Clinical management methods for out-patients with alcohol dependence

Abstract

Background: In France outpatient centres for the care of alcoholics are healthcare establishments providing medical, psychological and social support. Although they meet the practical needs of these patients, their degree of use in each of these domains and the respective mobilisation of different skills by the care team are not well understood. Our aim was therefore to determine in detail the management involved as a function of the severity of alcohol dependence. For this purpose, all the procedures involved were compiled in a thesaurus describing its type (psychological, medical, social, reception), its scheduled or unscheduled nature, its method (face-to-face, telephone, letter) and its duration. The severity of dependence was evaluated using the Addiction Severity Index (ASI).

Results: 45 patients were included and followed-up during 291 +/- 114 days. The mean initial ASI scores (+/- SD) were: medical (M) = 0.39 +/- 0.3, working-income (ER) = 0.5 +/- 0.3, alcohol (A) = 0.51 +/- 0.2, illicit drugs (D) = 0.07 +/- 0.08, legal (L) = 0.06 +/- 0.13, familial and social environment (FS) = 0.34 +/- 0.26, psychological (P) = 0.39 +/- 0.22. The total number of procedures was 1341 (29.8 per patient) corresponding to 754.4 hours (16.7 per patient). The intensity of management peaked during the first month of treatment, and then declined rapidly; the maximum incidence of abstinence was observed during the 3rd month of management. Interviews with patients, group therapy and staff meetings represented 68.7%, 9.9% and 13.9% of all procedures, respectively. In patients with severe dependence, as compared to moderate, management was twice as intense in the psychological and social domains, but not in the medical domain. The ASI questionnaire was completed a second time by 24 patients, after an average of 3.2 months. The improvement was significant in the M, A, D and P domains only.

Conclusion: This study provided an overview of the methods employed in managing a sample of patients consulting an alcoholism centre in line with standards for medical, psychological and social establishments. The predominance of the social and psychological domains over the medical domain was clearly established. Relapses were common after the third month of treatment, but a remobilisation of teams made it possible to contain them. These results provide a framework for discussions on the organisation of healthcare systems and highly suggest that staff need to maintain a constant level of care throughout the treatment process.

Figure 1

Boxplots of initial ASI sub-scores in the 45 studied patients.

Figure 2

Distribution of types of intervention (PI = patient interview; Staff = staff meeting; Group = group therapy; Other = Family interview + administrative procedures + support + visits).

Figure 3

Distribution of procedures as a function of domain (Psy = psychological; Med = Medical; Soc = Social; Mix = several domains).

Figure 4

Intensity of care (mean intervention time/patient) as a function of the month of follow-up in patients with moderate (4A) or severe (4B) dependence.