THE DETOXIFICATION EXPERIENCE OF ALCOHOLIC IN-PATIENTS AND PREDICTORS OF OUTCOME

Transcription

1 Alcohol & Alcoholism Vol. 33, No. 3, pp , 1998 THE DETOXIFICATION EXPERIENCE OF ALCOHOLIC IN-PATIENTS AND PREDICTORS OF OUTCOME G. K. SHAW, S. WALLER*, C. J. LATHAM 1, G. DUNN 2 and A. D. THOMSON 3 Elmdene Research Unit, Bexley Hospital, Old Bexley Lane, Bexley, Kent DA5 2BW, 'Department of Psychology, Goldsmiths College, University of London, London SE14 6NW, 2 Department of Biostatistics and Computing, Institute of Psychiatry, De Crespigny Park, London SE5 8AF and department of Gastroenterology, Greenwich District Hospital, London SE10, UK (Received 14 August 1996; in revised form 27 November 1997; accepted 16 December 1997) Abstract This paper reports the detoxification experience and outcome at 6 months and following detoxification from alcohol in 160 patients admitted to a south-east London in-patient detoxification unit. Patients' socio-demographic characteristics are also described. The sample was predominantly middle-aged, mainly male, and highly dependent on alcohol. Subjects had been drinking heavily for many years and suffered physical and social complications in consequence. The rate of convulsions was 3.1% and of delirium tremens 1.25%. The details of the level of drug usage during detoxification and the assessment of severity of the withdrawal syndrome are also reported. The severity of the withdrawal syndrome and the incidence of significant complications of withdrawal were higher in those with a previous history of four or more episodes of detoxification, a previous history of withdrawal fits or evidence of high levels of tolerance and dependence assessed either by the Severity of Alcohol Dependence Questionnaire (SADQ) or by drinking on a typical heavy drinking day in excess of 24 U of alcohol. It is suggested that subjects with one or more of these attributes should be treated on an inpatient, rather than an out-patient, basis unless adequate support and monitoring systems are in place. Overall, patients made improvements on a wide range of social and psychological variables, but the 'abstinent' and 'controlled drinking' groups made significantly higher improvements on all variables in both follow-up periods. When patients improved their drinking status and reduced the levels of drinkrelated physical and social complications, in both time periods, their use of social and health resources decreased significantly. Living circumstances at intake were predictive of drinking status at both followup stages. The amount drunk on a heavy drinking day, at both follow-up stages, was predicted by severity of withdrawal, SADQ and living circumstances at intake in that order of importance. INTRODUCTION the severity of withdrawal symptoms during detoxification. This study has made attempts to As part of a wider enquiry into the effects of analyse the predictive value of such variables, various interventions on outcome in chronic This paper also describes the treatment setting, alcohol abusers (Shaw et al., 1990), 160 consecu- patients' detoxification experience, factors which tive patients (131 male and 29 female) admitted, influence withdrawal severity and their sociofor detoxification from alcohol, to a south east demographic characteristics, and reports outcome London alcoholic treatment unit between January of detoxification from alcohol at 6-month and and August of 1990, were entered into a two-stage 1-year follow-up. (6 months and ) follow-up study. Follow-up studies of alcohol detoxification are few. More attempts are required to predict out- METHODS come from patient characteristics, previous history of severity of alcohol withdrawal symptoms and All patients were entered into the unit's standard detoxification procedure. The unit is fthis paper is dedicated to the memory of our distinguished multidisciplinary and the overall prevalent view Colleague, Dr G. K. Shaw, who sadly died before the writing- of ai co h o lism includes social and psychological MS i^stt^sstl^ be addressed at: conception, of causation. The detoxification unit Health Education Authority, Trevelyan House, 30 Great Peter IS an eight-bedded, functionally distinct, subsec- Street, London SW1P 2HW, UK. tion in a conventional psychiatric hospital, situated Medical Council on Alcoholism

2 292 G. K. SHAW et al. to the south east of London. Admission is restricted to patients whose degree of dependence on alcohol is such that medical detoxification is considered necessary. Sedative medication, usually chlormethiazole (Heminevrin), was prescribed on a reducing scale, the starting dose determined by severity of withdrawal. Vitamins were prescribed, normally Parentrovite (high potency, 10 ml i.v. for 5 days), but Orovite if there was evidence of previous intolerance to Parentrovite, if the patient declined frequent injections or if i.v. injections were particularly difficult. Patients were rated twice daily for severity of withdrawal by nursing staff using a structured schedule. The unit registrar specified daily maximum and minimum dosage of sedative medication in line with these assessments, whilst timing of medication and specific individual dosage were determined by nursing staff guided by degree of patient distress and response to medication. A previous history of withdrawal seizures usually prompted the administration of phenytoin at a starting dose of 300 mg, followed by 100 mg three times a day for 3 days and 50 mg three times a day for a further 3 days. Patients were encouraged to wear outdoor dress and took part in group discussions, which were educational and therapeutic. Following discharge, all patients were offered follow-up at a multidisciplinary out-patient clinic. Source of referral Half of the sample (54%) were referred from general practitioners, a quarter (23%) from various social agencies and a quarter (23%) were selfreferred. Half (from referring agents) were initially seen and assessed in associated out-patient clinics and the other half were accepted directly. Data collected at intake Structured interview. All patients were interviewed by an experienced research sociologist who collected, by means of a structured schedule, data relating to basic socio-demographic variables; further data were obtained on the following variables taking as point of reference, where applicable, the 6 months prior to admission: Living circumstances: this variable referred to living alone, living with an adult companion or living in lodgings or hostel or being of no fixed abode. Employment status: total number of days in employment were recorded. Criminal involvement: the number of alcoholrelated offences and criminal offences unrelated to alcohol in the 6 months prior to intake were recorded separately. Social stability: this scale, derived from that of Straus and Bacon (1951), consists of a four-point rating scale, one point being allocated for each of the following with reference to the preceding 6 months: (a) married or cohabiting; (b) employed for at least 5 months; (c) no criminal offences; (d) living in own home or rented accommodation (as opposed to lodgings, hostels or being of no fixed abode). Number of days of abstinence: total number of days of abstinence in the previous 6 months. Longest period of abstinence: recorded in days for the previous 6 months. Daily intake on a heavy drinking day (units of alcohol): number of units (1 U = 0.5 pint beer or one glass of wine or one single measure of spirit a unit of alcohol contains approximately 9 g of ethyl alcohol) consumed on a typical heavy drinking day, obtained through a detailed reconstruction of 1 day's alcohol consumption representative of heavy drinking episodes. Pattern of drinking: categories included frequent (four or more in 6 months) and infrequent (three or less in 6 months) drinking bouts with periods of abstinence or controlled drinking, and continuous alcoholic drinking. Frequency and length of heavy drinking bouts were recorded. Physical complications of drinking: one point was allocated for mild withdrawal symptomatology and two points for severe withdrawal symptomatology. A further point was scored for each of the following symptoms amnesia, fits, relief drinking, and loss of control over drinking. Total scores achieved in the 6 months prior to intake were recorded (scale 0-6). Social complications of drinking: one point was allocated for each of the following complications experienced over the previous 6 months: (a) got into debt because of drinking; (b) pawned or sold possessions; (c) stole drink or money for drinking; (d) lost a job because of drinking; and (e) was in trouble with police, friends or neighbours due to drinking (scale 0-5). Hospitalization: total number of days spent as

3 DETOXIFICATION AND PREDICTORS OF OUTCOME 293 in-patient, for general medical reasons, psychiatric reasons or for alcoholism, over the previous 6 months. Visits to out-patient facilities: total number of visits to general or psychiatric hospitals, to a general practitioner or to an alcohol treatment clinic over the previous 6 months. Use of social/religious resources: total number of occasions on which patients had been to Alcoholics Anonymous, to church or to other support services over the previous 6 months. Intelligence: assessed by the National Adult Reading Test (NART, Nelson, 1982). Self-completion scales. A self-completion questionnaire, comprising the following scales, was completed at intake: Satisfaction with life situations: subjects were required to rate their level of satisfaction with the following seven life situations on a five-point scale ranging from very satisfactory rated as 1 to very unsatisfactory rated as 5 relationships (current relationships with spouse, friends, and relatives), employment, accommodation, use of day, use of leisure, physical health, and mental health (scale 7-35). In the case of the unmarried patient without close relationships, the degree of social contact with people was assessed. Self-esteem scale: to assess self-esteem/selfconfidence, subjects were asked to rate 18 statements describing self-perception on a fivepoint rating (Litman et al., 1983). Lower scores reflect higher levels of self-confidence and selfesteem (scale 18-90). Severity of Alcohol Dependence Questionnaire: to measure dependence on alcohol, this scale (Stockwell et al., 1983) consists of 16 statements, describing alcohol-related symptoms and quantity and frequency of alcohol consumption during a recent month of heavy drinking and four additional statements referring to frequency of 'morning-after' symptoms at the end of 2 days of heavy drinking following several weeks of abstinence (scale 0-60; scores of 31 or more indicate severe dependence on alcohol). Beck Depression Inventory: the Long Beck Depression Inventory (scale 0-63) was used to assess depression at the three time periods (Beck et al., 1961). Scores between 0 and 9 are not suggestive of depression, between 10 and 20 suggest mild depression, between 21 and 29 moderate depression, and 30 or greater severe depression. Spielberger Self-evaluation Questionnaire: this measures current anxiety state (Spielberger, 1983). Total scores based on 20 statements range from Scores above 36 indicate a high level of anxiety. Biochemical data: blood samples were collected for assessment of serum bilirubin, alkaline phosphatase, aspartate aminotransferase, y-glutamyl transpeptidase, haemoglobin, MCV, and the protein electrophoretic pattern. Data collected throughout admission Assessment of withdrawal severity. Patients were rated twice daily by trained nursing staff using a scale modified from Gross et al. (1974) and previously described (Murphy et al., 1983). Data collected at the 6-month and 1-year followup stages Structured interview. At 6-month and 1-year follow-up, the intake interview was repeated using the structured and self-completion schedules taking as point of reference the relevant 6-month period, but excluding descriptive variables collected at intake. Clinical categorization by drinking status. At follow-up, on the basis of patient report and clinical assessment, subjects were assigned to the following drinking status categories abstinent, controlled, greatly improved, slightly improved or unchanged, defined as follows: (a) abstinence, no drinking throughout the relevant period; (b) controlled drinking, drinking on not more than three occasions in any 1 week and not more than 4 U of alcohol on any drinking occasion; (c) improved, a beneficial change in the drinking style; for example, from continuous drinking to periods of abstinence with short-lived bouts of drinking and an associated major reduction in alcohol consumption. Since the number of days of abstinence, of heavy drinking and of controlled drinking had been recorded for each patient, as had the average number of units of alcohol consumed on each type of drinking occasion, it was possible to compute approximate measures of total alcohol consumption over specific time periods for each patient. Using this method of assessment, subjects were rated as (a) greatly improved, those who had reduced their consumption by 75% or

4 294 G. K. SHAW et al. more; (b) slightly improved, those who had reduced their consumption by 50-74%; and (c) unchanged, failure to fulfil any of the above criteria. Statistical analyses were carried out using the Statistical Package for the Social Sciences. RESULTS Description of sample Socio-demographic characteristics. The mean age of the sample (131 male, 29 female) was years. The majority (86%) were of British nationality. One-third of patients (31%) were married or cohabiting and 45% lived alone, were of no fixed abode or lived in common lodgings or hostels. Fifty-nine per cent of the sample were socially unstable, scoring 2 or less on the Social Stability Scale. One-third (33%) were in regular employment and a comparison of current social class with 'highest ever' social class (Registrar General, 1980) suggested downward social mobility. More than half of the sample (57%) had a record of criminal convictions but, surprisingly, two-thirds had no record of drunkenness offences. Thirty per cent had experience of imprisonment and a small number had spent time in approved schools (3.8%) or Borstals (4.2%). As a group, they were poorly nourished, only 23% reporting taking regular meals. The majority (79%) were smokers, most smoking in excess of 10 cigarettes daily. Psychological characteristics. The sample was of average intelligence, as assessed by the NART, had spent years in full-time education, had high levels of anxiety and depression and low levels of self-esteem and of satisfaction with life situations. Family of origin and childhood. Most (82%) of the sample were brought up by both parents, 11% by a single parent or a parent and step-parent, 4% by other relatives and 3% by adoptive parents, or in children's homes or orphanages. Almost onethird (30.6%) of patients reported a significant period of separation from one or both parents, the age of separation being evenly distributed throughout childhood. One-third (34%) either considered their childhood unhappy or had mixed feelings about it. A history of alcoholism in the family was common. One-third (36%) of the sample reported alcoholism in one or more firstdegree relatives and a further 13% reported alcoholism in second-degree relatives. Drinking variables. As a group, they had been drinking heavily for an average of 12 years and two-thirds scored more than 30 on the SADQ, levels which imply severe dependence on alcohol. On heavy drinking days, they drank approximately 300 g of alcohol, equivalent to a bottle of spirits, but, surprisingly, had enjoyed an average of 47 days of abstinence in the 6 months prior to intake. Half of the sample were continuous drinkers, the remainder dividing equally between frequent and infrequent bout drinkers. Two-thirds had experienced severe withdrawal symptoms over the preceding 6 months and only one patient had been free from withdrawal symptomatology. Two-thirds reported one or more social complications and physical problems were common. Almost half the sample suffered from conditions thought to be alcohol-related; in most instances peripheral neuropathy (70 patients), but there were also a few cases of epilepsy or of myopathy. Additionally, 40 patients suffered from physical conditions not specifically alcohol-related. The commonest of these were asthma or chronic bronchitis (12 patients), hypertension or cardiac problems (10 patients) and endocrinological conditions such as diabetes or thyrotoxicosis (five patients). Use of health and social resources. Only a minority of patients had been hospitalized in the preceding 6 months. Twenty-two per cent had spent up to 14 days in hospital and 7% from 2 weeks to 2 months, giving a mean of 3.63 days of hospitalization for the group. Most patients had made use of out-patient facilities, the average number of attendances being Forty per cent of patients made use of religious or social support systems and a small number (6%) were frequent users. Biochemical variables. Biochemical variables were typical of an alcoholic population. Mean MCV was 97.1 fl and 30% of the sample were outside the normal range of our laboratory. Mean GGT was 245 U/l (80% outside the normal range), mean AST was 77 U/l (62% outside the normal range), mean bilirubin was 17 umol/1 (35% outside the normal range) and mean albumin was 40.8 g/1 (5% outside the normal range).

5 DETOXIFICATION AND PREDICTORS OF OUTCOME Table 1. Demographic and drinking variables at intake in subgroups defined by severity of withdrawal 295 Severity of withdrawal Variable Low (n = 42) Moderate in = 77) High (n = 41) Total withdrawal score Duration of withdrawal (days) Variables at intake Age (years) SADQ Daily intake (U) on heavy drinking day No. of detoxifications (ever) No. of years heavy drinking 9.43 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 1.82* 8.20 ± 0.20* ± ± 1.32f ± 2.02t 6.61 ± 1.18f ± 1.34t Values are means ± SEM. Student's Mest was for independent samples; * indicates significant difference (P < tailed significance) between each of the subgroups, and indicates that the high severity subgroup differs significantly (P < tailed significance) from both the low and moderate severity subgroups. Detoxification experience During detoxification, patients were rated twice daily on the following symptoms of withdrawal: orientation; level of consciousness; hallucinations; convulsions; agitation; gastrointestinal disturbances; appetite; and sleep disturbance. A daily withdrawal score for each patient was calculated by summing the highest score awarded for each of the above symptoms on that day. A total withdrawal score was then obtained for each patient by summing the daily withdrawal scores. Thus calculated, scores ranged from 3-89 with a mean of 27.6 (SEM 1.3). An arbitrary decision was taken to grade severity of withdrawal as low (3-15, n = 42), medium (15-35, n = 77), and high (36-89, n = 41). Table 1 outlines the characteristics of these subgroups. Changes in the pattern of the mean daily total of autonomic and vegetative symptoms were similar for all severity groups, reaching their maximum at 48 h and declining thereafter. Group differences in both the intensity and duration of all symptoms were observed. For the low severity group, symptoms were less intense and declined to low levels by day 4 of withdrawal. They were, however, more intense for the medium severity group, declining to low levels by day 6. In the high severity group, symptoms indicative of autonomic over-activity, such as sweating, tremor and agitation, did not decline much below intake levels by the end of treatment day 8. Vegetative symptoms showed a similar pattern, but were lower than intake levels by day 8. Sedative medication was given to all patients, mainly chlormethiazole (Heminevrin). There was a relationship between units of medication and severity of withdrawal (r = 0.68), suggesting that the treatment strategy allowed satisfactory titration of sedative dose. Twenty-eight patients received chlorpromazine (average dose 360 mg) to enhance sedation. Compared to patients not given chlorpromazine, these patients had more previous detoxifications (5.77 vs 2.98) and a more severe withdrawal syndrome (score of vs 25.64), but they did not differ significantly in complications associated with withdrawal (14 vs 10% of cases). Overall, the incidence of significant complications during the detoxification period was low. Five patients (3.1%) experienced convulsions and two of these were known epileptics. Eighteen patients (11.3%) had hallucinatory experiences. In comparison to those who did not, these were older (46.3 vs 43.7 years), drank more units of alcohol on a typical heavy drinking day (38.6 vs 34.5 U), had more previous treatments for detoxification (4.7 vs 2.8) and had more relatives with a history of alcoholism. Prediction of severity of withdrawal Clinical experience, supported to some extent by the literature, suggests that severity of withdrawal can be related to drinking history, to severity of dependence, and possibly also to a family history of alcoholism. The predictive power of these variables was assessed using stepwise multiple regression with total withdrawal

6 296 G. K. SHAW et al. Table 2. Psychological variables at intake, 6-month and 1-year follow-up Variable n= months n = 127 «= months n = 124 «=124 Anxiety state (Spielberger) Depression (Beck) Self-esteem Satisfaction with life situation (1.42) (0.73) (0.90) (0.46) (1.23) (0.79) (0.97) (0.49) (1.45) (0.75) (0.90) (0.47) (1.26) (0.81) (0.99) (0.50) (0.95) (0.82) (0.96) (0.48) Values are means with SEM in parentheses. Student's Mest was for paired samples. With the exception of the difference on the Beck depression scale between 6-month and 1-year follow-up stages, which is not significant, all other comparisons are statistically significant at P < tailed. scores as the dependent variable. The number of previous detoxifications (partial regression coefficient, B = 0.943), severity of dependence on alcohol (B = 0.327), previous experience of withdrawal symptoms (B = 6.100) and a family history of alcoholism (B = 2.069) predicted severity of withdrawal giving a multiple r 2 of Since it may not always be possible to assess easily the severity of dependence on alcohol by means of the SADQ, further analyses used either the estimated total alcohol consumption over the preceding 6 months, or the estimated amount of alcohol drunk on a recent typical heavy drinking day, as the dependent variable. In the first case, the significant predictors were the number of previous detoxifications (B = 1.09) and previous experience of withdrawal symptoms (B = 7.95), giving a multiple r 2 of In the second case, significant predictors were the number of previous detoxifications (5=1.004) and previous experience of withdrawal symptoms (B = 7.23). Giving a multiple r 2 of In this study, withdrawal symptoms were in evidence despite the use of sedative and, in some cases, anticonvulsant medication. Using the amount of sedative prescribed as the dependent variable, a stepwise multiple regression was run entering the most likely predictors e.g. drinking and psychological variables. Only total withdrawal scores (B = 0.414) predicted level of sedative usage, giving a multiple r 2 of When total withdrawal scores were removed from the analysis, both amount of alcohol drunk on a recent typical heavy drinking day (B 0.159) and number of previous detoxifications (B = 799) were predictive, giving a multiple r 2 of Outcome at the 6-month and 1 -year follow-up stages One hundred and fifty-one patients at 6 months post-discharge and 148 at were reinterviewed and completed self-administered questionnaires. The fall off at the 6-month follow-up stage resulted from five male patients having died, three who could not be traced and one who was unwilling to cooperate. At 1-year followup, a further three patients could not be traced. Treatment interventions and length of stay. One hundred and thirty-two of the patient sample were treated by detoxification only and were in hospital for a mean of 7.81 days. Sixteen additional patients were hospitalized for a mean of days, usually to effect appropriate residential placement. Eleven further patients, who participated in a 4-week intensive treatment programme following detoxification, were in-patients for a mean days and the final patient required 67 days as an in-patient to allow detoxification, an intensive treatment programme and residential placement thereafter. The primary purpose of this study was to examine the impact of detoxification, thus, outcome is assessed in patients admitted for detoxification only. The number of patients who were homeless at intake was 18, but by the end of the study five further patients had become homeless, making a total of 23 or 15% of the total sample. There was a modest improvement in social stability from intake to 6 months, as assessed by

7 DETOXIFICATION AND PREDICTORS OF OUTCOME 297 Table 3. Group changes in drinking pattern between the 6-month periods prior to intake and the 6-month and 1-year follow-up periods n = months n = 128 1year n = 126 Parameter n % n % n % Total abstinence Controlled social drinking Infrequent bouts with periods of abstinence and controlled drinking Frequent bouts with periods of abstinence and controlled drinking Continuous alcoholic drinking Drinking status Table 4. Drinking status outcome and average alcohol consumption over 6-monthly periods Total abstinence Controlled social drinking Not more than three drinking occasions/week, not more than 6 U/occasion, mean = 4 U/week at 6 months and Greatly improved Consumption reduced by 75% or more, mean reduction = 87% at 6 months, 90% at Slightly improved Consumption reduced by 50-74%, mean reduction = 63.5% at 6 months, 63% at Unchanged A failure to achieve any of the above criteria Mean consumption (units of alcohol) per patient over 6-monthly periods Prior to intake Prior to 6-month follow-up stage Prior to 1-year follow-up stage Values are means with SEM in parentheses. the modified Straus and Bacon (1951) Scale (2.30 to 2.55; P < 0.001), but no significant change was found between 6 months and. The improvement occurred usually in the most disadvantaged of the group, those originally rated zero. There were no significant changes in marital status nor in measures of employment. Psychological characteristics. At 6 months, anxiety, depression, self-esteem, and satisfaction with life situation had all improved and, with the single exception of depression as rated by the Beck Long Scale, further significant improvements took place between 6 months and (Table 2). The proportion of patients classified as suffering from moderate or severe anxiety progressively declined from 61% at intake to 24% at _ _ months n= No. of patients (%) 10 (7.8) 6 (4.7) 41 (32.0) 25 (19.5) 46 (36.0) n= (12.7) 11 (8.7) 60 (47.6) 9 (7.0) 30 (24.0) 4139 (224.07) 1859 (183.97) 1070 (144.49) 6 months and 9% at. The proportion of those rated as moderately or severely depressed was decreased from 38% at intake to 25% at both 6 months and. Drinking characteristics. On all parameters, there were progressive improvements between follow-up stages. Days of abstinence and longest period of abstinence increased, whilst daily intake on a heavy drinking day and physical and social complications of drinking all reduced at high levels of statistical significance. Similarly, the proportion of patients experiencing symptoms of withdrawal or giving other evidence of alcohol dependence progressively decreased throughout the study period. Those being symptom-free ranged from 1% at intake to

8 298 G. K. SHAW et al. Table 5. Group changes in drinking status between the 6-month and 1-year follow-up stages Drinking status at 6 months Greatly Abstinent Controlled improved n=16 n=\\ «= 60 Slightly improved Unchanged Drop-out n = 9 /J = 30 n = 2 Abstinent (/? = 10) Controlled (n = 6) Greatly improved (n = 41) Slightly improved (n = 25) Unchanged (n = 46) [6] [5] 3 2 _ Table 6. Use of health, social and religious services in 6 months prior to intake and at the 6-month and 1-year follow-up stages Variable In-patient (days) Out-patient (visits) Social/religious services (No. of occasions) /i = (0.84) 5.69 (0.47) 4.99 (1.10) 6 months 7i = (0.62) 3.91** (0.46) 2.51* (0.60) _ 1 [32] n= (0.85) 5.54 (0.44) 5.06 (1.12) [3] [25] 6 months 7i= (0.63) 3.94 (0.47) 2.54 (0.61) 7i= (0.48) 3.32** (0.48) 1.56*** (0.47) Values are means with SEM in parentheses. Student's /-test was for paired samples; *P < 0.05; **P < 0.01; ***P < 0.001; 2-tailed significance levels. 13% at 6 months and 24% at. Drinking status outcomes. Drinking patterns are listed in order of desirability in Table 3. There was a progressive shift towards more desirable patterns over the follow-up period. At intake, 73% of patients were drinking in the least desirable fashion, either continuously or in frequent bout style. Six months following detoxification, the percentage of patients drinking in this fashion was decreased to 37% and at to 20%. A distinction between frequent and infrequent bouts was made: those regarded as having infrequent bouts had, in any 6-month period, less than four bouts on average, whilst those regarded as having frequent bouts had more than 17. There was no trend in either group towards a reduction in the number of bouts of drinking over unit periods of time but, in all of the groups, the length of bouts became shorter, and this was most marked in the 'infrequent bout' groupings, who reduced the mean length of drinking episodes from 27 days to 13 days at the 6-month stage and to 10 days at. If abstinence or controlled drinking are considered as the only satisfactory outcomes, results are not impressive (Table 4). These goals were achieved by only 12.5% of our patients at 6 months and by 21.4% at. It is, however, increasingly recognized that to categorize all who fail to achieve total abstinence as treatment failures is unduly pessimistic. Many of those formerly regarded as 'alcoholics', with all that implied, seemed able to improve their life situation significantly and to curtail their drinking without total abstinence. We note that our approximation of total consumption of alcohol over successive 6-monthly periods indicates that the sample as a whole reduced alcohol consumption by 50% over the first 6 months of follow-up and by 75% over the second 6 months of followup (Table 4). We therefore rated those who had successfully changed drinking patterns to a less harmful style and who had reduced their alcohol intake as 'greatly improved' if the reduction in alcohol intake was in excess of 75% and as 'slightly improved' if the reduction in alcohol was in excess of 50% but not as much as 75%. At 6 months (Table 4), 44.5% of patients in the 'detoxification only' group were greatly improved or better and 36% of patients were unchanged. By the 1-year stage, 69% of patients were greatly

9 DETOXIFICATION AND PREDICTORS OF OUTCOME 299 Table 7. Psychological variables in subsamples categorized by drinking status at 1-year follow-up Anxiety state (Spielberger) Depression (Beck) Self-esteem Satisfaction with life situation Drinking status Abstinent in = 16) Controlled (n = 10) Greatly improved (n = 60) Slightly improved (n = 8) Unchanged (n = 30) (4.34) (3.85) (2.11) (5.03) (3.06) 26.94*** (0.64) 25.30*** (1.03) 30.67*** (1.15) 30.75*** (2.07) 38.30*** (2.74) (2.22) (2.14) (1.08) (1.95) (1.72) 10.31*** (1.67) 8.10*** (1.52) 15.93*** (115) (2.51) (1.73) (2.81) (3.23) (1.30) (1.70) (1.89) 30.00*** (1.97) 26.20*** (1.55) 36.47*** (1.28) 37.25*** (2.16) 43.10*** (2.08) (1.25) (1.42) (0.69) (1.00) (1.06) 14.63*** (1.13) 11.30*** (0.83) 17.78*** (0.64) 16.75*** (1.29) 21.10* (0.92) Values are means with SEM in parentheses. Student's r-test was for paired samples; *P < 0.05; **P < 0.01; ***P < 0.001; 2-tailed significance levels. Table 8. Use of health, social, and religious services in subsamples categorized by drinking status at 1-year follow-up Drinking status Abstinent (n = 16) Controlled (n=ll) Greatly improved (n = 60) Slightly improved («= 9) Unchanged («= 30) 5.88 (2.97) 0.18 (0.18) 4.22 (1.53) 1.11 (0.99) 2.07 (0.82) In-patient days (0.70) 1.22 (0.85) 3.57 (1.37) Out-patient visits (no. of visits) 5.19 (1.01) 5.45 (1.48) 4.95 (0.67) 5.89 (1-91) 6.83 (0.85) 2.19 (1.36) 2.09 (1.00) 2.77** (0.63) 5.33 (2.65) 4.90 (1.04) Social/religious (no. of occasions) 5.31 (2.51) 3.91 (1.81) 4.87 (1.72) 3.44 (2.83) 6.20 (2.77) 2.06 (2.06) 1.18 (1.10) 1.58* (0.61) 0.44 (0.29) 1.70 (1.07) Values are means with SEM in parentheses. Student's West was for paired samples; *P < 0.05; **P < 0.01; 2-tailed significance levels. improved or better and only 24% were unchanged. Changes in drinking status between 6 months and. These are outlined in Table 5. The bracketed entries indicate those who have maintained their status at both follow-up stages, whilst figures to the left or below indicate those who have improved their status between 6 months and, and figures above or to the right those who have deteriorated. Fifty-five per cent of the sample (71 of 128 patients) maintained their status, 36% (46 patients) improved and 9% (11 patients, which includes three who dropped out) deteriorated. Of those rated 'unchanged' at 6 months, almost half improved over the second 6 months, as did three-quarters of the group rated 'slightly improved'. The bulk of the 'greatly improved' maintained their position, but of those rated as abstinent or drinking in controlled fashion, a third had slipped back. A longer period of follow-up is required to be confident that benefits are maintained in the longer term. Use of health and social resources. Over the follow-up period, fewer patients were admitted to hospital and the mean number of days of hospitalization was reduced (Table 6). Visits to out-patient clinics or to social (including Alcoholics Anonymous) and religious services were reduced and fewer patients made extensive use of such support services. Relationships between drinking status and other outcome parameters. In an attempt to validate externally our chosen drinking status categories,

10 Table 9. Age, SADQ, and variables relating to drinking behaviour and complications of drinking in subsamples categorized by drinking status at 1-year follow-up status Abstinent (n =16) Controlled ("=11) Greatly improved (n = 60) Slightly improved (n = 9) Unchanged (n = 30) Age (intake) (3.16) (2.82) (1.28) (3.97) (1.77) (intake) (3.21) (3.06) (1.29) (4.36) (2.05) Daily intake on heavy drinking day (3.60) (2.97) (1.68) (4.84) (2.37) o*** o*** 27.23*** (1.05) 28.44* (3.07) 31.73* (1.82) Days of abstinence in previous 6 months (15.03) (12.20) (7.05) (24.64) (10.74) *** (6.22) *** (5.91) *** (3.44) * (20.84) 61.00** (10.28) Physical of 3.44 (0.32) 2.82 (0.35) 4.12 (0.14) 2.89 (0.51) 4.07 (0.24) complications drinking 0.19*** (0.19) o*** 2.05*** (0.18) 2.00 (0.37) 3.17** (0.29) Social complications of drinking Values are means with SEM in parentheses. Student's f-test was for paired samples; *P < 0.05; **P < 0.01; ***P < 0.001; 2-tailed significance levels (0.37) 0.82 (0.26) 1.30 (0.16) 0.56 (0.29) 1.20 (0.22) 0** 0* 0.18*** (0.07) 0.22 (0.15) 0.60** (0.11) U> 8 P T > 5.

11 DETOXIFICATION AND PREDICTORS OF OUTCOME 301 we looked for associations between them and improvements in social variables, psychological status, drinking variables, and use of health service resources. Social variables: there were no significant alterations in days of unemployment in any of the subgroups. The 'controlled drinking' subgroup had a higher level of social stability at intake than the other subgroups. All groups made modest gains on this variable, the abstinent and 'greatly improved' at statistically significant levels. Psychological variables: all subgroups including those whose drinking status was 'unchanged' made significant improvements in levels of anxiety, in self-esteem, and in satisfaction with life situation, at both time periods. In general, the degree of improvement on these parameters paralleled the degree of improvement in drinking status (Table 7). In the case of depression, improvement was found only in those whose drinking status was rated as 'greatly improved' or better, whereas those who achieved either 'abstinent' or 'controlled drinking' status made more improvement on this parameter than those rated as 'greatly improved'. Use of health, social, and religious resources: the 'abstinent', 'controlled drinking' and 'greatly improved' groups reduced their days of hospitalization over the follow-up period; the reductions being greatest in the 'abstinent' and 'controlled drinking' subgroups (Table 8). Out-patient visits and use of social or religious services were also reduced in all groups at. Drinking variables: it is apparent from the data in Table 9 that the outcome subgroups were very similar at intake, although, perhaps, the unchanged group was a little younger and the controlleddrinking group less heavily dependent on alcohol. All subgroups, including the subgroup rated as unchanged, made improvements on all parameters (daily intake on a heavy drinking day, days of abstinence, physical and social complications of drinking). The degree of improvement usually reached statistical levels of significance and was, in general, greater in the groups rated as improved in terms of drinking status than in the group rated as 'unchanged'. Validation of drinking status parameters. The gradation of improvement in all outcome parameters, positively related to drinking outcome categories, affords support for the view that these drinking categories reflect meaningful distinctions between patient subgroups. Prediction of outcome. Psychological and sociodemographic variables measured at intake were entered into a stepwise multiple regression to determine the best predictors of drinking behaviour at 6-month and 1-year follow-up. The only significant predictors of drinking status for 6-month follow-up were self-esteem and living circumstances at intake. Together, these accounted for 20% of the variance (F = 14.9, P = ). At 1-year follow-up, only self-esteem was a significant predictor, accounting for 9% of the variance (F= 18.9, P = ). No variables were found to predict days of abstinence at either follow-up stage. The amount drunk on a heavy drinking day at both follow-up periods was predicted by self-esteem, SADQ and living circumstances. At the 6-month stage, these variables accounted for 22% of the variance (F=18.4, P = ) and at the 1-year stage 16% (F= 13.7, P = 0.004). DISCUSSION Points of clinical relevance emerge which may be helpful for those faced with the problem of selecting patients suitable for non-residential detoxification procedures. Different agencies treat differing patient samples by different means and have different treatment goals making comparison between studies difficult. If valid comparisons between different patient groups are to be possible, it becomes imperative to define the population under scrutiny and the treatment aims of the reporting unit. The sample was predominantly middle-aged, mainly male, and highly dependent on alcohol. Many were socially disadvantaged. Only a minority had been previously hospitalized, but almost all had frequent contact with out-patient services and with social or religious support agencies. Although a high proportion of patients had physical problems, in general, these were not of a serious degree, and in this respect they differed from alcoholic patients admitted to general hospitals, who are usually more ill but often less highly dependent on alcohol. Different views exist on the use of phenothiazines in alcohol withdrawal. The case for their inclusion has been discussed in a review article

12 302 G. K. SHAW et al. (Shaw, 1995). The incidence of convulsions in our study was low. Two of the patients were known epileptics maintained on anticonvulsants for a number of years, and the third was dependent on both chlormethiazole (Heminevrin) and alcohol. Theoretical objections may be raised about the use of phenothiazines, but resolution of this question has been frustrating due to the inability of researchers to demonstrate a significant difference between regimes, because the sample sizes were too small. The dosage of sedation used in this study was high, certainly higher than usually prescribed in out-patient or domiciliary detoxification, but there are few in-patient studies with which it can be compared. Milne et al. (1991), however, reported morbidity in a sample of 76 patients, admitted to a similar type of alcohol treatment unit, who received lower amounts of sedative. Their patient group was a little younger, but the mean daily consumption of alcohol and the rate of associated medical problems was similar. Severity of dependence was not reported but is most likely to have been high. Their total dose of sedation was not reported, but the starting dose of 2-3 g of chlormethiazole/day, equivalent to 2 or 3 sedative units described in this study, was considerably lower than our usual starting dose. This almost certainly implies that much lower total doses of sedative would have been used throughout the period of withdrawal. The rate of fitting across the two studies was comparable, three from 76 in their study and five from 160 in ours. There was, however, a marked difference in the incidence of delirium tremens, six from 76 in their study and two from 160 in ours. It seems therefore likely that higher doses of sedative are more effective in preventing this major complication. Whereas sedative drugs largely prevent fitting or delirium tremens, in the present study patients who had the most severe symptoms received most medication. It is clear that, in those experiencing a severe withdrawal syndrome, drugs exerted little effect on symptoms. Furthermore, they did not shorten the duration of the withdrawal syndrome which persisted for much longer than is usually recognized. In such cases, /?-blockers, for example propranolol or atenolol, have proved useful if used as a supplement to sedation (Gorelick and Wilkins, 1986; Bailly et al, 1992), as have a-adrenergic agonists (Robinson et al., 1989; Bohn, 1993). Neither of these groups of drugs should be used on their own, since they do not prevent fitting or delirium. The accent today on managing detoxification on an out-patient or domiciliary basis, whenever possible, highlights the need to define the types of patients who can safely be dealt with in this way and the characteristics which distinguish those who might better be treated on an in-patient basis. The research literature suggests that a prior history of significant withdrawal symptoms, multiple previous detoxifications (Brown et al., 1988; Lechtenberg and Worner, 1991; Booth and Blow, 1993) and known high dependency on alcohol as evidenced by a history of recent drinking at high levels (Gorelick and Wilkins, 1986) predict a severe withdrawal syndrome and an increased risk of complications. Data from this study support these views. Recent drinking above a level of 24 U of alcohol on heavy drinking days more than quadrupled the risk of a severe withdrawal syndrome (32 vs 7.3%), a previous history of withdrawal fits more than doubled the risk (46 vs 20.5%) and a history of more than four previous episodes of withdrawal more than tripled the risk (59 vs 16.7%). Similarly, the risk of a significant complication of withdrawal was almost doubled in those who drank more than 24 U of alcohol on recent heavy drinking days (12.6 vs 7.3%), or who underwent more than four previous episodes of detoxification (17.6 vs 9.5%), and was more than doubled in those with a previous history of fits (20.5 vs 8.3%). Consideration should be given to in-patient, as opposed to out-patient, management in patients with these characteristics, unless adequate support and monitoring systems are in place. Although outcome, if assessed by the gold standard of abstinence or controlled drinking, was not impressive, there were considerable improvements in most other respects. The major reduction in the amount of alcohol consumed was reflected by significant reductions in physical and social complications of drinking, while the group as a whole reduced the demands made on medical and social treatment services. There were also major changes in psychological status. Measures of anxiety were progressively reduced throughout the period of follow-up and subjects became more contented with their life circumstances. This was true even for the subgroup whose drinking did not change noticeably. Measures of depression improved in those who

13 DETOXIFICATION AND PREDICTORS OF OUTCOME 303 were able noticeably to moderate their drinking, though in this instance all improvement had taken place by 6 months. It is encouraging to note that results over the second 6 months of follow-up were always better than over the first 6 months. This was the case for all measures of outcome, not only for measures of drinking. All patients were offered out-patient follow-up, which may of course have exerted some effect. However, from Table 8, it is clear that those who did well made less use of out-patient follow-up than those who did less well. Interestingly all patients made less use of social and religious support systems, suggesting a reduced need for such support as the group improved their drinking status and made gains on social and psychological variables. Outcome at 6 months was related to outcome at. There were indications that a severe withdrawal syndrome predicted a poor outcome at least on some drinking variables. This is of theoretical interest and has practical implications in the current climate where in-patient treatment is likely to be compared to a variety of out-patient procedures. The comparisons can be unfair, since subjects who develop severe withdrawal are more likely to be in-patients. Additionally, more intensive interventions and increased ongoing support for those who have a severe withdrawal syndrome are required for this group of patients. Acknowledgements The authors gratefully acknowledge the South-East Thames Regional Board for their funding of this study. We also thank Mrs Jean Johns for her invaluable administrative and secretarial assistance. REFERENCES Bailly, D., Servant, D., Blandin, N. et al. (1992) Effects of beta-blocking drugs in alcohol withdrawal: a double-blind comparative study with propranolol and diazepam. Biomedicine and Pharmacotherapy 46, 419^24. Beck, A. T., Ward, C. H., Mendelson, M. et al. (1961) An inventory for measuring depression. Archives of General Psychiatry 4, Bohn, M. J. (1993) Alcoholism. In Psychiatric Clinics of North America: Psychopharmacology II, Booth, B. M. and Blow, F. C. (1993) The kindling hypothesis: further evidence from a US national study of alcoholic men. Alcohol and Alcoholism 28, Brown, M. E., Anton, R. F., Malcolm, R. et al. (1988) Alcohol detoxification and withdrawal seizures: clinical support for a kindling hypothesis. Biological Psychiatry 23, Gorelick, D. A. and Wilkins, J. N. (1986) Special aspects of human alcohol withdrawal. In Recent Developments in Alcoholism, Galanter, M. ed., pp Plenum Press, New York. Gross, M. M., Lewis, E. and Hastey, J. (1974) Acute alcohol withdrawal syndrome. In The Biology of Alcoholism, Vol. 3, Kissin, B. and Begleiter, H. eds, pp Plenum Press, New York. Lechtenberg, R. and Worner, T. M. (1991) Relative kindling effect of detoxification and non-detoxification admissions in alcoholics. Alcohol and Alcoholism Litman, G., Stapleton, J., Oppenheim, A. N. et al. (1983) An instrument for measuring coping behaviour in hospitalised alcoholics: implications for relapse, prevention and treatment. British Journal of Addiction 78, Milne, S., Gayford, J. J. and Wylie, A. S. (1991) Physical morbidity in patients admitted for detoxification from alcohol. Alcohol and Alcoholism 26, Murphy, D. J., Shaw, G. K. and Clarke, I. (1983) Tiapride and chlormethiazole in alcohol withdrawal: a double-blind trial. Alcohol and Alcoholism 18, Nelson, H. E. (1982) National Adult Reading Test. NFER Nelson, Windsor. Registrar General (1980) Classification of Occupations. Office of Population Census, Guildford. Robinson, B. J., Robinson, G. M., Maling, T. J. B. et al. (1989) Is clonidine useful in the treatment of alcohol withdrawal? Alcoholism: Clinical and Experimental Research 13, Shaw, G. K. (1995) Detoxification: the use of benzodiazepines. Alcohol and Alcoholism 30, Shaw, G. K., Waller, S., McDougall, S. et al. (1990) Alcoholism: A follow-up study of participants in an alcohol treatment programme. British Journal of Psychiatry 157, Spielberger, C. D. (1983) Manual for the State-Trait Anxiety Inventory. Consulting Psychologists Press, Palo Alto, CA. Stockwell, T., Murphy, D. and Hodgson, R. (1983) The severity of alcohol dependence questionnaire: its use, reliability and validity. British Journal of Addiction 78, Straus, R. and Bacon, S. D. (1951) Alcoholism and social stability: a study of occupational integration on 2023 male clinic patients. Quarterly Journal of Studies on Alcohol 12,