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Effective Interventions Unit: Residential detoxification and rehabilitation services for drug users: A review

Chapter 1: Description of residential detoxification and rehabilitation

Residential detoxification and residential rehabilitation are very different in terms of their aims, duration and interventions. The main differences are summarised below. It is important to note that in the context of residential rehabilitation services, "abstinence" usually means free of all illicit and prescribed drugs, including methadone.

This review does not include information about residential crisis services or supported accommodation, although both of these may also have a role in the treatment, care and support of drug users at different stages in their recovery.

In Scotland, it is actually quite difficult to distinguish between some types of supported accommodation services and residential rehabilitation. Many supported accommodation services also have abstinence as an aim and they similarly provide a structured daily programme of activities for their residents. This point will be discussed in further detail in Chapter 3.

Residential detoxification

The primary aim of residential detoxification programmes is to provide the means for safe and humane withdrawal from a drug of dependence. Detoxification programmes may also provide individuals with a period of respite from drug use and its consequences, and, therefore, they give clients an opportunity to think clearly about their drug use and whether to seek further help. Detoxification is not so much a form of treatment for drug misuse as a gateway to treatments that are aimed at long-term abstinence (Robertson and Wells, 1998).

The nature of a detoxification programme will vary according to the drug or drugs of dependence. The symptoms of acute opiate withdrawal are unpleasant and often severe, but not life-threatening. The need for clinical intervention in residential detoxification programmes largely relates to moderating these symptoms and encouraging an individual to continue with the process. In contrast, detoxification from benzodiazepines and other sedatives / hypnotics and from alcohol requires careful clinical management, since sudden withdrawal may produce symptoms such as delirium and fits, which can result in sudden death. Withdrawal from stimulants such as cocaine does not usually result in visible physical symptoms, but may include severe depression, extreme fatigue, vivid and unpleasant dreams, agitation, and intense craving for the drug. Again, with stimulant withdrawal, the need for intervention by a detoxification service largely relates to ameliorating these symptoms and supporting and encouraging the individual to persevere.

For most drug users, the acute withdrawal period is followed by a longer period of general malaise which may last for months. It is during this period that the risk of relapse is greatest.

Because residential detoxification programmes must be tailored to the nature of a person's drug use, the duration of residential detoxification programmes is often variable. In the UK, different programmes last between a few days and a maximum of 12 weeks. In-patient Rapid Opiate Detoxification (IROD) programmes, such as Detox5 in Harrogate and the Green Door Clinic in Falkirk, involve the sedation of the patient under general anaesthesia for a period of 2-3 days, so that he / she does not consciously experience the acute symptoms of withdrawal (Rae, Matheson & Bond 2001). IROD programmes are ordinarily followed by a short period of maintenance prescribing with an opioid antagonist, such as naltrexone.

Other residential detoxification programmes provide detoxification over a slightly longer (but still relatively short) period of time through a programme of reduced prescribing. Such programmes may also provide support to the drug user through respite, crisis intervention, counselling in relapse prevention, or one-to-one counselling. They might also include practical support, through linking the client to other services such as supported housing or long-term rehabilitation. Depending on the client, some programmes may focus more on stabilising an individual's drug use rather than detoxification alone.

Residential rehabilitation

In contrast to residential detoxification programmes, residential rehabilitation programmes provide intensive psychosocial support and a structured programme of daily activities which residents are required to attend. It is important to note that residential rehabilitation programmes are not all the same. Programmes differ markedly on the basis of their underlying philosophy and in the details of programme structure, intensity and duration of treatment. The National Treatment Outcomes Research Study (NTORS) identified three distinct types of programmes in England:

• 12-step / Minnesota Model programmes

• Therapeutic communities

• Christian houses

A fourth category, referred to as "General houses", included all those programmes that did not fit neatly into one of the other three categories (Stewart et al, 2000; Gossop, personal communication). This same classification may also be used for programmes in Scotland (Saville, personal communication). However, a comprehensive directory of residential rehabilitation programmes in England and Wales suggests that, in reality, programmes may use a combination of approaches. ¹

The published research literature provides information about 12-Step / Minnesota Model Programmes and Therapeutic Communities, but not about Christian houses.

• 12-step / Minnesota Model programmes provide information to residents about the disease model of addiction (i.e. that chemical dependency is a chronic illness affecting one's physical, mental and emotional well-being) while combining professional care with instruction in 12-Step principles. The main therapeutic mechanism is provided through group work, namely fellowship in Alcoholics / Narcotics Anonymous. (Castle Craig in West Linton is an example of a 12-Step residential programme.)

• Therapeutic communities emphasise social learning, behavioural and cognitive-behavioural approaches to achieving a healthy pro-social lifestyle characterised by abstinence (Lang & Belenko, 2000). Therapeutic communities promote change by developing self-worth and personal responsibility, challenging individual attitudes and behaviour and encouraging the development of life and social skills through engagement in daily work and activity routines. Structured group work uses Cognitive Behavioural Therapy methods. Residents pass through three distinct programme stages, which are designed to help them prepare and plan for an independent lifestyle before moving back out into the community. (Phoenix House in Glasgow is an example of a therapeutic community.)

Residential rehabilitation programmes may be either short-term (varying from 6-12 weeks) or long-term (usually lasting 3-12 months). Some programmes also provide facilities for opiate detoxification, usually using methadone. The length of the detoxification stage may vary between 3-28 days, depending on the programme. Since abstinence is the aim of all residential rehabilitation programmes, drug use by residents is considered to be grounds for ejection, and routine drug-testing is a feature of most programmes.

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