Patient characteristics predicting attendance for elective in-patient treatment of substance use disorder

Aim

The aim of this study is to determine whether age, gender, post withdrawal plans, substance use pattern or coercion from legal or child welfare agencies predict attendance for an elective IWM admission for treatment of SUD.

Methods

This study was undertaken at a 15-bed, regional New South Wales IWM unit situated within the local general hospital. Sixteen to eighteen elective admissions are booked each week, and a variable number of emergency admissions present via the Emergency Department. Elective patients self-refer to a telephone intake line, when a comprehensive assessment is undertaken. This assessment is reviewed by the IWM unit nurse manager and medical staff. If considered clinically appropriate for admission, the patient is telephoned and an admission date agreed.

In this retrospective cohort study, medical records of all patients with planned admission to this service between 1 March 2019 and 30 June 2019 were reviewed. Inclusion criteria were

Urgent admissions from the emergency department were excluded.

The record was reviewed from the time of initial contact to the day of proposed admission. Data fields extracted were sex, age, substance(s) used, which substance use related to the proposed admission, pre-arranged rehabilitation admissions after discharge, legal issues or child welfare agencies motivating admission, wait time and attendance for admission. Substance use of problem was alcohol, cannabis, stimulants, opioids, benzodiazepines or other. Tobacco was not included.

Descriptive statistics for demographic characteristics were analysed using Microsoft Excel. Binomial logistic regression was performed using IBM SPSS Statistics.

The Research Governance Office of the Central Coast Local Health district approved the study as low and negligible risk. STROBE guidelines were followed in the conduct and reporting of this trial. ⁶

Results

Demographics

During the 17-week period, 274 elective admissions were planned; 159 (58%) were male and 115 (42%) were female (Table 1). Average age was 40 (range 18–82, mode 27); 184 (67%) admissions were 45 years of age or younger.

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Table 1.

Characteristics of patients who attended or did not attend for elective admission

	All	Sex (n)		Rehab* (n)		FACS (n)		Legal (n)		Wait days (mean)	Substance identified (n)
		M	F	Y	N	Y	N	Y	N		All	Alcohol	ATS*	THC	Opioid	BZ	HDT	Other
Attend	193	111	82	40	153	14	179	15	178	34.7		118	59	86	12	14	11	2
Not attend	81	48	33	1	80	2	79	8	73	36.4		34	36	33	1	2	3	0
Total	274	159	115	41	233	16	258	23	251	35.2	411	152	95	119	13	16	14	2

Note. *p < .05. Rehab = residential rehabilitation; ATS = amphetamine type stimulants; THC = cannabis; HDT = high dose transfer; BZ = benzodiazepine; FACS = Family and Community Services. Y = yes; N = no.

Substance use profile

In pre-admission screening, the 274 individuals reported 411 substances of concern. The majority identified misuse of one (60%) or two (34%) substances (Figure 1).

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Figure 1.

Percentage of subjects reporting one, two, three, four, or five or more substances as problematic.

The most prevalent substances were alcohol, cannabis and amphetamines:

- 55% identified alcohol as problematic

- 43% identified cannabis as problematic

- 35% identified amphetamines as problematic

Of the 164 patients using only one substance, 84 were using alcohol only, 33 amphetamines only, and a further 33 cannabis only. Ninety-three people reported two substances as problematic (Figure 1), of whom 48 were using alcohol in combination with either cannabis (n = 33) or amphetamines (n = 15). Thirty-two people were using both cannabis and amphetamines.

External agency involvement

External agencies were involved in 64 (23%) planned admissions (Figure 2). Forty-one admissions had residential rehabilitation beds prior to attending IWM. Of these, 14 also had involvement from child welfare services and/or legal involvement. Sixteen admissions were referred by the government child welfare agency Family and Community Services (FACS). Of these, nine also had legal involvement and/or had residential rehabilitation beds post-discharge. Twenty-three admissions had some legal involvement.

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Figure 2.

External agency involvement. Rehab = pre-planned residential rehabilitation.

Discussion

Our study identifies that approximately 30% of planned admissions for IWM do not attend for treatment consistent with other studies. ⁴ These studies identify barriers of financial burden, logistical difficulties (including distance, wait times and childcare), perceived stigma, attitudinal and cultural factors.^7–10 Our exploration of patient characteristics shows that non-attenders are younger, use amphetamines, and do not have plans for continuing to residential treatment programmes.

Australian amphetamine users do not readily access treatment, ⁸ and our study shows poorer attendance in this group. Identified reasons for particular difficulties for amphetamine users include more pervasive SUD, adverse socio-economic factors and younger age. Stigma, perceptions of lack of treatment effectiveness, privacy and preference for self-management can also act as barriers.^8,9

Age impacts on perceptions of treatment. Younger people report more concern about stigma, while the older population report concern about practicalities, cost and perceived need for treatment. ³ Younger people are less likely to complete an episode of withdrawal management, with high attrition rates ¹¹ and poorer treatment outcomes. ¹² Our study reinforces the need to improve engagement with younger treatment seekers.

Successful transition from withdrawal management to post-withdrawal SUD care improves outcomes. ¹¹ Our study showing that the majority of those with pre-planned residential rehabilitation beds attended for treatment emphasises the importance of facilitating seamless transitions.

The role of stigma and attitudinal beliefs has a significant effect on engagement with treatment.^2,3,9 Interventions such as the Brief Intervention can be effective in reducing stigma. ² These could be structured within the pre-admission treatment planning telephone assessment to reduce treatment barriers.

Financial burdens caused by the cost and logistical difficulties such as wait times are identified as problematic in the US population.^2,13 Cost as a barrier has less of a relevance in an Australian setting, as there is no charge for treatment at the point of care in a public hospital setting.

Our study has implications for patient care. When rescheduling admissions because of bed capacity, priority for those with pre-arranged rehabilitation beds can be considered. Supporting patients to develop structured plans prior to withdrawal may improve attendance. Directed strategies should be developed for younger people and amphetamine users who are least likely to attend.

There are limitations to this study. As a retrospective study, there is risk of reporting bias and we did not explore the reasons for non-attendance. Numbers in the study overall, and particularly the legal and child welfare coercive treatment groups, were small.

Future studies could explore the reasons for non-attendance. The roles of stigma, the perceptions of treatment effectiveness and the impact of practical barriers should be explored. This would allow development and assessment of directed interventions to improve attendance. The impact of child welfare and legal coercion on attendance should be explored in larger studies.

Conclusion

This study investigating patient characteristics that predict attendance for in-patient treatment of SUD identifies being younger and amphetamine use as predictors of non-attendance. Confirmed plans for a residential rehabilitation bed predict attendance. No correlation with gender, admission motivated by legal or child welfare concerns or with polysubstance use was identified. Future studies should investigate the reasons for non-attendance and assess interventions to address these.