Full text of DOI:10.1093/fampra/18.5.545

Fam ily Practice
Vol. 18, No. 5
© Oxford University Press 2001
Printed in Great Britain
Residential rehabilitation for drug users: a review
of 13 m onths’ intake to a therapeutic com m unity
J enny Keen, Phillip Oliver, Georgina Row se and Nigel Mathers
Keen J , Oliver P, Rowse G and Mathers N. Residential rehabilitation for drug users: a review of
13 m onths’ intake to a therapeutic com m unity. Fam ily Practice 2001; 1 8 : 545–548.
Ba c k g ro u n d . Residential rehabilitation based on ‘therapeutic com m unity’ treatm ent for drug
users is a treatm ent option which is attractive to GPs and others referring drug users for treatm ent.
Whilst there is evidence that m aintenance-based program m es for drug users are effective, there
have been fewer attem pts to evaluate the effectiveness of abstinence-based program m es which
are relatively m ore intensive and expensive interventions.
Ob je c t ive . This paper reports and evaluates the outcom es for 13 m onths’ intake of 138 drug
users to a residential com m unity.
Me t h o d s . We carried out a retrospective cohort study using existing clinical and residential
record data. The setting is a residential rehabilitation centre run by the charity Phoenix House in
Sheffield, UK, offering a 1-year program m e for heroin addicts including com m unity detoxification
overseen by prim ary care specialist doctors and residential rehabilitation. Participants were all
patients who entered treatm ent between 1 February 1998 and 28 February 1999 inclusive. An
analysis was carried out of clinical records and other records kept by clinicians and staff at the
centre. Outcom e m easures were num bers of days of retention in treatm ent and reasons for
departure, categorized as com pleted treatm ent, planned or unplanned departure and expulsion
from the program m e. For patients who underwent in-house detoxification, a further outcom e
m easure was whether or not detoxification was com plete at discharge.
Re s u lt s . Heroin was the m ain drug of abuse in 85% of adm issions. Mean length of tim e for
which individuals had been drug dependent was 8 years (range 1.3–20.1 years). The m ean
length of stay was 80.2 days (range 1–394, 95% confidence interval 61.8–98.6). Thirty-four indi-
viduals (25%) com pleted 90 days or m ore. No association was found between length of stay and
age, sex, route of adm inistration, polydrug use, length of tim e addicted or age of first addiction.
Sixty-five per cent of those who received in-house detoxification com pleted the detoxification
period. When patients were classified as ‘successes’ or ‘failures’ by reason for departure from
the program m e, 94 (68.1%) were classified as failures and 18 (13.0%) as successes. Data were
unavailable for 26 patients. Success was not associated with any characteristic at entry apart
from being drug free as opposed to requiring detoxification (P = 0.048, chi-square = 6.06,
df = 2).
Co n c lu s io n . This study shows overall low levels of program m e com pletion and high levels of
unplanned departure and eviction from the program m e am ongst these long-term drug users.
On the other hand, the im portance of abstinence for those who achieve it in residential rehabili-
tation should not be underestim ated, nor should the possibility that long-term outcom es are
influenced by the learning process involved in the intervention. It m ay be possible to operate
better selection procedures in order to optim ize outcom es.
Ke yw o rd s . Addiction, detoxification, heroin, rehabilitation, substance abuse.
Introduction
Research into residential rehabilitation programmes for
drug users, with or without an integral detoxification, has
been fraught with difficulties. Comparability between
different programmes has been hard to establish; follow-
up of residents who have left the programmes is difficult
Received 31 October 2000; Revised 20 February 2001;
Accepted 4 May 2001.
Institute of General Practice and Primary Care, Community
Sciences Centre, Northern General Hospital, Herries Road,
Sheffield S5 7AU, UK.
545

Family Practice—an international journal
546
because of the relative instability of many drug users;
and selection bias affects interpretation of the results.
Nevertheless, the question remains for policy makers
and referrers whether or not this intensive intervention
is a valid treatment option. This paper reports the results
from 13 months’ intake of 138 drug users to a residential
community.
detoxification using only methadone mixture 1 mg per ml
at starting doses not higher than 40 ml. The dose would
be reduced typically by 5 mg per 1 or 2 days over an
average period of 7–10 days until detoxification was
complete. No additional psychoactive medication was
used for these patients, and no other patients received
any psychoactive medication.
Context
In their review of the effectiveness of detoxification
programmes,1 Mattick and Hall make the point that
detoxification, as a treatment aimed at achieving ab-
stinence, is not especially effective. They point out that
many countries adopt services based on the idea that
detoxification can bring about lasting changes in drug
use, despite evidence to the contrary. However, the authors
do accept that even temporary abstinence followed by
relapse may be of value.
The generally agreed aim of residential rehabilitation,
such as that studied in this investigation, is to achieve
long-term abstinence. Nonetheless, the conclusions of
Mattick and Hall make it clear that a fairly low rate of
‘success’ can be expected if abstinence is the desired
goal. Studies looking at other outcomes of residential
rehabilitation, however, such as reductions in illicit drug
use, improved family outcomes,2 reductions in criminal
activity and overall harm minimization, have demonstrated
more positive results.3–5 Gossop6 makes the point that
these goals may co-exist with the goal of abstinence. This
study looks at short-term outcomes for residential rehabili-
tation with or without on-site detoxification in a resi-
dential therapeutic community setting in Sheffield, UK.
Method
Records of the admissions of all the patients were
obtained from the therapeutic community as well as
medical records held by the doctors overseeing the
detoxifications. This information was provided in MS
Excel format and exported into a statistical package
(SPSS v 9.0) using ODBC (Open Database Connectivity)
for analysis. Data analysis was then carried out using a
range of statistical tests including chi-square, t-tests and
tests for correlation.
Outcome measures
Retention in treatment, especially for periods of 90 or
more days, has been identified by a number of
authors3,5,7 as a good predictor of long-term success on a
number of measures; therefore, in the absence of long-
term follow-up data, the number of days in treatment
was selected as the main measure of outcome. In
addition, the reason for departure, categorized as
completed treatment, planned or unplanned departure
and expulsion from the programme, was chosen as a
secondary outcome measure, with completed treatment
and planned departure suggesting favourable outcomes
at the point of leaving the programme. For patients who
underwent in-house detoxification, a further secondary
outcome measure was whether or not detoxification was
complete at discharge. These outcomes were used to
measure the effectiveness of the intervention in
retaining patients in treatment, but also to attempt to
ascertain whether any of the patient characteristics
measured at entry to the programme would be found to be
predictive of retention in the programme and/or
successful completion.
Study design
This is a records-based retrospective cohort study of all
138 drug users who were admitted to the residential thera-
peutic community in Sheffield, UK for drug rehabilitation
with or without on-site detoxification duringthe 13months
beginning 1 February 1998.
Intervention
The residential programme lasts 1 year and all patients
are expected to participate from the outset in the thera-
peutic community, which is based on a concept of lifetime
abstinence and uses all the individuals in the community,
staff and patients, as therapeutic tools. Urine testing is
carried out on a random basis and if there is suspicion of
illicit drug use, the penalty for this is expulsion from the
programme. Individuals are under no compulsion to stay
in the programme, and unplanned departure generally
indicates a return to illicit drug use. On the other hand,
planned early departure from the programme may occur
because of funding difficulties or childcare problems
without implying failure to maintain abstinence.
Drug users who were still opiate dependent at the time
of entry were seen by one of two Primary Care Special-
ists in Drug Dependence and provided with a medical
Results
Patient profile
One hundred and thirty-eight patients were admitted to
the centre between 1 February 1998 and 28 February
1999. Eighty-eight (64% ) were male and 50 (36% ) female.
Fifty patients (36% ), who were still opiate-dependent
at admission, and of whom 32 were men and 18 women,
received an in-house methadone detoxification. Mean
age at admission was 26.7 years (range 19–42), with no
significant difference between the sexes or between those
who did or did not receive detoxification. The sample

Residential rehabilitation for drug users
547
was predominantly white (93% ), with the remainder
Asian, Afro-Caribbean or mixed race.
and the individuals who were drug-free at entry. When
individuals were divided into those who stayed 90 days
or more and those who did not, there similarly was no
association with the factors listed above.
Drug use prior to admission
The preferred drug of abuse was overwhelmingly heroin
(85% ) followed by cocaine (6% ) and amphetamines
(4% ); however, 87% of the sample regularly abused
more than one drug. Of the sample, 65.9% were regular
injectors. High levels of risk-taking behaviour were
reported, with 86% having injected at least once, 53%
having shared injecting equipment and 11% having shared
equipment in the past month. Twenty-two per cent of
the sample were in receipt of a methadone prescrip-
tion immediately prior to admission, and these were
all included in the group who received in-house
detoxification.
Reason for departure
For the purposes of this analysis, patients who left the
programme because they had completed their treatment
or as planned departures or transfers were classified
as successes; those who left as unplanned departures
or were evicted were classified as failures. Overall, 94
(68.1% ) of the 138 entrants were classified as failures
and 18 (13.0% ) successes. Data were unavailable for the
remaining 26 patients. Success or failure was not asso-
ciated with sex, age at admission, length of time addicted,
age of first addiction, mode of administration of drugs,
or whether or not the patient had received a methadone
prescription. However, it appeared that those who were
already drug free on admission were more likely to
be successes than those who required detoxification
(P = 0.048, chi-square = 6.06, df = 2).
The length of time for which individuals had been
dependent upon their main drug of abuse ranged from
16 to 241 months (1.3–20.1 years) with a mean of 95.4
months (8 years).
Length of stay
The number of days for which patients stayed in treat-
ment ranged from 1 to 394, with a mean of 80.2 (95%
confidence interval 61.8–98.6) (Fig. 1). Thirty-four indi-
viduals (25% ) completed 90 days or more. No association
was found between length of stay and age, sex, route of
administration, polydrug use, length of time addicted
or age of first addiction. Sixty-five per cent of those
individuals who received in-house detoxification stayed
for 14 days or more and therefore successfully completed
the detoxification period, but there was no significant
difference in mean overall length of stay between these
Discussion
An analysis of data of this sort faces two major problems:
the identification of what constitutes success or failure
and the difficulty in assessing the impact of one treatment
episode on the future course of a patient’s addiction.
This study shows overall low levels of programme
completion, low levels of retention in treatment for 90
days or more, and high levels of unplanned departure
and eviction from the programme. On the other hand, as
noted by the NTORS study of patients entering similar
programmes,8 these patients were very markedly at the
‘heavy end’ of drug users, being predominantly long-
term heroin injectors many of whom were polydrug
abusers. Only one patient had been addicted for less than
2 years, and only five patients for less than 3 years. In
the absence of long-term outcome data, it is impossible
to judge whether other measures of success such as
improved overall functioning and reduction of drug-
related harm may have been achieved by participants in
spite of failing to complete the programme. Furthermore,
whilst the failure of 87.5% of programme participants to
achieve the stated goal of abstinence even for the 1-year
period of residential treatment would seem to raise
questions about the value of the intervention, this none-
theless represents a considerable achievement for the
17 individuals (12.5% ) who did remain abstinent for
the duration of their treatment.
This in turn raises the question as to whether it is
possible to maximize the number of individuals likely to
benefit from a treatment such as this one. Our study
shows that the mean age of entry to the programme was
26 years and the mean length of addiction was 8 years.
FIGURE 1 Number of days spent by patients in treatment

Family Practice—an international journal
548
Amongst this group, no factor at entry seemed to predict
abstinence. However, there were very few younger users
with shorter addiction histories in the programme.
This may simply represent confirmation of the view
of Seivewright,9 amongst others, that abstinence is a
difficult outcome to achieve in older patients with longer
histories of dependent opiate use, who may benefit more
from maintenance treatment.
Whilst there is far more good evidence for measurably
successful outcomes with maintenance programmes10
than with abstinence-based programmes, nevertheless
the importance of achieving abstinence cannot be under-
estimated in individuals who achieve success. Addition-
ally, there may be long-term effects derived from the
learning process undergone during the residential
programme.
Acknowledgements
The authors would like to thank Dr Roger Smith and
staff at Phoenix House, Storth Oaks, Sheffield.
References
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