REPEAT ADMISSIONS TO RESIDENTIAL SUBSTANCE ABUSE TREATMENT PROGRAMS: A DESCRIPTIVE STUDY
ABSTRACT
The purpose of this research was to test the hypothesis that a majority of patients who have access to substance abuse treatment programs use them multiple times. In order to confirm that, the roster of patients (n=23) at a long-term residential substance abuse treatment program at a veterans’ facility on a single day was reviewed and their treatment histories examined. Following that, a second review was conducted of all the discharges (n=2,847) at a second residential substance abuse treatment program at the same facility over a five-year period, and the results of both reviews were tabulated. Finally, a partial overview of the literature was conducted, including treatment of nicotine addiction, to compare the effectiveness of different treatments. The results showed that 96% of subjects in the long-term treatment program had anywhere from one-to-88 previous admissions for substance abuse treatment; and one-third of the subjects in the short-term program had already been through that same program anywhere from one-to-five times. Additional research along these lines should be conducted; but these results suggest that the very concept of residential treatment for substance abuse should be revisited, with consideration toward more outpatient treatment and more effective use of ancillary resources.
INTRODUCTION:
Mental health providers who treat patients with substance abuse see individuals going through various treatment programs multiple times, often repetitively through the same program. These patients are seen as being readmitted through a “revolving door” to medicine wards or the ICU for detoxification, and/or psychiatric wards for the depression, suicidal ideation and/or auditory hallucinations that accompany their relapses. Once stabilized, bed availability at inpatient and/or residential substance abuse treatment programs are once again explored, with no clearly delineated expectations, other than finding an acceptable rationale for discharging the patient (1). In order to determine the extent to which this repetitive treatment is factual, a review of patients at two substance abuse programs in one VA hospital was conducted. Beyond that is the question of whether it is rational to continue going about the treatment of substance abuse as we have been, or whether radical changes should be entertained.
METHOD:
On
Following that, the discharges over a 5-year period in another substance abuse program at the same VA facility were reviewed to determine how many residents had been re-admitted to that program itself more than once. The Addictions Rehabilitation Unit (ARU) has a designated LOS of 35 days (5 weeks), and frequently precedes transfer to the longer-term DDTC program. Admissions/discharges in 2001-2005 were reviewed.
RESULTS:
Of the 23 veterans in residence at the DDTC on that day, only one individual (4.3%) was currently in his first treatment for substance dependence. The remaining 22 patients (95.6%) all had at least one prior admission to a substance abuse treatment program. That tends to verify the hypothesis that substance abusers who have access to treatment programs go through them more than once. Exploring further, the actual numbers turned out to be fairly remarkable (Table 1).
Age-wise, only one patient was in his 20’s (Pt. #17, age 28 yrs.). The other patients ranged in age from 38 to 58 yrs. The average age was 48 years, but discounting the 28-year-old outlier, the average age was 49 years.
The 23 patients had a total of 298 admissions among them. The number of admissions-per-patient ranged from one (Pt. #20) to 88 admissions (Pt. #21). That works out to an average of 12.9 admissions-per-patient; or 9.5 if the 88-admission outlier is eliminated.
The total number of days of treatment given to each individual ranged from 40 (Pt. #17) to 1,392 days (Pt. #19). The total number of days of treatment for all 23 patients amounted to 10,629. That averages out to 462 days of treatment for each patient. If the two outliers (#17 and #19) are eliminated, the remaining 21 patients had 9,197 days of treatment among them, or 438 days each.
The total 298 admissions represented several different kinds of treatment: Detoxification, ICU (for example, chest pain secondary to cocaine use), psychiatric sequelae of substance abuse (for example, patients who relapsed and claimed to be suicidal, homicidal, hearing voices or such, due to their relapse), and formal substance abuse program treatment and its extensions. All of the admissions, however, revolved around substance abuse and included substance abuse as the primary diagnosis or primary contributing factor for the admission. That might suggest that although substance abuse was contributory, these admissions were not all for substance abuse treatment programs. Therefore, the length-of-stay (LOS) patterns were reviewed. The shorter LOS’s generally represented the first three kinds of admissions (detox, ICU, psychiatric); LOS’s for 21 days or more represented formal substance abuse treatment and rehabilitation. 119 admissions out of the 298 total were greater than 21 days (Table 2).
Fifteen patients (65.2%) – nearly two-thirds of all the residents in the program – had at least one previous treatment of at least 3 months (90 days) or more. Seven of those (30.4%) had multiple admissions of 3 to 10 months at a time (Table 3).
Twenty-two of the 23 individuals (95.6%) admitted to the DDTC long-term residential treatment program were repeat admissions. That was a “snapshot” of the census on a single day. Following that, a retrospective review was conducted of all the admissions to another residential substance abuse treatment program at the same facility over the previous 5-year period. The Addictions Rehabilitation Unit (ARU) also treats both alcohol and drug abuse, and is considered relatively “short-term,” programmed for 35 days (5 weeks). Patients are admitted to this program directly, or after a short detox period; and many of them transfer on to a longer-term program following completion.
Between 2001 and 2005, there were a total of 2,847 discharges from the ARU program. 406 patients had multiple admissions to the ARU program, accounting for 937 (33%) of the total discharges. Of those 937 discharges, 632 (67%) were for patients who had been through the ARU twice; 192 (21%) had been through it three times; 68 (7%) had been through it four times; and 45 (5%) had been through it 5 times. The records of these patients were not checked for admissions to other substance abuse programs at this or other facilities.
There is no dearth of literature on substance abuse success and recidivism, and a wide variety of approaches to studying the issues. The following studies represent a sampling of the current literature on substance abuse treatment:
Of all the studies reviewed, only one actually acknowledged the fact that “treatment gains are often short-lived and even multiple treatment episodes do not always succeed in breaking the addiction cycle.”(24)
In the research presented here, 96% of the patients in one single program had been treated multiple times in the same or other facilities; and 33% of the patients in another program had been through that same program from two to five times, without exploring how many had been in programs elsewhere.
Nicotine is an even more-pervasive addiction than alcohol, according to Dr. John R. Hughes, past president of the Society for Research on Nicotine and Tobacco – about 10 percent of people who experiment with alcohol or cocaine will become addicted, versus 20 to 25 percent of those who use nicotine (25). The National Cancer Institute offers the following information: “Based on solid evidence, drug treatments including nicotine replacement and antidepressants, counseling by a health professional, and even simple advice from a physician” improves smoking cessation rates (26). The cogent point is that it is hard to find a mention anywhere of residential treatment for smoking cessation in spite of the pervasiveness and addictive quality of nicotine; yet, “Since 1965, more than 40% of all adults who have ever smoked have quit.”(27)
DISCUSSION:
The research herein suggests that the very concept of residential treatment for alcohol and drug abuse should be revisited. The actual cost of substance abuse treatment is beyond the scope of this paper; but consideration should be given to whether we are using our public federal and state dollars wisely. Beyond medical detoxification, inpatient and residential substance abuse treatment may be triggering the “rescuing-enabling” and “co-dependency” phenomena that actually reinforce substance abuse, rather than alleviating it.
Sobriety is not successful if it is not maintained outside of the hospital walls, in the community. Perhaps that – just as it is with smoking – is where treatment should be focused for success. Future research may elucidate the issue by following a cohort with outpatient treatment only; and a similar group who are given inpatient or residential treatment. Such research may influence the way in which we allocate our human and financial resources to substance abuse programs in the future. In particular, the human resources may be better utilized by having the night-shift staff running additional groups or meetings during the day instead. Many of these staff, with or without higher level degrees, are former substance abusers themselves, and have a great deal to offer in the way of counseling and experience that is otherwise lost to the night.
Finally, the homelessness and unemployment factors that tend to accompany alcohol and drug abuse require attention for more widespread success. Rather than residential or inpatient treatment facilities, however, resources may be better utilized in developing a network of clean, comfortable and safe shelter facilities, with shuttles to meetings, vocational rehab, and work venues.
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Accessed
TABLES:
Table 1. Age, Admissions, and Days of Treatment:
|
Patient Number |
Age of Patient |
Total Admissions |
Total Days of Care (thru |
|
1 |
54 |
6 |
839 |
|
2 |
42 |
5 |
368 |
|
3 |
51 |
4 |
273 |
|
4 |
44 |
6 |
416 |
|
5 |
42 |
5 |
221 |
|
6 |
38 |
4 |
528 |
|
7 |
55 |
3 |
162 |
|
8 |
47 |
12 |
562 |
|
9 |
52 |
7 |
342 |
|
10 |
51 |
12 |
741 |
|
11 |
46 |
21 |
520 |
|
12 |
44 |
12 |
242 |
|
13 |
45 |
11 |
410 |
|
14 |
51 |
25 |
475 |
|
15 |
51 |
9 |
794 |
|
16 |
58 |
24 |
519 |
|
17 |
28 |
2 |
40 |
|
18 |
56 |
8 |
157 |
|
19 |
58 |
17 |
1,392 |
|
20 |
56 |
1 |
145 |
|
21 |
44 |
88 |
817 |
|
22 |
52 |
8 |
456 |
|
23 |
39 |
8 |
210 |
|
|
|
|
|
|
Totals: |
|
298 |
10,629 |
|
|
|
|
|
|
Averages: |
48 yrs. |
12.9 Adm. per pt. |
462 days per pt. |
|
Adjusted Avg: |
48.9 yrs.‡ |
9.5 Adm. per pt.• |
438 days per pt.□ |
‡Excluding outlier #17 (age 28)
•Excluding outlier #21 (88 admissions)
□Excluding outliers # 17 and #19 (40 days and 1,392 days, respectively)
Table 2.
Previous admissions with LOS >21 days:
|
LOS (Days) |
No. of admissions |
|
21-34 |
34 |
|
35-89 |
59 |
|
90-179 |
4 |
|
180-199 |
6 |
|
200-249 |
13 |
|
250-299 |
2 |
|
315 |
1 |
Table 3.
Patients with at least 1 previous admission of > 3 months each:
|
Patient |
LOS |
LOS |
LOS |
LOS |
LOS |
|
#1 |
315 |
219 |
193† |
|
|
|
#2 |
230 |
|
|
|
|
|
#4 |
239 |
|
|
|
|
|
#5 |
113 |
|
|
|
|
|
#6 |
232† |
228 |
|
|
|
|
#8 |
192 |
121 |
118† |
|
|
|
#9 |
219 |
|
|
|
|
|
#10 |
231 |
192 |
|
|
|
|
#11 |
208 |
|
|
|
|
|
#13 |
153† |
96 |
|
|
|
|
#15 |
255 |
246 |
165 |
|
|
|
#19 |
268 |
246 |
225 |
141 |
123 |
|
#21 |
96 |
|
|
|
|
|
#22 |
240 |
|
|
|
|
|
#23 |
122 |
|
|
|
|
†Present admission
through
Table 4.
No. of Patients and No. of Discharges at ARU 2001-2005:
|
No. of Patients |
1,910 |
316 |
64 |
17 |
9 |
2,316 Total |
|||
|
Multiple d/c’s |
x1 |
x2 |
|||||||