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- Early exit: Estimating and explaining early exit from drug treatment
Early exit: Estimating and explaining early exit from drug treatment
- By Misc Author
- Published 05/23/2008
- Harm Reduction Theory
- Unrated
By Alex Stevens1, Polly Radcliffe1, Melony Sanders2, and Neil Hunt1,3
1 EISS, Keynes College, University of Kent, Canterbury, Kent CT2 7NP, UK
2 The Institute for Criminal Policy Research, 8th floor, Melbourne House King's College London, Strand, London WC2R 2LS, UK
3 KCA (UK), 44 East Street, Faversham, Kent ME13 8AT, UK
Harm Reduction Journal 2008, 5:13doi:10.1186/1477-7517-5-13
Abstract
Background
Early exit (drop-out) from drug treatment can mean that drug users do not derive the full benefits that treatment potentially offers.
Additionally, it may mean that scarce treatment resources are used inefficiently. Understanding the factors that lead to early exit from treatment should enable services to operate more effectively and better reduce drug related harm. To date, few studies have focused on drop-out during the initial, engagement phase of treatment.
This paper describes a mixed method study of early exit from English drug treatment services.
Methods
Quantitative data (n = 2,624) was derived from three English drug action team areas; two metropolitan and one provincial. Hierarchical linear modelling (HLM) was used to investigate predictors of early-exit while controlling for differences between agencies.
Qualitative interviews were conducted with 53 ex-clients and 16 members of staff from 10 agencies in these areas to explore their perspectives on early exit, its determinants and, how services could be improved.
Results
Almost a quarter of the quantitative sample (24.5%) dropped out between assessment and 30 days in treatment. Predictors of early exit were: being younger; being homeless; and not being a current injector. Age and injection status were both consistently associated with exit between assessment and treatment entry.
Those who were not in substitution treatment were significantly more likely to leave treatment at this stage. There were substantial variations between agencies, which point to the importance of system factors. Qualitative analysis identified several potential ways to improve services.
Perceived problems included: opening hours; the service setting; under-utilisation of motivational enhancement techniques; lack of clarity about expectations; lengthy, repetitive assessment procedures; constrained treatment choices; low initial dosing of opioid substitution treatment; and the routine requirement of supervised consumption of methadone.
Conclusion
Early exit diminishes the contribution that treatment may make to the reduction of drug related harm. This paper identifies characteristics of people most likely to drop out of treatment prematurely in English drug treatment services and highlights a range of possibilities for improving services.
Background
Although opioid maintenance is the central component of those drug treatment programmes that have been most clearly shown to reduce drug-related harm, these are most effective when provided alongside psycho-social support [1,2]. In the UK, much of this support is collectively termed 'structured treatment' and typically includes two main modalities: structured counselling and day programmes.
Treatment provision largely comprises community-based programmes; however, a minority of people also enter residential rehabilitation services. Drug problems are not limited to opiate users and, in Britain, frequently comprise poly-drug use, or may be dominated by stimulant use – notably cocaine/crack. Consequently, some people's treatment is focused exclusively on the psycho-social support components.
Since 1998, the UK has seen a big expansion in provision that has led to a 113% increase in the numbers of people being assessed for such structured drug treatment [3]. Increasing attention is now being given to ensuring that those who are assessed for treatment are retained long enough to benefit from it.
The available research on retention has tended to look at the predictors of retention over several months, but reveals that a large proportion of those who drop out do so in the first few days and weeks of treatment. For example, in an earlier study of retention in an English region, 48% of treatment clients dropped out within the first six months of treatment, and predictors of this drop out were examined.
However, 26% of those who dropped out did so before two weeks in treatment, although the predictors of this early exit were not examined [4].
To date, 'early exit' has received little attention. Although the outcome of some assessments might be a judgement that treatment is not needed it otherwise probably represents a waste of resources, because time and money that is invested in initial contacts and assessment is lost when people do not go on into treatment.
There is some possibility that the assessment itself operates as a brief intervention by enabling people to take stock of their situation and receive advice or information that leads to action. But in general it represents a missed opportunity for individual drug users to access and receive the help that they may need in order to achieve their own aims, such as reduction or cessation of drug use and improving their health.
It is clear that there is attrition at each stage of the process – between referral and assessment, assessment and treatment and within the first month of treatment – and that there is a need to look at different ways of maintaining clients in services at these points of contact.
The retention literature points towards a number of individual and system variables that may also influence early exit. Individual factors include ethnicity; employment status; co-morbidity of mental health problems; gender; age; problems with drugs other than opiates; and, previous treatment experience [5-9].
System factors include: referral from the criminal justice system; waiting times; levels of support and contact during waiting times; the extent to which services are welcoming and empathetic; the use of motivational enhancement approaches; and, the dose-adequacy and speed of titration of opioid substitution treatment [10-20].
This existing literature is not extensive and is derived from services provided in varied cultural contexts with differing treatment systems: variables that proved significant in one study are not consistently found to be so in other investigations.
There is also some suggestion in the available research [21] that different factors may be associated with dropping out before and after treatment entry.
This is important, as if these factors can be identified; it would enable agencies to focus efforts on the most vulnerable people at the most appropriate stage of their treatment journey with service enhancements that are most likely to increase their engagement and success in treatment.
The strongest influences on retention that have so far been found are system variables rather than individual factors; with people attending the poorest performing services being 7.1 times as likely to drop out early as those attending the best, which suggests that important determinants of early exit may be amenable to change through service improvements.
This article describes a mixed-method study that examined this phenomenon of early exit from drug treatment. It aimed to estimate the rate of early exit, to identify those drug users who are most likely to exit early, to analyse why they do so, and to provide recommendations for reducing early exit in order to boost retention, effectiveness and the impact of drug treatment.
This paper is based on a fuller report that was originally provided to the research funders (available as a PDF version supporting document from the Harm Reduction Journal website). The full report provides more detail of the background to the study, methodology and, in particular, the qualitative analysis.
Methods
It was anticipated that different factors would be associated with dropping out before treatment started and dropping out in the first month of treatment, so two stages of early exit are defined. The first refers to people assessed at a drug service, but who do not enter this programme (referred to as Exit1). The second refers to people who enter treatment (i.e. attend a first treatment appointment), but leave early (measured as staying less than 30 days in treatment and referred to as Exit2).
Quantitative methods
From the previous research in this area, we developed the following hypotheses for testing through multivariate analysis.
1. That transition from treatment offer to treatment entry is negatively associated with (a) being male, (b) being a primary stimulant user, (c) being a member of an ethnic minority, (d) being homeless, (e) longer waiting times, (f) being younger, (g) treatment modality (i.e. other than substitute prescribing) and (h) with being referred by the criminal justice system.
2. That transition from treatment entry to retention in treatment at one month is negatively associated with the same factors (a-h).
3. That transition from assessment to retention in treatment at one month (i.e. any early exit) is negatively associated with the same factors (a-h).
4. That different factors predict drop-out from assessment to treatment entry and drop-out in the first month of treatment.
Hypothesis 4 may seem to contradict hypotheses 2 and 3, as it would be contradicted if both hypotheses 2 and 3 were completely confirmed. It is phrased in the way it is in order that we could test whether the null hypothesis (i.e. that there was no difference in the variables influencing exit at each stage) could be rejected.
We primarily used data available from the National Drug Treatment Monitoring System (NDTMS) through the National Treatment Agency for Substance Misuse (NTA).
This is a standardised data set used nationally. Intentions to use additional data available in case-file records held by a random sample of drug treatment agencies in the three Drug Action Team (DAT) areas on which we focused were largely unsuccessful due to difficulties in obtaining it (these are discussed in the full report: Additional file 1).
Continued on original document:
Harm Reduction Journal 2008, 5:13doi:10.1186/1477-7517-5-13
1 EISS, Keynes College, University of Kent, Canterbury, Kent CT2 7NP, UK
2 The Institute for Criminal Policy Research, 8th floor, Melbourne House King's College London, Strand, London WC2R 2LS, UK
3 KCA (UK), 44 East Street, Faversham, Kent ME13 8AT, UK
Harm Reduction Journal 2008, 5:13doi:10.1186/1477-7517-5-13
Abstract
Background
Early exit (drop-out) from drug treatment can mean that drug users do not derive the full benefits that treatment potentially offers.
Additionally, it may mean that scarce treatment resources are used inefficiently. Understanding the factors that lead to early exit from treatment should enable services to operate more effectively and better reduce drug related harm. To date, few studies have focused on drop-out during the initial, engagement phase of treatment.
This paper describes a mixed method study of early exit from English drug treatment services.
Methods
Quantitative data (n = 2,624) was derived from three English drug action team areas; two metropolitan and one provincial. Hierarchical linear modelling (HLM) was used to investigate predictors of early-exit while controlling for differences between agencies.
Qualitative interviews were conducted with 53 ex-clients and 16 members of staff from 10 agencies in these areas to explore their perspectives on early exit, its determinants and, how services could be improved.
Results
Almost a quarter of the quantitative sample (24.5%) dropped out between assessment and 30 days in treatment. Predictors of early exit were: being younger; being homeless; and not being a current injector. Age and injection status were both consistently associated with exit between assessment and treatment entry.
Those who were not in substitution treatment were significantly more likely to leave treatment at this stage. There were substantial variations between agencies, which point to the importance of system factors. Qualitative analysis identified several potential ways to improve services.
Perceived problems included: opening hours; the service setting; under-utilisation of motivational enhancement techniques; lack of clarity about expectations; lengthy, repetitive assessment procedures; constrained treatment choices; low initial dosing of opioid substitution treatment; and the routine requirement of supervised consumption of methadone.
Conclusion
Early exit diminishes the contribution that treatment may make to the reduction of drug related harm. This paper identifies characteristics of people most likely to drop out of treatment prematurely in English drug treatment services and highlights a range of possibilities for improving services.
Background
Although opioid maintenance is the central component of those drug treatment programmes that have been most clearly shown to reduce drug-related harm, these are most effective when provided alongside psycho-social support [1,2]. In the UK, much of this support is collectively termed 'structured treatment' and typically includes two main modalities: structured counselling and day programmes.
Treatment provision largely comprises community-based programmes; however, a minority of people also enter residential rehabilitation services. Drug problems are not limited to opiate users and, in Britain, frequently comprise poly-drug use, or may be dominated by stimulant use – notably cocaine/crack. Consequently, some people's treatment is focused exclusively on the psycho-social support components.
Since 1998, the UK has seen a big expansion in provision that has led to a 113% increase in the numbers of people being assessed for such structured drug treatment [3]. Increasing attention is now being given to ensuring that those who are assessed for treatment are retained long enough to benefit from it.
The available research on retention has tended to look at the predictors of retention over several months, but reveals that a large proportion of those who drop out do so in the first few days and weeks of treatment. For example, in an earlier study of retention in an English region, 48% of treatment clients dropped out within the first six months of treatment, and predictors of this drop out were examined.
However, 26% of those who dropped out did so before two weeks in treatment, although the predictors of this early exit were not examined [4].
To date, 'early exit' has received little attention. Although the outcome of some assessments might be a judgement that treatment is not needed it otherwise probably represents a waste of resources, because time and money that is invested in initial contacts and assessment is lost when people do not go on into treatment.
There is some possibility that the assessment itself operates as a brief intervention by enabling people to take stock of their situation and receive advice or information that leads to action. But in general it represents a missed opportunity for individual drug users to access and receive the help that they may need in order to achieve their own aims, such as reduction or cessation of drug use and improving their health.
It is clear that there is attrition at each stage of the process – between referral and assessment, assessment and treatment and within the first month of treatment – and that there is a need to look at different ways of maintaining clients in services at these points of contact.
The retention literature points towards a number of individual and system variables that may also influence early exit. Individual factors include ethnicity; employment status; co-morbidity of mental health problems; gender; age; problems with drugs other than opiates; and, previous treatment experience [5-9].
System factors include: referral from the criminal justice system; waiting times; levels of support and contact during waiting times; the extent to which services are welcoming and empathetic; the use of motivational enhancement approaches; and, the dose-adequacy and speed of titration of opioid substitution treatment [10-20].
This existing literature is not extensive and is derived from services provided in varied cultural contexts with differing treatment systems: variables that proved significant in one study are not consistently found to be so in other investigations.
There is also some suggestion in the available research [21] that different factors may be associated with dropping out before and after treatment entry.
This is important, as if these factors can be identified; it would enable agencies to focus efforts on the most vulnerable people at the most appropriate stage of their treatment journey with service enhancements that are most likely to increase their engagement and success in treatment.
The strongest influences on retention that have so far been found are system variables rather than individual factors; with people attending the poorest performing services being 7.1 times as likely to drop out early as those attending the best, which suggests that important determinants of early exit may be amenable to change through service improvements.
This article describes a mixed-method study that examined this phenomenon of early exit from drug treatment. It aimed to estimate the rate of early exit, to identify those drug users who are most likely to exit early, to analyse why they do so, and to provide recommendations for reducing early exit in order to boost retention, effectiveness and the impact of drug treatment.
This paper is based on a fuller report that was originally provided to the research funders (available as a PDF version supporting document from the Harm Reduction Journal website). The full report provides more detail of the background to the study, methodology and, in particular, the qualitative analysis.
Methods
It was anticipated that different factors would be associated with dropping out before treatment started and dropping out in the first month of treatment, so two stages of early exit are defined. The first refers to people assessed at a drug service, but who do not enter this programme (referred to as Exit1). The second refers to people who enter treatment (i.e. attend a first treatment appointment), but leave early (measured as staying less than 30 days in treatment and referred to as Exit2).
Quantitative methods
From the previous research in this area, we developed the following hypotheses for testing through multivariate analysis.
1. That transition from treatment offer to treatment entry is negatively associated with (a) being male, (b) being a primary stimulant user, (c) being a member of an ethnic minority, (d) being homeless, (e) longer waiting times, (f) being younger, (g) treatment modality (i.e. other than substitute prescribing) and (h) with being referred by the criminal justice system.
2. That transition from treatment entry to retention in treatment at one month is negatively associated with the same factors (a-h).
3. That transition from assessment to retention in treatment at one month (i.e. any early exit) is negatively associated with the same factors (a-h).
4. That different factors predict drop-out from assessment to treatment entry and drop-out in the first month of treatment.
Hypothesis 4 may seem to contradict hypotheses 2 and 3, as it would be contradicted if both hypotheses 2 and 3 were completely confirmed. It is phrased in the way it is in order that we could test whether the null hypothesis (i.e. that there was no difference in the variables influencing exit at each stage) could be rejected.
We primarily used data available from the National Drug Treatment Monitoring System (NDTMS) through the National Treatment Agency for Substance Misuse (NTA).
This is a standardised data set used nationally. Intentions to use additional data available in case-file records held by a random sample of drug treatment agencies in the three Drug Action Team (DAT) areas on which we focused were largely unsuccessful due to difficulties in obtaining it (these are discussed in the full report: Additional file 1).
Continued on original document:
Harm Reduction Journal 2008, 5:13doi:10.1186/1477-7517-5-13
