Dropout from addiction treatment: predictors, patient profiles, outcomes, and recommendations to improve care.
Background: Treatment dropout, usually defined as failure to complete a planned treatment program, frequently occurs among patients with substance-related disorders (SRD). Conversely, treatment retention is a strong predictor of successful treatment, found associated with longer term abstinence, and reduced risk of death among patients. This study investigated service use and patient sociodemographic and clinical characteristics that predicted treatment dropout, and subsequently adverse outcomes. Profiles of patients with SRD who did or did not drop out from SRD treatment were also investigated, and subsequently associated with adverse outcomes.
Methods: Medical administrative databases of Quebec (Canada) were used to investigate a cohort of 16,179 patients with SRD who received addiction treatment from 14 SRD centers. Logistic regressions and survival analysis were used to measure risk of treatment dropout and assess the odds of subsequent frequent emergency department (ED) use (3+visits/year) and death. Latent class analysis identified patient profiles, based on outpatient service use, including the same outcomes plus hospitalization.
Results: Of the 55% of patients reporting dropout from SRD treatment over a 3-year period, 17% were frequent ED users, and 1% died in the subsequent 12 months. Patients more socially deprived, having polysubstance-related disorders or personality disorders, and having previously dropped out from treatment had increased odds of current treatment dropout. Older patients, those with a history of homelessness, past SRD treatment, with more other outpatient care than SRD had decreased odds of treatment dropout. Patients who dropped out were subsequently at higher risk of frequent ED use and death. Four patient profiles of treatment dropout were identified: Profile 1-did not drop out and were low service users; Profile-2 did not drop out and were high service users; Profile 3-dropped out and were low service users; Profile 4-dropped out and were high service users. Profile 1 had the best health and social conditions, while Profile 4 had the worst. The risks of being frequent ED users, being hospitalized or dying were highest in Profile 4, followed by Profiles 3, 2 and 1.
Conclusions: Patients with more severe problems and previous dropout may need more sustained longer care and adequate comprehensive help to prevent subsequent treatment dropout. Assertive community treatment may be suited to Profile 4 and intensive case management to Profile 3. Collaborative care with higher psychosocial interventions and regularity of care may be extended to Profile 2 and interventions integrating motivational treatment to Profile 1. Overall, much better care from SRD centers and other social and health providers, and outreach services are needed to prevent treatment dropout.
