REHAB EVIDENCE & NTORS

by George Christo
BSc, PhD, PsychD, AFBPsS, CPsychol

Link to Rehab works: evidence

Further to the Rehab works evidence, this post is an extract from the paper about rehab I wrote eight years ago. I think you will find it says it all, including the cost-effectiveness element.

REFERRAL PATTERNS 

The UK National Treatment Outcome Research Study - NTORS - reported disappointing outcomes for the widespread alcohol abuse among drug users in outpatient prescribing services ^28,29,30,31. However it also noted that dependent polydrug, alcohol ³² and crack or cocaine ³³ users tended to be referred to residential rehabilitation, where substantial reductions in drug use including alcohol were made ³⁴.

Such individuals appropriate for residential settings were also associated with higher rates of overdose ³⁵, crime and psychological problems ³⁶, injecting and sexual risk behaviours ³⁷, and psychiatric symptoms ³⁸.  There is no doubt these problems create great costs for the health care, social service and criminal justice system responses ^32,39 and the increased investment associated with residential treatment for this group produces worthwhile returns ^40,41.

Longer stays in treatment are generally predictive of better outcomes ³⁴ although TCs with excessively long programmes may be associated with poorer outcomes due to premature dropout ^42,43.  In their excellent review of the USA’s Drug Abuse Treatment Outcome Studies, Franey and Ashton ⁴⁴ noted similar findings to the above and concluded that although residential care cost eight times as much as non-residential treatment [later note: this gap can be greatly closed], it achieved far greater savings in the long run.  This was because residential centres took in far more criminally active clients and achieved greater reductions in the costs of crime. Clients with the greatest problems who stayed for at least three months gained the clearest advantage from residential treatment.

Appropriate referrals:
* Should satisfy DSM-IV criteria for substance dependence rather than substance abuse
* Should be prepared to abstain from all drugs including alcohol during treatment
* May be multiply and severely dependent on any combination of stimulants, sedatives, opiates and alcohol
* May have high criminality and poor support networks or social functioning
* Should reduce their alcohol, tranquilliser, or opiate use as much as possible prior to treatment entry in order to save time on detoxification
* Should not be referred to secondary treatment unless they are detoxified and have already had experience of primary treatment
* Should not have untreated serious medical or psychiatric conditions, or severe personality problems characterised by persistent poor impulse control, violent behaviour, or repeated self-harm.

OUTCOMES

Outcomes ^45,46 are hard to generalise due to variations between treatments ⁴⁷, samples, follow-up periods and outcome measures.  But recent UK evaluations of residential rehabilitation indicate approximately 50% ‘success’ rates ^{34,48,49,50,51}.  However, even those who had ‘relapsed’ at follow-up maintained some improvement in comparison to their pre-treatment levels of dysfunction ^50,51, probably by gaining a period of respite from their drinking or drug use.

Common reasons for treatment failure and premature discharge

Relevant UK evaluation studies indicate that only 5% to 32% of premature leavers have a good outcome at 6 months whereas 71% to 79% of treatment completers have a good outcome ^48,49,50. Prospective residents should thus be made aware that any of the following behaviours may result in the premature discharge of individuals concerned:
* Any use of illicit drugs or alcohol on or off the premises interferes with the treatment process and creates temptation for others.  Treatment staff are adept at identifying covert substance use, and will take urine screens or breath tests if they have any suspicions.
* Smoking in no-smoking areas, particularly bedrooms, is a fire risk and invalidates the TC’s fire insurance, it is looked upon very seriously.
* Sexual liaisons with other members of the community are generally discouraged as they distract individuals from focusing on their treatment programme and interfere with effective group work.  This is a frequent cause for discharge, particularly when residents may be on rebound from the libido suppressing effects of opiates.
* Theft or destruction of property.
* Any violent behaviour or threats of violence.
* Disrespectful verbal abuse, particularly if of a sexist or racist nature.
* Continued non compliance with treatment assignments or non participation in groups.
* Formation of cliques among selected residents considered to be a negative influence.
* Witnessing but failing to disclose any of the above behaviours.  Collusion by failure to report undermines the positive treatment atmosphere and this is taken seriously by staff.

Factors affecting outcome

Retention in treatment and consequent good outcome is consistently predicted by the relationship between readiness for treatment and change, motivation at intake, commitment, therapeutic involvement, compliance, and therapeutic relationships ^{14,50,52,53,54,55,56,57}. These indicators of intrinsic motivation were found to be more important predictors of engagement and retention than socio-demographic, drug use and other background variables ^50,53. Assessments that focus on compliance, therapeutic relationships, and stages of readiness for change could help improve treatment outcomes.

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Comments

[Andrew MacDonald]

A great article George - helpful to DAAT commissioners in straightened times.
Andrew MacDonald
DAAT Alcohol Coordinator Salford
NHS Salford Public Health Lead

[Andrew MacDonald]

Great article for commissioners and providers in straightened financial times and a new political landscape around residential treatment.

Andrew MacDonald
Salford DAAT Alcohol Commissioner and NHS Salford Public Health Team Alcohol Lead