Effects of Comorbid Opiate Dependency on Patients Admitted for Alcohol detoxification: Retrospective Chart Review and 2 Year Outcome
Fayyaz Ahmad*, Duncan W Stewart and Polash Shajahan
New Craigs Hospital, Inverness, IV38NP, UK
Received June 29, 2012; Accepted October 29, 2012; Published October 30, 2012
Citation: Ahmad F, Stewart DW, Shajahan P (2012) Effects of Comorbid Opiate Dependency on Patients Admitted for Alcohol detoxification: Retrospective Chart Review and 2 Year Outcome. J Addict Res Ther 3:137. doi: 10.4172/2155-6105.1000137
Copyright: © 2012 Ahmad F, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Background: Alcohol abuse is an important cause of medical complications in patients receiving opiate replacement therapy (ORT) and is associated with increased mortality rates. We aimed to compare the outcomes of patients receiving alcohol detoxification and were on ORT to those who were not on ORT over a 2 year period.
Method: A retrospective study assigning clinical global impression (CGI) severity and improvement subscales at the time of initial detoxification and after 2 years. The data was collected over a 2 year period from the index episode of inpatient alcohol detoxification.
Results: Individuals on ORT requiring alcohol detoxification had high CGI severity and low improvement scores, and were not discharged on a planned basis at the end of two years period compared to those who were not receiving ORT. Males were over represented in former group and they were significantly younger.
Conclusion: Our study showed that male gender and young age were poor prognostic factors and individuals on ORT who required alcohol detoxification had a worse prognosis. This might reflect adverse social circumstances, increased physical and psychiatric co-morbidity in this group. This patient group requires additional support and treatment to meet their complex needs.
Addiction services; Opiates replacement; Alcohol detoxification; Alcohol dependence; Co-dependence
Worldwide alcohol related harm and dependence caused 4% of the global disease burden and the proportion is greatest in Europe and America . The level of alcohol dependence in the UK population is 4%  but levels are much higher in opiate users for example 20- 40% of patients undergoing opiate replacement therapy had alcohol dependence [3-6].
There is evidence to suggest that chronic alcohol abuse is an important cause of medical complications during methadone treatment , which is frequently linked to premature discharge from treatment  and is associated with increased mortality rates . Individuals with opiate dependence are at increased risk of developing Hepatitis C infection, the majority of which remain undiagnosed  and alcohol abuse further exacerbates disease progression.
Within our locality, it was noted that a significant population requiring inpatient alcohol detoxification were also receiving opiate replacement therapy (ORT). We aimed to compare the outcomes of patients requiring alcohol detoxification not on ORT with those on ORT.
This was a retrospective study comparing characteristics of patients requiring an alcohol detoxification with those who required an alcohol detoxification who were also on opiate replacement therapy. The data was collected over a 2 year period from the index episode of inpatient alcohol detoxification.
Patients admitted for the first time for alcohol detoxification to our local acute psychiatric unit between the period of November 2003 and December 2006, were identified. Clinical and demographic details were extracted from their case records. In addition, clinical global impression scale (CGI)  severity and improvement subscales were retrospectively assigned at the time of initial detoxification, and after 2 years. Such retrospective assignment has been performed by others in assessing treatment response . Patient records were examined by scrutinising case records and computer based patient information systems to monitor subsequent progress over a 2 year period. This included contact with medical or surgical wards, accident and emergency departments or psychiatric services within the local NHS (Lanarkshire) Health Board authority. The following clinical variables were recorded; time taken from the initial detoxification admission to the next admission (medical or psychiatric), whether admissions were planned, for example, a further detoxification, or were unplanned, patient’s daily alcohol consumption (units per day) and whether patients were still engaged with psychiatric or addiction services at the end of the 2 year follow up period. It was also noted whether formal discharge from psychiatric or addiction services was planned or unplanned. The rationale for this being that planned discharges from psychiatric or addiction services were considered to be a positive health outcome indicating stability or recovery from addiction.
Table 1 illustrates characteristics of those who required an alcohol detoxification (n=64) and those who required an alcohol detoxification while receiving ORT (n=31). In our study males were over represented in both groups and were significantly greater in proportion in the group requiring alcohol detoxification that were on ORT. This patient group was significantly younger (by approximately 10 years) than patients who required alcohol detoxification. There was no significant difference in mean alcohol consumption between the two groups. There were no planned discharges in individuals admitted for alcohol detoxification and were receiving ORT compared to 20% of patients who were discharged on a planned basis. The 2 year Clinical Global Impression improvement scores were more favourable for the alcohol group not on ORT. Patients admitted for alcohol detoxification compared with those with alcohol problems on opiate substitution therapy (ORT) showed statistically significant improvement in illness severity at the end of 2 years as reflected by improvement of CGI severity scores.
|Alcohol dependence n=64||*Alcohol and opiate dependence n=31||P value|
|Mean age, years (95% C.I.)||42.1(39.3-44.8)||31.6
|Male, % (n)||63 (40)||84 (26)||0.03b|
|Mean alcohol units per day
|24.5 (22.2-26.7)||27.2 (24.2-30.1)||NS|
|Planned discharges, at 2 year follow up, % (n)||20 (13)||0 (0)||0.0008c|
|Initial CGI-S score (95% C.I.)||4.7 (4.5-4.8)||4.5 (4.3-4.8)||NS|
|2 year CGI-S score (95% C.I.)||4.1 (3.8-4.5)||4.5 (4.2-4.9)||NS|
|2 year CGI-Imp score (95% C.I.)||4.3 (3.9-4.7)||5.1 (4.6-5.5)||0.01d|
|Mean time to re-admission, days (95% C.I.)||536 days (472-600)||595 days (517-673)||NS|
*Maintained on opiate substitute prescription (methadone or buprenorphine)
a2-sided t =5.0. d.f. =93, p<0.0001
bχ2=4.5. d.f. =1, p=0.03
cχ2=14.3. d.f. =2, p=0.0008
d2-sided t =2.5. d.f. =90, p=0.01.
Table 1: Clinical and record profile of alcohol dependent patients with or without opiate dependency.
Our study showed that individuals on ORT who required alcohol detoxification had a worse prognosis at the end of the 2 year study period compared to those who were not on ORT. Planned discharges were considered a marker of stability and positive outcome. Individuals on ORT who required alcohol detoxification were not discharged on a planned basis whereas a significant proportion (20%) of patients admitted for alcohol detoxification not on ORT were discharged on a planned basis at the end of 2 year study period. This is consistent with findings of previous studies; for example, Gossop et al.  found poor drinking outcomes among drug misusers at 5 year follow up and Marcovici et al.  noted that problem drinkers receiving methadone maintenance were more likely to continue drug abuse, were involved in more criminal activity and showed more evidence of co-morbid anxiety and depression. In our study, there were significant differences with regards to the individual characteristics of two groups. Studies have shown that these characteristics are the most consistent predictor of change in pattern of substance misuse . We found that individuals on ORT who required alcohol detoxification were significantly younger than those who were not on ORT. This is consistent with previous studies which have found a poor short and long term prognosis for younger patients with substance misuse problems [15-17]. We also noted that more males required alcohol detoxification, who were on ORT than those who were admitted for alcohol detoxification not on ORT. Evidence suggests that outcomes of alcohol problems in patients with opiate addiction are better for women than men [18,19]. Therefore, our findings and that of others support the idea that younger age and male gender are poor prognostic factors.
Poorer prognosis of Individuals requiring alcohol detoxification receiving ORT may reflect their poor social circumstances, increased physical and psychiatric co-morbidity and lack of socio-economic resources . This is a particularly vulnerable patient group and is at risk of being neglected, especially if there is a false dichotomy of drug and alcohol problems seen as distinct entities. Interventions and programs specially designed to tackle alcohol related problems in individuals receiving ORT should be developed and strengthened. These individuals would benefit from regularly updated assessment of patterns of substance abuse and psycho-social needs as they are more likely to have severe psychiatric co-morbidities . They also have considerable differences in treatment response and hence would require additional support and treatment to meet their needs . Interventions to help develop social networks and participation in support groups during treatment would improve outcomes for these individuals.
We do not know whether increases in alcohol related problems develop before initiating ORT or during treatment, with alcohol being used in a self-medicating way to substitute for heroin. Further research in the form of prospective studies would help identify the prevalence and extent of alcohol use among individuals on ORT. It would be beneficial to supplement this with qualitative research to look at what point alcohol disorders evolve during the course of opiate substitution. This may allow the identification of risk factors which could be identified at an earlier stage of developing alcohol problems and could inform subsequent shaping and redesign of services.
There are certain limitations to our study. Apart from the inherent limitations due to its retrospective design, data was not available to consider other parameters including duration of alcohol related disorders, co-morbid physical and mental disorders and whether alcohol disorders developed before or during ORT. The 2 year time period within our study is also a limitation as it only provided a snapshot of the long journey that patients with addictions often endure. Furthermore, it is worthwhile noting that individuals who are on ORT are more likely to engage with treatment due to the ongoing prescription of ORT.