An evaluation of detoxification as an initial step in the treatment of heroin addiction

Predicting Long-term Treatment Utilization among Addicts Entering Detoxification: The Contribution of Help-seeking Models

Detoxification is the entry point into the drug treatment system for many heroin and cocaine addicts. In this paper, we examine both socio-demographic predictors of utilization of long-term treatment and constructs based on theories of help-seeking. Data for this paper were collected from 279 heroin and cocaine dependent individuals, at entry into two detoxification programs and 30 or more days later, to determine their long-term treatment status in the 30 days following detoxification. We find that homeless individuals, those on parole, and those who have used drugs for fewer than 20 years are more likely than their counterparts to be in treatment. Even when an array of sociodemographic characteristics are controlled, constructs drawn from the theory of planned behavior (Ajzen, 1988) –viz. intention to enter treatment, behavioral beliefs favoring treatment, and perceived behavioral control (self-efficacy) contribute significantly to the prediction of treatment utilization.

ONE-, THREE-, AND SIX-MONTH OUTCOMES AFTER BRIEF INPATIENT OPIOID DETOXIFICATION

The purpose of this study was to investigate short-term outcomes of a 3-day inpatient medical detoxification. Heroin abusers (n = 116; 66% male, 77% African-American, X = 38 years old), completed the Addiction Severity Index during detoxification, and at 1, 3, and 6 months after detoxification; 94.5% of the postdetoxification interviews were completed. During the 30 days before detoxification, mean days of self-reported use for heroin was 28, for cocaine 19, and for alcohol 14; a mean of $1,975 was spent on drugs. Across the postdetoxification interviews, mean days of reported heroin use ranged from 11 to 14; 21-30% of patients reported no heroin use, whereas 25-36% reported almost daily use. Reported use of cocaine and alcohol showed similar reductions from pre- to postdetoxification. Reports of heroin and cocaine abstinence were generally verified through urine tests. Other psychosocial factors improved as well from pre- to postdetoxification (e.g., employment increased and needle use decreased). During the 6-month evaluation, at least 41% reported engaging in formal inpatient or outpatient treatment; another 25-33% reported attending self-help groups. Engaging in formal treatment (at least 7 days duration) was associated with significantly better outcome. Nevertheless, pre- to postdetoxification changes were significant and robust for the entire study sample. These findings demonstrate that brief inpatient detoxification is followed by reduced drug use over several months and is accompanied by substantial treatment-seeking behavior. Thus brief detoxification may serve as an effective harm-reduction intervention.

Aftercare Plans of Inpatients Undergoing Detoxification

Drug use relapse rates are high following residential detoxification. This study examined the aftercare plans and desired services of participants currently enrolled in residential detoxification programs. Participants completed a survey regarding their aftercare plans and services that they desired from an aftercare program. Participants (98%) reported some form of aftercare plans following detoxification. Among the services that participants endorsed wanting were individual counseling, help with finding a job, and Narcotics Anonymous (NA) meetings. With low rates of enrollment in aftercare programs, the findings of this study may be of help in determining what services will best assist individuals recovering from addiction.

Reinforcement-based therapy: 12-month evaluation of an outpatient drug-free treatment for heroin abusers

This controlled study examined the efficacy of reinforcement-based therapy (RBT) for producing enhanced abstinence outcomes over 12 months in opioid-dependent patients exiting a brief residential detoxification. Patients were randomly assigned upon completing their medically managed taper (i.e., detoxification) to RBT (N=66) or usual care (N=64) referral to community treatment programs. The 6-month RBT program offered an array of abstinence-based incentives including rent payment for recovery housing, program-led recreational activities and skills training for procuring employment. RBT produced significantly higher self-report and urinalysis-confirmed rates of abstinence from opioids and cocaine relative to usual care at 1 (42% versus 15%) and 3 (38% versus 17%) months during treatment but not at 6 or 12 months after enrollment. The RBT but not the usual care group showed significant increases in the number of days worked and the amount of legal income earned at 3, 6 and 12 months. The results of this randomized study suggest that an intensive reinforcement-based therapy that includes abstinence-based recovery housing is a promising approach; however, further research is needed to determine the role of treatment intensity and the specific efficacy of RBT's component parts.

Short-term outcomes after brief ambulatory opioid detoxification with buprenorphine in young heroin users

AIMS

This study examines the outcomes at 1, 3 and 6 months after a very brief outpatient detoxification with buprenorphine in 18-25-year-old heroin users.

DESIGN

Prospective follow-up study.

SETTING

Outpatient drug treatment clinic, providing brief detoxification in downtown Baltimore, Maryland, USA.

PARTICIPANTS

One hundred and twenty-three subjects between 18 and 25 years old; 56% male; 95% Caucasian; seeking detoxification; living in Baltimore City and five surrounding counties.

INTERVENTION

Detoxification with buprenorphine over 3 days. Follow-up at 1, 3 and 6 months.

MEASUREMENTS

Drug use history, the Addiction Severity Index at baseline and follow-up, urine drug screens, evaluation of the detoxification experience.

FINDINGS

By self-report, 37% of the total sample were not currently using heroin at 1 month, 32% at 3 months and 29% at 6 months, and 6.7%, 10.1% and 11.8% had an opioid negative urine test at 1, 3 and 6 months, respectively. There was a significant reduction from the baseline in mean Addiction Severity Index drug use composite score, as well as the mean number of days of heroin and cocaine use during past 30 days, that was sustained over the three follow-up points. Engagement in aftercare was generally poor.

CONCLUSIONS

The findings show a reduced frequency and intensity of drug use, suggesting a possible role for brief outpatient detoxification in reducing the severity of dependence for some younger heroin users who may not yet be ready to engage in long-term abstinence-oriented or opioid substitution treatments.

Detoxification as a gateway to long-term treatment: assessing two interventions

Two interventions designed to increase the likelihood of entry into long-term treatment upon discharge from hospital detoxification are compared in a randomized controlled trial. The 279 study participants were treated for heroin and/or cocaine dependence on detoxification wards in two hospitals in a poor, predominantly Hispanic, neighborhood in New York City. One-third of the participants entered and remained in long-term treatment for the first 30 days after discharge from detoxification, 23% were in treatment for 1-29 days, and 43% received no treatment in the 30 days. Neither of the interventions--one, a brief motivational psychotherapy, the other, a series of treatment-related videos--is found to be significantly superior to treatment as usual in increasing the likelihood of utilization of long-term treatment. While weaknesses in the interventions themselves need to be examined, it is also concluded that conditions on the detoxification wards may hamper effective intervention.

Methods for enhancing transition of substance dependent patients from inpatient to outpatient treatment

This study examined methods for increasing transition of substance dependent patients from inpatient detoxification to outpatient aftercare. One hundred and ninety-six patients were randomly assigned to, (1) standard referral (standard); (2) standard referral with an incentive (incentive); or (3) staff escort from detoxification to aftercare with an incentive (escort+incentive). Incentives (worth US$13.00) were dispensed for completing aftercare intake procedures on the day of discharge from detoxification. More escort+incentive participants (76%) than those in the incentive (44%) or standard conditions (24%) completed intake. The escort+incentive procedure may be useful for improving transition from detoxification to aftercare.

Reinforcement-based outpatient treatment for opiate and cocaine abusers

A reinforcement-based intensive outpatient treatment was delivered to 37 recently detoxified, inner city, heroin and/or cocaine abusers who did not want methadone treatment. Attendance was scheduled and urine collected daily for the first 2 weeks, four times weekly for the next 2 weeks, and then thrice weekly for the final 8 weeks. As attendance incentives, patients received transportation assistance (bus tokens), and $28-$30 per week in vouchers to be spent on activities/items chosen and agreed upon with their counselor. As abstinence incentives, patients received weekend supported recreational activities, lunches, $42-$45 per week in vouchers, and rent or utilities payment ($150 over 4 weeks). Total potential earnings was $1,435 per patient; actual mean earnings was $583. Forty-three percent (n=16) completed 10 or more weeks of treatment. These 16 long-stay patients submitted 92% (SD=19) opiate- and cocaine-negative urines during their enrollment compared with 56% (SD=42) drug-negative urines submitted by 21 drop-outs, F(1,35)=9.99, p=0.003. Overall, 32% of clients became employed during their treatment episode; 94% of long-stay patients were employed at the end of their treatment episode. Patients who were drug-positive at intake were highly likely to drop out. Treatment outcomes compare favorably with those reported in the literature for outpatient nonmethadone treatment of opiate and cocaine abusers. Continued evaluation of this new treatment appears warranted.

P300 assessment of opiate and cocaine users: effects of detoxification and buprenorphine treatment

We assessed cognitive function following heroin and cocaine detoxification and investigated whether buprenorphine treatment improves the disruptive effects of detoxification. Three groups of male volunteers meeting DSM-III-R criteria for concurrent opiate and cocaine dependence were tested using an auditory oddball paradigm before and after detoxification, and again on the 15th day of either buprenorphine or placebo treatment. There were no significant differences in P300 amplitude, latency, or topographic distribution between drug-dependent subjects and controls on admission day. Following detoxification there was a significant decrease in P300 amplitude in the drug-dependent group at a time when self-reported signs of withdrawal were minimal. Buprenorphine treatment significantly reversed the P300 amplitude decrement following detoxification, whereas placebo-treated subjects continued to show depressed P300 amplitudes. These data demonstrate that buprenorphine treatment is effective in eliminating detoxification-induced impairments in one measure of cognitive ability.

Outcomes of a 21-day drug detoxification program: retention, transfer to further treatment, and HIV risk reduction

We investigated the outcomes of a 21-day inpatient drug detoxification and rehabilitation program including length of stay, transfer to further treatment, and HIV risky behavior. Clients (n = 567) were predominantly White, male, currently unemployed, and their treatment was not covered by third party payment. 78% were detoxified with methadone. The median length of stay was 18 days. Higher education, not living with spouse or children, English as primary language, admission during fall or winter months, and greater knowledge of HIV transmission were independent predictors of greater length of stay. Among those with follow-up (n = 450), 19% were transferred to residential drug-free programs and 7% to outpatient programs. Taking into account loss to follow-up, the overall rate of treatment transfer could be as low as 21%. Greater length of stay was associated with higher rates of transfer to residential treatment. Relapse rates to either any drug use or injection drug use were lower among subjects transferred to residential treatment than either clients transferred to outpatient programs or those with no further treatment. Among subjects who continued to inject drugs at follow-up, no reduction in HIV risky behaviors was found regardless of further treatment. We conclude that detoxification programs have the potential for reducing relapse to drug use when followed by residential drug-free treatment.

"It takes your heart": the image of methadone maintenance in the addict world and its effect on recruitment into treatment

Using data gathered on 368 current methadone clients and 142 narcotics users not in treatment in structured interviews and through ethnographic fieldwork, the study examines the image of methadone maintenance treatment in the drug-using community and discusses the effect of that image on recruitment of addicts into methadone treatment. The results indicate that the image of the methadone client as a "loser," fear of the long-term effects of methadone, and the perception of treatment as an intrusion in the user's daily life make addicts often difficult to recruit and, once in treatment, ambivalent about their participation. The image of methadone is based on both misinformation about treatment and the user's contrasting of a treatment status with the stereotypic ideal of the "righteous dope fiend." Policy implications and suggestions derived from the data are discussed.

Benefits of recurrent, outpatient heroin detoxification

Recurrent heroin detoxification, or the "revolving-door" process, is the treatment of choice for many addicts. Forty-five heroin addicts were detoxified 145 times (mean = 3.2 per patient) on an outpatient basis over a 3-year period and showed significant improvement in arrest and hospitalization rates but not employment or intact marriages. Another group of 74 patients who had detoxified two or more times were compared to a similar group of 61 methadone maintenance (mean maintenance time = 17.9 weeks) patients, and no significant difference was found in a variety of health, employment, and social indicators. These findings indicate that recurrent, outpatient heroin detoxification has some therapeutic benefits and provides an explanation for patient popularity.

Predicting treatment dropouts from a drug abuse rehabilitation program

Seventy-five drug addicts who completed an opiate detoxification program were compared with 75 addicts who dropped out prematurely on 14 variables. Results showed that patients were more likely to complete detox when the number of staff absences and primary therapist absences increased, when more patients were admitted during their hospitalization, and if they were prescribed methadone. A discriminant function analysis successfully classified 88% of the sample into stay/leave categories. The results were cross-validated on an independent sample of 25 completers and 25 dropouts, resulting in 75% classification accuracy. Primary drug of abuse (heroin/Talwin) was not a factor on any measure. Results indicate that treatment dropout among drug addicts is based more on situational interactionism than on individual determinism.

Heroin addict responses to six weeks of detoxification with LAAM

This paper describes the range of experience of 28 heroin addicts who received LAAM instead of methadone over six weeks in an outpatient detoxification program. Four patients are singled out to illustrate the variety of response during withdrawal, temporary abstinence from drugs, and social adjustment. The paper explores the motivation of patients and both their physical and subjective responses to the detoxification attempt. By describing a variety of patients, the paper documents clinical responses that cannot be communicated in statistical summaries or single-case reports. Overall, the cases illustrate the difficulties of brief-stay outpatient detoxification from heroin. Clinicians should expect to see only small steps toward rehabilitation during a patient's attempt to taper from opiates, but even minimal progress may justify the use of detoxification programs as a link between "street life" and the decision to enter long-term treatment.

Influence of a cash fee on outpatient heroin detoxification

Twenty-eight employed heroin addicts who were admitted to 10-day, outpatient detoxification and paid a modest fee were compared to 28 poverty-level, unemployed patients who received free detoxification. Patients were matched for admission date within +/- 30 days, sex, age within +/- 5 years, total length of heroin use within +/- 3 years, and parole/probation status. At the end of detoxification treatment, 9 of 28 (32.1%) patients who paid a fee, and 11 of 28 (39.3%) patients who were given free treatment had urines which were devoid of heroin derivative (PNS). Three of less patients in each group chose to remain in longer-term treatment (PNS). These results suggest that a patient fee did not favorably influence outcome of outpatient heroin detoxification.