Detoxification, the medical management of substance withdrawal to prevent complications, does not serve as standalone care for substance dependence. Rather, detoxification should be an entry point to addiction treatment. Successful transitions from detoxification to addiction treatment benefit outcomes such as reduced relapse, criminal justice system involvement, and crisis-related health care utilization, and increased employment and stable housing (Ford & Zarate, 2010). Nevertheless, many patients do not successfully transition from detoxification to treatment (Carrier et al., 2011).
Facilitators of detoxification-to-treatment transitions have been identified at the levels of the patient, program, and system. Patient-related facilitators of entering treatment after detoxification include difficult circumstances caused by substance use, such as lost housing or relationships (Raven et al., 2010), and pressures from friends and family to enter treatment (Kenny, Harney, Lee, & Pennay, 2011). They also include personal motivation, often due to fatigue with the drug-using way of life (Corsi, Kwiatkowski, & Booth, 2007). Increased drug use, a recent overdose, health or legal problems, and previous treatment admissions also facilitate addiction treatment initiation (Jackson & Shannon, 2012; Siegal, Falck, Wang, & Carlson, 2002).
Program-level characteristics that are facilitators of addiction treatment have been identified in both detoxification and addiction treatment programs. Active discharge planning with clients during detoxification facilitated addiction treatment admission (Carroll, Triplett, & Mondimore, 2009). Transition rates may improve when addiction programs have more clinically skilled, engaged, and supportive providers (Broome, Flynn, Knight, & Simpson, 2007), and provide motivational enhancement therapy (MET) and peer support (Blondell et al., 2011). The availability of case management, women-only programs, and assistance with child care and housing may also improve addiction treatment rates (Rapp et al., 2008; Sun, 2006).
One system-level characteristic that facilitates addiction treatment after detoxification is detoxification treatment integration. Transfer rates from a detoxification unit to a rehabilitation unit were highest when both units were contained within a single setting (Ross & Turner, 1994). Integration across the continuum of care to address all of patients’ needs within a single system enhances the likelihood of transitions between types of services (Appel, Ellison, Jansky, & Oldak, 2004).
Barriers to the detoxification-to-treatment transition have been identified at the patient, program, and system levels. At the patient level, detoxification patients may resist treatment because they are not motivated to stop using substances, or feel that problems will get better on their own (Mowbray, Perron, Bohnert, Krentzman, & Vaughn, 2010). Competing responsibilities of having a job and family, or lack of a stable living situation or transportation, are barriers to treatment entry (Appel et al., 2004; Kenny et al., 2011). Perceived stigma associated with substance use and treatment need is a major deterrent to seeking treatment (Mojtabai, Chen, Kaufmann, & Crum, 2014). Individuals resist seeking treatment for fear of being labeled an addict, negatively judged or treated (Allen, Copello, & Orford, 2005; Luoma et al., 2007) or repercussions such as losing child custody (Boeri, Tyndall, & Woodall, 2011).
Program characteristics also serve as barriers to treatment utilization postdetoxification. These include wait times for available beds or appointments, requirements for meeting eligibility criteria, and inconvenience of services (Appel et al., 2004; Boeri et al., 2011). Wait times are exacerbated by staffing shortages, and staff members having heavy caseloads and too many administrative tasks (Pullen & Oser, 2014).
System barriers such as cost and location limit addiction services’ accessibility (Motjabai et al., 2014; SAMHSA, 2014). Barriers to addiction treatment entry include lack of coordination across components of the health system in qualifying, enrolling, and supporting persons needing detoxification and treatment (Appel et al., 2004). A lack of interprogram cooperation, communication, and collaboration deters addiction treatment availability following detoxification (Pullen & Oser, 2014).
This study used a conceptual model of determinants of health care transitions, which describes transitions’ patient-, provider-, and system-level facilitators and barriers (Cucciare, Coleman, & Timko, 2015). It used qualitative methods to inform detoxification and addiction treatment providers, and the health systems in which they work, about how to improve detoxification-to-treatment transitions, by reporting detoxification providers’ views of transition facilitators and barriers. The aim was to identify factors that can be altered or transformed to improve addiction treatment utilization after detoxification, and thus increase the likelihood of improved patient outcomes and sustained recovery.
Participants and Procedures
We interviewed thirty providers from thirty Veterans Health Administration (VHA) detoxification programs. To obtain this sample, we used a VHA database to calculate, for each of the 141 VHA facilities during a single fiscal year (2014), the proportion of patients diagnosed with alcohol and/or opiate dependence who utilized detoxification and then obtained addiction treatment within sixty days. To ensure representation of a range of facilities with regard to transition success, the fifteen facilities with the highest and the fifteen with the lowest proportions of patients obtaining addiction treatment following detoxification were targeted for participation. Project staff contacted each facility’s detoxification director or main provider.
We used semistructured interviews to examine participants’ perspectives on facilitators and barriers, at the patient, program, and system levels, that affect patients’ transition from detoxification to addiction treatment (Cucciare et al., 2015). Interviews were audio-recorded and transcribed verbatim. Transcriptions were coded and analyzed using methods derived from grounded theory (Glaser & Strauss, 1967) with the qualitative data analysis software program ATLAS.ti.
The thirty detoxification providers were mostly male (n = 16, 53.3 percent) and Caucasian (n = 22, 73.3 percent), and had a mean age of 50.8 years (SD = 9.9). Providers primarily had medical (n = 11, 36.7 percent) or advanced nursing (n = 10, 33.3 percent) degrees, and had a mean of 10.5 years (SD = 8.8) of experience providing detoxification services. They described their detoxification patients as typically middle-aged (forty to sixty years old; N=17, 58.1 percent of interviews), of lower socioeconomic status or homeless (N=23, 77.4 percent), having utilized detoxification more than once (N=25, 83.9 percent), and most commonly detoxing from alcohol (N=26, 87.1 percent), although one-half of providers noted a recent increase in younger, opiate-dependent patients (N=15, 50.0 percent).
Patient Facilitators and Barriers
Providers’ interview responses yielded two patient-level facilitators of the transition from detoxification to addiction treatment: patients’ life context, and patient characteristics (see Table 1). Regarding life context, patients were more likely to transition when they had suffered negative consequences associated with their substance use. Provider #2 (P2) said, “The more they’ve lost, the better chance I think there is that they will actually engage treatment,” and P4 said, “Yeah, often a crisis will precipitate it, like suddenly lose housing. Then they decide to get in treatment.” Patients were more likely to transition when their life context involved pressure or support from others to transition from detoxification to treatment; as P9 specified, “family pressures or probation officers.”
For the patient characteristic facilitating the transition was being motivated for treatment, P11 explained, “If you’re going straight from detox into a treatment program, you’re pretty motivated to be engaging in some kind of services because certainly no one can force you to go into treatment.” Characteristics also included previous experience with treatment in that it lessens uncertainty about what to expect—P7 stated, “They are not as wary about what goes on in terms of a rehab program”—living in close proximity to treatment, and older age.
Patient-level barriers to detoxification treatment transitions were represented in two themes: patients’ circumstances and lack of follow-through (see Table 1). Circumstances included being too distant from, or without transportation to, treatment; having responsibilities that “compete” with treatment such as employment or child care; having comorbid conditions like traumatic brain injury or posttraumatic stress disorder (PTSD); financial consequences of sustained treatment; involvement with the criminal justice system; or living in a difficult environment, such as poor-quality housing or lacking family support.
Financial consequences as a treatment barrier were explained by P23: “If they have Social Security disability or nonservice connected disability, after ninety days we start taking funds from them. . . . so the problem with a longer stay is whatever their money source, they might have trouble getting it restarted. They may lose some funds.” P29 summarized, “Loss of wages, just the time commitment, is really probably the downside of treatment.”
The patient barrier of lack of follow-through was ascribed to stigma. P4 said, “Some people, I think, don’t want the stigma of being called an addict. They may not want to go to the specialty care for that reason. They prefer to see their primary care doctor.” Low motivation was also identified with regard to lack of follow-through. As P6 said, “A lot of them are much more entrenched in their addiction and sicker and the energy just isn’t there.”
Program Facilitators and Barriers
Table 2 lists program-level facilitators and barriers of the detoxification-to-addiction treatment transition. One program-level facilitator (see Table 2) concerned the detoxification program’s practices, including the provision of discharge planning and referrals to treatment. P8 said, “When they come back for their [detoxification] follow-up visit, that’s the day I talk to them about ‘would you be interested in maybe signing up for the substance abuse treatment program?’” Detoxification program facilitators also included patient education—P3 stated, “I would say we give a concerted effort or message to the veterans, especially if they need an inpatient detox, the importance of engaging in a residential program and/or outpatient”—and rapport building with patients, as P5 explained: “I think that’s just building a good rapport and being a good physician, good clinician along the way. Because establishing trust is the best way you can go on an individual level to get people in when they come in.”
A second program-level facilitator was the addiction treatment program’s provision of evidence-based practices, as listed on Table 2. A third program-level facilitator, patient-centered care, included providing a menu of options for patients to consider as part of treatment—“There’s a whole set of groups that look at relapse prevention, coping skills, psychoeducation of the medical complications, introducing people to AA, relaxation training,” P9 explained. Patient-centered care also included special services for women.
Within the theme of patient-centered care, providers noted that facilitative addiction treatment is individualized, in terms of patient preferences for type of addiction treatment (e.g., residential or outpatient; individual or group), and what patients experience in the type obtained. P2 stated,
We just make sure that the treatment that we envision for them is the treatment that they need. We don’t really like the idea of just shoving people into groups without having a visit with them, because there’s all kinds of potential problems and their needs may be different. They may have PTSD so bad that a group may be impossible in the beginning. Okay, well, let’s do individual sessions.
Providers also reported that the detoxification-to-treatment transition is facilitated by the addiction treatment program providing care coordination. This consisted of regular case management within the program, and the provision of housing while patients are in addiction treatment. Programs also made efforts to keep patients engaged with the health care system, especially when wait-listed for or unwilling to consider treatment. At one facility, addiction treatment services assigned a nurse to call patients who completed detoxification with reminders about treatment appointments. P6 said, “I think she does do a wonderful job to help engage the patients. That maybe if they were a little ambivalent and thinking ‘Oh I’m not coming back there, I’m not going to go to that appointment,’ she really helps kind of rope them in. . . . That has been a big change and a big improvement,” and P11 explained, “For those who aren’t willing to go into specialty treatment, we still have great follow through with them . . . keep working with them and enhancing their motivation and working on their problems.”
Care coordination also included outreach to patients receiving detoxification, and their health care providers, to inform them of addiction treatment services: “We’ll do outreach. We have interactions with their PC [primary care] staff. If they identify somebody, we will do some outreach with them, calling them, encouraging them to come in and meet with us,” P12 stated.
Finally, care coordination also involved peer support for transitioning, with peers being either paid peer support specialist employees or nonemployee, Twelve Step group members: “The increased support of peer support specialists, peer involvement—and we’ve always had that from the AA community. They really support people getting into detox and do interventions,” P3 stated.
Some providers regarded the addiction treatment program’s provision of aftercare as a facilitator of the detoxification treatment transition. That is, patients continue to receive care after detoxification and addiction treatment completion. Aftercare includes provision of outpatient after residential care, and ongoing individual or group sessions after outpatient care. P11 explained, “We provide follow-up for veterans as long as they’re willing to engage in follow-up. So we have continuing care, both individual and group, available for as long as a veteran is willing to engage with us. So we have veterans who have been in recovery for fifteen years and they keeping coming back to group and we keep working with them and helping them stay in recovery.”
Another theme with regard to addiction treatment programs’ facilitation of transitions was programs being convenient; that is, patients have immediate access to treatment after detoxification completion. P11 stated, “If they’re interested in going directly into specialty treatment, we can place them, for sure, if they’re willing to be flexible about their placement. And so nobody has to leave detox without entering directly into treatment.”
Also making addiction treatment convenient was its availability after hours (e.g., outside normal business hours, including weekday evenings, weekends, and holidays), providing transportation to treatment, and offering treatment via telehealth.
Another theme that emerged as to facilitators of transitions from detoxification to treatment was having well-trained and professional addiction staff. This included staff members having many years of experience providing addiction treatment in a variety of settings (state hospital, private agency), and being skilled and committed: “I think if there’s a pervasive attitude across everybody that they interact with, that is professional, nonjudgmental, matter-of-fact but concerned, but with a certain degree of treatment optimism. . . . The more that general philosophy pervades the system, that facilitates people’s access into treatment,” P25 said.
With regard to program-level barriers to patients transitioning from detoxification to addiction treatment, two themes emerged (see Table 2): lack of accessible addiction treatment and program inflexibility. Lack of accessibility covered wait times between detoxification and treatment, as P4 explained, “If they are not engaged quickly after the detox, and readily get back into the specialty care treatment, if there’s a long lag time, I see that the patients often go back to using.” P25 also said, “The biggest problem in our whole continuum of care here is typically a person who completes detox at our inpatient detox is going to have to wait some weeks, even if they want to go to rehab and we agree with it, before they get accepted and get an admission date. . . . Then when they of course relapse they have to be redetoxed to be sober to go into the rehab, which is not a great situation.”
Lack of accessibility also covered the problem of patients having no housing while obtaining treatment. P2 said, “Some of these guys come from two, three hours away and I think the biggest problem is trying to find them shelter in the local area.” Lack of accessibility also included staff shortages and workload—P11 stated, We have an overwhelming workload and more patients who need help than we have staff to help them”—having too few treatment beds, and limited treatment hours.
Addiction treatment programs’ inflexibility that deterred transitions from detoxification included staff resistance to treating detoxification patients. P11 stated, “There’s some pretty nonprogressive attitudes here about addiction and detoxification, and the biggest barriers we face are attitudinal,” P12 added, “Staff tend to have particular biases—I think sometimes some of us don’t realize where those lie and can be significant barriers to keeping people engaged in treatment,” and P25 also said, “The terminology seems to be more punitive and judgmental towards this population when they are cycling in and out. . . . I think the judgmental aspect actually gets in the way.”
Program inflexibility also included strict program policies regarding patient eligibility for services, as P25 stated, “We find some of the programs to be kind of frustrating in terms of what are their criteria. . . . It feels as though there’s this narrow window of eligibility that you’re either too sick or not sick enough.”
An example of strict policies was at P30’s location: when patients are administratively discharged for breaking the addiction treatment program’s rules, they are required to wait one year to reenter an addiction treatment program, even if they complete detoxification at any point during that year. P30 observed, “And then you lose people quite naturally that return to using because they’re denied services.”
System Facilitators and Barriers
System-level facilitators of patients transitioning from detoxification to treatment were communication between detoxification and addiction treatment, integration of detoxification and treatment, and handoffs from detoxification to treatment (see Table 3). Communication involved a good working relationship between the detoxification and addiction treatment programs and providers: “I just think it’s relationships, relationships, relationships, phone calls, that coordination of care that goes on between facilities,” P3 stated.
Communication was related to the integrated, rather than sequential, provision of detoxification and addiction treatment services, as P18 explained, “Detox is embedded within the specialty clinic. . . . There really isn’t a transition at that point because it’s embedded.”
Furthermore, integration of detoxification and treatment allows for warm handoffs from detoxification to treatment. P19 said, “We work extremely closely—the outpatient staff and the rest of the staff, whether it be the residential staff—but the medication providers work very closely geographically and we have meetings and we’re always available to talk to each other. So I think it’s a matter of kind of warm handoffs, kind of ‘these are some special things that I think are going on with this patient that need attention.’”
Only one theme appeared for system-level barriers to treatment after detoxification, which was limited integration between the two services. P4 observed, “I think integration could be better. You lose people in between transitions. Inpatient to residential works well. Inpatient to outpatient, we tend to lose more people.”
In this study, detoxification providers identified transition facilitators and barriers at the patient, program, and system levels. Most of the themes identifying facilitators of successful transitions focused on modifiable practices of addiction treatment programs, but modifiable factors were also identified within the patient and system domains.
Patient motivation was seen by detoxification providers as related to the detoxification-to-treatment transition; its presence was a facilitator, and its lack was a barrier (Corsi et al., 2007). Considerable research has focused on bolstering patient motivation in order to facilitate initiation and engagement with addiction treatment. Motivation is viewed as a dynamic and fluctuating state that can be enhanced (SAMHSA, 2013). In light of providers in our study advising that discharge planning and referral to treatment should take place within detoxification programs to facilitate transitions, it may be possible to incorporate motivational strategies during planning and referral sessions (Vederhus, Timko, Kristensen, Hjemdahl, & Clausen, 2014).
Motivational counseling approaches may have the additional advantage of helping patients consider other patient-level transition facilitators and barriers that detoxification providers identified, such as negative consequences of substance use, and social support for obtaining treatment (see Table 1). In addition, detoxification programs’ efforts to facilitate transitions via discharge planning and referral, educating patients about the benefits of addiction treatment, and building rapport with patients (see Table 2) may need to be adapted for patients with co-occurring problems such as the presence of traumatic brain injury, PTSD or criminal involvement, which were patient-level transition barriers. Patients with these problems may face reduced frustration tolerance and problem-solving skills, and increased disinhibition and impulsiveness, which can lead to poor choices around health behaviors (Trudel, Nidiffer, & Barth, 2007). Adaptations with regard to detoxification programs’ transition facilitators may include addressing patients’ comprehension and memory challenges by increasing the number of brief treatment planning and referral counseling sessions while limiting session content to help facilitate learning, retention, and following through with new information.
Providers viewed patients’ negative financial consequences of sustained treatment and recovery as a barrier to treatment transitions (see Table 1). Disability income (e.g., Social Security), provides a vital safety net to people who need funds for housing and other necessities, and substance-using individuals do not want to give up the stability provided by their disability benefits (Rosen, McMahon, Lin, & Rosenheck, 2006). Resolution is needed at the policy level to consider patient needs for both disability payments and long-term, residential treatment stays to enable recovery.
Concerns that disability income is associated with substance use (Rosen et al., 2006) contribute to the stigma of addiction being a barrier to treatment after detoxification. Providers offered that addiction treatment is less stigmatizing when it is available in primary rather than specialty care. However, primary care physicians report low levels of preparedness to identify and assist patients with substance use disorders, in part because treating addiction is rarely taught in medical school or residency training (Shapiro, Coffa, & McCance-Katz, 2013). Research supports the effectiveness of integrated primary-addiction care, but there are obstructions to implementation, including insurance and payment issues, long-standing conflicting treatment cultures, and workforce issues (Urada, Teruya, Gelberg, & Rawson, 2014).
Providers viewed addiction programs’ evidence-based treatments and aftercare to be facilitators of the transition to treatment (see Table 2). Previous research found that programs offering evidence-based practices—those supported by scientific evidence sufficient to merit widespread implementation—were more likely to have other positive attributes that are similar to addiction program-level transition facilitators identified by our sample (Power, Nishimi, & Kizer, 2005). These attributes include the program having the ability to provide patient-centered (reflecting the patient’s preferences, values, and needs) and individualized (comprehensive, continuous over time, and coordinated) care, and procedures to ensure timely access to care. Such programs also had a strong process for developing and measuring staff competence and providing appropriate clinical supervision, thereby ensuring the availability of appropriately trained staff. Further, such programs fostered a collaborative model by ensuring staff communication, which was a system-level facilitator of transitions identified by providers in this study (Power et al., 2005).
Whereas a well-trained staff was a transition facilitator, staffing shortages were a barrier (see Table 2). There is a growing staffing crisis in the addiction field due to shortages, high turnover rates, an aging workforce, stigma, and inadequate compensation. Research to promote staffing retention suggests the usefulness of workplace interventions to enhance quality of worklife and reduce workplace stress and burnout, such as providing staff members with greater autonomy, participation in work-related decisions, and career development opportunities; and enhancing leadership effectiveness and coworker relationships through teambuilding, conflict management training, and clearer role expectations (Eby, Burk, & Maher, 2010).
Finally, care coordination within addiction treatment programs was a facilitator of the detoxification-to-treatment transition (see Table 2), and case management was important within this theme. Case management is associated with treatment retention, patient satisfaction, and quality of life, and reduced use of acute inpatient services (Rapp, Van Den Noortgate, Broekaert, & Vanderplasschen, 2014). Case management’s focus on collaborative problem-solving regarding barriers to treatment initiation, including helping patients identify feasible transportation options and overcome geographical barriers, may partially account for our finding (see Table 1).
Another solution to overcoming transportation and distance barriers, under the theme of making addiction treatment convenient for patients (see Table 2), is the provision of telehealth services. Telephone- and Internet-based screening and treatment, videoconferencing, and smartphone mobile applications (apps) may enhance the flexibility of addiction treatment and help address the patient-level transition barrier of responsibilities that “compete” with treatment (see Table 1), because they can be obtained in patients’ offices or homes. Research supports telehealth development and implementation for facilitating addiction treatment following detoxification (Young, 2012).
Detoxification providers identified themes that suggest feasible approaches for improving the transition from detoxification to treatment. Facilitators of this care transition included delivering discharge planning and referral while receiving detoxification services, increasing the availability of evidence-based addiction treatments, and providing patient-centered, coordinated, and convenient care from well-trained and professional staff. Findings are clinically useful because they suggest multiple options for quality improvement efforts to manage ways to increase treatment entry, and decrease the “revolving door” of repeated detoxifications. Identifying, implementing, and evaluating suggested program-level approaches to facilitating treatment transitions after detoxification are important for increasing treatment engagement, improving patient outcomes, and reducing high-cost readmissions.
Acknowledgements: This research was supported by the Department of Veterans Affairs (VA) Substance Use Disorder Quality Enhancement Research Initiative (QUERI; RRP 12-525), and Dr. Timko by the VA Health Services Research and Development (HSR&D) Service (RCS 00-001). The views expressed are the authors’ and do not necessarily reflect those of the VA. No conflicts of interest are reported by any of the authors listed on this manuscript.
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Editor’s Note: This article was adapted from an article by the same authors previously published in the Journal of Substance Abuse Treatment (JSAT). This article has been adapted as part of Counselor’s memorandum of agreement with JSAT. The following citation provides the original source of the article:
Timko, C., Schultz, N. R., Britt, J., & Cucciare, M. A. (2016). Transitioning from detoxification to substance use disorder treatment: Facilitators and barriers. Journal of Substance Abuse Treatment, 70, 64–72.