Inpatient drug treatment

GENERAL CATEGORIES OF INPATIENT DRUG TREATMENT PROGRAMS... 

In general, schizophrenic psychoses have to be treated by a multimodal approach including medication, psychotherapeutic interventions, and in chronic cases, rehabilitation. During the acute state of the psychosis, inpatient treatment and antipsychotic medication are required as the most important components. Drug treatment is the most important component during the first inpatient phase. 

Inpatient hospital treatment and residential rehabilitation are very different in character, and in average length of stay. It is very useful to have both available as options for selected cases, but clearly they cannot be used at all routinely, because of the sheer numbers of drug users presenting, and the strong preference which most have for being treated from home. 

The concept of treatment-resistant schizophrenia, which was developed to delineate a market for the relaunch of clozapine, has lead to public acknowledgment of the extent of non-response to treatment with other neuroleptic drugs. It is now widely admitted that at least 25% of patients do not show any significant clinical improvement with drug treatment. A recent comparison of two of the newer neuroleptic drugs, risperidone and olanzapine, found that 46% and 56% of patients, respectively, did not respond after four months of treatment (Robinson et al. 2006). In addition, the majority of inpatients with psychosis are treated with other sedative drugs in addition to... 

In 1986, the surge in demand for drug treatment, particularly in the residential or inpatient setting, arose from two major sources crack and AIDS. These worked in a political climate that was strongly in favor of eradicating drugs and drug abuse. 

Cost consciousness has led to a far more restricted use of inpatient alcohol and drug treatments, at least those that are paid for by health insurers. When inpatient stays are covered, they are often much shorter than 28 days. Instead, outpatient treatment is the insurer s preference. This policy is ba,scd on research that suggests that, on average, inpatient treatment is no more effective than the much cheaper outpatient treatment (Miller Hester, 1986). 

It seems that the trend to less inpatient and more outpatient care will continue. Many treatment providers, however, arc concerned that this prescription for care is based too much on money and not enough on proven differences (or lack thereof) in treatment benefits. Some treatment providers ask What does a lack of difference in benefits overall tell us What is outpatient treatment anyway (We saw earlier in this chapter that what constitutes outpatient alcohol and drug treatment is highly variable.) Is the finding of no difference true for everybody When is the more structured, more intense inpatient treatment indicated, and when is it not ... 

XX Legarda and M. Gossop, A 24-h Inpatient Detoxification Treatment for Heroin Addicts A Preliminary Investigation. Drug Alsohol Dependence, 35,91-93,1994. 

Williams H, Oyefeso A, Ghodse AH Benzodiazepine misuse and dependence among opiate addicts in treatment. It J Psychol Med 13 62-64, 1996 Wiseman SM, Spencer-Peet J Prescribing for alcoholics a survey of drugs taken prior to admission to an alcoholism unit. Practitioner 229 88—89, 1985 Wolf B, Grohmann R, Biber D, et al Benzodiazepine abuse and dependence in psychiatric inpatients. Pharmacopsychiatry 22 54—60, 1989 Wood MR, Kim JJ, Han W, et al Benzodiazepines as potent and selective bradykinin B1 antagonists. J Med Chem 46 1803—1806, 2003 Zawertailo LA, Busto UE, Kaplan HL, et al Comparative abuse liability and pharmacological effects of meprobamate, triazolam, and butabarbital. J Clin Psycho-pharmacol 23 269-280, 2003... 

Based on two clinics specialized in AIDS treatment, Papaevangelou et al. (1995) calculated lifetime costs per patient in Greece at US 24,160, consisting of drug costs (US 9,022), costs for outpatient care (US 963), and inpatient care (US 14,175). 

Outpatient group members were very similar to the inpatient PCP abusers in most sociodemographic and drug-use characteristics. Their mean age was 29 years, educational level 12.6 years, and number of prior arrests 1.5. The majority of outpatients were black (83 percent), unmarried (67 percent), and unemployed (67 percent). Their mean duration of PCP use was almost 8 years, with, usually, no prior or recent substance abuse treatment. Thirty-seven percent used PCP at least daily, always by smoking. Like the inpatient PCP abusers, outpatients frequently (87 percent) reported abuse of other drugs alcohol (46 percent), marijuana (46 percent), and cocaine (37 percent). Several outpatients for whom cocaine was the preferred drug of abuse used PCP as a "cheaper high" when cocaine was not affordable. 

There are currently no systematic data to guide a decision on inpatient vs. outpatient treatment. However, the cheap and easy availability of PCP reported by outpatients in their living environments, and the frequent continued use of PCP by outpatients suggest that a brief period of inpatient treatment might be useful in initiating drug abstinence. There is clearly a strong need for research on specific treatment modalities for PCP abuse. 

Even with the intense involvement of the inpatient program and a carefully devised treatment plan, many drop out of outpatient treatment and return to drug use. Nevertheless, we have found various psychotherapeutic strategies and methods worthwhile. 

Prescribing of psychotropic drugs, such as antipsychotics, antidepressants, anxiolytics and mood stabilizers, is common in psychiatric inpatients for acute and maintenance treatment of psychiatric illness. 

It is common for both the depressive and manic phases to occur simultaneously in what is termed a mixed state or dysphoric mania. During these mixed episodes, the patient s mood is characterized by symptoms of both a depression and mania. Mixed episodes often have a poorer outcome than classic euphoric mania and, as a rule, respond better to certain anticonvulsants and atypical antipsychotic drugs than to lithium. As many as 50% of admissions to inpatient psychiatric facilities for the treatment of manic episodes appear to be for mixed manic states. The recognition... 

The advantage of venlafaxine in terms of more rapid onset of action is apparently only seen when the drug is escalated rapidly to the high dose. In a recent study comparing venlafaxine with imipramine in inpatients with severe depression, a significant difference was observed between the two active treatments by the second week [Benkert et al. 1996. ... 

To date, only one antidepressant, amoxapine, has proven effective in the treatment of PMD as the sole therapy. Amoxapine is a chemical congener of the antipsychotic drug loxapine, so it possesses both dopamine-blocking and monoamine-enhancing properties. One double-blind study has confirmed that amoxapine appears to be as effective as the combination of a TCA and an antipsychotic. R. F. Anton and Burch [1990] randomly selected 46 inpatients with psychotic depression to either amoxapine [to 400 mg/day] or ami-... 

Several small, open-label studies have supported TCA/antipsychotic combinations in the treatment of PMD. Minter and Mandel [1979) studied 54 inpatients with PMD who were treated openly with either TCAs alone, TCAs and antipsychotic combination, antipsychotics alone, or electroconvulsive therapy [ECT] in treatment failures. Although only 3 of 11 patients treated with TCAs alone responded, 16 of 16 patients treated with the combination of a TCA and an antipsychotic responded. Interestingly, 14 of 15 patients treated with antipsychotic drugs alone also responded, which is contrary to findings in other studies [Spiker et al. 1985). Several other open-label studies have confirmed the utility of the combination treatment for PMD [Charney and Nelson 1981 Frances et al. 1981), but few controlled studies have been completed. 

TCAs in more serious forms of depression such as melancholic or psychotic depression. Some studies have suggested that the SSRls do not work as well as the TCAs in melancholic depression (Roose et al. 1994]. Likewise, one study has suggested that venlafaxine, a drug with a mechanism of action similar to that of the TCAs, was superior to fluoxetine in the treatment of inpatients with melancholic depression (Clerc et al. 1994]. Still, other metaanalyses have failed to find a difference in the efficacy of SSRls versus TCAs in serious forms of depression [Nierenberg 1994]. Nonetheless, given that most studies have employed TCAs, and some debate exists about the utility of SSRls in severe subtypes, it may be prudent to start with a TCA in most patients until the debate is further resolved. For patients who present a significant suicide risk or who have not been able to tolerate TCAs, the SSRls in combination with a standard antipsychotic appears an effective option. 

The costs associated with the treatment of a disease are categorized as direct costs and indirect costs. Those who are responsible for the payment of healthcare services are usually most interested in direct costs, or costs that are incurred directly as a result of the care of the patient s condition. These costs include hospitalization, physician visits, drugs, laboratory tests and procedures. They also include the treatment of drug-related side effects, the treatment of unfavorable drug drug interactions and the costs of switching from the current therapy to a new therapy. Direct costs may also include savings due to costs that are avoided inpatient days, outpatient visits, procedures and laboratory tests that do not occur. 

This introductory chapter takes one step back from the treatment situation, to examine the social background against which drug misuse is often set, some of the aetiological factors, and the place which clinical treatment occupies in the wider scheme of things. It is by way of a fairly subjective and partly historical overview, before the treatment approaches are examined in greater detail, in various international contexts. In our own services we use inpatient or residential options only very rarely, and so they are summarized at the end of the chapter, with some additional consideration where relevant in later chapters. 

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