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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 24  |  Issue : 1  |  Page : 23-26

Predictors of inpatient completion of detoxification in patients with substance use disorders


Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India

Date of Web Publication4-Jun-2020

Correspondence Address:
Ajeet Sidana
Department of Psychiatry, Government Medical College and Hospital, Sector - 32, UT, Chandigarh - 160 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_62_19

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  Abstract 


Background: Despite the availability of adequate indoor treatment facility for patients with substance use disorders (SUDs), a substantial number of patients do not undergo complete detoxification process. Incomplete detoxification leads to premature termination of treatment and relapse. Aims and Objectives: To see the association of various sociodemographic and clinical variables with completion of detoxification in hospitalized patients with SUDs. Materials and Methods: Case record files of patients with SUDs as per ICD-10, who were admitted in the de-addiction ward of a tertiary care teaching hospital of North India from January 1, 2019, to August 31, 2019, were retrieved and analyzed for various sociodemographic and clinical variables. Results: A total of 85 patients with SUDs were admitted during an 8-month period; majority of the patients were male with a mean age of 32 years, middle economic status, and from Punjab. Major substances of abuse were opioid (43.5%), followed by alcohol (37.6%) and nicotine and cannabis (5.9%). The most common route of administration was oral, followed by injecting, chasing, and smoking. Overall, 32 patients completed the detoxification during hospitalization. Age of the patient, withdrawal severity, and duration of stay in the ward are good predictors of completion of detoxification. Conclusion: It can be concluded from the study that older patients, increased severity of withdrawals, and longer duration of stay are good predictors of successful detoxification.

Keywords: Addiction, detoxification, predictors, substance use disorders


How to cite this article:
Sidana A, Saroye R, Agrawal A. Predictors of inpatient completion of detoxification in patients with substance use disorders. J Mental Health Hum Behav 2019;24:23-6

How to cite this URL:
Sidana A, Saroye R, Agrawal A. Predictors of inpatient completion of detoxification in patients with substance use disorders. J Mental Health Hum Behav [serial online] 2019 [cited 2020 Jul 10];24:23-6. Available from: http://www.jmhhb.org/text.asp?2019/24/1/23/285996




  Introduction Top


Substance use disorder (SUD) is a public health problem that affects millions of individuals worldwide. In industrialized countries, alcoholism is among the leading causes of death.[1] Qualified detoxification treatment is the first and important step in inpatient substance abuse treatment. Premature termination of detoxification is a common outcome, which leads to early relapse and further complications. Inpatient treatment of individuals with SUDs is often considered when the individual has been actively taking substance and requires a safe environment for detoxification, past attempts with outpatient department-based management have been unsuccessful, past history of complicated withdrawals, severe dependence and associated medical/psychiatric comorbidity, etc.[2] Noncompletion of treatment in SUDs is associated with unfavorable long-term outcome. Whereas, successful completion of detoxification process increases the possibility of retention in treatment and long-term outcome.[3] However, the reason for completion/noncompletion of detoxification varies. Sofin et al.[4] found that younger male, living alone, low educational level, unemployed, history of imprisonment, injecting drug use, and history of previous dropouts were associated with a premature treatment dropout. A retrospective chart review by Sarkar et al.[5] reported that treatment completers had greater age and were dependent on opioid, whereas noncompleters had shorter duration of stay and were dependent on alcohol. However, the authors did not assess association of severity of withdrawals with completion or noncompletion. Hence, understanding the factors associated with successful completion of detoxification including severity of withdrawal symptoms has outmost importance in terms of improving the outcome during inpatient detoxification as well as reducing the frequency of rehospitalization and reducing the burden on health-care system.

The purpose of the present study was to see the association of sociodemographic and clinical factors with successful completion of detoxification in hospitalized patients with SUDs.

Prediction of treatment outcome provides the opportunity to improve inpatient detoxification treatment. Therefore, we conducted a retrospective study to determine the influence of sociodemographic as well as clinical variables on treatment outcome on patients with SUDs.


  Materials and Methods Top


The present retrospective chart-based study was conducted at a tertiary care de-addiction center at Government Medical College and Hospital of North India. There is a facility of eight beds for inpatient treatment of patients with SUDs, along with outpatient treatment, services for psychotherapeutic interventions, and psychosocial rehabilitation. It is a government-funded institution. The patients are charged Indian rupees 90/day for the duration of admission and these admission charges are waived for patients from economically weaker sections of the society.

Patients are primarily admitted at the center for alcohol and opioid detoxification. The duration of admission is typically for 10–15 days. During the stay in the de-addiction ward, patients are provided medications for symptomatic management of withdrawal symptoms along with motivation enhancement sessions. Medications for detoxification typically include benzodiazepines for alcohol dependence and clonidine and flupirtine for opioid dependence. After detoxification of opioid, patients are started on naltrexone as relapse prevention measure and on baclofen for alcohol dependence after assessing the motivation of the patient. Treatment for co-occurring psychiatric disorders is also provided, and the center has a close liaison with other departments of hospital for the management of concurrent medical and surgical illnesses.

Case record files of patients with SUDs as per ICD-10,[6] who were admitted in the de-addiction ward of a tertiary care teaching hospital of North India from January 1, 2019, to August 31, 2019, were taken out. The study utilized data from the information in the nursing and administrative records of the patients, supplemented by the patient case files. The study had approval from the institutional ethics committee.

Data analysis

The information extracted included age, gender, residence of the patient, the primary substance of abuse, and duration of inpatient stay. Further, the association of duration, quantity of substance and method of substance use, and severity of withdrawals on completion of detoxification were seen. Withdrawal severity was assessed with the severity scales available for particular substance, i.e., Clinical Opiate Withdrawal Scale[7] for opioid dependence, Clinical Institute Withdrawal Assessment for Alcohol[8] for alcohol dependence, and Fagerstrom Test for Nicotine Dependence.[9] Data on medical history comprised the addiction diagnoses, and if applicable, addiction/associated disorders and other psychiatric and medical comorbidities were also collected. The data were analyzed using statistical analysis system software. All the variables were compared for difference between patients who completed treatment versus those who did not. The study was approved by the institutional ethics committee.


  Results Top


A total of 85 patients were admitted during the time period of 8 months. Out of total, 84 (98.8%) patients were male and 1 (1.2%) was female. The mean age of sample was 32 years. A total of 10 (11.8%) patients were from upper socioeconomic status, 68 (80%) patients were from middle socioeconomic status, and 7 (8.2%) patients were from lower socioeconomic status. More than half of the samples (n = 43, 50.6%) were residents of Punjab, 32.9% (28) of Chandigarh, 10.6% (9) of Haryana, and 5.9% (5) of other states. Of the 85 patients included, the most common diagnoses were opioid dependence with 43.5% (n = 37), followed by 37.6% (n = 32) harmful alcohol use, 12.9% (n = 11) nicotine dependence, and 5.9% (n = 5) cannabis dependence. While 35.2% of patients had dependence on single substance only, 64.7% had dependence on more than one substance. The most common route of use was oral 45.8%, followed by IDU 21.2%, chasing 17.7%, and smoking 15.3%.

Overall, 32 (37.6%) of the 85 patients completed detoxification treatment and 54 (63.5%) of the 85 patients were started on anticraving treatment. The average duration of stay was 11 ± 2 days.

There is a positive correlation between age of patient and withdrawal severity after 48 h (P = 0.046). This may be due to occurrence of reverse tolerance with increasing age or longer duration of substance use translating into more severe dependence as shown in [Table 1] and [Table 2].
Table 1: Scores of withdrawal severity of various substances at the time of admission and after 48 h

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Table 2: Comparison of sociodemographic and clinical variables with completion of detoxification

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Duration of stay in ward and withdrawal severity was also positively correlated, i.e., the duration of stay increases with the increase in withdrawal severity (P = 0.036). The duration of stay was predictive for the completion of detoxification. The duration of substance use is also associated with completion of detoxification, but this is not significant statistically as shown in [Table 3].
Table 3: Comparison of sociodemographic and clinical variables between completers of detoxification and noncompleters

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In addition, age of the patient, withdrawal severity (P = 0.021), duration of substance use (P = 0.003), and duration of stay (P = 0.03) are good predictors of starting the anticraving medicines as shown in [Table 4].
Table 4: Comparison of sociodemographic and clinical variables with initiation of anticraving

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Furthermore, it is found that there is a significant association between age of the patients with initiation of anticraving as well as noninitiation of anticraving medicine (P = 0.004), i.e., patients with greater age are more likely to be started on anticraving as shown in [Table 5].
Table 5: Comparison of sociodemographic and clinical variables between initiators of anticraving and noninitiators

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Logistic regression confirms that having no medical disorder increases the risk of premature treatment completion significantly.


  Discussion Top


The aim of the present study was to see the sociodemographic and clinical predictors of successful completion of detoxification in hospitalized patients with SUDs.

Our findings indicate that increasing age of patients has a positive association with completion of detoxification, which is consistent with other studies, which have also reported that middle-aged and older adults have better remission and abstinence outcomes compared with younger adults and that life transitions vary by age group and these patterns persist over time. They highlight the relatively favorable long-term prognosis of older adults in treatment.[10],[11]

Similarly, length of stay for detoxification has been associated with completion of detoxification, i.e., more days of stays in ward and more chances of successful detoxification, and the same has been supported by other study, which concluded that greater initial length of stay in treatment predicts good outcomes.[12]

Furthermore, severity of withdrawal is associated with successful detoxification and duration of stay, i.e. more severe is withdrawal, more likely to increase the duration of stay in ward and complete detoxification, and the same has been reported in other study.[13] More severe withdrawal requires longer duration of inpatient stay for complete detoxification. This is possibly because of more time for intensive psychosocial interventions and motivation enhancement sessions, thus increasing the duration of stay

Interestingly, patients having no medical comorbidity were more likely to leave treatment prematurely. It is possible that patients and family members do not take SUDs in itself that seriously until and unless the patient develops comorbid medical illness. It is also likely that patients with comorbid medical/surgical problems seek and get more intensive treatments during ward stay; hence, they do not ask for premature discharge and complete the detoxification process. Another important finding is duration of dependency and successful completion of detoxification. Patients having longer duration of dependence are likely to complete the detoxification. As reported in earlier studies as well suggests that with increasing duration of dependence, the patients and family members who face increasing problems and seek permanent solutions.[14],[15]

Although the present study was conducted in a real clinical scenario of de-addiction ward of a tertiary care teaching hospital over a period of 8 months with detailed clinical assessments using standardized tools, it still has certain limitation which needs to be considered when interpreting the results, which includes retrospective study with small sample size and motivation for treatment was not compared between two groups.


  Conclusion Top


This study addresses the need to identify factors responsible for successful and premature termination of detoxification. Age of the patient, withdrawal severity, duration of dependence, and duration of stay are found to be good predictors for completion of detoxification. It is also evident from the study about the need to psychoeducate patients and families about the medical/surgical complications of substance use, so that they should complete the detoxification process without development of additional medical/surgical burden. Application of these findings in clinical practice will help in identifying high-risk individuals for which targeted interventions can be planned.

Financial support and sponsorship

NDDTC, AIIMS, New Delhi.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mokdad H, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States. J Am Med Assoc 2004;291:1238-45.  Back to cited text no. 1
    
2.
Stark MJ. Dropping out of substance abuse treatment: A clinically oriented review. Clin Psychol Rev 1992;12:93-116.  Back to cited text no. 2
    
3.
Delic M, Pregelj P. Factors associated with the outcome of drug addiction treatment. Psychiatr Danub 2013;25 Suppl 2:S337-40.  Back to cited text no. 3
    
4.
Sofin Y, Danker-Hopfe H, Gooren T, Neu P. Predicting inpatient detoxification outcome of alcohol and drug dependent patients: The influence of socio-demographic environment, motivation, impulsivity, and medical comorbidities. J Addict 2017.p. 1-11. Available from: https://doi.org/10.1155/2017/6415831. [Last accessed on 2019 Dec 21].  Back to cited text no. 4
    
5.
Sarkar S, Balhara YP, Gautam N, Singh J. A retrospective chart review of treatment completers versus noncompleters among in-patients at a tertiary care drug dependence treatment centre in India. Indian J Psychol Med 2016;38:296-301.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
World Health Organization. ICD-10 Classification of Mental and Behavioural Disorder: Clinical Description and Diagnostic Guidelines. Geneva: World Health Organization; 1992.  Back to cited text no. 6
    
7.
Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs 2003;35:253-9.  Back to cited text no. 7
    
8.
Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: The revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict 1989;84:1353-7.  Back to cited text no. 8
    
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Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: A revision of the Fagerström Tolerance Questionnaire. Br J Addict 1991;86:1119-27.  Back to cited text no. 9
    
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Satre DD, Mertens J, Areán PA, Weisner C. Contrasting outcomes of older versus middle-aged and younger adult chemical dependency patients in a managed care program. J Stud Alcohol 2003;64:520-30.  Back to cited text no. 10
    
11.
Satre DD, Chi FW, Mertens JR, Weisner CM. Effects of age and life transitions on alcohol and drug treatment outcome over nine years. J Stud Alcohol Drugs 2012;73:459-68.  Back to cited text no. 11
    
12.
Greenfield SF, Brooks AJ, Gordon SM, Green CA, Kropp F, McHugh RK, et al. Substance abuse treatment entry, retention, and outcome in women: A review of the literature. Drug Alcohol Depend 2007;86:1-21.  Back to cited text no. 12
    
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Ciraulo DA, Piechniczek-Buczek J, Iscan EN. Outcome predictors in substance use disorders. Psychiatr Clin North Am 2003;26:381-409.  Back to cited text no. 13
    
14.
Bottlender M, Soyka M. Efficacy of an intensive outpatient rehabilitation program in alcoholism: Predictors of outcome 6 months after treatment. Eur Addict Res 2005;11:132-7.  Back to cited text no. 14
    
15.
Hopfe SD, Neu G. Predicting inpatient detoxification outcome of alcohol and drug dependent patients: The influence of socio-demographic environment, motivation, impulsivity, and medical comorbidities. Hindawi J Addict 2017;24:1-11.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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