use Benzodiazepines Cannabis Crack Cocaine Heroin Methadone Alcohol 59 7

8 3.2 Previous Detoxification Experiences Inpatient Detoxification Community Detoxification Prison Detoxification Unsupported Detoxification Relapse Prevention Aftercare Activities One- to-one Detoxification Results DAAT Joint Commissioners Current Detoxification Provision One to One Detoxification Provision Conclusions Interaction Safe and Secure Environment Isolation Understanding and Caring Staff Limitations Summary and Recommendations Summary 86 8

9 7.2 Recommendations Prior to the Implementation of A Oneto-One Detoxification Service being established 7.3 Recommendations to the Implementation of A One-to-One Detoxification Service References 89 9

10 Tables Independence Initiative Page number Table 1 Accommodation Type 31 Table 2 Cannabis Use 32 Table 3 Heroin Use 33 Table 4 Alcohol Use 34 Table 5 Independence Initiative-Age First Used Substances 35 Table 6 Table 7 Type(s) of Drugs Clients were Detoxifying From in an In- Patient Setting Type(s) of Drugs Clients were Detoxifying From in a Community Based Setting Table 8 Medication Provided in a Community Detoxification Setting 41 Table 9 Table 10 Table 11 Table 12 Type(s) of Drugs Clients were Detoxifying from in a Prison Setting Medication Provided in a Prison Detoxification Setting Type(s) of Drugs Clients were Detoxifying from in an Unsupported Setting Aftercare Activities Clients from the Independence Initiative are Currently Undertaking Results Community Drug Team Clients 13 Accommodation Type Heroin Use Alcohol Use Community Drug Team Clients-Age First Used Substances 17 Type(s) of Drugs Clients from the Community Drug Teams were Detoxifying From in an In- Patient Setting 18 Type(s) of Drugs Clients from the Community Drug Teams were Detoxifying From in a Community Based Setting

11 19 Type(s) of Drugs Clients from the Community Drug Teams were Detoxifying From in a Prison Setting 20 Type(s) of Drugs Clients from the Community Drug Teams were Detoxifying From in an Unsupported Setting 21 Aftercare Activities Clients from the Community Drug Teams are Currently Undertaking

12 1.0 Introduction The aim of this study was to investigate the feasibility of establishing a new model for inpatient detoxification at the Independence Initiative, located in Bootle, Merseyside. The model requires individuals to engage in personal development, day programs, education and/or training and relapse prevention activities solely on a one-to-one basis. At present, current detoxification provisions are carried out in specialist inpatient detoxification units, hospitals (usually psychiatric wards), in the community, or in prisons. The client undergoing detoxification will receive specialist care and treatment in a group setting where peer support is encouraged. The one-to-one model differs from current provision in that clients are not encouraged to associate with other individuals undergoing detoxification. In the present study, the feasibility of this type of detoxification provision was determined through interviews with (a) drug users who had previously undertaken a one-to-one approach to relapse prevention in other schemes; (b) drug users in contact with services from the community drug teams who had experience of current detoxification provision in Merseyside; and (c) with local D(A)AT commissioners/managers The Independence Initiative The Independence Initiative is a relapse prevention service based in Bootle, Merseyside. It was established in 1998, with the main aim of providing support to recovering drug users who have made a commitment to a drug free lifestyle, or those that have reached a particular level of stability in their lives (in drug use, accommodation and lifestyle). The organisation concentrates on providing tailored action plans on a one-to-one basis, in order to meet the client needs. Justification for this distinct form of intervention derives from the notion that treating clients on a one- 12

13 to-one basis will help relapse prone individuals stabilise their lives. The project discourages contact with other recovering clients in the centre thereby minimising access to potential sources of drugs, which is believed to help prevent further relapse. This one-to-one approach is believed to be particularly suitable for clients perceived as being vulnerable such as those prone to peer pressure, or those who are at a disadvantage in a group setting (McVeigh & Duffy, 2002). The Independence Initiative offers a multifaceted model of intervention in that; all interactions with clients is on a one-to-one basis; all clients are referred to the service by other agencies (after consultation with the Independence Initiative); and staff members provide a befriender mentoring scheme in which social skills and social networks are developed through staff members accompanying clients on various outings such as, trips to the town centre, going to the gym and attending open days at local colleges. Services offered to clients on a one-to-one basis are tailored to suit client s needs and to encourage natural talents. As well as relapse prevention and counselling, clients can engage in a range of complementary therapies (e.g. aromatherapy, meditation, massage, Tai Chi and Yoga), educational and pre-vocational training (i.e. basic skills, ICT, history, maths and English), and various recreational and leisure activities such as, sewing, music production, arts and crafts, cookery and photography. The Independence Initiative is successful at engaging (recovering) drug users. This is evident in the number of clients that pass through the service each year. From March 2004 to March 2005 the Independence Initiative assessed a total of 302 clients and 13

14 254 action plans were completed. Moreover, 44 clients gained an accredited qualification and 24 individuals went on to further education or training within mainstream society. Seven people took up positions within the community drug teams and 15 clients gained employment. The Centre for Public Health previously evaluated this model of treatment at the Independence Initiative and found lower levels of drug use amongst established drug users (in contact between six months and two years) compared to new clients to the service (in contact less than six months) (McVeigh and Duffy, 2001). A similar outcome was observed with respect to criminal behaviour, with established clients reporting lower occurrences of criminal activity in the previous six months than new clients. The perceived and actual health and well-being of new and established clients was also recorded with both user groups reporting lower Accident and Emergency (A&E) visits. Furthermore, both client groups rated physical and mental health, as well as, the quality of relationships as positive outcomes. Staff representatives from various referral agencies were very positive about the Independence Initiative echoing the views of clients, in that, in their opinion they believed that the one-to-one intervention was the main strength of the service. There was a general consensus among referral staff that the Independence Initiative maintains high standards and that they do more than just stabilise drug problems, gradually integrate drug users back into employment and into mainstream society. The Independence Initiative provides services that are viewed positively by both referral agencies and clients. As described in the earlier evaluation, decreases in drug 14

15 use, criminal behaviour and Accident & Emergency attendance were recorded by clients and increases in their perceptions of drug stabilisation, mental and physical health, as well as the gradual normalisation of integrating clients into mainstream society and employment, all point to a successful and effective service. 1.2 Detoxification and Treatment Approaches The most common definition of detoxification is to remove poison or the effects of poison from the body. In substance abuse treatment the term is used in an analogous manner; in that, drugs or the effects of drugs are eliminated from the body and the person enters a period of withdrawal (Preston & Malinowski 1997). Signs of opioid withdrawal usually manifest during the first 8-12 hours after the last dose, and are characterised by a number of symptoms including eye-watering, runny nose, yawning, sweating, restlessness, dilated pupils, piloerection, tremor, irritability, anorexia, bone and joint pain, and stomach cramps (Mattrick et al., 1996, p97). After a period of hours withdrawal symptoms tend to peak and the individual can experience insomnia, more pronounced lack of appetite, violent yawning and sneezing, severe eye-watering, profuse nasal discharge, and inflammation of the nasal mucous membranes. In general, symptoms subside after 7-10 days although often the individual feels a general malaise for a few months after detoxification and frequently drug cravings do occur. While withdrawal from opioids is rarely a life threatening situation, individuals often describe it as having a sever case of influenza. According to Mattrick and Hall (1996) there are many factors that actually influence the completion rates of withdrawal from opioids. These range from the reasons the person wants to engage in detoxification, to be stabilised from methadone, to having a 15

16 criminal justice order put in place, to reduce the amount of heroin being used by the client, through to total abstinence from illicit substances. There are various different kinds of detoxification services in place, including, pharmacological interventions such as Naltrexone prescribing, general anaesthesia and Ultra Rapid Detoxification (URD), inpatient and residential rehabilitation as well as community detoxification. However, a one-to-one model for detoxification is a unique intervention intended for substance misusers who may be at a disadvantage through being placed in a group setting Naltrexone Heroin is a drug of dependence. It is quickly metabolised in the liver to morphine, which binds to specialised opioid receptor proteins in the brain. Most opioid receptors are located in areas of the brain involved in pain and emotions. The effects of heroin are partly mediated through the actions of the neurotransmitter dopamine, which amongst its numerous functions is associated with (the anticipation of) pleasure or recall of pleasurable experiences, and so plays a major role in establishing and maintaining dependence. The desirable short-term effects of heroin usually consist of an increase in positive mood, and a reduction in pain and anxiety, as well as increased nausea and drowsiness. The long-term effects of heroin use are tolerance and dependence (with associated withdrawal); with possible other physical effects and risks associated with injecting such as skin infections, ulcers, hepatitis and HIV/AID. Naltrexone is an opioid receptor antagonist (i.e. blocks the receptors that heroin would otherwise bind to) that prevents or reduces the effects of endogenous (i.e. produced 16

17 within the body) and exogenous (i.e. externally administered, e.g. heroin) opioids (Grusser et al, 2005). The euphoric effects of opioids such as heroin are blocked when an individual is pre-treated with Naltrexone. The repeated lack of reward, as well as the perceived "pointlessness" of using the drug, gradually results in the reduction of heroin use. Naltrexone is therefore given to recovering heroin users as part of relapse prevention in order to stop the user from experiencing the euphoric effects of the drug. Therefore, should the individual use heroin whilst taking Naltrexone the person would not incur any of the usual positive feelings. In a comprehensive review of the Naltrexone literature, Tucker and Ritter (2000) concluded that opioid users do not generally accept this form of treatment. Various justifications and reasons have been proposed as to why this is, including fear of withdrawal, anxiety regarding a new drug or potential aversive reaction which might be experienced, and the absence of euphoric producing effects of opioids. Out of the 157 studies reviewed, the authors found that after using Naltrexone, participants generally reported lower levels of craving, significantly higher rates and longer periods of abstinence, and a significant improvement of psychosocial functioning than placebo or standard drug treatment programs (e.g. methadone). Moreover, being employed, receiving good social support, being older, and having a higher number of previous treatments were all associated with successful outcomes. The authors argued that while poor acceptability of Naltrexone is common, this drug is most effective and successful for individuals that are highly motivated to obtaining a drug free lifestyle. 17

18 1.3.1 Ultra Rapid Detoxification (URD) Lawental (2000) compared treatment outcomes and findings of URD clients with clients in inpatient detoxification. In this sample, 87 participants received inpatient detoxification and 139 participants URD. All were clients over the age of 18 who had successfully completed detoxification and had agreed to take part in a telephone survey months afterwards. Data were also collected from participant s files, the initial interview and a current examination. Results showed that a significant difference was obtained with regards to inpatient detoxification, with more clients reporting abstinence (43%) than in the URD group (22%). Furthermore, the cost of URD was almost twice as expensive than inpatient detoxification. There were two variables in the inpatient group that were significant predictors of positive treatment outcomes, higher education and lack of probation status, while in the URD group only one variable could be counted as a significant predictor, higher educational level. In a similar vein, De Jong and colleagues (2005) investigated URD from opioid dependence using Naltrexone. Moreover, they aimed to establish if general anaesthesia, compared to an opioid antagonist such as Naltrexone, could be a more beneficial option in terms of withdrawal symptoms and abstinence from opioids. Alternative approaches to detoxification are commonly introduced in contemporary practice in order to attempt to reduce detoxification time from opioids, while at the same time encouraging the completion of assisted detoxification programs. Anaesthesia has been proposed as a fast and pain free detoxification treatment and has been introduced in order to shorten the detoxification period and to reduce experience of negative symptoms (De Jong et al, 2005). Two treatment groups were recruited into this study; the first group consisted of 135 patients who were given a rapid 18

19 detoxification with an opioid antagonist (Naltrexone). The second group consisted of 137 patients who were given an anaesthetic for four hours as soon as withdrawal symptoms began to emerge. Groups were well matched in terms of age, drug use and the number of previous detoxification treatments. Interestingly, while no adverse effects were observed in the URD group, in the anaesthetic group, five individuals experienced adverse effects ranging from extreme drowsiness resulting from the anaesthetic, to agitation and anxiety in clients that had a history of psychiatric episodes. Results from this study indicated that there were no significant differences between groups with regards to the severity of withdrawal symptoms or in opioid abstinence at follow up. However, at the end of the first day of withdrawal and at the beginning of second, the anaesthetic group reported significantly higher withdrawal stress than patients receiving Naltrexone. These results indicated that anaesthetic did to reduce opioid withdrawal symptoms as effectively as Naltrexone. The authors concluded that, general anaesthetic should no longer be used in rational detoxification guidelines (De Jong et al., 2005, p214) Residential Rehabilitation and Community Detoxification The general consensus from studies focusing on opiate detoxification is that inpatient detoxification shows higher success rates than outpatient detoxification provision (Mattick and Hall, 1996; Ghodse et al., 2002; Mark et al., 2002; Gossop, 2004). The main aim of both in-patient and community detoxification programs are to aid and support the client to achieve abstinence and a stable lifestyle. However, before 19

20 the individual enters into the detoxification process many treatment services will have already attempted to stabilise the person s drug use. This is usually undertaken through a methadone maintenance program and advice is given to ensure harm reduction practices are put in place. The National Treatment Outcome Research Study (NTORS) was the first large scale study of treatment outcomes of drug users in the United Kingdom (UK) and reported that compared with community services (e.g. methadone maintenance) clients engaging with residential services were more likely to be older, have a longer history of heroin use, were more likely to have shared injecting equipment, and were poly drug as well as alcohol users (Gossop et al., 2001). No one method of detoxification is effective for all clients and the method used should depend on the clients characteristics as well as the nature of their drug use. Completion rates for clients in residential rehabilitation programs have a higher success rate (75-80%) than in community settings (20-53%) (Meier et al., (2005)). However, relapse back into drug use often occurs during the process of maintaining abstinence. Generally, there appears to be a number of factors that influence how effective inpatient detoxification services are. These range from the amount of time spend in treatment, retention rates, the characteristics of the clients, as well as the provision of a structured aftercare plan (Meier et al., 2005). In light of this, the National Treatment Agency (NTA) has acknowledged retention as a central part of treatment objectives. 20

21 In a national survey of 57 (out of 87 approached) residential rehabilitation services in England, detoxification provision was provided by 34 (39.1%), and treatment duration varied from 1 to 12 months with an average of 22 weeks (Meier, 2005). Fees ranged from 215 to 3,800 per week. The average weekly fee for detoxification and primary treatment (excluding private hospitals) was 667, and for services that provided detoxification, primary and secondary treatment the average price per week was 476. Predictors of retention tended to stem from individual counselling and domestic duties as well as the amount of overall programme time an individual was planned to attend. Significantly more clients remained in treatment when required to undertake up to 38 hours of treatment per week. Individual counselling sessions lasting one to two hours had the highest completion rates compared to organisations that provided up to one hour per week. Interestingly, those services that provided single room occupancy had better retention rates than services that provide room-sharing facilities. A greater number of beds and housekeeping duties (0 to 8 hours) were associated with lower completion rates and high service fees and more individual counselling (perhaps resulting in the higher fee) were related to higher completion rates. This survey highlights the importance of sufficient resourcing, as single room occupancy appears to result in better retention and lower drop out rates. Moreover, the NTA have stated that in accordance with national care standards residential rehabilitation provision should mainly consist of single rooms. In order to successfully retain clients in residential rehabilitation, providing a treatment program that is not over challenging or demanding for clients in terms of housekeeping responsibilities or in structured actives is key. Furthermore, by integrating sufficient 21

22 levels of individual counselling into their programs clients are more likely to complete treatment. Substance misusers that decide to leave the service or to drop-out early, in general, cannot be labelled as failures as even a short time in residential rehabilitation can be beneficial to the client in the long term (Meier, 2005). Yet, client characteristics do seem to play a significant role in producing good outcomes. As highlighted previously, the NTORS study showed that substance misusers with a long history of drug use and more severe problems in entry to residential rehabilitation had lower drop out rates. Lang and Belenko (2000) reported that those clients with close friends, fewer drug convictions, who had a partner, and engaged in less risk taking behaviour, were more likely to complete treatment. As suggested by the results of study by Ghodse and colleagues (2002), better outcomes are achieved if followed by a structured aftercare plan. This study highlighted the need to engage clients in aftercare following detoxification. Clients that had undertaken an aftercare programme showed better treatment outcomes, in that; positive changes were made in drug using patterns, resulting in a better quality of life. 1.4 Models of Care Models of Care, (NTA, 2002), is a national framework which has been put in place for the commissioning of adult drug misuse treatments in England. Models of Care has categorised services for substances misusers into a four tier hierarchical system 22

23 that assigns drug users to the relevant provision that is most suitable to address their particular needs. For example Tier 1: Tier 2: Tier 3: Tier 4a: Tier 4b: Non-substance misuse specialist services Open access substance misuse services Structured community based substance misuse Residential substance misuse specific services Highly specialist non-substance misuse specific services In-patient detoxification falls under the Tier 4a category which is targeted at individuals with a high level of presenting need and is made up of abstinenceoriented programs, detoxification services, or services which stabilise clients (Models of Care, 2005, p19). A recent study focusing on Tier 4a provision in England (NTA, 2005) set out to investigate the current provision of Tier 4a services, regionally and nationally, and to estimate future levels of needs for both inpatient detoxification (IPD) and residential rehabilitation (RR). Two main pieces of research underpinned this study; a review of the current type and organisation of provision of IPD and an assessment of needs for all Tier 4a provisions. In relation to the IPD review (Best et al, 2005), a survey method was employed and 91 (71%) of the 129-inpatient detoxification units that were approached responded. Findings across England showed inconsistencies in the delivery of detoxification provisions from the three main detoxification facilities (specialist units, residential 23

24 rehabilitation services, generic medical and psychiatric wards). In general, medical cover, staffing levels and effective care planning showed the most variation between the three-detoxification provisions. An estimated 10,771 IPD admissions were recorded for 2003/4 and the average length of stay ranging from four to 77 days. The study also showed: 6,829 substance misusers were admitted to specialist detoxification units 2,077 detoxifications took place on psychiatric wards 1,085 drug users detoxified in residential settings. The survey found that IPD services were poor and one third of detoxification services did not require clients to have a care plan in place. Furthermore, 63% of specialist clinicians felt that the number of beds currently available for detoxification was inadequate or totally inadequate and more than half of the clinicians surveyed felt the range of services offered was inadequate or totally inadequate. There is current a lack of suitable facilities for IPD, a lack of treatment options, a limited number of detoxification services, and mixed views of the efficacy of current treatment approaches. In general, outcome research on opiate detoxification is lacking in the opiate literature. However, Day (2005) set out to examine and review the current literature and the situation of inpatient and detoxification provision in the UK (excluding ultrarapid detoxification with anesthesia). Inpatient rather than outpatient detoxification provision appeared to be a more successful environment for clients withdrawing from substances. In general, studies have found that clients who benefited most from 24

25 inpatient detoxification were usually socially unstable, had an acute dependency problem, reported simultaneous medical and psychological problems and had, on previous occasions, failed to complete a community based detoxification program. Day (2005) concluded that certain predictors of detoxification can be acknowledged but firm conclusions cannot be drawn because there was great variation in the methodology of studies reviewed. However, a range of predictors for detoxification completion were proposed, which included reduced levels of anxiety and depression upon entrance into detoxification services, good family function and life stability, good self-efficacy, greater social interaction, a minimum of drug related medical problems and reduced cocaine and crack use. Key accomplishment factors to successful detoxification were also established which include; effectiveness of specialist general settings (Drug Dependent Units rather than a hospital setting), length of stay (28 days was associated with greatest chance of abstinence) and linking detoxification with aftercare (Day, 2005) Waiting Times for Detoxification Provisions in the United Kingdom Nationally The National Treatment Agency has published national average waiting times for treatment (December 2001 to March 2005) (Donmall et al, 2005). D(A)AT services reporting to the NTA have shown a significant decrease in waiting times over the previous three years. In the last year (March March 2005) a decrease from 2.7 weeks to 2.5 weeks was reported. In general, this means a decrease of 1.25 days. Furthermore, since December 2001 waiting times have been reduced by an average of nine weeks. In DIP areas, average-waiting times from January to March 2005 was 1.9 weeks, compared with the national average of 2.5 weeks. 25

26 Nationally, from December 2001, waiting times for inpatient treatment was on average 12.1 weeks. By March 2005 it had been reduced to 3.0 weeks. Regionally With regards to the North West of England, a sharp decrease in waiting times for detoxification from 9.2 weeks in December 2001 to 1.9 weeks in March 2005 was recorded, which equates to a reduction of 7.3 weeks (Donmall et al, 2005). The North West of England reduced its waiting times for inpatient treatment from 13.6 weeks in December 2001 to 2.7 weeks in March 2005 resulting in an overall reduction of 10.9 weeks Aftercare, ICT and Basic Skills Provision Once clients have successfully completed detoxification from a particular substance, they often become involved in rehabilitation programs. Through incorporating Information Communication and Technology (ICT) provision into the rehabilitation process substance misusers can be motivated into joining the workforce. For example, in Scotland a number of projects are under way that have made use of ICT in their rehabilitation programs with the aim of encouraging recovering substance misusers into education and employment. A feasibility study carried out by the Effective Interventions Unit (Scotland) provided information and evidence to support effective interventions designed to help recovering drug users into education, training and employment (Richards et al, 2002). This review found that most substance misusers were unemployed and relied on benefits. Although the main barriers to drug users gaining employment were directly 26

27 related to their use of substances, where successful, employment could actually help with the recovery process. The study also established that many drug treatment services were beginning to extend their service provision to include access to learning, training and employment. Pathfinder reports (set up by the Learning and Skills Council to aid individuals with numeracy skills) have highlighted the benefits of including drug users in ICT programs. For example, Gloucester Reintegration Service are currently involved in helping previous drug users into employment through the use of training in ICT packages in order to develop numeracy skills Summary and Aim of the Current Study In summary, the changing needs and circumstances of today s drug users needs to be addressed, alongside the attempts of service providers to accommodate and aid their requirements. No single method of detoxification is effective for all clients; therefore, a comprehensive approach is warranted that can be adapted to individual needs. Consequently, the Independence Initiative were keen to investigate the possibility of providing a detoxification service congruent with the one-to-one model currently in operation at the service. If found feasible, clients would have the choice between conventional in-patient group work, community detoxification interventions or a new one-to-one detoxification option. Aims To investigate the feasibility of a new model for one-to-one inpatient detoxification 27

28 This was achieved through the following: Examination of the views and perceptions of clients attending the Independence Initiative regarding their experience of the current detoxification interventions and their views on the proposed one-to-one model of care. Examination of the views and perceptions of recovering drug users from other service providers in order to determine their experience of detoxification and their views on the one-to-one model of care. Investigation of Merseyside D(A)AT Commissioners/Managers current inpatient detoxification services and to establish views on a possible one-toone detoxification model. Also to establish if they would be willing to run a one to one pilot within their area or with clients living in their D(A)AT. 28

29 1.7. Research Methodology A multi method approach was employed in order to ascertain the feasibility of a one to one method of detoxification. Participants In all, a total of 35 clients and 4 D(A)AT commissioners and mangers were recruited to participate in the study, 20 individuals were from the Independence Initiative (3 female and 17 male, mean age 39.1) and a cross section of 15 recovering drug users were recruited from the community drug teams (four female and 11 male, mean age 35.13). Clients from the Independence Initiative were identified through key workers and asked if they would be willing to participate in this study. Community drug teams clients were recruited from services based in Waterloo and in Southport and a similar recruitment procedure was in place for clients in the community drug teams, in that, key workers identified prospective clients and asked if would they would be willing to take part in the study. The requirement for inclusion into this feasibility study was that clients had previously engaged in a detoxification program Materials Client Questionnaires Participants were asked to respond to various questions relating to their current drug use, accommodation type, experiences of detoxification, aftercare provision, one-toone model of detoxification, employment history and training and learning experiences. 29

30 D(A)AT Questionnaires Commissioners and or managers were asked to respond to several questions describing their current detoxification intervention, the feasibility of a one-to-one model of detoxification and learning and training provision. Procedure In order to ensure consistency, accuracy and completeness, all interviews were undertaken by the same researcher. Interviews were conducted firstly at the Independence Initiative, then with D(A)AT commissioners/managers, followed by clients from the community drug teams. All participants were informed regarding the purpose of the research and were advised of their right to withdraw from the study at any time. Confidentially was assured at all times 30

31 2.0. Results Independence Initiative Clients In total, 20 respondents from the Independence Initiative completed the questionnaire, 17 (85%) of which were males and three of whom were females (15%). The mean age of respondents was 39.1 (SD 6.6) years and the age range was between 28 and 54 years. As shown in Table 1, the majority of clients lived in local authority rented accommodation followed by privately rented homes. The majority of respondents, 12 (60%), stated that they lived alone, six (10%) clients reported living with family members and two (10%) individuals said that they lived with a partner. Only one member of the sample was registered as homeless and had slept rough in the previous 12 months. Table 1. Accommodation Type Accommodation N % Private (rented) 5 (25) Local Authority (rented) 7 (35) Housing Association 3 (15) Private (own home) 2 (10) Hostel 3 (15) Total 20 (100) 2.1 Current and Previous Drug Use Clients from the Independence Initiative were asked about their current and previous drug use. With regards to current drug use, clients were asked the type of drugs they 31

32 had used in the previous four weeks to completing the questionnaire, the frequency of use and the quantity of the drug used Cannabis Half the sample stated that they (10, 50%) had engaged in cannabis use. Six (60%) clients were using this drug on a weekly basis, three (30%) clients were using on daily basis and one (10%) client was taking it on a monthly basis. The amount of cannabis used varied among clients with five (50%) respondents saying that they smoked a quarter ounce, four clients (40.0%) mentioned that they used 1 gram of cannabis and one (10%) individual saying they used two grams of cannabis (see Table 2). Table 2. Cannabis Use Amount Frequency N % Quarter Ounce Daily 1 10 Quarter Ounce Weekly gram daily gram Weekly gram Monthly grams Daily 1 10 Total Cocaine Only one person had used cocaine in the prior four weeks. This person admitted to using 1.5 grams of cocaine per week. 32

33 Crack Cocaine Again, only one person reported to using crack cocaine in the preceding four weeks. The person said that when they engaged in crack use they were using a 10 rock on a weekly basis Heroin Five clients (25.0%) from the Independence Initiative were engaging in heroin use. While two (40.0%) clients were taking heroin weekly, one (20.0%) client was using daily, another client (20%) was using on a fortnightly basis and one (20.0%) client was using occasionally. The quantity of heroin being used varied among this cohort, two (40.0%) individuals were using a 20 bag, two (40.0%) individuals were using a 10 bag and one (20) client was using a 15 bag (see Table 3). All five heroin-using clients mentioned that were smoking rather than injecting it. Table 3. Heroin Use Amount Frequency N % 10 bag Occasional bag Fortnightly bag Weekly bag Daily bag Weekly Total Methadone With regards to methadone use, six clients were taking methadone as a prescribed drug and on a daily basis. Four (66.7%) clients were consuming 50mls, one (16.7%) client was taking 40mls and another client (16.7%) was using 20mls of methadone. 33

34 Alcohol Alcohol consumption was limited to eight clients (40.0%) from the Independence Initiative with the frequency of use varying between two (25.0%) individuals who were using alcohol daily and six (75.0%) clients who were consuming it on a weekly basis. With regards to units of consumption, one (12.5%) client each had consumed one, three, six and ten units of alcohol, two (25.0%) individuals had consumed four units of alcohol and two (25.0%) people had drank a total of eight units of alcohol (see Table 4). Table 4. Alcohol Use Units of Alcohol Frequency N % 3 Daily Weekly Weekly Weekly Weekly Total Table 5 shows the age that clients from the Independence Initiative first used various substances. The youngest age reported for alcohol use was seven years and the oldest for first using this substance was 17 years old (mean age 13.3, SD=2.5). Most of the clients from the Independence Initiative reported that they had used cannabis. The youngest age of first using cannabis was nine years and the oldest age of first use was 43 years (mean age 15.6, SD=7.2). Interestingly, while the youngest age of first use for heroin was 15 years old (mean age 22.95, SD=9.632) and for crack cocaine 16 years old (mean age 29.26, SD=8.905), the oldest age of first use for both of these drugs was 50 years. 34

35 Table 5. Independence Initiative-Age First Used Substances Drug N Min Age Max Age Mean SD Benzodiazepines Cannabis Cocaine Crack Heroin Methadone Ecstasy Amphetamine Alcohol LSD N.B. One client reported the use of Psilocybin Mushrooms (aged 18 years) and one client reported using Ketamine (18 years). 35

36 2.2. Previous Detoxification Experiences All participants were asked about their previous experiences of detoxification. This included the type of detoxification they had engaged in (i.e. in-patient, community, prison or unsupported), whether or not they had completed their detoxification program, the total number of days they had spent detoxifying, how many occasions they had attempted this particular type of detoxification and if they had received any form of aftercare In-Patient Detoxification With regards to in-patient detoxification, eight (40%) clients said that they had participated in this specific type of detoxification. Of the eight respondents, five (62.5%) asserted that they had completed their detoxification and three (37.5%) participants disclosed that they had not completed the program. The number of days clients spent in in-patient detoxification varied from between seven to 180, with the mean number of days spent in detoxification being 43.3 (SD=61.819). Table 6, shows the type and combination of drugs that clients were withdrawing from in the in-patient setting. The most common substances appear to be heroin, methadone and crack, although some clients were also detoxifying from alcohol and benzodiazepines. 36

37 Table 6. Type(s) of Drugs Clients were Detoxifying From in an In- Patient Setting Drug (s) N % Heroin 2 (25.0) Heroin & Methadone 1 (12.5) Heroin, Crack & Methadone 2 (25.0) Heroin & Cocaine 1 (12.5) Heroin, Alcohol & Crack 1 (12.5) Methadone 1 (12.5) Total 8 (100) Clients were asked if they had received any form of medication during their stay at inpatient units. Four (50.0%) clients mentioned that they had received no medication and each of the remaining four clients said that they had been prescribed, either Subutex, Lofexadine, sleeping tablets or methadone Respondents were also asked if they had previously attempted an in-patient detoxification program and had been unsuccessful in their efforts to complete it. Six (75.0%) clients said that they had tried to detoxify once before, one client (12.5%) had attempted to detoxify three times and one (12.5%) person four times. When respondents were asked the reasons as to why they had not completed or had relapsed from their detoxification program, one client said that they were in detoxification for the wrong reasons at the time and that some other clients were able to buy drugs in inpatient detoxification units. Another respondent admitted to being bullied by other clients and mentioned that staff members were not helpful in trying to resolve this issue. 37

38 Individuals were then asked what they considered to be the most positive and negative aspects of their experiences in in-patient detoxification settings. With regards to the positive aspects of in-patient detoxification, the general theme to emerge from responses was identification. This was because clients were able to identify and to empathise with each other. People wanted to be in there for the right reasons all help each other Another client mentioned that We supported each other. I was able to develop my social skills and got to know people again While, one client said that they were able to address their underlying psychological problems during their stay as an in-patient, two people mentioned that they did not have any positive experiences of in-patient detoxification. Although, they attempted to justify their responses by explaining their negative experiences of in-patient detoxification. Interestingly, both clients claimed that they had difficulty working in a group setting. Set out below is their responses. We had group sessions and I wanted to be left alone. Felt like a guinea pig. Group work was difficult 38

39 The negative aspects of staying at in-patient detoxification units tended to stem from problems with staff. Thus, the general theme to emerge from client perceptions of the negative aspects of in-patient detoxification was inadequate care from staff. For example, one client complained that other clients were being bullied and that staff were not very helpful. No steady regime, other clients could not focus as some were avoiding prison. Staff were not helpful and didn t care. In addition, another client mentioned that Clients bring in drugs. Staff need to help more and to listen to people. One client mentioned that they had experienced no negative aspects of in-patient detoxification, while another client said that they did not feel comfortable in group sessions and just wanted to be left alone. According to Ghodse and colleagues (2002), better outcomes will be achieved after detoxifying if an aftercare plan is put in place. Therefore, when respondents were asked if they had an aftercare plan in place the majority (six, 75.0%) of clients said that they received no aftercare. Only two (25.0%) of the eight clients mentioned that they had received any form of aftercare when they left the in-patient detoxification unit. 39

40 Community Detoxification Community detoxification programs support people with substance use problems in order to detoxify in a community based or home setting. Of the sample attending the Independence Initiative, nine individuals had been involved in a community detoxification program. Eight respondents had completed (88.9%) and one client (11.1%) said that they had failed to complete the detoxification program. The number of days spent in community detoxification programs ranged from five to 90 days with the mean number of days being 30.5 (SD=25.5) Table 7 shows the type of drugs that individuals involved in community detoxification programs were withdrawing from. Again, the most common drugs that clients were detoxifying from in this cohort were heroin and methadone. Interestingly, no individuals were withdrawing from crack cocaine whilst involved in community detoxification programs. Table 7. Type(s) of Drugs Clients were Detoxifying From in a Community Based Setting Drug (s) N % Heroin 2 (22.2) Heroin & Methadone 4 (44.4) Heroin & Cocaine 1 (11.1) Heroin & Benzodiazepines 1 (11.1) Heroin and Cocaine combination (Speedballs), Benzodiazepines Alcohol & Methadone 1 (11.1) Total 9 (100) 40

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