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

Chapter 2: Effectiveness of residential detoxification and rehabilitation

The significant cost of residential services compared to community services may lead DAATs and partner agencies with responsibility for commissioning services to want to compare residential and community services, in order to answer the question, "Which form of treatment is most effective in treating addiction?". While it may be natural to ask this question, a straight-forward comparison is actually quite difficult for several reasons.

1. The immediate aims and duration of residential and community treatments for drug misuse are different.

The ultimate aim of both residential and community drug services is the same - namely the attainment by the client of a sustainable drug-free lifestyle. However, many community programmes will seek, in the first instance, to stabilise an individual's drug use - usually through methadone maintenance prescribing and basic education about harm reduction, before moving on to support clients towards a lifestyle free of all drugs. The key to attaining this will be the ongoing assessment of the client's needs, wishes and circumstances.

2. The interventions provided by community and residential programmes are different. Residential programmes provide a highly structured programme of intensive psychosocial support over a clearly defined period of time. In contrast, different types of community services provide different types of interventions. Most community programmes provide only low intensity psychosocial interventions, and NTORS found that the majority of community methadone services did not have a planned treatment duration (Stewart et al, 2000), although many community rehabilitation programmes do have more structured interventions with defined durations.

3. The characteristics of clients entering community services are often quite different than those entering residential services. NTORS found that clients entering residential services in England had more serious problems than clients entering community methadone services. The reasons for this relate to complex processes of self-selection and referral. In order to truly compare the effectiveness of community and residential services, individuals would need to be randomly allocated to both treatment modalities. It is questionable whether such a random allocation would be possible, or ethical.

In addition to the practical difficulties of making a fair comparison between community and residential treatments, the question of comparable effectiveness is perhaps not helpful for another reason. Namely, the question implies that community and residential treatments are mutually exclusive options. Residential detoxification and rehabilitation programmes are not stand-alone interventions. These interventions must be seen as components of an integrated package of care, with community services actively involved in the client's preparation for residential admission and aftercare following the client's completion of the programme.

This chapter presents evidence on effectiveness of residential detoxification and residential rehabilitation. Our review of the literature was not a systematic review - that is, no particular criteria were used to inform decisions about including or excluding certain studies. Instead, an effort has been made to include a wide range of studies, and to refer as much as possible to research from the UK. Inevitably, however, in a review of this type, reference is also made to the sizeable literature from the US.

Most of the studies described here do not compare residential and community treatments; instead they compare residential treatment with no treatment. Some also compare clients who complete residential programmes with those who do not.

Before presenting the evidence on the effectiveness of residential detoxification and rehabilitation programmes, it is perhaps worth mentioning briefly the subject of waiting times. Sixty percent of the residential programmes that participated in the NTORS study had a waiting list, but for the majority of these programmes, waiting times were only 1-2 weeks (Stewart et al, 2000). Contrary to what might be expected, there is some evidence to suggest that clients who experience delays prior to entering a residential programme do not have poorer outcomes as a result (Christo 1998).

Effectiveness of residential detoxification

No one method of detoxification is effective for all clients. Methods will and should depend entirely on the characteristics of the individual and the nature of their drug use.

Since the primary aim of a detox programme is removal of all illicit chemical substances from the body, completion of the programme is very important. Completion rates for residential (or in-patient) detoxification programmes are high - around 75-80% - and in fact, are considerably higher than those for community detoxification programmes, which vary between 20 - 53% (Marsden & Farrell 2002; Mattick & Hall 1996). Severity of drug use immediately prior to treatment is associated with early drop-out from residential detoxification programmes (Ghodse et al 2002).

Despite the growth in recent years of rapid opioid detoxification services, it is not clear that there is any benefit from detoxifying a client over a number of days rather than over a number of weeks. In-patient rapid detox is a very expensive way of providing relief from the symptoms of withdrawal. The use of general anaesthesia adds a small risk of death during the detoxification process (Mattick & Hall 1996).

The evidence indicates that even successful detoxification is often followed by lapse or relapse (Robertson & Wells, 1998). Relapse is so common that many addiction service providers would not consider it to be a sign of treatment failure, since the majority of drug users will have to make a number of attempts at detoxification (assisted or unassisted) before they can successfully live a drug-free lifestyle.

However, the evidence strongly suggests that detoxification programmes will result in better long-term outcomes if they are followed up by some form of structured aftercare or supportive counselling (Inkster et al, 2001; Ghodse et al 2002; Best Practice Working Group 2000). It is also important to keep in mind that the risk of drug-related death is very high in the period immediately following detoxification because of an individual's reduced tolerance (Strang et al 2003). This fact alone makes it absolutely vital that support and aftercare is provided to drug users following detoxification.

Effectiveness of residential rehabilitation

The explicitly stated goal of all residential rehabilitation programmes is the client's long-term abstinence from illicit and prescribed drugs. Therefore, this must be the primary outcome against which the effectiveness of these programmes is assessed. However, a number of research studies have also measured other types of outcomes from residential rehabilitation and good outcomes could also be considered to include:

• longer periods of abstinence

• shorter periods of relapse

• less severe drug / alcohol use

• less involvement in crime

• movement towards employment

• improvements in physical and mental health

• less involvement in risk behaviours such as injecting or risky sexual behaviour.

There are four main factors that impact on and influence the effectiveness of residential rehabilitation programmes. These are:

Time in treatment

Retention in treatment

Client characteristics

Provision of aftercare

Each of these factors is explored in further detail below.

Time in treatment

Time in treatment is the single most important predictor of good outcomes from residential rehabilitation programmes. The longer an individual is in treatment, the better the outcomes. For residential rehabilitation programmes, three months appears to be a significant threshold. Programmes that are at least three months long result in better outcomes for clients than shorter programmes (Gossop et al 1999; Christo 1998; McCusker et al 1997). There may be some further benefit from programmes lasting six months, but programmes lasting longer than six months may not necessarily result in further improvements (McCusker et al, 1997). On the other hand, there is some evidence that programmes of one year or longer may result in better outcomes for patients with more severe symptoms at intake, including patients with severe psychiatric co-morbidity (Brunette et al 2001).

Retention in treatment

Because of the clear, consistent and strong association between time in treatment and outcomes, it is therefore crucial to retain clients in treatment. Programme completers are consistently more likely to have good long-term outcomes than those who leave prematurely. And indeed, a number of research studies of residential programmes use treatment retention as a proxy measure for good client outcomes.

Unfortunately, residential rehabilitation programmes have high drop-out rates. Studies commonly show that 25% of clients leave within two weeks of entering a programme and 40% by three months (Marsden & Farrell 2002). Some UK research studies have reported early discharge rates as high as 70%. There is some evidence to indicate that the majority of early discharges are due to client self-discharge, rather than ejection from the programme for drug use or behaviour problems. One study of residential care placements in London found that 15 out of 21 premature discharges were the result of clients leaving the programme early against staff advice (Christo 1998). The evidence also suggests that the majority of these early discharges occur shortly after detoxification (Saville, unpublished report; Keen et al, 2001; Christo 1998).

However, those who leave prematurely cannot necessarily be considered to be treatment failures. Research has suggested that even a short time in a residential programme can have long-term beneficial outcomes for clients, even if these fall short of complete abstinence (Gossop et al 1999).

There is no clear evidence about which types of programmes (i.e., which programme philosophies) result in better client retention. Instead, research studies generally try to explain client retention in terms of client characteristics.

Client characteristics

In general, clients with more severe problems at treatment entry are at greater risk of premature drop-out (Christo 1998; Lang & Belenko 2000). There is some evidence to suggest that those who are in contact with services prior to their entry to residential rehabilitation may have better outcomes than those who are not (Christo 1998). Similarly, being drug-free prior to programme entry may also result in better outcomes. As mentioned above, it appears that the majority of drop-outs from long-term residential programmes leave shortly after detoxification.

At first glance, these findings may seem to suggest that clients with fewer, or less severe problems are more likely to succeed in residential rehabilitation programmes. However, it must be remembered that the clients who get referred to residential rehabilitation programmes are generally more likely to have more severe problems than drug users accessing community services. As mentioned above, the NTORS study found that clients entering residential programmes had greater problems, in terms of drug use, physical and psychological health, criminal behaviour and drinking behaviour, than clients of community methadone programmes. However, these same clients also made some of the greatest treatment gains.

In addition, a number of studies have shown that, if identified early, even individuals with very severe problems, including dual diagnosis, can achieve similar outcomes to those with less severe difficulties, if more intensive, individualised services are made available to them (Carroll et al, 1994; Hoffman et al, 1994; McKay et al 1997; Nuttbrock et al 1997).

Residential services may be particularly appropriate for individuals dependent on cocaine. The needs of these clients often relate to inadequate housing, serious crime, severe psychiatric problems and low levels of support. Residential rehabilitation may significantly improve outcomes for these individuals (NTA 2002; Seivewright et al 2000).

Provision of aftercare

To sustain the good outcomes achieved following completion of a residential rehabilitation programme and to prevent relapse, some form of community aftercare is often necessary. NTORS found that the provision of aftercare was more common following residential rehabilitation programmes than either in-patient or methadone services (Stewart et al, 2000). Aftercare may take many forms including on-going counselling, participation in Narcotics Anonymous (NA), residence in a supported housing scheme and involvement in an employability or training programme. In the US, it is common for individuals to attend NA meetings following completion of residential programmes. These meetings are seen to provide an important source of support and on-going encouragement for recovering drug users. The evidence indicates that those who attend NA meetings are more likely to remain drug-free than those who do not.

There is little information available in the research literature about the role that aftercare can play for clients who drop out of residential rehabilitation programmes.

The next chapter will look in more detail at residential services in Scotland, and how these services are currently used.

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