Timely Linkage to Treatment from Detox Saves Lives

If substance use care is not coordinated across the various phases of recovery, then recovery is threatened by relapse and possibly death. This study quantifies the magnitude of the beneficial effect of timely outpatient care immediately following discharge from detoxification from alcohol or opioids.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Any gap in substance use treatment once abstinence is obtained leads to increased rates of relapse and higher risks of death (ASAM guidelines 2014 performance measures). Practice guidelines developed by the American Society of Addiction Medicine and the Veterans Administration recommend outpatient treatment within seven days of having completed detoxification from alcohol or opioids. The effect of receiving follow-up care within 14 days discharge from detoxification has been examined (Lee at al 2014; Harris et al 2015) and many studies have shown that detoxification alone (without subsequent treatment) leads to worse outcomes. However, the magnitude of the benefit of minimizing the lag between discharge from detoxification and initiating outpatient treatment has not been quantified across a number of measures including mortality (i.e., death).

HOW WAS THIS STUDY CONDUCTED?

A national sample (n= 25,354) of patients who received detoxification (specifically medically managed withdrawal either inpatient or outpatient) from alcohol or opioids in 2009 was identified in the Veterans Health Administration administrative data. The authors modeled the associations between receiving outpatient follow-up within seven days of completing detoxification and a variety of patient outcomes. Using statistical controls for variability (propensity score-weighted mixed-effects regressions) they controlled for patient-level variability, facility-level performance and clustering of patients within facilities (i.e. within-facility care vs. care across various treatment facilities).

WHAT DID THIS STUDY FIND?

Most patients did not receive outpatient follow-up within seven days of discharge from detoxification: Only 40% of patients attended an outpatient follow-up appointment scheduled within a week of discharge from detoxification. Interestingly, though the population of those attending or not attending timely outpatient follow-up were demographically and medically similar prior to detoxification, those who did attend prompt follow-up were more likely to have been homeless.

Receiving timely outpatient treatment (within one week) significantly reduced two-year mortality: The odds of mortality with two years of the baseline detoxification was 53% lower for those who entered outpatient treatment shortly after detoxification (p<0.001). In the two years following detoxification, 7% of those receiving the outpatient care within seven days had died (all-cause mortality) as compared with 12% of patients not attending outpatient appointments shortly after detoxification. This is an even larger effect on mortality than that seen in a separate study, where individuals receiving intensive outpatient treatment for at least a week (vs. those not receiving intensive treatment within the first six months following detoxification), which showed a 48% lower odds of two-year mortality (Schmidt et al 2016).

The group with the lowered mortality odds also had significantly higher utilization of mental health and substance use treatment: Those who engaged in outpatient treatment within a week of detoxification discharge also showed higher numbers of outpatient appointments and inpatient admissions for both substance use and other mental health conditions over the two years following detoxification. This was an unexpected finding.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

This is a very large study (over 25,000 patients analyzed) showing robustly that follow-up within a week of discharge from detoxification is associated with significantly lower mortality rates two years after detoxification. This is not the first study demonstrating the importance of care coordination in the early phases of sobriety. However, despite the magnitude of the effect shown here, most patients discharged from detoxification programs are not attending outpatient follow-up appointments within a week, the current practice guidelines. The implication is that if the guidelines were adhered to in a higher percentage of cases, there could be a substantially beneficial effect on a variety of outcome measures including all-cause mortality.

LIMITATIONS

Since this is not a prospective, randomized trial, it is possible that those attending prompt follow-up (for example, if they are the ones requesting timely follow-up) are more likely to be actively involved in follow-up care, regardless of the timing of their first appointment. The baseline characteristics of both populations and the propensity score weighting by individual reduce the probability that this is the case.
This study only includes veterans treated within the Veterans Administration system, a system that is expected to have both better integration of care in parallel with more delays in treatment depending on geographic location. Though some of these variations have been controlled for, the comparative mortality in a civilian population and the effects of care coordination in this very different setting might be fundamentally different.
Substance use in the veteran population is complicated by a much higher percentage of comorbid PTSD than is generally found in the civilian population, which confounds the mortality rate (as there is higher mortality by suicide in the veteran population).
The administrative data upon which this study is based does not include measures of withdrawal severity that may be a confounder in the timing of follow-up that would not be accounted for with the propensity weighting score.

BOTTOM LINE

For individuals & families seeking recovery: There is a large predicted benefit of attending outpatient follow-up within a week of completing detoxification, in terms of further engagement in subsequent treatment and lower odds of mortality. Emphasizing and encouraging care coordination from the point of entry seems to enhance engagement in subsequent treatment.
For scientists: Though a significant association has been shown here between care coordination and decreased mortality, without a prospective analysis, it cannot be concluded that it is the care coordination per se that is resulting in the decreased mortality (although this study does an admirable job of attempting to control for confounders). Since randomized controlled trials with one arm designed to have poorer care coordination is not ethically appropriate, more studies of this association, including prospective studies and studies across civilian care systems are needed to validate these findings. Furthermore, studies including measures of substance use and withdrawal severity are needed, as this study cannot address those variables.
For policy makers: Though lower care utilization and cost is often a desired societal goal, this study suggests that good care coordination following detoxification is associated with higher care utilization (including subsequent detoxifications) but lower mortality risk. This suggests that more short-term spending may result in better long-term outcomes.
For treatment professionals and treatment systems: Measures of care coordination, including timing of follow-up appointments following detoxification, should be monitored and the ASAM guidelines should be held as a goal to be met by the participating facilities in a patient’s care system.

CITATIONS

Schmidt, E. M., Gupta, S., Bowe, T., Ellerbe, L. S., Phelps, T. E., Finney, J. W., … & Harris, A. H. (2017). Predictive validity of a quality measure for intensive substance use disorder treatment. Substance abuse, 38(3), 317-323.