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EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL MISUSE IN SCOTLAND: A LITERATURE REVIEW

CHAPTER NINE DETOXIFICATION

Introduction

9.1 Detoxification refers to the period during which patients become alcohol free. Stopping drinking can produce a range of symptoms, collectively referred to as alcohol withdrawal syndrome. Depending upon the severity of symptoms, the withdrawal process may be managed on an inpatient or outpatient basis. The studies reviewed are summarised briefly in tables 9.1 (effectiveness) and 9.2 (cost-effectiveness) at the end of the chapter.

Effectiveness of detoxification

Types of intervention

9.2 A range of drug therapies has been assessed for use during detoxification. The broad categories of drug interventions and their effects are:

There are also reports of acupuncture as a treatment for withdrawal symptoms (Brewington et al, 1994; ter Riet et al, 1990).

Effectiveness

9.3 The literature supports the use of benzodiazepines as the first choice therapy on the basis of safety and effectiveness (Fuller and Hiller-Sturmhofel 1999; O’Connor and Schottenfield 1998; Williams and McBride 1998). Antiepileptics are also effective in treating major withdrawal symptoms but have serious potential side effects and higher cost (Williams and McBride 1998). Other drug therapies have been reported as having some effect on withdrawal symptoms but are considered to be adjunct treatments as they do not prevent major withdrawal effects such as delirium tremens (O’Connor and Schottenfield 1998).

9.4 There are 2 small trials showing a positive effect of acupuncture on withdrawal symptoms (Brewington et al 1994; ter Riet et al 1990).

Population groups

9.5 There are no reports of differential effects in different population groups.

Settings

9.6 Outpatient treatment is safe and effective for patients with mild to moderate symptoms (Fuller and Hiller-Sturmhofel 1999; O’Connor and Schottenfield 1998). Completion rates may be lower and there is a greater risk of short-term relapse but outcomes at 6 months are not significantly different (Fuller and Hiller-Sturmhofel 1999).

Providers

9.7 No evaluations of alternative providers have been reported. One review considers the potential role for nurses (Ryan et al 1999)

Intensity of treatment

9.8 Few studies have been carried out. Results from two studies of inpatient treatment suggest that reduction from 6 weeks to 4 weeks or from 28 days to 21 days had little effect on outcomes (NIAAA 2000).

Quality and relevance of the evidence

9.9 The available trials have not assessed drugs on a common basis, making comparisons across trials difficult.

Cost-effectiveness

Home versus inpatient detoxification

9.10 Bartu and Saunders (1994) examined different settings for detoxification, comparing home detoxification and inpatient detoxification in the treatment of alcohol problems. Twenty subjects on home detoxification were matched to 20 subjects with inpatient detoxification. Subjects were interviewed between 9 and 22 months after detoxification to compare client outcomes and costs. The study was from the perspective of the health care provider and included 40 subjects at the Australian Alcohol and Drug Authority Community Nursing Service detoxification facility.

9.11 In the home detoxification component, the client was visited at home by a nurse to ensure that the home was suitable. Daily visits were provided for 3 to 4 days and then as frequently as required for 10 days to monitor symptoms. The average number of visits was 5.4 per client and the average duration was one hour. The comparison programme was an inpatient detoxification programme. The costs used in the study were inpatient days and hours of contact for home visits. One inpatient day cost $128, whilst an average inpatient detoxification cost $1280 per client. An average home detoxification cost $154.44 (£55) per client.

9.12 With respect to health outcomes, the home detoxification group fared better on self reported drinking behaviour after treatment, and on quality of relationships and health status.

9.13 Home detoxification provides better outcomes at lower cost than inpatient detoxification and is therefore considered a dominant programme. However, combining costs and effects would have been more informative in this study.

Quality and relevance of evidence

9.14 The relevance of this study outside the treatment population depends on client characteristics and local costs. Costs are likely to resemble similar intensities in that home is cheaper than inpatient, but a generalised application must closely examine outcomes. Furthermore, a serious limitation of this study is the small sample size with just 20 patients in each treatment. In addition, the wider consequences beyond health care costs should be considered in a more comprehensive economic analysis.

Inpatient versus outpatient detoxification

9.15 Hayashida et al (1989) compared the costs and effectiveness of inpatient and outpatient detoxification for patients with mild to moderate alcohol withdrawal syndrome. The treatment population was 164 male veterans, of low socio-economic status, 87 in the outpatient and 77 in the inpatient arm. Data were taken from a randomised prospective trial of patients prescribed either decreasing doses of oxazepam on the basis of daily clinic visits (outpatient treatment) or oxazepam, psychiatric and medical evaluation and initiation of rehabilitation treatment (inpatient treatment). The health outcomes of the trial showed that at 6 month follow up 48% of inpatients and 46% of outpatients had remained sober (not significant), whilst 59% of outpatients and 51% of inpatients refrained from intoxication (non significant). At one month follow up, 9% of the inpatient group compared with 0% of the outpatient group reported being hospitalised. In terms of completion, 95% of inpatients and 72% of outpatients completed treatment.

9.16 Costs were taken from direct cost surveys conducted for the study and from cost data provided from the fiscal service of the Medical Center. High and low estimates were provided based on different workload assumptions. The low estimates showed average costs of $3,319 (£2,260) (inpatient care), and $175 (£119) (outpatient). For the high estimates, the average cost of inpatient care was $3,665 (£2,497) and outpatient care was $388 (£264). The authors concluded that the cost per successful detoxification was significantly cheaper in the outpatient group.

Further research

9.17 Studies that provide direct comparisons of different drug interventions are required. There are no studies of the added value for drugs that are seen as an adjunct to the main therapy. More information is required about treatment settings, providers and intensity of treatment in a UK context.

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