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1 Repet Admissions to Residentil Substnce Abuse Tretment Progrms: A Descriptive Study Lorrine S. Roth, MD The VHA hs requested more thn $453 million to tret substnce buse in fiscl yer When the most recent dt indicte nerly hlf of the dmissions to stte-funded substnce buse tretment progrms re repet dmissions, this uthor sks whether lloction of resources to residentil tretment should be revisited. Dr. Roth is n ttending psychitrist in the deprtment of psychitry t North Chicgo VA Medicl Center, North Chicgo, IL. Mentl helth providers who tret ptients with substnce buse often observe the sme individuls going through multiple tretment progrms nd often repetitively through the sme progrm. Repet ptients re seen s being redmitted through revolving door to medicine units or the intensive cre unit (ICU) for detoxifiction tretment nd to psychitric units for tretment of the depression, suicidl idetion, homicidl idetion, nd uditory or visul hllucintions tht ccompny their relpses to drug nd lcohol use. 1 Once these ptients conditions re stbilized, bed vilbility t residentil substnce buse tretment progrms is explored in dischrge plnning, generlly without regrd to previous dmissions to the sme or similr progrms. 2 This rticle explores the problem of repet dmissions by looking t the substnce buse tretment histories of ptients enrolled in two seprte substnce buse tretment progrms t one VA medicl center. Additionlly, the extent of the problem is discussed ccording to ntionl dt on utiliztion nd cost of substnce buse services, with more detiled look t VA dt nd services. The implictions for the tretment of substnce buse in the future lso re exmined. REVIEW OF ptients READMISSION HISTORIES IN TWO tretment PROGRAMS The progrms North Chicgo VA Medicl Center (NCVAMC), North Chicgo, IL offers two substnce buse tretment progrms, the Drug Dependency Tretment Center (DDTC) nd the Drug nd Alcohol Rehbilittion Unit (DARU). Both progrms offer full rnge of tretment services tht include residentil cre, generl medicl cre, psychitric cre (including psychotropic mediction, when indicted, but excluding opite replcement therpy), individul nd group psychotherpy sessions, psychologicl nd voctionl testing, voctionl trining, socil services, ftercre ppointments nd meetings, nd behviorl tools for relpse prevention. The DDTC hs 90-dy durtion nd is considered long-term residentil progrm. The DARU is considered to be short-term residentil progrm, providing 35 dys of bsic instruction to help ptients recognize the chrcteristics of ddiction nd their own prticulr triggers tht led to substnce buse nd relpse. Ptients my be dmitted to the short-term progrm directly from the street or trnsferred in from nother fcility fter short detoxifiction or stbiliztion period. Mny of the ptients in this progrm go on to trnsfer to longer-term progrm following completion. The primry difference between the DDTC nd the DARU is the length of tretment the short-term progrm is considered specificlly for erly postdetoxifiction nd the long-term progrm for extended postdetoxifiction rehbilittion nd community reintegrtion. Ptients frequently trnsition from the former to the ltter, especilly if they were homeless or unemployed t the time of initil dmission. Redmission history review The roster of ptients in dmission t the long-term DDTC progrm on single dy in the summer of 2005 ws reviewed to determine their prior dmissions to NCVAMC substnce buse tretment progrms nd to the hospitl or emergency deprtment for substnce buse relted tretment (such s detoxifiction nd psychitric or medicl stbiliztion 32 FEDERAL PRACTITIONER MAY 2008

2 of symptoms directly relted to drug or lcohol buse). Tretment received outside of the NCVAMC ws not reviewed. The present dmission to the DDTC ws included in ech ptient s totl dmissions. For ech dmission, the length of sty ws determined. A second review ws conducted of ll the dischrges t the shortterm DARU progrm over five-yer period (Jnury 2001 to December 2005). Multiple dischrges from the DARU were tbulted. Whether ny of these ptients hd received tretment through dditionl substnce buse tretment progrms outside of this VA fcility ws not explored. These two progrms were evluted differently (single-dy prevlence versus five-yer retrospective) with the rtionle tht long-term progrm would be expected to hve been preceded by detoxifiction or psychitric stbiliztion nd, possibly, short-term substnce buse tretment progrm; wheres shortterm progrm would be considered more s first step in tretment, nd the bsic or elementry instruction lerned therein should not need to be repeted. Therefore, the long-term progrm ws evluted by single-dy prevlence in order to identify ptients with ny previous substnce buse progrm dmissions nd the short-term progrm ws reviewed in order to identify ptients with histories of being treted in the sme progrm more thn once. DDTC results As expected, dmissions for ptients in the long-term progrm represented severl different kinds of tretment: detoxifiction, ICU (for exmple, for chest pin secondry to cocine use), psychitric (for exmple, for ptients who expressed suicidl or homicidl thoughts or hllucintions tht the ptients ttributed directly Tble 1. Age, dmissions, nd dys of cre for 23 ptients in residence t the 90-dy DDTC Age No. of Totl dys Ptient no. (yers) dmissions b of cre c , Totl ,629 Averge Adjusted verge 48.9 d 9.5 e 438 f DDTC = Drug Dependency Tretment Center. b Admissions to North Chicgo VA Medicl Center substnce buse tretment progrms, s well s ll dmissions to this hospitl nd emergency deprtment tht indicted substnce buse s the primry dignosis or primry contributing fctor (includes the present dmission). c Totl dys of cre through the dy of review. d Excluding outliers (ptient 17, ged 28). e Excluding outliers (ptient 21, 88 dmissions). f Excluding outliers (ptient 17 nd 19, 40 dys nd 1,392 dys, respectively). to their substnce buse), nd forml tretment through substnce buse progrm. On the dy of the review, 23 veterns were in residence t the DDTC. Only one ptient (4.3%) ws currently in his first substnce buse relted dmission (Tble 1). All of the ptients rnged in ge from 38 to 58 yers, except one who ws 28. Continued on next pge MAY 2008 FEDERAL PRACTITIONER 33

3 Continued from previous pge The 23 ptients hd totl of 298 dmissions mong them, with 119 (40%) greter thn 21 dys (Tble 2). The number of dmissions per ptient rnged from one to 88, for men of 12.9 dmissions per ptient. If the 88-dmission outlier is eliminted, the men drops to 9.5 dmissions per ptient. The totl dys of cre for ech ptient rnged from 40 to 1,392. The totl number of dys of cre for ll 23 ptients mounted to 10,629 or pproximtely 462 dys per ptient. If the two outliers (40 nd 1,392) re eliminted, the remining 21 ptients received 9,197 dys of tretment mong them, or 438 dys per ptient. Fifteen ptients (65.2%) hd t lest one previous dmission of 90 dys or more. Of these, seven (30.4% of the entire group) hd multiple dmissions of three to 10 months t time (Tble 3). DARU results Between Jnury 1, 2001 nd December 31, 2005, there were totl of 2,847 dischrges from the 35-dy DARU progrm (Tble 4). A totl of 406 ptients hd multiple dmissions to the DARU, ccounting for 937 (33%) of the totl dischrges. Of the 406 ptients with multiple dischrges, 316 hd two (ccounting for 632, or 22%, of the dischrges), 64 hd three (ccounting for 192, or 7%, of the dischrges), 17 hd four (ccounting for 68, or 2.5%, of the dischrges), nd nine hd five (ccounting for 45, or 1.5%, of the dischrges). THE LARGER PICTURE The problem with repet substnce buse tretment dmissions found t the NCVAMC is reflected ntionwide. According to the Drug nd Alcohol Services Informtion System (DASIS), of the 1.3 million nnul dmissions to stte-funded substnce buse tretment progrms in 1999, pproximtely 40% were first tretment episodes, pproximtely 45% were redmissions of people who hd been in tretment one to four times previously, nd 13% were redmissions of those who hd been in tretment five or more times previously. 3 Cost of substnce buse in the VA The Ntionl Drug Control Strtegy Fiscl Yer (FY) 2009 Budget for the VHA indictes tht over $435 million ws encted for expenditure on substnce buse tretment services through the VA s 19 inptient, 155 outptient, nd 66 residentil rehbilittion nd tretment progrms in FY 2008, nd $453.8 million hs been requested for FY More thn $180 million of the requested mount for FY 2009 ccount for inptient nd residentil rehbilittion nd tretment progrms. Inptient tretment includes costs ssocited with cre, tretment nd support of inptients in loclly designted subcute substnce buse psychitry bed; dignosis nd tretment of ptients dmitted to drug, lcohol, or combined lcohol nd drug tretment unit; Psychitric Residentil Rehbilittion Tretment Progrm focusing on the tretment nd rehbilittion of substnce buse ptients; nd stff nd contrct costs ssocited with the Alcohol nd Drug Contrct Residentil Tretment Progrm. Inptient progrms typiclly tret ptients for 14 to 28 dys. 4 The rest, nd the mjority, of the VA s 24-hour substnce buse tretment cre is provided through residentil rehbilittion nd tretment progrms. These progrms re bsed in on-site VA domiciliries nd in onnd off-site residentil rehbilittion centers. They re distinguished from inptient progrms s hving less Tble 2. No. of dmissions, ccording to LOS, b for ptients in residence t the DDTC c LOS (dys) No. of dmissions Admissions to North Chicgo VA Medicl Center substnce buse tretment progrms, s well s ll dmissions to this hospitl nd emergency deprtment tht indicted substnce buse s the primry dignosis or primry contributing fctor (includes the present dmission). b LOS = length of sty. c DDTC = Drug Dependency Tretment Center. medicl stff nd services nd longer lengths of sty (bout 50 dys). 4 rethinking the tretment strtegy The findings of the DASIS report tend to support the perception of prctitioners tht ptients with substnce buse disorders who hve ccess to tretment progrms tend to go through them more thn once. 1,5 Considertion should be given to whether we re using our public dollrs (federl nd stte) wisely. Beyond tht, it is resonble to sk the question of whether residentil tretment progrms help ptients with substnce buse problems. Are they ctully contributing to the problem? Enbling nd codependent re two terms frequently used in the substnce buse tretment ren. The definition of enbling is 34 FEDERAL PRACTITIONER MAY 2008

4 doing for nother wht they need to do for themselves. And codependent is one who tries to tke cre of situtions cused by the [drug user], nd protects the drug user from the negtive consequences of [his or her behvior]. 6 It cn be rgued tht residentil tretment progrms which ccept ptients who re court-ordered to receive substnce buse tretment with the potentil for dismissl of legl chrges upon progrm completion re fulfilling the role of codependent. In this, s well s in other situtions, residentil tretment my be triggering the rescuing-enbling nd codependency phenomen tht tend to reinforce substnce buse rther thn llevite it. The substnce buse literture revels wide vriety of pproches to studying these issues. Studies tht compile the sttistics of substnce buse tretment progrms with differing prmeters bound In ddition to compring long-term with short-term residentil tretment in generl, specific residentil tretment progrms for women who receive socil support nd employment services hve been compred to residentil tretment progrms for women who do not receive socil support nd employment services, 7,8 residentil tretment settings hve been compred to inptient tretment settings, 18,27 nd types of posttretment cre hve been compred to one nother. 12,13 Severl outcomes re evluted in these studies, s well, but with wide vrition in how success nd recidivism re defined. Success, for exmple, often is reltive nd defined ccording to the length of follow-up for tht prticulr study. Only one rticle reviewed mde the observtion tht tretment gins re often short lived nd even multiple tretment episodes do not lwys succeed in breking the ddiction cycle. 5 Despite these mbiguities, sobriety clerly is only successful if it is mintined outside the hospitl wlls, in the community. Perhps tht is where tretment should be focused. Future reserch is needed to elucidte the issue by following cohort who receives outptient tretment only nd similr group who receives inptient or residentil tretment. In the pst, such studies hve provided differing conclusions. For exmple, in 1986 review of 26 controlled studies on inptient lcoholism tretment, Miller nd Hester concluded tht residentil tretment consistently showed no overll dvntge over tretment in nonresidentil settings nd tht the outcome of lcoholism tretment is more likely to be influenced by the content of interventions thn by the settings in which they re offered. 27 Five yers lter, Cummings noted tht controlled studies hve replced the previous reserch literture, which ws lrgely composed of uncontrolled studies, nd went on to dvise tht A reserch consensus is developing tht sttes inptient rehbilittion hs no dvntges over outptient tretment nd tht even hospitliztion for detoxifiction is unnecessry for 90% of ptients. 28 In 1993, Pettinti s group disgreed with Miller nd Hester s recommendtions, identifying shortcomings such s the use of rndom ssignment designs, which excluded psychitriclly-complicted ptients. 29 They concluded, Ptients with high psychitric severity nd/or poor socil support system re predicted to hve better outcome in inptient tretment, while ptients with low psychitric severity nd/or good socil support system my do well s outptients without incurring the higher costs of inptient tretment. Homelessness nd unemployment re prt nd prcel of lcohol nd Tble 3. Admissions tht exceeded 90 dys durtion (LOS b ) for ptients in residence t the DDTC c s of the dte of review Ptient no. LOS (in dys) of dmissions 1 315, 219, 193 d , d , 121, 118 d , , d , 246, , 246, 225, 141, Admissions to North Chicgo VA Medicl Center substnce buse tretment progrms, s well s ll dmissions to this hospitl nd emergency deprtment tht indicted substnce buse s the primry dignosis or primry contributing fctor. b LOS = length of sty. c DDTC = Drug Dependency Tretment Center. d Present dmission through the dte of review. drug buse. Of the 23 ptients in the DDTC review, ll were unemployed nd 21 were homeless. Providing ptients with help in those res will continue to be requisite for successful tretment. There my be ptients who go through residentil tretment progrm only once, lern how to recognize nd void their relpse triggers; find or renew their employment, MAY 2008 FEDERAL PRACTITIONER 35

5 Tble 4. Ptients with single nd multiple dischrges from the 35-dy DARU between Jnury 2001 nd December 2005 No. of dischrges No. (%) Totl no. (%) per ptient of ptients of dischrges 1 1,910 (82.5) 1,910 (67.0) (13.6) 632 (22.0) 3 64 (2.8) 192 (7.0) 4 17 (0.7) 68 (2.5) 5 9 (0.4) 45 (1.5) Totl 2,316 (100.0) 2,847 (100.0) DARU = Drug nd Alcohol Rehbilittion Unit. housing, nd support systems; nd remin clen nd sober for the rest of their lives. Wht is uncler nd wrrnts firm study is whether repeted dmissions to residentil progrms re useful or, in fct, reinforce relpse. As the study presented here ws n informl dmissions/dischrge review, the dt herein re limited. Nevertheless, they suggest tht the prctice of repeted residentil tretment for substnce buse should be revisited, with considertion towrd more outptient tretment nd more effective use of ncillry resources. Author disclosures The uthor reports no ctul or potentil conflicts of interest with regrd to this rticle. Disclimer The opinions expressed herein re those of the uthor nd do not necessrily reflect those of Federl Prctitioner, Qudrnt HelthCom Inc., the U.S. government, or ny of its gencies. This rticle my discuss unlbeled or investigtionl use of certin drugs. Plese review complete prescribing informtion for specific drugs or drug combintions including indictions, contrindictions, wrnings, nd dverse effects before dministering phrmcologic therpy to ptients. REFERENCES 1. Tomsson K, Vglum P. The role of psychitric comorbidity in the prediction of redmission for detoxifiction. Compr Psychitry. 1998;39(3): Roth L. I feel sfe here Dischrging the undischrgeble ptient. Fed Prct. 2006;23(3): The DASIS Report: New nd Repet Admissions to Substnce Abuse Tretment. Office of Applied Studies, Substnce Abuse nd Mentl Helth Services Administrtion, Deprtment of Helth nd Humn Services. Arlington, VA: Synectics for Mngement Decisions, Inc; April 26, gov/2k2/repettx/repettx.htm. 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