Home detoxification from alcohol: its safety and efficacy in comparison with inpatient care

In-patient treatment for the alcohol-dependent person: a public health perspective

In accordance with public health principles, this paper is concerned with examining the individual, economic and political outcomes of in-patient treatment for alcohol dependence. It is argued that in-patient treatment for alcohol dependence per se is not justifiable at any of these levels, although in-patient treatment is justifiable for the treatment of the serious biomedical sequelae of dependence. For the alcohol-dependent person, the drinking, social, financial, psychological, work-related and health outcomes of out-patient treatment are as good as those for in-patient treatment; economically, out-patient programmes are more cost-effective than in-patient programmes; politically, moving the focus of treatment away from in-patient services is more likely to contribute to a cultural milieu which recognizes problems associated with alcohol dependence early and in their many different forms, rather than only by their long-term health consequences.

Effectiveness of home detoxification: a clinical audit

AIM

An audit of home detoxifications undertaken during a 2-year period in a community drug and alcohol service was performed to explore the impact of suitability criteria on the successful completion of the intervention, and to inform future practice.

METHOD

A retrospective analysis of home detoxifications was undertaken in a community setting using a designed audit tool.

RESULTS

Of the 154 referrals for home detoxification, 59 commenced detoxification and 95 did not. The absence of a suitable carer and a pre-existing medical-psychiatric condition were the main reasons for home detoxification being deemed an unsuitable intervention. Of those who commenced detoxification, 96.6% completed the programme.

CONCLUSION

Clear and rigorous screening by an experienced professional before home detoxification is commenced is important to ensure positive treatment outcomes; however, more can be done to improve the service offered and ensure appropriate referrals.

The addition of a psychological intervention to a home detoxification programme

AIMS

Home detoxification is a recognized method of treating problem drinkers within their own home environment. The aim of this research is to determine whether a relatively brief psychological intervention adds to its effectiveness.

METHODS

A pragmatic trial with 91 participants randomly assigned to either the psychological intervention or treatment as usual. Community Psychiatric Nurses were trained to administer the brief psychological intervention involving motivational interviewing, coping skills training and social support. A manual was developed in order to standardize the training and implementation.

RESULTS

At the 3 month and 12 month follow-up the psychological intervention resulted in significant positive changes in alcohol consumption, abstinent days, social satisfaction, self-esteem and alcohol-related problems. Further, a cost analysis confirmed that the psychological intervention was a ninth of the cost of inpatient treatment.

CONCLUSIONS

Adding a psychological intervention to a home detoxification programme was successful and cost-effective.

Self-detoxification attempts among methadone maintenance patients: what methods and what success?

In a study of patients attending a methadone maintenance clinic in South London, 66 of 114 (58%) had previously attempted to detoxify themselves from opiates without medical assistance. The total number of self-detoxification attempts was 237, an average of 3.6 attempts per individual. Forty subjects (61%) reported attempting self-detoxification with the help of drugs or alcohol. The drugs most commonly used were diazepam, alcohol, and cannabis. The most commonly reported reasons for attempting self-detoxification were "fed-up with the lifestyle" (61%) and "for their family" (12%). The reasons given for why patients had decided to detoxify themselves rather than access treatment services included 23% who reported that "they could cope on their own and that they didn't need any help." The short-term success rate (abstinent for at least 24 hours) was moderate, at 41% (97/237). Patients who had been unsuccessful were asked why their last self-detoxification attempt had not resulted in abstinence, with 27% reporting that they were "tempted to use again" and 23% reported that they "didn't know why they started using again." The prevalence of both attempts and success suggests that, for some opiate users, self-detoxification may be a pathway to abstinence.

Introducing an in-patient treatment for alcohol detoxification into a community setting

Alcohol detoxification in the UK is not standardized and treatment is usually determined by local policies. Drug regimens are often predetermined and unrelated to the extent and duration of dependence, recent consumption, or previous withdrawal symptoms. Diazepam loading shortens the detoxification period and avoids the indiscriminate use of medication. It has been shown to be effective as an in-patient treatment. This paper examines the feasibility of introducing diazepam loading in a community setting, and discusses the implications that this would have for clinical practice.

How safe is hospital-in-the-home care?

OBJECTIVE

To describe the rate of negative, unexpected and adverse events associated with hospital-in-the-home (HIH) care in an established unit, and to validate indicators of safety for HIH care.

DESIGN

Prospective descriptive survey.

PATIENTS AND SETTING

231 patients, who would otherwise have required hospitalisation, accepted for acute home-based care by the HIH unit at Frankston Hospital, a 350-bed hospital serving a population of 240,000 on the south-eastern boundary of Melbourne.

MAIN OUTCOME MEASURES

The following indicators of safety: patient telephone calls to the on-call service; unscheduled staff callout to patients' homes; return to hospital during an HIH admission; and return to hospital after discharge.

RESULTS

190 acute admissions were examined. Planned same-day admissions were uneventful and excluded from the analysis. The therapies provided were intravenous therapy (mainly antibiotics), anticoagulation, and wound care. Unplanned patient telephone calls were received in 6.3% of admissions; 5.8% of acute admissions required an unscheduled staff home attendance; 4.2% of episodes resulted in a return to hospital, of which 2.6% required continued care in hospital; 2.2% of episodes resulted in a return to hospital within 14 days of discharge for a related problem. The rate of iatrogenic adverse events was 3.5%.

CONCLUSIONS

HIH care is very safe. This study may help define safety standards for HIH care so that future studies can compare them with those of traditional inpatient care.

Pharmacotherapies for alcohol abuse. Withdrawal and treatment

Pharmacologic management of alcoholism is only one part of the management of both alcohol dependence and withdrawal, which also includes the provision of a calm, quiet environment; reassurance; ongoing reassessment; attention to fluid and electrolyte disorders; treatment of coexisting addictions and common medical, surgical, and psychiatric comorbidities; and referral for ongoing psychosocial and medical treatment. For further discussion of these topics, the reader is referred to previously published sources. A survey of alcoholism treatment programs revealed that although benzodiazepines were the most commonly used drugs, standardized monitoring of patients' withdrawal severity was not common practice, and a significant minority of clinicians were using a variety of other drugs, some not known to prevent or treat the complications of withdrawal. Treatment should be based on the available evidence (Working Group on Pharmacological Management of Alcohol Withdrawal: American Society of Addiction Medicine Committee on Practice Guidelines: Pharmacological management of alcohol withdrawal: An evidence-based practice guideline. Unpublished draft, 1997). Patients with significant symptoms, patients with complications such as seizures or delirium tremens, and patients at higher risk for complications of alcohol withdrawal should receive benzodiazepines, particularly chlordiazepoxide, diazepam, or lorazepam, because of their safety and documented efficacy in preventing and treating the most serious complications of alcohol withdrawal. These drugs may be dosed on a fixed schedule for a predetermined number of doses on a tapering schedule over several days, or they may be administered by front-loading. An alternative approach for selected patients without seizures or acute comorbidity is symptom-triggered therapy, which individualizes treatment and decreases the duration and dose of medication administration. With either of the regimens, patients should have their withdrawal severity monitored until symptoms are resolving. Once withdrawal from alcohol is safely completed, the focus should turn to helping to prevent relapse. Disulfiram may be useful in highly motivated subsets of patients and when compliance-enhancing strategies are used. Naltrexone is useful in the broader population of patients entering treatment for alcohol dependence. These pharmacologic interventions should be given in the context of ongoing psychosocial support. There is substantial evidence that pharmacologic management of alcohol abuse and dependence is effective. As would be predicted from alcohol's myriad cellular effects, no panacea exists for alcoholism. For alcohol withdrawal, however, although treatment regimens have only recently been refined, evidence for effective treatment of symptoms and prevention of complications with benzodiazepines has been available for decades. Within the last decade, effective treatments, including naltrexone, have been shown to reduce alcohol intake in alcohol-dependent persons. Given the prevalence and cost of alcohol-related problems, all effective therapies (including pharmacologic treatments) should be considered to treat alcohol abuse and dependence.

Alcohol withdrawal: an adaptation to heavy drinking of no practical significance?

Markedly differing views can be found among both clinicians and researchers regarding whether alcohol withdrawal is a phenomenon of any practical or theoretical importance. Evidence has mounted that alcohol withdrawal, even in a severe form, is rarely life-threatening and the great majority of cases can be managed in non-medical settings, including the home. There is also a widely held view among clinicians that withdrawal symptoms have little motivational significance and may be best regarded as but epiphenomena of prolonged heavy drinking. There are also experimental data from both human and animal laboratory studies to the effect that withdrawal symptoms do not readily trigger further alcohol consumption. Against this most unpromising background a case is presented for alcohol withdrawal being but one manifestation of important biological and psychological adaptive processes which occur almost whenever alcohol is consumed with any regularity. It is proposed that understanding this more general phenomenon is critical to a better understanding of the factors which maintain heavy and problematic drinking. Recent evidence also suggests that minor alcohol withdrawal symptoms are far more common in the general population than had previously been realized, and that this has important implications for prevention policy.