Breaking the ‘detox-loop’ for alcoholics with social detoxification

Drug and Alcohol Dependence, 13 (1984) Elsevier Scientific Publishers Ireland Ltd

65-73

BREAKING THE ‘DETOX-LOOP’ DETOXIFICATION*

FOR ALCOHOLICS

ALEX RICHMANs and BRIGITTE

65

WITH SOCIAL

NEUMANNb

aDepartments of Psychiatry and Community Health and Epidemiology, Dalhousie University and bNova Scotia Commission on Drug Dependency, Halifax, Nova Scotia (Canada) (Received November 29th, 1983)

SUMMARY

A significant number of alcoholics do not respond to detoxification as a step on the way to rehabilitation. Instead, they periodically ‘dry out’ and subsequently return to alcohol abuse. They do not accept the responsibilities inherent in the sick role (cooperation in order to improve status of health by entering and continuing treatment), although they do accept the privileges (care, shelter and asylum). Repeated detoxifications (within medical and non-medical settings) of persons who do not commit themselves to entering rehabilitation, are of minimum benefit to the patient and absorb resources which could be better used by those more amenable to treatment. An appropriate level of care - social detoxification - should be provided for ‘detox-loopers’. Such a model can focus on the alcoholic’s social welfare needs. Social detoxification provides both respite and basic care. The door to ongoing rehabilitation through professional services, as well as self-help groups, can remain open, without being the main objective of the centre. Key words: Detoxification - Social detoxification - Rehabilitation Readmission - Recidivism - Level of care - Program evaluation

entry -

INTRODUCTION

Many alcohol detoxification programs see a significant number of readmitted patients. In these circumstances, the detoxification program, instead of being the entry to rehabilitation, becomes a ‘drop in’ for ‘detox-loopers’, who are admitted repeatedly without demonstrating longer-term rehabilitation gains. The problem is serious because: (a) the proportion of read*Presented at the Annual Meeting of the American Psychiatric Association, New York, NY, May 4,1983. 0376-8716/84/$03.00 o 1984 Eleevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland

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missions increases over time [l]; (b) the persons with repeated detoxifications are least likely to enter rehabilitation programs [ 21 ; (c) at the same time, these detox-loopers use disproportionate amounts of clinical resources

L21. The continuing appearance of recidivists results in possible displacement of patients who might benefit more. Both staff and patient morale diminish with rising recidivism rates. Finally, the cost of resource absorption is a serious concern. In view of the ample commitment to detoxification programs in Canada [3], these ‘detox-loopers’ represent a significant cost. Who are they? .What treatment options can be implemented by policy makers and program planners? This paper discusses the importance of developing program alternatives which might better meet the needs of the ‘detox-loopers’, and recommends social detoxification as a program that meets these needs. ASSESSING

DETOXIFICATION

PROGRAMS

There are many methodological problems in the published reports of detoxification programs. However, there are a few reports which have dealt with most of these problems [1,2,4]. Alcohol detoxification programs have a substantial number of readmissions. National data from the U.S. show that readmissions form 47% of the admissions and that 4% of the individual patients provide 24% of the readmissions [5]. The use of disproportionately large amounts of services by a minority of patients - resource absorption - has been reported from state systems and from individual programs. Even when programs are effective for a majority of new admissions, resource absorption can still be significantly high [ 61. There is a subgroup of chronic alcoholics who show patterns of recurrent, persistent readmission over extended periods of time, and for whom additional, novel treatment or alternative approaches are required [ 7 1. Programs rarely focus on the problem of detox-looping. Usually, clinical programs claim to be ‘unique’, ‘too new to be assessed’ or ‘have circumstances different from others’. Sometimes programs regard resource absorption as inevitable. Frequently, detoxification units claim that there are no suitable data for comparison. Readmission rates to detoxification programs in the literature ranged from 70% readmitted within 2 years [8] to 17% of ambulatory detoxification patients repeating within 1 month [9]. Reports on rehabilitation entry after detoxification vary widely in definition, duration and follow-up methods. Up to 45% were reported as entering rehabilitation, one of the primary goals of detoxification programs [2]. The Nova Scotia detoxification study [lo] examined 3221 alcoholics who were first detoxified in any specialized alcohol treatment service between 1977-1979. These patients were followed within the province-wide information system to the end of 1980. When entry to rehabilitation occurred,

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DETOXIFICATIONS

2

I

4

MONTHS

6

AFTER

INITIAL

Fig. 1. First entry to rehabilitation ber of detoxifications. 1977-19’79

8

10

12

DETOXIFICATION

program cohort.

by time from initial detoxification

by num-

it was predominantly within 2 months of the initial detoxification; 30.2% had entered rehabilitation within 2 months. By 12 months, that percentage had only risen to 35.8%. The proportion of persons first entering rehabilitation after each detoxification progressively decreased, from 29.7% after the first through 15.1% after the fourth. For all cases, 35.8% had entered rehabilitation within 1 year after initial detoxification (Figs. 1 and 2).

_

29.7

_..

/

I

19.9

r-;/ I

SECOND THIRD FIRS’ DOOXIFlCATiONDEIOXlFlCATiONDETOXlFlCATIONDLTOXlFlCAilON n = 959 n = 369 n i 3221

Fig. 2. Entry to rehabilitation

following

FOURTH n

ii9

successive detoxifications,

1977-1979

cohort.

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The Nova Scotia experience does not confirm Korcok’s [ll] view that detoxification services fail to be stations in the recovery process of alcoholics; however, as the readmission rate was 31.3% within a year, there is no doubt that a significant minority of patients are detox-loopers. THE

ROLE

OF

DETOXIFICATION

PROGRAMS

IN

ALCOHOLISM

TREATMENT

Detoxification is meant to lead to rehabilitation entry; however. this does not always occur. The detoxification centre may function as a ‘last resort’ for many recidivists. Certainly, the purpose for seeking admission to detoxification may have only a pro forma relationship to motivation for rehabilitation. Nevertheless, the recidivist patient has a number of needs which are traditionally met through various institutions. As Parsons [12] pointed out in relation to psychiatric hospitals, the goal of such institutions is ‘to cope with the consequences of (mental) illness’ through four major responsibilities: custody, protection, socialization and therapy. Therapy, rehabilitation, and socialization are the functions most strongly emphasized by most alcoholism treatment facilities. The socialization function includes getting the patient to accept this role, and to realize that he does suffer from alcoholism. The problematic nature of this task is suggested in the emphasis within the alcoholism field on processes of denial, and on patient education. The responsibilities of custody and protection have also had an important role in the development of detoxification centres. Historically, many centres developed as an alternative to jail for public inebriates. There is general consensus that the criminal justice system did not deter alcoholic offenders from repeating their ‘crime’. However, there is some evidence that custodial care and protection of the alcoholic may have been accomplished more effectively by a stay in jail than by a stay in a detoxification centre, as jail sentences were typically longer. Also, as Giesbrecht et al. [13] report, ‘skid row’ alcoholics may appreciate greater police leniency and the opportunity to dry out in detoxification centres, but they also display the following results: more time spent drinking, more use of drugs in addition to alcohol, worse health, and more muggings and beatings. For skid row alcoholics, the development of detoxification centres has had some of the same effects as the movement toward de-institutionalization of psychiatric patients, where the diversion from customary institutions also has some negative consequences for patients’ physical health and safety. For skid row alcoholics who are unwilling to enter longer term rehabilitation, detoxification centres essentially provide ‘asylum’ in the traditional sense of the word: a place of refuge and safety, providing a respite from drinking and the predicaments associated with life as an alcoholic. Most treatment centres, however, do not regard asylum as a central part of their mandate and, thus, may resist the ‘abuse’ of their services for this purpose.

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Perhaps the most common approach to the readmission dilemma has been to ration treatment by setting admission criteria which bar alcoholics from readmission within a designated time period, or which give preference to first admissions in the event of waiting lists. However, manipulation of admission criteria is at best an incomplete response to those patients who, on the basis of previous treatment history, are not prepared to enter rehabilitation programs and, at the same time, are unable to stop abusing alcohol. TREATMENT

RESISTANCE

Persons become patients when they recognize their illness and seek help or treatment. In seeking treatment, the alcoholic is expected to adopt the sick role. However, some are not ready to comply with the major demand of the sick role, that is, acceptance of responsibility for compliance with therapeutic regimens. Detox-loopers seem to seek the care, shelter, and asylum provided by health care institutions, but reject the treatment. The small number of detox-loopers do not uniformly display skid row characteristics. It appears that an essential characteristic of this group of difficult patients is the reason for seeking detoxification. In contrast to alcoholics appropriately socialized into the sick role, detox-loopers do not accept the responsibility of participation in therapeutic activity in order to improve health status. It is precisely this failure to accept the obligations (as opposed to the privileges) of the sick role that makes rehabilitation so difficult, and which generates the negative responses of moral castigation and exclusion from services on the one hand, to periodic consideration of compulsory treatment [ 141 on the other. OPTIONS

FOR CLINICAL

CARE

In recent years, there has been a profound shift in the role of hospitalization for the treatment of acute alcohol withdrawal syndromes. In 1970 it was felt that ‘prompt hospitalization should be secured’ in all but the mildest cases [15]. In marked contrast, 10 years later, Whitfield [ 161 stated that uncomplicated alcohol withdrawal is not usually an indication for hospitalization. About 95% of alcoholics can be detoxified from alcohol by outpatient or social setting procedures [ 171. Other patients require short-term residential accommodation because they are homeless, and some patients with acute medical complications require hospitalization [ 181. Ballenger and Post [ 191 reported that 91% of the alcoholics observed during their index admission, who had been drinking for less than 3 years, had no withdrawal symptoms, and none experienced more than a mild tremor. A majority of patients with mild to moderately severe alcohol withdrawal symptoms can improve rapidly without drug treatment [20].

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The concept of ‘level of care’ recognizes that patients differ in their needs for specialized staff and accommodation, and that services should be organized to provide the level of staff, treatment, care, and accommodation needed by the patient. Moore [ 211 identified four models of detoxification which have evolved, and which coincide with various levels of care, (a) The medical model involves hospitalization. These medical detoxification units are receiving increasing attention by hospitals which are experiencing reductions in general occupancy [ 22,231. However, research findings do not support the current U.S. emphasis on hospital detoxification [71. (b) Non-medical detoxificution is not hospital-based, but has medical back-up, has physicians on call, rather than on staff, may have few licensed staff members, and uses medications minimally. (c) Ambulatory detoxification was described by Feldman et al. [9]. Patients attend an outpatient clinic or private practitioner’s office, where they may receive medication. Treatment orientation (e.g., education about alcoholism) is offered within a very short period after start of treatment. Residential support is not provided; thus, the model is not suitable for those without basic shelter. Ambulatory detoxification was designed to link the patient to ongoing treatment almost immediately upon admission. (d) Social or non-chemical detoxification entails the provision of a supportive environment in which alcoholics are eased through withdrawal without medication, but with close supervision and reassurance by trained staff. If major medical symptoms are identified, patients are sent to medical centres [ 241. The Nova Scotiu model, delineated by Burke 125,261, incorporates various aspects of the basic models proposed by Moore [21]. In Nova Scotia, detoxification programs were designed to serve a wide range of patients, varying in severity, type and duration of problems. In addition, detoxification was planned as the first step in a process which includes assessment and treatment orientation as part of an overall primary care process. Staffing is quite diverse, including nurses and counsellor attendants, with social workers or psychologists and community health workers (usually recovering themselves) playing an active role. Medical back-up is available on call [25,26]. The medical, non-medical and ambulatory types of detoxification are, undoubtedly, appropriate for alcoholics whose motivation includes longterm rehabilitation. However, they may be counter-productive, when the alcoholics enter detoxification programs for ‘asylum’, rather than as a bridge to rehabilitation. General health services are increasingly recognizing the problems of inappropriate levels of care, of patients not receiving the services they need, and of patients being in programs which provide more services than needed. There has been increasing emphasis on finding the ‘right’ treatment, and on matching the alcoholic patient with a treatment that will be effective.

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This approach assumes that, for each patient, there is a spectiic treatment modality which will induce the necessary motivation. While the search persists for treatment modalities that will engender the required compliance, it is useful to consider other approaches for the detox-loopers, such as social detoxification. SOCIAL

OR NON-CHEMICAL

DETOXIFICATION

This paper proposes that an appropriate level of care - social detoxification - should be provided for detox-loopers. Such a model, perhaps embodied in a hostel setting, can focus on the alcoholic’s social welfare needs. Social detoxification provides both respite and basic care. The door to ongoing rehabilitation through professional services, as well as self-help groups, can remain open, without being the main objective of the centre. Alcoholics would stay in these programs for the same lengths of time as in conventional detoxification programs, up to 5 -7 days. The primary aim of non-chemical detoxification is to provide a nonthreatening, positive environment. The person, should be kept ambulatory when possible, given a regular diet and should be encouraged to perform purposeful activities such as carrying out small duties [ 171. Social detoxification staff need not be from the customary professional disciplines, but should be ‘street smart’, thoroughly familiar with the alcoholics’ way of life, and be able to act as advocates and brokers on behalf of patients to ensure that existing community services, such as housing, pensions and social assistance are accessible to them. Traditional community agencies may be reluctant to extend their services to alcoholics, working with a perception that problems require sequential treatment; i.e., ‘once the patient’s alcoholism is under control, we can work with him’. Such a position is inconsistent with the fact that an individual’s immediate survival needs may be more critical than the drinking problems. The social detoxification program, then, should foster and maintain close, though informal, links with a wide range of public and private services. These include those governmental programs designed to meet minimal financial needs; charitable organizations such as those providing meals, tolerant rooming house accommodation provided by private entrepreneurs and ‘wet hotels’. DISCUSSION

While alcoholism is a treatable condition, at any given time not all alcoholics presenting themselves are being helped to recover. There is no indication that current research activities will soon result in dramatically improved treatment outcomes. Resource constraints on available alcoholism treatment services increase the need to search for methods to manage recidivism and reduce resource absorption.

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This paper argues that an appropriate level of care, as provided by the social care setting, would meet the needs of detox-loopers effectively. The social care setting provides an environment for detoxification in supportive surroundings, promotes access to the social services of the community, and can divert patients who are ready for it to rehabilitation programs. The advantages for detox-loopers of the social detoxification setting over other models are: (a) it recognizes the reality that it is care and not recovery that is wanted (at the time); (b) the necessary respite and support is provided, i.e., a need for asylum is filled, for those persons who want this level of care; (c) treatment programs can concentrate on alcoholics who have accepted the ‘patient’ role and who therefore could have a better chance for recovery. It might be argued that the provision of asylum for alcoholic recidivists represents a version of therapeutic nihilism. This would be true if the development of social and ambulatory detoxification implied reduced access to other rehabilitation programs when the patient was prepared to participate. This should, of course, not be the case. A more cost-effective balance of services must be developed, with explicit recognition that, for some patients, expectations of entry to rehabilitation at that particular time are illusory. The general health care system makes provision for different levels of care, from intensive care units through to nursing homes, hostels and ambulatory care. Treatment services for alcoholics should become more sensitive to the needs of patients by matching them with a spectrum of health and social settings that are appropriate at that particular time. ACKNOWLEDGEMENTS

This paper represents the personal views of the authors. The comments of M.M. Burke, RSW and D. Pittman, PhD and the assistance of Jane Bagnall, BA, are acknowledged. REFERENCES 1 A. Richman and R.G. Smart, Drug Alcohol Depend., 7 (1981) 233. 2 A. Richman and B. Neumann, Does detoxification of alcoholics lead to entry into rehabilitation programs? Manuscript, Departments of Psychiatry and Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, 1983. 3 A.E. Reid, National Alcohol Drug Treatment Study. Final Report, University of Manitoba, duplicated, 1979. 4 E. Gordis et al., Outcome of alcoholism treatment among 5578 patients in an urban comprehensive hospital-based program: application of a computerized data system. Paper presented in part at the Medical-Scientific Meeting of the National Alcoholism Forum, Seattle, WA, 1980. 5 A. Richman, Proceedings of Social Statistics Sessions, American Statistical Association, 1977, Part II, pp. 557-562. 6 A. Richman, Eval. Progr. Plan., 6 (1983) 49. 7 H. Diesenhaus. in: Alcohol and Health Monograph no. 3 : Prevention, Intervention and Treatment: Concerns and Models, U.S. Department of Health and Human Services, National Institute on Alcohol Abuse and Alcoholism, Rockville, MD, 1982, pp. 219290.

73 8 H.M. Annis and C.B. Liban, Readmission to an alcoholic detoxification centre: demographic behavioral and detox-related predictors, Substudy No. 765, Addiction Research Foundation, Toronto, 1976. 9 D.J. Feldman et al., Am. J. Psychit., 132 (1975) 407. 10 A. Richman, Detoxification programs in Nova Scotia: readmission and rehabilitation entry, Report prepared for Nova Scotia Commission on Drug Dependency, Halifax, 1981. 11 M. Korcok, Can. Med. Assoc. J., 116 (1977) 206. 12 T. Parsons, in: M. Greenblatt, K.J. Levinson and R.H. Williams (Eds.), The Patient and the Mental Hospital, The Free Press, Glencoe, IL, 1957. 13 N.A. Giesbrecht et al., Can. J. Public Health, 72 (1981) 101. 14 A. Luks (Ed.), Compulsory treatment results. Legal Issues, International Council on Alcohol and Addictions, 1983. 15 S.C. Kaim, in: N.K. Mello and J.H. Mendelson (Eds.), Recent Advances in Studies of Alcoholism: an Interdisciplinary Symposium, Washington, 1970, National Institute of Mental Health, RockviIIe, MD, 1970, pp. 767-780. 16 C.L. Whitfield, in: J.H. Masserman (Ed.). Current Psychiatric Therapies, Vol. 19 1980 (Presidential Issue II), Grune & Stratton, New York, 1980, pp. 101-109. 17 C.L. Whitfield, Psychiat. Ann., 12 (1982) 447. 18 Health and Welfare Canada, Working Group on Special Services in Hospitals, Guidelines for Standards in the Planning, Organization and Operation of Special Services in Hospitals: Detoxification Unit, Ottawa, Health Programs Branch, Health and Welfare Canada, 1977. 19 J.C. BaIIenger and R.M. Post, Br. J. Psychiat., 133 (1978) 1. 20 C. Naranjo. The Journal, 1982, May 1. 21 R.A. Moore, Am. J. Psychit., 134 (1977) 542. 22 W. Hawthorne, Hospitals, 57 (1983) 86. 23 M.D. Shugarman, Health Care Man. Rev., 8 (1983) 81. 24 J. Quint, ‘I%e Social Setting Alcoholism Treatment Center: An Evaluation, Vera Institute of Justice, New York, 1978. 25 M.M. Burke, Comprehensive Provincial Program and Description of Facilities, Nova Scotia Commission on Drug Dependency, Halifax, 1972. 26 M.M. Burke, Program Policy Statement 1980/81,1982/83, Nova Scotia Commission on Drug Dependency, Halifax, 1982.