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AIDS
Journal of Substance Abuse Treatment, Vol. 16, No. 1, pp. 87–95, 1999 Copyright © 1998 Elsevier Science Inc. Printed in the USA. All rights reserved 0740-5472/99 $–see front matter
PII S0740-5472(98)00013-0
IN THE SPOTLIGHT
Residential Detoxification for Substance Abusers with HIV/AIDS Walden House Detoxification Program
San Francisco, California
Abstract – Substance abusers with HIV/AIDS have a complex array of problems that are not easily addressed in outpatient or long-term residential programs. A new but promising treatment modality is residential detoxification for substance abusers with HIV/AIDS, such as described by this paper. The purpose of the program is profiled, as well as its general components and the aspects that address the special needs of HIV clients. Data indicating the successes and limitations of the program are presented, along with recommendations for further addressing the needs of substance abuses with HIV/AIDS. © 1998 Elsevier Science Inc. Keywords – HIV/AIDS; detoxification; drug abuse; residential treatment.
INTRODUCTION James L. Sorensen is at the Department of Psychiatry, San Francisco General Hospital. This project is funded by a grant from the Substance Abuse and Mental Health Services Administration, the Health Resources and Services Administration and the National Institutes of Health. The authors appreciate the support of Elaine Dennis who encouraged us in developing the manuscript; the staff and residents of Walden House, especially Olivia Lam, Angela Lenoremand, and Dan Sprague, who provided administrative coordination and data for this article; and William Schlenger and staff of Research Triangle Institute who provided information on psychiatric diagnoses of the clients. Requests for reprints should be addressed to James L. Sorensen, Department of Psychiatry, Building 20 Ward 21, UCSF at San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110. E-mail: [email protected]
Substance abusers with HIV/AIDS have numerous issues that warrant attention. Aside from a large array of medical disorders and complications related to HIV or substance dependence (Swan & Benjamin, 1993), many also have psychiatric disorders (Katz, Watts, & Santman, 1994). Further, many are homeless, have legal problems, and have limited financial, vocational, and social resources (Joseph & Roman-Nay, 1990). Although any group of substance abusers can experience similar problems, HIV disease often exacerbates these issues. Limited treatment options have been available to address these multiple issues of substance abusers with HIV/
Received September 26, 1997; Accepted February 5, 1998.
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AIDS. For example, outpatient services do not adequately address the housing needs of many in this population. In contrast, residential services may provide shelter, but have often failed to address the broad range of medical and psychiatric issues of this important group of clients. Outpatient detoxification programs have generally shown poor long-term outcomes (Nurco, Kinlock, & Hanlon, 1994; Simpson & Sells, 1982), and there is little reason to believe that these results will be better with substance abusers who also have HIV/AIDS. In 1992, Walden House opened a residential detoxification program to meet the growing need for detoxification among substance abusers with HIV/AIDS. To assist in the development of similar programs for these clients, we profile the purpose of the program, general program components, special components that address the needs of HIV clients, and indications of the success and limitations of the program. PROGRAM DESCRIPTION Context and Purpose The detoxification program is part of a comprehensive array of services for substance abusers that Walden House has developed in San Francisco, California over the past 27 years. The service array of Walden House includes 12-month residential substance abuse treatment for both adults and adolescents, day treatment, outpatient services, and several treatment programs in criminal justice settings. Based on the concepts and philosophy of the therapeutic community (hereafter “TC”), Walden House promotes recovery from drugs and alcohol through participation and involvement in the TC, referred to as the “family.” This family model regards all clients and staff as members of a close-knit unit that values honesty, self-reflection, self-determination, safety, self-help, and the belief in each individual’s ability to change (Guydish, Werdegar, Sorensen, Clark, & Acampora, 1995). Although the TC has traditionally been used in long-term residential settings, it recently has been modified for use in shorter-term treatment (De Leon, 1995), day treatment (De Leon et al., 1995; Guydish et al., 1995), and criminal justice settings (Inciardi, 1996). A primary purpose of the Walden House detoxification program is to provide a safe and supportive environment in which a substance abuser with HIV/AIDS can begin the process of recovery from drugs or alcohol. The Walden House detoxification program also provides comprehensive assessment (treatment addressing substance abuse, psychiatric, and medical needs) and referrals to additional services. The Walden House detoxification program uses a social model (Shaw & Borkman, 1990). That is, clients are assisted in their early recovery from drugs and alcohol through various interactions with others and participation in the treatment community. The social model contrasts with
medical model detoxification services, which include pharmacologic interventions, often in a hospital setting. In the social model program, clients are screened to determine the level of physiological withdrawal present, and only clients who do not require medical assistance for their withdrawal symptoms are accepted into the detoxification program. Nontraditional techniques (e.g., massage) are often used to assist clients with the physical and emotional discomfort associated with withdrawal. Target Population The target population of the detoxification program comprises adult substance abusers with HIV/AIDS. As a publicly funded clinic, the detoxification program frequently serves those who are uninsured, homeless, and who are without financial resources. A large proportion of the population are members of minority groups. Additionally, individuals of varied sexual orientations are overrepresented in AIDS cases, and the program attempts to provide treatment specific to their needs, such as groups addressing the issues of being lesbian or gay. The source of referrals is most frequently self-referral from people who have heard of the program or been to Walden House previously. Another frequent referral source is brief-stay inpatient detoxification programs. For example, the 3-day medical detoxification program at a local hospital addresses the physiological withdrawal often associated with detoxification, but clients then come to the Walden House detoxification program because they require longer care to address the nonmedical sequelae of withdrawal. Treatment Components The detoxification program’s components encompass three major service areas: (a) assessment, (b) treatment, and (c) referral. Although assessment and referral are commonly considered subcomponents of treatment, they are differentiated in this article to better highlight their important roles in detoxification. Assessment. A comprehensive assessment process is used to determine client needs and refer clients to appropriate services. Upon entry into the program, clients are assessed to determine the type and severity of their medical, substance abuse, and psychiatric impairment. Part of the assessment includes a determination of clients’ need for legal, housing, and vocational services. Because clients are in the detoxification program a mean of 15 days, it is critical that the assessment be completed within a few days after admission to permit sufficient time to treat and refer to services. Assessment occurs in three phases that are concluded by day 5 of treatment. First is a telephone interview before admission that screens a client to determine appropriateness for the program. Intake staff conduct this
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screening, which determines broadly the level of psychological and medical functioning and the appropriateness of a nonmedical detoxification in assisting the client. The second phase occurs when a client first enters the program. An intake worker conducts a comprehensive structured interview, which yields information on the social, occupational, medical, psychiatric, and drug use history of the client. A comprehensive diagnostic interview comprises the third phase: Trained interviewers administer the Composite International Diagnosis Instrument (CIDI; World Health Organization, 1990), which yields a Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994) diagnosis. This third phase was made possible by a federal demonstration project sponsored by the Center for Mental Health Services (1997). Following the third phase, a treatment plan, completed with the client’s input, is constructed to identify short- and long-term goals. Depending on the needs identified in this assessment process, additional evaluations may occur (e.g., psychiatric, legal, medical). Further, assessment of a less formal nature continues throughout the client’s stay at the detoxification program. The results of all evaluations are discussed in weekly team meetings, so that the information is included in modifying treatment plans. The comprehensive assessment, together with the relatively long average length of stay in detoxification (as opposed to the common 3 days for many detoxification programs), allows the program to distinguish between psychiatric problems and substance-related problems or even HIV dementia. Treatment. The treatment offered at the detoxification program addresses the broad and complex nature of the impairments in the clientele. Medical services, both traditional and nontraditional, address their numerous medical concerns. Mental health services, including medication monitoring, psychotherapy, and crisis intervention, address the broad range of mental health issues presented. Substance abuse services, including individual and group counseling, education, and relapse prevention, address the chemical dependency issues of the clients. Medical services include both traditional care and alternative medicine. Nurses dispense medications at the facility, as well as education about the medical conditions for which they are prescribed. Nontraditional medical services include acupuncture, herbal treatments, and somatic therapies (e.g., massage) to assist clients with detoxification symptoms and medical complaints, including those that are HIV related. Each client’s case manager uses the findings from the initial and continuing assessments to appropriately refer clients to these various medical services. Mental health services are provided to address the psychiatric problems of clients at the detoxification program. Physicians trained as psychiatrists provide evaluation and medication monitoring to stabilize psychiatric symptomatology, which is often severe and sometimes
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includes major mood and psychotic symptoms. A variety of mental health professionals provide supportive psychotherapy to assist with stabilization of symptoms and highlight issues for further exploration. Crisis intervention is also provided for acute psychiatric symptoms requiring immediate attention. Substance abuse counseling, both individual and group, is provided to establish the foundation for a drugfree lifestyle. The counseling focuses on peer support and identification of high-risk situations for relapse (Marlatt & Gordon, 1985). The counseling includes education about HIV, such as instruction on proper nutrition and prevention strategies (avoiding relapse into unsafe sex and drug use). The detoxification program itself, as a TC, provides a supportive environment for early recovery from drug problems and maintaining abstinence. Each client’s counselor also serves as a case manager, coordinating the multiple types of treatment and referrals for his or her clients. Referral. In the detoxification program, referral and treatment are equally important. The comprehensive assessment reveals clients’ needs at the time of entry into the program, and the referral process begins almost as soon as the client enters treatment. While clients are receiving services at the program, they are also being referred to services needed while at the detoxification program and beyond. The in-treatment referrals allow the program to assist with the successful link to follow-up services. For example, the program can physically transport a client to an admission interview at a long-term care facility and then back to the detoxification program. Clients referred to residential services beyond those received at the detoxification program will not only be transported to the residential service, but will also have their belongings transported by Walden House. Staff training and dedication to referrals are key elements in maintaining a high rate of successful referrals. An administrative specialist trains new counselors in how to match their clients’ needs to available services. Weekly inservice training reviews treatments available in the community. The staff learn to be proactive in linking their clients with services and to use the resources of the program to successfully complete referrals. Staff are in regular communication with referral agencies. Program Staff The detoxification program staff number about 10 fulltime equivalent (FTE) workers from several disciplines to run the detoxification program at a 12-bed capacity. A multidisciplinary staff, with experience working as part of multidisciplinary teams, is necessary to address the often complex needs of these clients. Paraprofessionals (former drug users) comprise the largest group, including two FTE administrative staff (administrative coordinator
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and data clerk), three FTE front-line counselors, and one FTE clinical interviewer. Two psychiatrists are on call for emergencies, and one provides supervision to therapists. Two other part-time psychiatrists provide psychiatric assessments, prescription of medications, and medication monitoring and follow-up. Four psychologists are involved, as project director, project coordinator, evaluator, and therapist. Two part-time master’s level social workers provide psychotherapy. Nursing staff include a licensed psychiatric technician and licensed vocational nurse who provide medication dispensing, monitoring, and education about medical conditions. In traditional TCs the preponderance of treatment is carried out by paraprofessionals, with professional staff serving an adjunctive role. In a detoxification program for clients with HIV/AIDS there is greater need for professional expertise. Mental health professionals provide psychiatric assessment, prescription of appropriate medications, and psychotherapy. Medical professionals dispense and monitor medication. With this professional overlay, the paraprofessionals can ply their craft of encouraging clients in early recovery and linking them with services that will postdate their treatment at the detoxification program. The mixture of paraprofessional and professional staff can be very powerful in treating a client population with many needs. Maintaining the staff morale in the detoxification program requires ongoing attention. The underlying philosophy is that staff work together as a close-knit “family.” This viewpoint encompasses addressing one’s own personal, mental health, and spiritual needs to more effectively serve the clients. Stress and burnout are addressed so that they do not interfere with job performance. Regular process groups, built-in time off, and supervision all decrease work stress and lead to increased teamwork. The management also encourages staff to participate in outside psychotherapy to address the stress and grief associated with working in HIV/AIDS treatment. The management allows flexibility within work schedules so that staff can attend therapy. Every year the program treats its staff and clients to an outing at an amusement park as a way to increase morale and express appreciation. SPECIAL ISSUES WITH HIV/AIDS IN DETOXIFICATION The HIV residential detoxification has three features that contribute to its success in treating this population. These are (a) the expedient entry of clients into the program, (b) their flexible stay in detoxification, and (c) the comprehensive nature of the assessment process. Expedient entry into the program is appealing to prospective clients who are often experiencing the acute symptoms associated with drug withdrawal, HIV/AIDS, psychiatric impairment, and the hardships of homelessness. Further, many prospective clients have impulse control problems with low frustration tolerance, which interfere
with focused concentration on a goal (e.g., the numerous steps and often prolonged time required to get into programs). In addition, many come after their first major HIVrelated medical illness and so are experiencing crisis. Highly symptomatic or homeless clients are placed high on the admissions list and brought into the program immediately (or transported to another suitable program) as soon as beds become available. A brief telephone screening determines eligibility for immediate admission, and the comprehensive psychosocial and diagnostic assessment of clients is completed after the client is admitted into the residential detoxification. Completing the assessment after admission is another way to expedite the client’s entry into the detoxification program. The program also uses its own transportation resources, as well as its strong relationships with free community transportation services and with other residential programs, to either get clients quickly into the detoxification program or other appropriate programs. A unique aspect of the detoxification program is its flexibility in the time allowed for clients to remain in the program. As a general rule clients can remain in the program up to 42 days (6 weeks), yet there is considerable variation. For the 1995–96 fiscal year, the mean length of stay was 15 days (median, 12 days, range, 1–60 days). The flexible duration often appeals to those not ready for longer-term treatment. Similarly, it appeals to other clients who may want ongoing services after the detoxification program, because additional time often leads to successful service linkages. Time is an essential ingredient in successfully referring clients. Depending on the referral, varying amounts of time are required to make necessary phone calls, complete requisite paperwork, gather necessary information, and physically transport the client to the referral agency for required interviews. The type of referral depends on the comprehensive assessment and the resources available to the client. A comprehensive assessment is especially vital in substance abusers with HIV/AIDS. They are subject to numerous medical conditions and complications that require evaluation, treatment, and follow-up. Many also have psychiatric symptoms and disorders related to HIV or substance abuse that require assessment, diagnosis, and intervention. Further, many in this population have meager financial resources and legal problems. Any of these domains can seriously impact an individual’s functioning. Substance abuse coupled with HIV—with or without psychiatric, legal, and financial problems—is complex and must be accurately assessed. The comprehensive assessment and the acquisition of necessary resources to achieve a successful referral often take considerably longer than the 3 days typical of detoxification programs. The possibility of allowing clients to stay for up to 42 days provides needed time, which allows for more comprehensive and accurate assessments, as well as successful completed placements into additional services, including long-term, stable housing.
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The client’s perception of the assessment process must also be considered. Clients can view assessment as either a help or a hindrance to getting desired services. Individuals in the midst of addiction, especially if physically and/or psychiatrically ill, often have neither the energy nor frustration-tolerance to endure barriers to services. The admission immediately links them into treatment and provides safe and supportive housing. With these basic needs addressed, the client is more able to endure the comprehensive assessment that is needed to obtain long-term treatment. EVALUATION INFORMATION To provide information about the operation of the program and its impact, we examined program data for a 1-year period, from July 1, 1995 to June 30, 1996. The sample comprised all admissions to the detoxification program during the 1-year period. As part of a larger project funded by the Center for Mental Health Services (CMHS), during part of this year all admissions received a comprehensive diagnostic interview. The CIDI (World Health Organization, 1990) is a 90-minute interview designed to yield a DSM-diagnosis. Interviewers were primarily master’s level practitioners with degrees in counseling or psychology. The Project Director (G.E.), a clinical psychologist with thorough knowledge of the CIDI, provided thorough training, which included role plays and case examples. In addition to the CIDI, another data source was the Walden House admission and discharge information, extracted from the larger Walden House database. It included demographic data, source of referral, drug use data, financial information, and legal information. Finally, the detoxification program kept a log that recorded the disposition of each discharge, which was completed as clients left the program; this log book provided the most accurate record of whether or not a client entered other services upon discharge from the detoxification program. Background and Diagnostic Information Table 1 presents the background of the clients admitted in the 12-month period. The client population was predominantly men, three quarters between 25 and 44 years old, half were from minority ethnic backgrounds, from varied sexual orientations, and only 4% were married or living with a sexual partner. The most frequent referral source was self, followed by a medical facility. Fortyfour percent were covered by MediCal (California’s MedicAid program), but another 22% had medical coverage. About one quarter of the admissions reported their primary drug problem as heroin, cocaine, or amphetamines. Nearly half reported receiving services at an emergency room in the past year. In summary, the client population came from diverse backgrounds, used several different drugs, and many had recently used high-cost medical services.
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Table 1 also includes information about the psychiatric problems of the clientele. Attesting to the degree of psychiatric impairment of the client population, wholly 18% of clients admitted to prior suicide attempts. In addition to the information in Table 1, on the Global Assessment of Functioning (GAF) Scale of the DSM-IV the mean score was 45: Scores in the range of 41 to 50 indicate “Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)” (American Psychiatric Association, 1994, p. 32). Table 2 displays information on a subsample of 105 of the 211 admissions who participated in a CMHSsponsored baseline assessment that included administration of the CIDI. The number of admissions receiving the CIDI in the 12-month period was roughly 50%, yet it was representative of the client population. The CIDI assessments began about 5 months into the target period, and those excluded once assessments began were principally clients who left the program after only a day or were missed because of an initial lack of assessment personnel. Table 2 indicates that 78% of the clients met criteria for a psychiatric diagnosis other than drug or alcohol dependence. Over two thirds met criteria for major depressive disorder. Half of the clients met criteria for two or more psychiatric disorders in addition to drug or alcohol dependence. These data illustrate that the detoxification program was serving a group with considerable psychiatric problems. Information About Disposition The disposition of clients, taken from the log book, is summarized in Table 3. As the table illustrates, Walden House programs comprised the single greatest referral target for clients (105 of 291 dispositions, 35%). Nearly all of these were discharged to the residential programs of Walden House. In addition to obtaining Walden House residential care, another 17% of dispositions entered residential treatment sponsored by other agencies. Altogether, 147 of the dispositions (51%) were to human service programs where the intended length of stay was longer than that of the detoxification program, and 136 dispositions (47%) were to residential treatment programs. DISCUSSION This paper has described a residential detoxification program that treats substance abusers with HIV/AIDS. The clients comprise a varied group in terms of ethnicity, sexual orientation, and primary substance of choice. Although the clients were different in many ways, only 10% were married or living with a domestic partner. Forty-eight percent had received treatment in the hospital
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R. Sargent et al. TABLE 1 Background of Detoxification Clientsa Admitted in a 12-Month Period (July 1995–June 1996)
TABLE 1 Continued
Characteristic Characteristic
Gender Men Women Transgender Age in years (M 5 37.4) 18–24 25–34 35–44 45–54 551 Race African American Caucasian Asian/Pacific Islander Native American Latino/a Sexual orientation Gay/lesbian Heterosexual Bisexual Unknown or undecided Family status Single Married Living with domestic partner Divorced or separated Unknown Referral source Self Medical facility Family or friend Homeless services Residential program Criminal justice Social services Health department Outpatient City central intake 12-step Mental health facility Other
n
n
%
92 47 39 5 4 3 3 1 8 39
44 22 18 2 2 1 1 ,1 4 18
101 281 29 457
48 NA 14 NA
55 55 53 34 6 8
26 26 25 16 3 4
95 61 36 11 22
47 30 18 5 10
13 4 2 1
59 18 9 5
10 39
5 18
25 105 65
12 NA NA
%
169 36 6
80 17 3
22 78 87 22 2
10 37 41 10 1
78 104 2 5 22
37 49 1 2 10
74 91 38 8
35 43 18 4
152 8 6 33 12
72 4 3 16 5
87 34 12 9 8 7 7 3 3 3 1 1 28
41 16 6 4 4 3 3 1 1 1 ,1 ,1 13
(continued)
emergency room in the past year, and nearly half were receiving MedicAid at the time of admission to services. Fully 78% of those administered the CIDI warranted a psychiatric diagnosis in addition to drug or alcohol dependence, and 51% warranted two or more additional psychiatric diagnoses. Altogether, 52% of the discharges were linked with longer-term care, including 35% who were discharged to Walden House programs. The clientele of this detoxification program differ from other populations in some special ways. Some differences reflect their medical condition: Nearly half had received treatment in an emergency room in the past year. The fact that only a small number of clients were married or living with a domestic partner may reflect the
Primary health care coverage MediCal (California’s MedicAid) None Local clinic Veterans administration Emergency room Private physician Private insurance Alternative medicine Other Taking medications at admission Medical utilization in the last year Client treated in emergency room Total number of visits Client hospitalized Total days of hospitalization Primary substance of choice Heroin Crack or cocaine Amphetamine Alcohol Other Unknown Route of administration Injection Smoking Ingestion Nasal On probation or parole (%) Type of crime Drug Property Violence Prostitution Self-mutilation and suicide attempts Clients with prior history of self-mutilation Clients with a prior suicide attempt Clients with suicide attempt resulting in hospitalization Total number of suicide attempts Attempts resulting in hospitalization NA 5 not applicable. N 5 211 unduplicated clients.
a
local epidemiology of HIV/AIDS as well as the draw of the detoxification program. In San Francisco, over 90% of the people diagnosed with AIDS have been gay men (a predominantly unmarried population) (San Francisco Department of Public Health AIDS Office, 1997). In addition, there is some evidence that being unmarried or not living with a partner are associated with choosing to enter detoxification (as opposed to maintenance) treatment (Schutz, Rapiti, Vlahov, & Anthony, 1994). Seventy-eight percent of the clients warranted a psychiatric diagnosis in addition to drug or alcohol dependence, 51% warranted two or more additional diagnoses, and 18% reported prior suicide attempts. These proportions are high, but not startling. Epidemiological studies
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have found that the lifetime prevalence of comorbid psychiatric disorders among drug users is around 53% (Regier et al., 1990). The chemically dependent also have higher suicide rates than the general population (Marzuk & Mann, 1988). What is unusual is that fully 51% of clients warranted more than one psychiatric diagnosis, in addition to drug or alcohol dependence. The high prevalence of multiple psychiatric diagnoses among the clients illustrates that they have a complex set of problems, and this underscores the need for substance abuse programs to link closely with mental health resources when they treat substance abusers with HIV/AIDS. The ability to keep clients longer in detoxification may be a key factor in linking 48% of them with followup services. McCusker and colleagues studied outcomes of a 21-day inpatient detoxification program, finding that overall 19% were transferred to residential drug-free programs and 7% to outpatient care, and greater length of stay was associated with higher rate of transfer (McCusker, Bigelow, Luippold, Zorn, & Lewis, 1995). They also found that those transferred to residential care treatment displayed lower relapse rates than those transferred to outpatient programs or those with no further treatment (McCusker et al., 1995). In studies of a 6-month detoxification program, Reilly and colleagues found that patients’ ratings of their self-efficacy declined as the detoxification program neared its end, which indicates a need for services that postdate the detoxification episode (Reilly et al., 1995a). At a 6-month follow-up, 71% of patients had been in some form of substance abuse treatment since leaving the 180-day methadone detoxification program, including 40% who had enrolled in a longer-
term treatment, such as methadone maintenance (Reilly et al., 1995b). Others have recommended forming multimodality programs as a strategy to cope with the complicated problems of substance abusers with HIV/AIDS (Payte, 1989). In this program the availability of several treatment modalities within the umbrella of Walden House was a basic ingredient to linking many clients with ongoing services. Forty-seven percent of the discharges left the program prematurely, were discharged for breaking the program’s rules, or were discharged to “self.” This points out the limitations of the detoxification program and the treatment network available to serve clients after detoxification. Despite the enriched therapeutic milieu and relatively long planned length of stay, many clients were not linked with longer-term services. Our recommendations for the field begin with the positive aspects of integrating professionals with paraprofessionals to more effectively treat this population. The severity and complexity of medical and psychological problems in substance abusers with HIV/AIDS requires accurate assessment to inform both treatment and referral decisions. Because many of the clients are ill, programs need medical expertise, the capability to provide medications, and the ability to monitor adherence to medications. Further, acute psychiatric symptomology
TABLE 3 Client Disposition at Disachargea from Detoxification (July 1995–June 1996 Discharges)
Discharge Where Discharged To
TABLE 2 Psychiatric Diagnosis Using CIDI: Detoxification Clientsa in CMHS Sample
Client
Diagnosis Drug dependence Major depressive disorder Dysthymia Alcohol dependence Generalized anxiety disorder Panic disorder Agoraphobia Number of diagnoses (in addition to drug or alcohol dependence) 0 1 2 3 4 5
n
%
105 69 39 35 32 29 20
97 64 36 32 30 27 19
24 30 23 16 10 5
22 27 21 15 9 5
CIDI 5 Composite International Diagnosis Instrument; CMHS 5 Center for Mental Health Services. a N 5 108 unduplicated clients.
Longer-term human service programs Walden House Programs (105 discharges) Long-term (6–12 month) residential TC Short-term (3–6 month) residential TC 90-Day residential TC 45-Day residential TC Satellite living Day treatment Long-term housing Outpatient treatment Other residential programs Assisted independent living program Other dispositions Psychiatric emergency services General hospital Incarceration Residential detoxification Shelter Self Left prematurely, no referral (e.g., “splittee”) Discharged for breaking rules (violence, sex, drugs) Unknown (not stated) TC 5 therapeutic community. N 5 291 discharges.
a
n
%
19 2 26 48 4 3 2 1 37 5
7 1 9 16 1 1 1 0 12 2
1 1 1 1 2 93
0 0 0 0 1 32
27
10
15 3
5 1
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often requires psychotropic medication. The psychotherapists on staff add a foundation of professional competence when crises arise, such as suicide attempts and other impulse control problems. A positive feature is that most professional services are reimbursable, because the HIV/AIDS or mental health diagnoses of most clients can qualify them for federal MedicAid. The TC “family” atmosphere is helpful in working with these clients, so many of whom are not married or living with a partner. The family atmosphere decreases sexual intimacy among clients. Further, it educates and attempts to provide a model of healthy family functioning for clients, many of whom have had little exposure to a family life that has not involved abuse and unhealthy boundaries. Comprehensive, multimodality programs such as Walden House may be more able to place clients after discharge, especially to services within the greater organization. Smaller programs with less comprehensive services may need to adjust the staff mix to lend more focus to referral placements. There are a number of limitations to this work, or boundary conditions that can be expanded on in further clinical programming and evaluation. First, we describe only one limited program, in a unique setting. Walden House has a long history of developing innovative treatments, and San Francisco is a community that has a comprehensive assortment of services for HIV patients, which may make the present program uncommon. Second, federal support was provided by CMHS to enhance the mental health services in this program; although this supplementation was crucial to the program, this is a demonstration program that may not be available in other settings or even continued in the present program. Third, despite the advantages mentioned above, only half of the clients were linked to ongoing treatment programs when they left the program, and we believe considerably more clients were in need of ongoing care. Finally, although some evaluation data have been presented, there is a need for much more systematic investigation. For example, a database integrating admission data, psychiatric problems, and disposition could yield much more information about the predictors of successful postprogram linkage. Also, the characteristics of potential clients who were not admitted to the program or the client outcomes on crucial dimensions, such as abstinence, mental health status, or medical status are not clear. The evaluation of the CMHS demonstration project will provide some of this information, through a planned 6-month follow-up of clients. Such information about outcomes is important, so that future research can address issues of cost and cost-effectiveness of this approach. Nevertheless, this paper points out that substance abusers with HIV/AIDS are likely to have many types of problems, including psychiatric. This group often requires a massing of treatment services that address their many needs. This paper discussed an innovative, multi-
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layered treatment program, the residential detoxification program for substance abusers with HIV/AIDS, which provides promise for treating this complex population. Additional research is needed, yet initial analysis of this program’s components and comprehensive approach suggests that it has potential as a model for treating the population of substance abusers with HIV/AIDS. Robert Sargent, PhD* James L. Sorensen, PhD† Brian Greenberg, PhD* Gwen Evans, PhD* Alfonso P. Acampora, MBA* *Walden House, San Francisco, CA †University of California, San Francisco, CA
REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Center for Mental Health Services. (1997). HIV/AIDS mental health services demonstration program: Program summary. Rockville, MD: Center for Mental Health Services. De Leon, G. (1995). Residential therapeutic communities in the mainstream: Diversity and issues. Journal of Psychoactive Drugs, 27, 3–15. De Leon, G., Staines, G.L., Perlis, T. E., Sacks, S., McKendrick, K., Hilton, R., & Brady, R. (1995). Therapeutic community methods in methadone maintenance (Passages): An open clinical trial. Drug and Alcohol Dependence, 37, 45–57. Guydish, J., Werdegar, D., Sorensen, J.L., Clark, W., & Acampora, A. (1995). A day treatment program for substance abuse clients: Six month outcomes. Journal of Substance Abuse Treatment, 12, 441– 447. Inciardi, J.A. (1996). The therapeutic community: An effective model for corrections-based drug abuse treatment. In K.E. Early (Ed.), Drug treatment behind bars: Prison-based strategies for change (pp. 65–74). Westport, CT: Praeger Press. Joseph, H., & Roman-Nay, H. (1990). The homeless intravenous drug user and the AIDS epidemic. In C.G. Leukefeld, R.J. Battjes, & Z. Amsel (Eds.), AIDS and intravenous drug use: Future directions for community-based prevention research (pp. 210–253). (NIDA research monograph 93, NIH Pub. No. 89-1667). Washington, DC: U.S. Government Printing Office. Katz, R.C., Watts, C., & Santman, J. (1994). AIDS knowledge and high risk behaviors in the chronically mentally ill. Community Mental Health Journal, 30, 395–402. Marlatt, G.A., & Gordon, J. (1985). Relapse prevention: Maintenance strategies in addictive behavior change. New York: Guilford Press. Marzuk, P.M., & Mann, J. (1988). Suicide and substance abuse. Psychiatric Annals, 18, 639–645. McCusker, J., Bigelow, C., Luippold, R., Zorn, M., & Lewis, B.F. (1995). Outcomes of a 21-day drug detoxification program: Retention, transfer to further treatment, and HIV risk reduction. American Journal of Drug and Alcohol Abuse, 21, 1–16. Nurco, D.N., Kinlock, T.W., & Hanlon, T.E. (1994). The nature and status of drug abuse treatment. Maryland Medical Journal, 43, 51–57. Payte, J.T. (1989). Combined treatment modalities: The need for innovative approaches. Journal of Psychoactive Drugs, 21, 431–434. Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B.Z., Keith, S., Judd, L.L., & Goodwin, F.K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Journal of the American Medical Association, 264, 2511–2518. Reilly, P.M., Banys, P., Tusel, D.J., Sees, K.L., Krumenaker, C.L., & Shopshire, M.S. (1995a). Methadone transition treatment: A model
HIV/AIDS Residential Detoxification Program for 180-day methadone detoxification. International Journal of the Addictions, 30, 387–402. Reilly, P.M., Sees, K.L., Shopshire, M.S., Hall, S.M., Delucchi, K.L., Tusel, D.J., Banys, P., Clark, H.W., & Piotrowski, N.A. (1995b). Self-efficacy and illicit opioid use in a 180-day methadone detoxification treatment. Journal of Consulting and Clinical Psychology, 63, 158–162. San Francisco Department of Public Health AIDS Office. (1997). AIDS Surveillance Report, AIDS Cases Reported Through June 1997. San Francisco: Seroepidemiology and Surveillance Branch, San Francisco Department of Public Health AIDS Office. Schutz, C.G., Rapiti, E., Vlahov, D., & Anthony, J.C. (1994). Suspected determinants of enrollment into detoxification and metha-
95 done maintenance treatment among injecting drug users. Drug and Alcohol Dependence, 36, 129–138. Shaw, S., & Borkman, T. (1990). Social model alcohol recovery: An environmental approach. Burbank, CA: Bridge Focus. Simpson, D.D., & Sells, S.B. (1982). The effectiveness of treatment for drug abuse: An overview of the DARP research program. Advances in Alcohol and Substance Abuse, 2, 7–29. Swan, J.H., & Benjamin, A.E. (1993). IV drug use, dementia, and nursing home care for PWAs (persons with AIDS). Journal of Health and Social Policy, 4, 79–91. World Health Organization. (1990). Composite International Diagnosis Instrument, Core Version. Geneva, Switzerland: Division of Mental Health, World Health Organization.
PII S0740-5472(98)00013-0
IN THE SPOTLIGHT
Residential Detoxification for Substance Abusers with HIV/AIDS Walden House Detoxification Program
San Francisco, California
Abstract – Substance abusers with HIV/AIDS have a complex array of problems that are not easily addressed in outpatient or long-term residential programs. A new but promising treatment modality is residential detoxification for substance abusers with HIV/AIDS, such as described by this paper. The purpose of the program is profiled, as well as its general components and the aspects that address the special needs of HIV clients. Data indicating the successes and limitations of the program are presented, along with recommendations for further addressing the needs of substance abuses with HIV/AIDS. © 1998 Elsevier Science Inc. Keywords – HIV/AIDS; detoxification; drug abuse; residential treatment.
INTRODUCTION James L. Sorensen is at the Department of Psychiatry, San Francisco General Hospital. This project is funded by a grant from the Substance Abuse and Mental Health Services Administration, the Health Resources and Services Administration and the National Institutes of Health. The authors appreciate the support of Elaine Dennis who encouraged us in developing the manuscript; the staff and residents of Walden House, especially Olivia Lam, Angela Lenoremand, and Dan Sprague, who provided administrative coordination and data for this article; and William Schlenger and staff of Research Triangle Institute who provided information on psychiatric diagnoses of the clients. Requests for reprints should be addressed to James L. Sorensen, Department of Psychiatry, Building 20 Ward 21, UCSF at San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110. E-mail: [email protected]
Substance abusers with HIV/AIDS have numerous issues that warrant attention. Aside from a large array of medical disorders and complications related to HIV or substance dependence (Swan & Benjamin, 1993), many also have psychiatric disorders (Katz, Watts, & Santman, 1994). Further, many are homeless, have legal problems, and have limited financial, vocational, and social resources (Joseph & Roman-Nay, 1990). Although any group of substance abusers can experience similar problems, HIV disease often exacerbates these issues. Limited treatment options have been available to address these multiple issues of substance abusers with HIV/
Received September 26, 1997; Accepted February 5, 1998.
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AIDS. For example, outpatient services do not adequately address the housing needs of many in this population. In contrast, residential services may provide shelter, but have often failed to address the broad range of medical and psychiatric issues of this important group of clients. Outpatient detoxification programs have generally shown poor long-term outcomes (Nurco, Kinlock, & Hanlon, 1994; Simpson & Sells, 1982), and there is little reason to believe that these results will be better with substance abusers who also have HIV/AIDS. In 1992, Walden House opened a residential detoxification program to meet the growing need for detoxification among substance abusers with HIV/AIDS. To assist in the development of similar programs for these clients, we profile the purpose of the program, general program components, special components that address the needs of HIV clients, and indications of the success and limitations of the program. PROGRAM DESCRIPTION Context and Purpose The detoxification program is part of a comprehensive array of services for substance abusers that Walden House has developed in San Francisco, California over the past 27 years. The service array of Walden House includes 12-month residential substance abuse treatment for both adults and adolescents, day treatment, outpatient services, and several treatment programs in criminal justice settings. Based on the concepts and philosophy of the therapeutic community (hereafter “TC”), Walden House promotes recovery from drugs and alcohol through participation and involvement in the TC, referred to as the “family.” This family model regards all clients and staff as members of a close-knit unit that values honesty, self-reflection, self-determination, safety, self-help, and the belief in each individual’s ability to change (Guydish, Werdegar, Sorensen, Clark, & Acampora, 1995). Although the TC has traditionally been used in long-term residential settings, it recently has been modified for use in shorter-term treatment (De Leon, 1995), day treatment (De Leon et al., 1995; Guydish et al., 1995), and criminal justice settings (Inciardi, 1996). A primary purpose of the Walden House detoxification program is to provide a safe and supportive environment in which a substance abuser with HIV/AIDS can begin the process of recovery from drugs or alcohol. The Walden House detoxification program also provides comprehensive assessment (treatment addressing substance abuse, psychiatric, and medical needs) and referrals to additional services. The Walden House detoxification program uses a social model (Shaw & Borkman, 1990). That is, clients are assisted in their early recovery from drugs and alcohol through various interactions with others and participation in the treatment community. The social model contrasts with
medical model detoxification services, which include pharmacologic interventions, often in a hospital setting. In the social model program, clients are screened to determine the level of physiological withdrawal present, and only clients who do not require medical assistance for their withdrawal symptoms are accepted into the detoxification program. Nontraditional techniques (e.g., massage) are often used to assist clients with the physical and emotional discomfort associated with withdrawal. Target Population The target population of the detoxification program comprises adult substance abusers with HIV/AIDS. As a publicly funded clinic, the detoxification program frequently serves those who are uninsured, homeless, and who are without financial resources. A large proportion of the population are members of minority groups. Additionally, individuals of varied sexual orientations are overrepresented in AIDS cases, and the program attempts to provide treatment specific to their needs, such as groups addressing the issues of being lesbian or gay. The source of referrals is most frequently self-referral from people who have heard of the program or been to Walden House previously. Another frequent referral source is brief-stay inpatient detoxification programs. For example, the 3-day medical detoxification program at a local hospital addresses the physiological withdrawal often associated with detoxification, but clients then come to the Walden House detoxification program because they require longer care to address the nonmedical sequelae of withdrawal. Treatment Components The detoxification program’s components encompass three major service areas: (a) assessment, (b) treatment, and (c) referral. Although assessment and referral are commonly considered subcomponents of treatment, they are differentiated in this article to better highlight their important roles in detoxification. Assessment. A comprehensive assessment process is used to determine client needs and refer clients to appropriate services. Upon entry into the program, clients are assessed to determine the type and severity of their medical, substance abuse, and psychiatric impairment. Part of the assessment includes a determination of clients’ need for legal, housing, and vocational services. Because clients are in the detoxification program a mean of 15 days, it is critical that the assessment be completed within a few days after admission to permit sufficient time to treat and refer to services. Assessment occurs in three phases that are concluded by day 5 of treatment. First is a telephone interview before admission that screens a client to determine appropriateness for the program. Intake staff conduct this
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screening, which determines broadly the level of psychological and medical functioning and the appropriateness of a nonmedical detoxification in assisting the client. The second phase occurs when a client first enters the program. An intake worker conducts a comprehensive structured interview, which yields information on the social, occupational, medical, psychiatric, and drug use history of the client. A comprehensive diagnostic interview comprises the third phase: Trained interviewers administer the Composite International Diagnosis Instrument (CIDI; World Health Organization, 1990), which yields a Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994) diagnosis. This third phase was made possible by a federal demonstration project sponsored by the Center for Mental Health Services (1997). Following the third phase, a treatment plan, completed with the client’s input, is constructed to identify short- and long-term goals. Depending on the needs identified in this assessment process, additional evaluations may occur (e.g., psychiatric, legal, medical). Further, assessment of a less formal nature continues throughout the client’s stay at the detoxification program. The results of all evaluations are discussed in weekly team meetings, so that the information is included in modifying treatment plans. The comprehensive assessment, together with the relatively long average length of stay in detoxification (as opposed to the common 3 days for many detoxification programs), allows the program to distinguish between psychiatric problems and substance-related problems or even HIV dementia. Treatment. The treatment offered at the detoxification program addresses the broad and complex nature of the impairments in the clientele. Medical services, both traditional and nontraditional, address their numerous medical concerns. Mental health services, including medication monitoring, psychotherapy, and crisis intervention, address the broad range of mental health issues presented. Substance abuse services, including individual and group counseling, education, and relapse prevention, address the chemical dependency issues of the clients. Medical services include both traditional care and alternative medicine. Nurses dispense medications at the facility, as well as education about the medical conditions for which they are prescribed. Nontraditional medical services include acupuncture, herbal treatments, and somatic therapies (e.g., massage) to assist clients with detoxification symptoms and medical complaints, including those that are HIV related. Each client’s case manager uses the findings from the initial and continuing assessments to appropriately refer clients to these various medical services. Mental health services are provided to address the psychiatric problems of clients at the detoxification program. Physicians trained as psychiatrists provide evaluation and medication monitoring to stabilize psychiatric symptomatology, which is often severe and sometimes
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includes major mood and psychotic symptoms. A variety of mental health professionals provide supportive psychotherapy to assist with stabilization of symptoms and highlight issues for further exploration. Crisis intervention is also provided for acute psychiatric symptoms requiring immediate attention. Substance abuse counseling, both individual and group, is provided to establish the foundation for a drugfree lifestyle. The counseling focuses on peer support and identification of high-risk situations for relapse (Marlatt & Gordon, 1985). The counseling includes education about HIV, such as instruction on proper nutrition and prevention strategies (avoiding relapse into unsafe sex and drug use). The detoxification program itself, as a TC, provides a supportive environment for early recovery from drug problems and maintaining abstinence. Each client’s counselor also serves as a case manager, coordinating the multiple types of treatment and referrals for his or her clients. Referral. In the detoxification program, referral and treatment are equally important. The comprehensive assessment reveals clients’ needs at the time of entry into the program, and the referral process begins almost as soon as the client enters treatment. While clients are receiving services at the program, they are also being referred to services needed while at the detoxification program and beyond. The in-treatment referrals allow the program to assist with the successful link to follow-up services. For example, the program can physically transport a client to an admission interview at a long-term care facility and then back to the detoxification program. Clients referred to residential services beyond those received at the detoxification program will not only be transported to the residential service, but will also have their belongings transported by Walden House. Staff training and dedication to referrals are key elements in maintaining a high rate of successful referrals. An administrative specialist trains new counselors in how to match their clients’ needs to available services. Weekly inservice training reviews treatments available in the community. The staff learn to be proactive in linking their clients with services and to use the resources of the program to successfully complete referrals. Staff are in regular communication with referral agencies. Program Staff The detoxification program staff number about 10 fulltime equivalent (FTE) workers from several disciplines to run the detoxification program at a 12-bed capacity. A multidisciplinary staff, with experience working as part of multidisciplinary teams, is necessary to address the often complex needs of these clients. Paraprofessionals (former drug users) comprise the largest group, including two FTE administrative staff (administrative coordinator
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and data clerk), three FTE front-line counselors, and one FTE clinical interviewer. Two psychiatrists are on call for emergencies, and one provides supervision to therapists. Two other part-time psychiatrists provide psychiatric assessments, prescription of medications, and medication monitoring and follow-up. Four psychologists are involved, as project director, project coordinator, evaluator, and therapist. Two part-time master’s level social workers provide psychotherapy. Nursing staff include a licensed psychiatric technician and licensed vocational nurse who provide medication dispensing, monitoring, and education about medical conditions. In traditional TCs the preponderance of treatment is carried out by paraprofessionals, with professional staff serving an adjunctive role. In a detoxification program for clients with HIV/AIDS there is greater need for professional expertise. Mental health professionals provide psychiatric assessment, prescription of appropriate medications, and psychotherapy. Medical professionals dispense and monitor medication. With this professional overlay, the paraprofessionals can ply their craft of encouraging clients in early recovery and linking them with services that will postdate their treatment at the detoxification program. The mixture of paraprofessional and professional staff can be very powerful in treating a client population with many needs. Maintaining the staff morale in the detoxification program requires ongoing attention. The underlying philosophy is that staff work together as a close-knit “family.” This viewpoint encompasses addressing one’s own personal, mental health, and spiritual needs to more effectively serve the clients. Stress and burnout are addressed so that they do not interfere with job performance. Regular process groups, built-in time off, and supervision all decrease work stress and lead to increased teamwork. The management also encourages staff to participate in outside psychotherapy to address the stress and grief associated with working in HIV/AIDS treatment. The management allows flexibility within work schedules so that staff can attend therapy. Every year the program treats its staff and clients to an outing at an amusement park as a way to increase morale and express appreciation. SPECIAL ISSUES WITH HIV/AIDS IN DETOXIFICATION The HIV residential detoxification has three features that contribute to its success in treating this population. These are (a) the expedient entry of clients into the program, (b) their flexible stay in detoxification, and (c) the comprehensive nature of the assessment process. Expedient entry into the program is appealing to prospective clients who are often experiencing the acute symptoms associated with drug withdrawal, HIV/AIDS, psychiatric impairment, and the hardships of homelessness. Further, many prospective clients have impulse control problems with low frustration tolerance, which interfere
with focused concentration on a goal (e.g., the numerous steps and often prolonged time required to get into programs). In addition, many come after their first major HIVrelated medical illness and so are experiencing crisis. Highly symptomatic or homeless clients are placed high on the admissions list and brought into the program immediately (or transported to another suitable program) as soon as beds become available. A brief telephone screening determines eligibility for immediate admission, and the comprehensive psychosocial and diagnostic assessment of clients is completed after the client is admitted into the residential detoxification. Completing the assessment after admission is another way to expedite the client’s entry into the detoxification program. The program also uses its own transportation resources, as well as its strong relationships with free community transportation services and with other residential programs, to either get clients quickly into the detoxification program or other appropriate programs. A unique aspect of the detoxification program is its flexibility in the time allowed for clients to remain in the program. As a general rule clients can remain in the program up to 42 days (6 weeks), yet there is considerable variation. For the 1995–96 fiscal year, the mean length of stay was 15 days (median, 12 days, range, 1–60 days). The flexible duration often appeals to those not ready for longer-term treatment. Similarly, it appeals to other clients who may want ongoing services after the detoxification program, because additional time often leads to successful service linkages. Time is an essential ingredient in successfully referring clients. Depending on the referral, varying amounts of time are required to make necessary phone calls, complete requisite paperwork, gather necessary information, and physically transport the client to the referral agency for required interviews. The type of referral depends on the comprehensive assessment and the resources available to the client. A comprehensive assessment is especially vital in substance abusers with HIV/AIDS. They are subject to numerous medical conditions and complications that require evaluation, treatment, and follow-up. Many also have psychiatric symptoms and disorders related to HIV or substance abuse that require assessment, diagnosis, and intervention. Further, many in this population have meager financial resources and legal problems. Any of these domains can seriously impact an individual’s functioning. Substance abuse coupled with HIV—with or without psychiatric, legal, and financial problems—is complex and must be accurately assessed. The comprehensive assessment and the acquisition of necessary resources to achieve a successful referral often take considerably longer than the 3 days typical of detoxification programs. The possibility of allowing clients to stay for up to 42 days provides needed time, which allows for more comprehensive and accurate assessments, as well as successful completed placements into additional services, including long-term, stable housing.
HIV/AIDS Residential Detoxification Program
The client’s perception of the assessment process must also be considered. Clients can view assessment as either a help or a hindrance to getting desired services. Individuals in the midst of addiction, especially if physically and/or psychiatrically ill, often have neither the energy nor frustration-tolerance to endure barriers to services. The admission immediately links them into treatment and provides safe and supportive housing. With these basic needs addressed, the client is more able to endure the comprehensive assessment that is needed to obtain long-term treatment. EVALUATION INFORMATION To provide information about the operation of the program and its impact, we examined program data for a 1-year period, from July 1, 1995 to June 30, 1996. The sample comprised all admissions to the detoxification program during the 1-year period. As part of a larger project funded by the Center for Mental Health Services (CMHS), during part of this year all admissions received a comprehensive diagnostic interview. The CIDI (World Health Organization, 1990) is a 90-minute interview designed to yield a DSM-diagnosis. Interviewers were primarily master’s level practitioners with degrees in counseling or psychology. The Project Director (G.E.), a clinical psychologist with thorough knowledge of the CIDI, provided thorough training, which included role plays and case examples. In addition to the CIDI, another data source was the Walden House admission and discharge information, extracted from the larger Walden House database. It included demographic data, source of referral, drug use data, financial information, and legal information. Finally, the detoxification program kept a log that recorded the disposition of each discharge, which was completed as clients left the program; this log book provided the most accurate record of whether or not a client entered other services upon discharge from the detoxification program. Background and Diagnostic Information Table 1 presents the background of the clients admitted in the 12-month period. The client population was predominantly men, three quarters between 25 and 44 years old, half were from minority ethnic backgrounds, from varied sexual orientations, and only 4% were married or living with a sexual partner. The most frequent referral source was self, followed by a medical facility. Fortyfour percent were covered by MediCal (California’s MedicAid program), but another 22% had medical coverage. About one quarter of the admissions reported their primary drug problem as heroin, cocaine, or amphetamines. Nearly half reported receiving services at an emergency room in the past year. In summary, the client population came from diverse backgrounds, used several different drugs, and many had recently used high-cost medical services.
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Table 1 also includes information about the psychiatric problems of the clientele. Attesting to the degree of psychiatric impairment of the client population, wholly 18% of clients admitted to prior suicide attempts. In addition to the information in Table 1, on the Global Assessment of Functioning (GAF) Scale of the DSM-IV the mean score was 45: Scores in the range of 41 to 50 indicate “Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)” (American Psychiatric Association, 1994, p. 32). Table 2 displays information on a subsample of 105 of the 211 admissions who participated in a CMHSsponsored baseline assessment that included administration of the CIDI. The number of admissions receiving the CIDI in the 12-month period was roughly 50%, yet it was representative of the client population. The CIDI assessments began about 5 months into the target period, and those excluded once assessments began were principally clients who left the program after only a day or were missed because of an initial lack of assessment personnel. Table 2 indicates that 78% of the clients met criteria for a psychiatric diagnosis other than drug or alcohol dependence. Over two thirds met criteria for major depressive disorder. Half of the clients met criteria for two or more psychiatric disorders in addition to drug or alcohol dependence. These data illustrate that the detoxification program was serving a group with considerable psychiatric problems. Information About Disposition The disposition of clients, taken from the log book, is summarized in Table 3. As the table illustrates, Walden House programs comprised the single greatest referral target for clients (105 of 291 dispositions, 35%). Nearly all of these were discharged to the residential programs of Walden House. In addition to obtaining Walden House residential care, another 17% of dispositions entered residential treatment sponsored by other agencies. Altogether, 147 of the dispositions (51%) were to human service programs where the intended length of stay was longer than that of the detoxification program, and 136 dispositions (47%) were to residential treatment programs. DISCUSSION This paper has described a residential detoxification program that treats substance abusers with HIV/AIDS. The clients comprise a varied group in terms of ethnicity, sexual orientation, and primary substance of choice. Although the clients were different in many ways, only 10% were married or living with a domestic partner. Forty-eight percent had received treatment in the hospital
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R. Sargent et al. TABLE 1 Background of Detoxification Clientsa Admitted in a 12-Month Period (July 1995–June 1996)
TABLE 1 Continued
Characteristic Characteristic
Gender Men Women Transgender Age in years (M 5 37.4) 18–24 25–34 35–44 45–54 551 Race African American Caucasian Asian/Pacific Islander Native American Latino/a Sexual orientation Gay/lesbian Heterosexual Bisexual Unknown or undecided Family status Single Married Living with domestic partner Divorced or separated Unknown Referral source Self Medical facility Family or friend Homeless services Residential program Criminal justice Social services Health department Outpatient City central intake 12-step Mental health facility Other
n
n
%
92 47 39 5 4 3 3 1 8 39
44 22 18 2 2 1 1 ,1 4 18
101 281 29 457
48 NA 14 NA
55 55 53 34 6 8
26 26 25 16 3 4
95 61 36 11 22
47 30 18 5 10
13 4 2 1
59 18 9 5
10 39
5 18
25 105 65
12 NA NA
%
169 36 6
80 17 3
22 78 87 22 2
10 37 41 10 1
78 104 2 5 22
37 49 1 2 10
74 91 38 8
35 43 18 4
152 8 6 33 12
72 4 3 16 5
87 34 12 9 8 7 7 3 3 3 1 1 28
41 16 6 4 4 3 3 1 1 1 ,1 ,1 13
(continued)
emergency room in the past year, and nearly half were receiving MedicAid at the time of admission to services. Fully 78% of those administered the CIDI warranted a psychiatric diagnosis in addition to drug or alcohol dependence, and 51% warranted two or more additional psychiatric diagnoses. Altogether, 52% of the discharges were linked with longer-term care, including 35% who were discharged to Walden House programs. The clientele of this detoxification program differ from other populations in some special ways. Some differences reflect their medical condition: Nearly half had received treatment in an emergency room in the past year. The fact that only a small number of clients were married or living with a domestic partner may reflect the
Primary health care coverage MediCal (California’s MedicAid) None Local clinic Veterans administration Emergency room Private physician Private insurance Alternative medicine Other Taking medications at admission Medical utilization in the last year Client treated in emergency room Total number of visits Client hospitalized Total days of hospitalization Primary substance of choice Heroin Crack or cocaine Amphetamine Alcohol Other Unknown Route of administration Injection Smoking Ingestion Nasal On probation or parole (%) Type of crime Drug Property Violence Prostitution Self-mutilation and suicide attempts Clients with prior history of self-mutilation Clients with a prior suicide attempt Clients with suicide attempt resulting in hospitalization Total number of suicide attempts Attempts resulting in hospitalization NA 5 not applicable. N 5 211 unduplicated clients.
a
local epidemiology of HIV/AIDS as well as the draw of the detoxification program. In San Francisco, over 90% of the people diagnosed with AIDS have been gay men (a predominantly unmarried population) (San Francisco Department of Public Health AIDS Office, 1997). In addition, there is some evidence that being unmarried or not living with a partner are associated with choosing to enter detoxification (as opposed to maintenance) treatment (Schutz, Rapiti, Vlahov, & Anthony, 1994). Seventy-eight percent of the clients warranted a psychiatric diagnosis in addition to drug or alcohol dependence, 51% warranted two or more additional diagnoses, and 18% reported prior suicide attempts. These proportions are high, but not startling. Epidemiological studies
HIV/AIDS Residential Detoxification Program
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have found that the lifetime prevalence of comorbid psychiatric disorders among drug users is around 53% (Regier et al., 1990). The chemically dependent also have higher suicide rates than the general population (Marzuk & Mann, 1988). What is unusual is that fully 51% of clients warranted more than one psychiatric diagnosis, in addition to drug or alcohol dependence. The high prevalence of multiple psychiatric diagnoses among the clients illustrates that they have a complex set of problems, and this underscores the need for substance abuse programs to link closely with mental health resources when they treat substance abusers with HIV/AIDS. The ability to keep clients longer in detoxification may be a key factor in linking 48% of them with followup services. McCusker and colleagues studied outcomes of a 21-day inpatient detoxification program, finding that overall 19% were transferred to residential drug-free programs and 7% to outpatient care, and greater length of stay was associated with higher rate of transfer (McCusker, Bigelow, Luippold, Zorn, & Lewis, 1995). They also found that those transferred to residential care treatment displayed lower relapse rates than those transferred to outpatient programs or those with no further treatment (McCusker et al., 1995). In studies of a 6-month detoxification program, Reilly and colleagues found that patients’ ratings of their self-efficacy declined as the detoxification program neared its end, which indicates a need for services that postdate the detoxification episode (Reilly et al., 1995a). At a 6-month follow-up, 71% of patients had been in some form of substance abuse treatment since leaving the 180-day methadone detoxification program, including 40% who had enrolled in a longer-
term treatment, such as methadone maintenance (Reilly et al., 1995b). Others have recommended forming multimodality programs as a strategy to cope with the complicated problems of substance abusers with HIV/AIDS (Payte, 1989). In this program the availability of several treatment modalities within the umbrella of Walden House was a basic ingredient to linking many clients with ongoing services. Forty-seven percent of the discharges left the program prematurely, were discharged for breaking the program’s rules, or were discharged to “self.” This points out the limitations of the detoxification program and the treatment network available to serve clients after detoxification. Despite the enriched therapeutic milieu and relatively long planned length of stay, many clients were not linked with longer-term services. Our recommendations for the field begin with the positive aspects of integrating professionals with paraprofessionals to more effectively treat this population. The severity and complexity of medical and psychological problems in substance abusers with HIV/AIDS requires accurate assessment to inform both treatment and referral decisions. Because many of the clients are ill, programs need medical expertise, the capability to provide medications, and the ability to monitor adherence to medications. Further, acute psychiatric symptomology
TABLE 3 Client Disposition at Disachargea from Detoxification (July 1995–June 1996 Discharges)
Discharge Where Discharged To
TABLE 2 Psychiatric Diagnosis Using CIDI: Detoxification Clientsa in CMHS Sample
Client
Diagnosis Drug dependence Major depressive disorder Dysthymia Alcohol dependence Generalized anxiety disorder Panic disorder Agoraphobia Number of diagnoses (in addition to drug or alcohol dependence) 0 1 2 3 4 5
n
%
105 69 39 35 32 29 20
97 64 36 32 30 27 19
24 30 23 16 10 5
22 27 21 15 9 5
CIDI 5 Composite International Diagnosis Instrument; CMHS 5 Center for Mental Health Services. a N 5 108 unduplicated clients.
Longer-term human service programs Walden House Programs (105 discharges) Long-term (6–12 month) residential TC Short-term (3–6 month) residential TC 90-Day residential TC 45-Day residential TC Satellite living Day treatment Long-term housing Outpatient treatment Other residential programs Assisted independent living program Other dispositions Psychiatric emergency services General hospital Incarceration Residential detoxification Shelter Self Left prematurely, no referral (e.g., “splittee”) Discharged for breaking rules (violence, sex, drugs) Unknown (not stated) TC 5 therapeutic community. N 5 291 discharges.
a
n
%
19 2 26 48 4 3 2 1 37 5
7 1 9 16 1 1 1 0 12 2
1 1 1 1 2 93
0 0 0 0 1 32
27
10
15 3
5 1
94
often requires psychotropic medication. The psychotherapists on staff add a foundation of professional competence when crises arise, such as suicide attempts and other impulse control problems. A positive feature is that most professional services are reimbursable, because the HIV/AIDS or mental health diagnoses of most clients can qualify them for federal MedicAid. The TC “family” atmosphere is helpful in working with these clients, so many of whom are not married or living with a partner. The family atmosphere decreases sexual intimacy among clients. Further, it educates and attempts to provide a model of healthy family functioning for clients, many of whom have had little exposure to a family life that has not involved abuse and unhealthy boundaries. Comprehensive, multimodality programs such as Walden House may be more able to place clients after discharge, especially to services within the greater organization. Smaller programs with less comprehensive services may need to adjust the staff mix to lend more focus to referral placements. There are a number of limitations to this work, or boundary conditions that can be expanded on in further clinical programming and evaluation. First, we describe only one limited program, in a unique setting. Walden House has a long history of developing innovative treatments, and San Francisco is a community that has a comprehensive assortment of services for HIV patients, which may make the present program uncommon. Second, federal support was provided by CMHS to enhance the mental health services in this program; although this supplementation was crucial to the program, this is a demonstration program that may not be available in other settings or even continued in the present program. Third, despite the advantages mentioned above, only half of the clients were linked to ongoing treatment programs when they left the program, and we believe considerably more clients were in need of ongoing care. Finally, although some evaluation data have been presented, there is a need for much more systematic investigation. For example, a database integrating admission data, psychiatric problems, and disposition could yield much more information about the predictors of successful postprogram linkage. Also, the characteristics of potential clients who were not admitted to the program or the client outcomes on crucial dimensions, such as abstinence, mental health status, or medical status are not clear. The evaluation of the CMHS demonstration project will provide some of this information, through a planned 6-month follow-up of clients. Such information about outcomes is important, so that future research can address issues of cost and cost-effectiveness of this approach. Nevertheless, this paper points out that substance abusers with HIV/AIDS are likely to have many types of problems, including psychiatric. This group often requires a massing of treatment services that address their many needs. This paper discussed an innovative, multi-
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layered treatment program, the residential detoxification program for substance abusers with HIV/AIDS, which provides promise for treating this complex population. Additional research is needed, yet initial analysis of this program’s components and comprehensive approach suggests that it has potential as a model for treating the population of substance abusers with HIV/AIDS. Robert Sargent, PhD* James L. Sorensen, PhD† Brian Greenberg, PhD* Gwen Evans, PhD* Alfonso P. Acampora, MBA* *Walden House, San Francisco, CA †University of California, San Francisco, CA
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