Community detoxification for alcohol dependence: A systematic review - Sangath
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R E V I E W
Drug and Alcohol Review (May 2017), 36, 389–399
DOI: 10.1111/dar.12440
REVIEW
Community detoxification for alcohol dependence: A systematic review
ABHIJIT NADKARNI1,2, PAIGE ENDSLEY3, URVITA BHATIA1,2, DANIELA C. FUHR2,
ANEESA NOORANI4, ARESH NAIK1, PRATIMA MURTHY5 & RICHARD VELLEMAN1,6
1
Sangath, Goa, India, 2London School of Hygiene and Tropical Medicine, London, UK, 3Columbia University Mailman School
of Public Health, New York, USA, 4Yale University, New Haven, USA, 5National Institute of Mental Health and Neuro
Sciences, Bangalore, India, and 6University of Bath, Bath, UK
Abstract
Issues. Despite the potential advantages of community detoxification for alcohol dependence, in many countries the available
resources are mostly focused on specialist services that are resource-intensive, and often difficult to access because of financial or
geographical factors. The aim of this systematic review is to synthesise the existing literature about the management of alcohol
detoxification in the community to examine its effectiveness, safety, acceptability and feasibility. Approach. The systematic
review was guided by an a priori defined protocol consistent with the PRISMA (Preferred Reporting Items for Systematic Re-
views and Meta-Analyses) statement. Cochrane library, Medline, EMBASE, PsycINFO, Global Health and CINAHL da-
tabases were searched using appropriate search terms. A qualitative synthesis of the data was conducted as the heterogeneity of
study designs, samples and outcomes measured precluded a meta-analyses. Key Findings. Twenty studies with a range of de-
signs were eligible for the review. Community detoxification had high completion rates and was reported to be safe. Compared to
patients undergoing facility based detoxification, those who underwent community detoxification had better drinking outcomes.
Community detoxification was cheaper than facility based detoxification and generally had good acceptability by various stake-
holders. Implications. For certain patients, community detoxification should be considered as a viable option to increase ac-
cess to care. Conclusions. Although the current evidence base to some extent supports the case for community detoxification
there is a need for more randomised controlled trials testing the cost effectiveness of community detoxification in comparison with
inpatient detoxification. [Nadkarni A, Endsley P, Bhatia U, Fuhr DC, Noorani A, Naik A, Murthy P, Velleman R.
Community detoxification for alcohol dependence: A systematic review Drug Alcohol Rev 2017;36:389–399]
Key words: alcohol, dependence, detoxification, community, review.
Introduction and sometimes a physiological withdrawal state’ [1].
AD, the most severe type of AUD, is not only a direct
The World Health Organization’s International Classifi- cause for premature death and disability, but is also a risk
cation of Diseases 10th Revision classifies alcohol use dis- factor for other communicable and non-communicable
orders (AUD) as ‘harmful use’ (pattern of psychoactive diseases [2–4]. The risk of death because of AD is about
substance use that causes damage to health) and ‘alcohol 2 to 9 times that of the general population [5]. AD also
dependence (AD)’ [1]. AD is defined as ‘a cluster of be- impacts multiple domains of the affected person’s life
havioural, cognitive, and physiological phenomena that (e.g. reduced productivity, job loss or absenteeism, loss
develop after repeated alcohol use and that typically in- of relationships, problems with family roles, vandalism,
clude a strong desire to consume alcohol, difficulties in social drift downwards and stigma). Overall, AD ac-
controlling its use, persisting in its use despite harmful counts for 71% of the alcohol attributable mortality bur-
consequences, a higher priority given to alcohol use than den and a large proportion of the social costs attributable
to other activities and obligations, increased tolerance, to alcohol [5].
Abhijit Nadkarni MBBS, DPM, MRCPsych, MSc, Research Fellow, Paige Endsley BA, MPH, Student, Urvita Bhatia BA, MSc, MSc, Research
Fellow, Daniela C. Fuhr Dipl-Psych MSc DrPH, Lecturer, Aneesa Noorani BSc, Student Aresh Naik MSc, Lecturer, Pratima Murthy MBBS, MD,
Professor, Richard Velleman BSc, MSc, PhD, Emeritus Professor. Correspondence to Dr Abhijit Nadkarni, H No 451 (168), Bhatkar Waddo,
Socorro, Porvorim, Bardez, Goa 403501, India. Tel: 0091-7798889723; E-mail abhijit.nadkarni@lshtm.ac.uk
Received 22 December 2015; accepted for publication 07 May 2016.
© 2016 Australasian Professional Society on Alcohol and other Drugs390 A. Nadkarni et al.
The treatment of AD requires a range of treatment res- or early 2000s) [10,12,13]. These existing reviews con-
ponses, most of which should, ideally, take place outside clude that community detoxification is cost effective,
of residential and hospital facilities. This range broadly in- but cannot entirely replace inpatient detoxification. The
cludes detoxification (to minimise symptoms of with- aim of the current systematic review is to synthesise the
drawal) and relapse prevention using psychosocial and/or existing literature about the management of alcohol detox-
pharmacological interventions. Specialist inpatient care is ification in the community to examine its effectiveness,
indicated for patients with severe AD and for those pa- safety, acceptability and feasibility. Thus, besides being
tients who experience additional co-morbid health-related the most recent such review, it is different from existing re-
problems that may complicate treatment and worsen views as it follows a rigorously systematic and hence repli-
treatment outcomes. For less severely dependent patients, cable methodology; and also examines dimensions like
primary and community-based care is recommended [6]. acceptability and feasibility along with the more conven-
Thus management of patients requiring ‘assisted alcohol tional dimensions like effectiveness. Finally, this review
withdrawal’ may occur in inpatient, residential facilities was conducted as an integral part of the formative research
or even community-based settings, including general phy- in a project aiming to develop a community detoxification
sicians’ practices and patients’ homes [6]. For people with package for low resource LMIC settings. Hence, the
mild to moderate dependence, the National Institute for review was focused on evidence which had minimal or
Health and Care Excellence guidelines recommend an no involvement of specialist services (e.g. outpatient de-
outpatient-based assisted withdrawal program which in- toxification in specialist addiction services was excluded).
volves fixed dose medication regimens, a carer overseeing Although the management of AD might start with detoxi-
the process with daily monitoring by trained staff and psy- fication, successful long-term recovery is dependent on
chosocial support [6]. psychosocial interventions that focus on building motiva-
Unfortunately, treatment of AUDs has been accorded tion to change, and support changing of maladaptive be-
a low priority, particularly in low and middle income haviours and expectations about alcohol. This review is
countries (LMIC). National alcohol policies and dedi- by no means a comprehensive review of the management
cated resources within the health system are still largely of AD, but narrowly focuses on just one aspect of that,
missing or inadequate in these countries, which hinders namely community detoxification.
the effective management of patients with AUD and
worsens their outcome [7,8]. Furthermore, the available
resources are mostly focused on specialist services that
Methods
are resource-intensive, and often difficult to access be-
cause of financial or geographical factors [6,7]. Hence The systematic review was guided by an a priori defined
the treatment of AD in existing platforms of institutional protocol consistent with the Preferred Reporting Items
care in LMICs is both limited by its accessibility, and for Systematic Reviews and Meta-Analyses (PRISMA)
sub-optimal as community-based care is rarely available statement [14]. The following electronic databases were
despite it being recommended in most cases [6] as both searched: Cochrane Library, Medline, EMBASE,
a viable and efficient solution [9]. PsycINFO, Global Health and CINAHL. AN1 conducted
Community-based detoxification for moderate or se- the search using the appropriate search terms under the
vere AD is essentially based on the principle of collabora- following concepts: AUD (e.g. alcohol dependence, alco-
tive care, by involving a range of health professionals who hol withdrawal), detoxification (e.g. detoxification, detox)
provide services at different stages of treatment (e.g. and setting (e.g. community, home). The search strategy
medical care by a trained doctor, and monitoring by a for Medline is presented in Appendix 1.
nurse). The key strengths of community-based detoxifi- AN2 and UB independently assessed the titles and ab-
cation include its effectiveness in improving clinical stracts of the studies identified through the search of the
outcomes, cost effectiveness and acceptability [10]. Fur- electronic databases. If the title and abstract did not offer
thermore, community-based detoxification increases ac- enough information to determine inclusion, the full
cessibility and acceptability of treatment, and overcomes paper was retrieved to ascertain whether it was eligible
facility and resource-related challenges that are often for inclusion. AN2 and UB then discussed their inde-
found in low resource settings [11]. All these factors pendent selections and arrived at a final list of eligible
(e.g. cheap, monitoring through primary care) make papers. In case of any disagreement regarding inclusion,
community detoxification a particularly good fit for the a third reviewer (RV) was consulted for a final decision.
requirements of low resource settings in LMICs. AN2 inspected the reference lists of eligible papers and
The published literature about community detoxifica- relevant reviews to include additional eligible papers that
tion of AD is sparse, and the synthesis of such evidence is were not retrieved by the search of the electronic data-
relatively non-systematic (i.e. narrative reviews) and bases. Finally, AN2 conducted a forward search on
mostly non recent (i.e. most reviews published in 1990s Web of Science using the eligible papers to identify
© 2016 Australasian Professional Society on Alcohol and other DrugsDetoxification for alcohol dependence 391
studies which might have been missed in the original AD and/or alcohol withdrawal with or without comorbid
electronic database search and to identify eligible studies physical/mental/substance use disorders were included.
which cited any of the included papers. For inclusion in the review AD had to be diagnosed in
one of the following ways: clinical diagnosis, or accord-
ing to the International Classification of Disease, Diagnos-
Eligibility criteria tic and Statistical Manual, any other standardised criteria
or any other structured diagnostic instrument. Studies
There were no restrictions on year of publication, gender were included if they tested any evidence-based interven-
and age of the participants. Only English language pub- tion package designed specifically to treat alcohol
lications were included. Randomised controlled trials withdrawal syndrome. For a study to be included, the
(RCT), published audits, observational studies, case se- intervention had to be delivered at home or in primary care
ries and qualitative studies were included while system- outpatient settings. If the intervention was based in a
atic reviews with or without meta-analyses and case specialist addictions centre, it was excluded even if it was
reports were excluded. Studies with participants having delivered to outpatients, unless the dispensing and
Table 1. Details of studies included in the review
Sample
Author, year Study design Country size, n Age (mean or range) Gender
Allan, Quasi-experimental UK 65 Home group: 46.4 (SD 12.2) 67% male
2000 [30] Hospital group: 45.1 (SD 9.8) 33% female
Alterman, Case series USA 49 40 Only males
1988 [19]
Alwyn, RCT UK 91 21–77, mean 43 (SD 10.16) 59% male
2004 [15] 41% female
Bartu, Quasi-experimental Australia 40 Not specified 70% male
1994 [31] 30% female
Bennie, RCT UK 76 23–72, mean 48.5 (SD 11.8) 77.6% male
1998 [16] 22.4% female
Bryant, Mixed methods (audit of case notes UK 62 Not specified Not specified
2001 [33] and qualitative)
Callow, Observational (audit of case notes) UK 154 22–71, mean 40.9 71.4% male
2008 [24] 28.6% female
Carlebach, Qualitative UK 24 Not specified 50% male
2011 [21] 50% female
Collins, Observational (audit of case notes) UK 173 85% aged between 26 and 55 78% male
1990 [25] 22% female
Evans, Case series Canada 4 66–77 50% male
1996 [20] 50% female
Haigh, RCT UK 50 18–68, mean 42.42 96% male
1990 [17] 4% female
Klijnsma, Observational (treatment cohort) UK 28 Male: 28–65, mean 43 85.7% male
1995 [26] Female: 38–57, mean 46 14.3% female
Moraes, RCT Brazil 120 43 (SD 8.6) 90% male
2010 [18] 10% female
Roche, Qualitative Australia 52 19–70, mean 40.5 61.5% male
2001 [22] 38.5% female
Sharpley, Observational (audit of case notes) UK 118 Not specified Not specified
1999 [27]
Stockwell, Observational (cross-sectional survey) UK 145 Not specified Not specified
1986 [28]
Stockwell, Mixed methods (treatment cohort with UK 41 Male: mean 39.2 68.3% male
1990 [34] quantitative and qualitative interviews) Female: mean 47.9 31.7% female
Stockwell, Quasi-experimental (with matching) UK 70 40.7 Not specified
1991 [32]
Van Hout, Qualitative Ireland 9 Not specified Only females
2012 [23]
Wiseman, Observational (treatment cohort) USA 517 41.8 (SD 8.1) 98% male
1997 [29] 2% female
RCT, randomised controlled trial.
© 2016 Australasian Professional Society on Alcohol and other Drugs392 A. Nadkarni et al.
monitoring was done through primary care. This was done Measurement of AD and alcohol withdrawal
as specialist addictions centres are rare in low resource set-
The Severity of Alcohol Dependence Questionnaire was
tings and outpatient monitoring of detoxification in such
used to diagnose AD in seven studies [15–18,26,32,34],
centres is not feasible because of their poor accessibility
and International Classification of Diseases 10th Revision
for large sections of the population. If the intervention
criteria were used to define AD in two studies [21,27].
was based in a specialist addictions centre, but was deliv-
One study defined ‘severe alcoholism’ using the Michigan
ered at home, it was included. There were no limitations
Alcoholism Screening Test [19]. Two studies relied upon
to comparison groups and studies were included if the
self-reports of heavy alcohol consumption and treatment
comparison group was a placebo, treatment as usual, or
seeking to indicate an alcohol use disorder [35,36].
any other active intervention. Studies were included if they
One study defined alcohol withdrawal syndrome as pre-
reported one or more of the following outcomes: initiation
sentation with hand tremors and one other physical man-
and/or completion of detoxification, abstinence, quantity
ifestation of withdrawal [19]. Some studies used
and frequency of drinking, adverse effects or events related
standardised tools, such as the Severity of Withdrawal
to detoxification, mortality, costs, alcohol related prob-
Symptom Checklist [16,30] and the Modified Selective
lems, uptake of follow up services and treatment satisfac-
Severity Assessment [29] to monitor the severity of with-
tion measured using standardised scales. Qualitative
drawal. These tools were used to determine withdrawal
studies were included if they explored and/or reported
status for entry into the study. The tools used to monitor
themes signifying acceptability and feasibility of home de-
withdrawal status during the detoxification process are
toxification packages.
listed later in the ‘detoxification procedures’ section.
Data extraction Eligibility/ineligibility criteria for home detoxification
Following PRISMA guidelines, a record was made of the There was an overlap in both the eligibility and ineligibil-
number of papers retrieved, the number of papers ex- ity criteria for home detoxification used in the included
cluded and the reasons for their exclusion, and the number studies, summarised in Box 1. Common eligibility
of papers included. A formal data extraction form was de- criteria for home detoxification included the following:
signed to extract data relevant to the study aims. PE and
AN3 independently extracted the data and any disagree- Box 1
ments about extracted data were discussed and resolved.
A qualitative synthesis of the data was conducted as the Eligibility criteria.
heterogeneity of study designs, samples and outcomes • Motivation
measured precluded a meta-analysis. • GP consent
• Clinical need
• Ability to reach clinic
• Ability to follow medication instructions
Results • Relatively healthy
• Availability of carer
Twenty studies were eligible for the review and these • Safe home
included four RCTs [15–18], two case series [19,20], • No other substance use in home
three qualitative studies [21–23], six observational • Ability to stop work for 1 week
studies [24–29], three quasi-experimental studies • Inability to self-detoxify
[30–32] and two mixed-methods studies [33,34]. Thir-
teen studies were conducted in United Kingdom (UK)
[15–17,21,24–28,30,32–34], two each in the United Ineligibility criteria.
States of America (USA) [19,29] and Australia [22,31], • Alcohol withdrawal-related: Severe withdrawal,
and one each in Ireland [23], Brazil [18] and Canada delirium tremens and withdrawal seizures.
[20]. The monitoring of the detoxification was done either • Mental health problems: Psychoses, suicidality, severe memory
difficulties, hallucinations, depression, abuse of substances
at home [15–17,20,21,23,24,27,30–34] or in outpatient
other than alcohol
settings [18,19,25,26,29]. Sample sizes ranged from 4 to • Physical health problems: Epilepsy, hypertension, unexplained
517, and the wide range was because of the range of study loss of consciousness, jaundice, hematemesis, melena, ascites,
designs included in the review. Eighteen studies included severe peripheral neuritis, cerebrovascular disease, coronary
both males and females (one each looked solely at males heart disease, type 2 diabetes, hypertension
• Severe physical/psychological disorders (unspecified)
[19] or females [23]), although most (>70%) had pre-
• No stable residence
dominantly males. The age of participants ranged from • Repeated failure to complete community detoxification
18 to 77 years (mean age for pooled studies being 40 years)
(Table 1).
© 2016 Australasian Professional Society on Alcohol and other DrugsDetoxification for alcohol dependence 393
Requisite for detoxification in any setting. (i) clinical need Benzodiazepine was the primary medication for alco-
for alcohol detoxification assessed in one of several ways: hol detoxification. Seven studies utilised a fixed reducing
presence of alcohol withdrawal syndrome [19], presence dose regime [15,16,25–27,29,30], whereas two studies
of AD [18,20,25,26], self-report of heavy drinking [29] each allowed medication dosing to be determined by
and breath analysis [19,29]; and (ii) expressed motivation the GP [32,34], or as per symptoms [19,24]. The pri-
to stop drinking [17,20,24,26,27,29,30,32,34]. mary medications prescribed for detoxification included
chlordiazepoxide [16,17,27,29,30], oxazepam [19], di-
azepam [25,26] and chlormethiazole [32,34]. In two
Specific for home detoxification. (i) another person avail- studies, there was a choice given between medications,
able in the home to care for the patient, and provide sup- chlordiazepoxide or diazepam [20] and diazepam or
port and monitoring [24,27,31,33]; (ii) a safe home lofexidine [24]. In three studies thiamine was prescribed
environment [20,21,24,31,32,34]; (iii) no other sub- in addition to a benzodiazepine [20,25,36].
stance use within the home [35,37,38]; and (iv) consent All but six studies included daily medication monitor-
from the general practitioner (GP) [24,30,32,34]. Other ing [17,19,24–27,29–31,33]; one study had less than
not so commonly described criteria included the patient’s daily monitoring [15] and three studies had more than
ability to reach the clinic [19,25], ability to follow medi- daily monitoring [16,32,34]. Withdrawal symptoms
cation instructions [19], ability to stop working for one were monitored using standardised scales, such as
week [24], inability to self-detoxify [25] and the patient Severity of Withdrawal Symptom Checklist [16,30],
being relatively healthy [31]. Symptom Severity Checklist [24,32,34], Modified Se-
Ineligibility criteria included a range of medical condi- lected Severity Assessment [19,29], Alcohol Withdrawal
tions, such as a history of epilepsy [15,27,31], unex- Scale [20] and Withdrawal Symptom Score [17].
plained unconsciousness [27,33], jaundice [27,33],
haematemesis [27,33], melaena [27,33], ascites [27,33],
severe peripheral neuritis [27,33], cerebro-vascular acci- Safety
dent or coronary heart disease [20,27,33], type 2 diabetes There were no differences in the proportion/number
[20], hypertension [20,31] and severe physical illness of detoxification related adverse events during home
(unspecified) [15,24,32,34]. History of withdrawal- detoxification compared to in-patient detoxification
specific complications, such as severe withdrawal (i.e. visual hallucinations, 10% vs 8% [30] and one
[19,20,26,31], delirium tremens (current or past) case of seizures vs one case each of seizures and hallu-
[24,27,30], withdrawal fits [15,24,27,32–34] and re- cinations [32]). One patient with a schizophrenia
peated failure to complete community detoxifications diagnosis reported suicidality during community
[24] were also contraindications for home detoxification. detoxification, and had to be admitted to the hospital
Other reasons for ineligibility for home detoxification in- [19]. However there was no information to indicate
cluded mental health problems, such as psychoses [30], whether the reported suicidality was directly related
suicidality [30], severe memory difficulties [30], active to home detoxification. Five studies reported that no
hallucinations or history of hallucinations [27,33], de- adverse events took place during community detoxifi-
pression [27,33], other substance abuse with alcohol cation [17,25–27,31].
[25] and other severe mental illness (unspecified)
[15,24,31,32,34]. Also, patients with no stable residence
[15,31] were considered to be ineligible for home Initiation and completion of detoxification
detoxification.
Detoxification was initiated in 100% of the patients in all
but two studies. Among the latter, 38.3% of those pre-
scribed detoxification initiated community detoxification.
Detoxification procedures
Reasons for not initiating community detoxification in-
Medications for detoxification were prescribed either in cluded undertaking day or inpatient detoxification, absti-
primary care [15–17,20,27,30,32,34] or in community- nence at the time of assessment, not attending or
based addiction services [18,19,21,24–26,29,33]. cancelling appointment and not meeting criteria for home
Detoxification symptoms and signs were monitored detoxification [24]. In the other study, 88% of homeless
either at the patient’s home [15–17,20,21,24,27,30–34] men living in a hostel who were prescribed detoxification
or in outpatient settings (e.g. primary care clinics initiated the detoxification. Reasons for not initiating de-
[18,19,25,26,29]). The detoxification period ranged toxification were because the hostel was filled to capacity,
from 3 to 12 days, with many studies specifying that the and age of the patient (394 A. Nadkarni et al.
100% completion rate for detoxification [18,20,35]. In a were completely sober, one patient had marked im-
retrospective audit of services, Wiseman et al. found that provements in cognitive and functional status despite
88% of those patients who began detoxification com- failure to maintain abstinence, and the remaining pa-
pleted it, while 4% dropped out, 3% were discharged tient was actively drinking and had cognitive impair-
and 5% were moved to inpatient care [36]. Two studies ments [20]. Finally, in a treatment cohort of 30
compared completion rates between home detoxification patients undergoing home detoxification, compared
and facility-based detoxification. In one study, detoxifi- to baseline there was a significant reduction in quantity
cation completion rates were 90% for home detoxifica- and frequency of drinking and Alcohol Problems
tion and 78% for detoxification in the day hospital Inventory scores at follow-up [38].
[30]. In the other study, 50% of the community (hostel)
detoxification group completed detoxification, com-
pared to 36.4% of the inpatient hospital group [17]. Cost
Except for one study [36], none of the other studies In Australia, detoxification in a general hospital costs
defined detoxification completion. The former defined 10.6 to 22.7 times that of home detoxification [35].
detoxification completion as attendance at all program In the UK, inpatient detoxification for homeless peo-
appointments and negative breath analyses for alcohol ple was roughly four times the cost of that in a com-
on all days enrolled. Table 2 describes the effectiveness, munity hostel [17]. Another study conducted in the
costs and acceptability of community detoxification. UK reported that inpatient detoxification costs were
six times greater than those of outpatient detoxifica-
tion [26]. A retrospective audit conducted in the UK
Effectiveness/Efficacy/Impact reported a 50% reduction in patient admission to the
Across studies there was heterogeneity of outcomes mea- hospital for alcohol detoxification within the first year
sures, precluding a quantitative synthesis of the effective- of the community detoxification program, giving an
ness data. estimated savings of 74 inpatient weeks [25]. A
similar study completed in the US projected
$600 000 savings within the first year of the outpatient
Experimental studies program [36].
In this section we report results from RCTs, matched
cohorts and unmatched cohorts with mostly insignifi- Uptake of continuing care
cant (statistically) differences between the two cohorts.
Compared to patients undergoing facility based detox- Two studies reported high levels of continuation of ser-
ification, those who underwent community detoxifica- vices among participants who completed community de-
tion were more likely to be drinking less or abstinent toxification, ranging from 52% to 74% [30,36].
[17,30,31]. However, when home detoxification was However, in one study the uptake of continuing care by
compared to ‘minimal intervention’ (assessment only) the home detoxification care was not much different from
there were no significant difference in abstinence rates the day hospital group (52% vs 53%). Two other studies
at 6 month follow-up between the two groups, al- reported that there was no difference between the
though the home detoxification group remained absti- amount and type of continued services utilised by home
nent for a significantly longer time than the minimal detoxification patients and the respective comparison
intervention group (P < 0.001) [16]. Similarly another groups in those studies [16,35].
study did not find any significant difference in absti-
nence rates when an outpatient detoxification interven- Acceptability
tion was compared to an outpatient detoxification
intervention supplemented by home visits [18]. Timely support following initial help-seeking was seen to
be an important element in the initiation and completion
of detoxification. Long waiting periods to initiate detoxi-
Observational studies
fication led to patients feeling ‘desperate’ and ‘anxious’;
In a treatment cohort receiving community detoxifica- and their family members struggled to maintain motiva-
tion, 20.6% of community detoxification completers tion in the patient during this time [21]. On the other
were drinking at follow-up (measured using a daily hand patients were significantly more likely to attend
breath analysis) but, compared to non-completers, their assessment appointment if the waiting period was
the former drank on a fewer number of follow up days less than 24 h [17].
(10% vs 35%) [19]. In a case series (n = 4) of a com- Studies reported that the majority of patients pre-
munity detoxification, at three months, two patients ferred detoxification in the home [22,38], and some
© 2016 Australasian Professional Society on Alcohol and other DrugsDetoxification for alcohol dependence 395
Table 2. Effectiveness, costs, acceptability of community detoxification
Completion Uptake of
Author, Initiation of of Follow-up follow-up Cost
year detoxification detoxification length Effectiveness services outcomes
Allan, 2000 100% Home group: 60 days Home group: 45% good Home group: —
[30] 90% outcome, 17% improved, 28% 52%
Hospital group: unimproved, 10% unknown. Hospital group:
78% Day hospital group: 31% good 53%
outcome, 3% improved, 44%
unimproved, 19%unknown, 3%
dead.
Alterman, 100% 69% — Drinking in 20.6% of — —
1988 [19] completers, and reported on
only 10% follow-up
appointments.
Drinking in non-completers
found for 35% of follow-up
appointments.
Alwyn, 100% — 3 and 3 months: 25 of the treatment — Inpatient 9
2004 [15] 12 months group compared to 10 of the times cost of
control group were abstinent or home
drinking 3 or less units per day; detoxification
18 of the treatment group and 32
of the control group were
drinking more than 3 units per
day. (P = 0.01).
12 months: 15 of the treatment
group and 3 in control group
were abstinent or drinking 3 or
less units per day; 23 of the
treatment and 37 of control were
drinking greater than 3 units per
day (P = 0.001).
Bartu, 100% 100% 6 months No significant difference No difference Cost benefit
1994 [31] between abstinence, but in uptake of ratio of home
significant difference in weeks of services to inpatient
abstinence between groups. between groups between 3.9
Mean number of weeks and 8.3.
abstinent for home group was General
16.3 (SD 6.8) and 9.6 (SD 8.1) Hospital
for minimal intervention group. detoxification
(P < 0.001) 10.6–22.7
times cost of
home.
Bennie, — — — — No difference —
1998 [16] in amount and
type between
groups
Bryant, 100% — — — — —
2001 [33]
Callow, 38.3% 96.6% — — — —
2008 [24]
Carlebach, — — — — — —
2011 [21]
Collins, — 79% — — — Savings of 74
1990 [25] inpatient
weeks in first
year
Evans, 100% 100% 3 months 50% abstinent; 50% actively 100% —
1996 [20] drinking continued with
counsellor;1/4
(Continues)
© 2016 Australasian Professional Society on Alcohol and other Drugs396 A. Nadkarni et al.
Table 2. (Continued)
Completion Uptake of
Author, Initiation of of Follow-up follow-up Cost
year detoxification detoxification length Effectiveness services outcomes
used other
services
Haigh, 88% Community 1 month Hostel group: 33.3% abstinent — Inpatient 4
1990 [17] hostel: 50% Inpatient group: 14.3% times cost of
Inpatient: abstinent community
36.4% hostel detox.
Klijnsma, 100% 82.1% Mean 28.6% good outcome; 32.1% 52%; 87.5% Inpatient 6
1995 [26] 72 days improved, 39.3% not improved; with good times
(range 25% were abstinent outcome, outpatient
55–149) 44.4% cost
improved, 25%
not improved
Moraes, 100% 100% 3 months 44% more abstinent patients in — —
2010 [18] home group than control
treatment group (P = 0.101)
Roche, — — — — — —
2001 [22]
Sharpley, — — — — — —
1999 [27]
Stockwell, — — — — — —
1986 [28]
Stockwell, 100% 85.4% 60 days 46.7% (14/30) good outcome, 90.9% attended —
1990 [34] (35/41) 43.3% improved outcome; follow-up
number of drinking days, units appointment
of alcohol consumed in previous
week, and Alcohol Problems
Inventory scores dropped
significantly from previous two
months (P < 0.001)
Stockwell, 100% 94.2% 10 days 41.5 (17/41) drank an average of — —
1991 [32] (33/35) 24.7 units in 10 days
Van Hout, — — — — Cost of
2012 [23] aftercare seen
as prohibitive
Wiseman, 100% 88% — — 96% referred, Projected
1997 [29] 74% of referred $600 000
completed savings in first
year of
program
reasons for that were the ability to continue working team, lack of information about the service, absence
and scheduling of home visits around work shift times of one single co-ordination centre [21] and the prohib-
[21], and the perception that more attention was given itive cost of aftercare impacting sustainability of absti-
to outpatients than inpatients during counselling ses- nence following detoxification [23].
sions [25]. Patients and carers rated support from the In general, GPs supported the concept of home detox-
community alcohol team nurses most highly, even ification and their own involvement, but concerns were
above medication; and caregivers also highly valued raised about time constraints, ability of patients to self-
telephone support, breathalyser checks and medica- medicate during home detoxification and availability of
tions [38]. Positive feedback was received from users support and resources [22,28]. GPs listed unsupportive
of community detoxification programs that involved a family or friends, unreliable or unmotivated patients, so-
collaboration between the community, hospital and cial isolation, severe mental or physical illness, history of
primary care teams [21,30,33]. However some short- repeated failures, severe AD, inadequate housing and
comings of such programs included gaps in communi- young children at home as contraindications for home
cation between voluntary staff and the detoxification detoxification [28].
© 2016 Australasian Professional Society on Alcohol and other DrugsDetoxification for alcohol dependence 397
Feasibility Despite the preliminary evidence about the utility
of home detoxification as summarised above, it is
Despite such findings, GPs question the safety and
not a commonly followed approach in low resource
effectiveness of home detoxification for those with
settings where facility based detoxification possesses
severe alcohol withdrawal and were hesitant to take
several practical barriers to access. In such low re-
responsibility for such patients [22]. However, se-
source settings, one of the solutions to the treatment
verely dependent patients undergoing home detoxifi-
gap for a range of mental, neurological and sub-
cation reported high levels of satisfaction [30], with
stance use disorders has been using relatively easily
community detoxification being seen to be feasible
accessible platforms of care (e.g. primary care) to de-
even for patients with chronic alcohol problems hav-
liver evidence based interventions by non-specialist
ing limited social and environmental support [19].
health workers [40]. The preliminary evidence for
On the other hand home detoxification is deemed
community detoxification lends itself well for making
to be unsafe in those unable to procure stable,
a case for delivering this intervention through pri-
short-term living arrangements and in those without
mary care platforms and needs further exploration
sufficient control of psychotic symptomology [19].
using robust study designs.
GPs from Australia expressed concerns about their
It is notable that for a treatment delivery approach
own ability to prescribe and oversee home detoxifica-
that possesses many potential advantages, including pre-
tion, suggesting the use of standardised protocols,
liminary evidence of effectiveness/impact, acceptability,
assessment schedules and prescription regimes for
accessibility and feasibility and one that is increasingly
different levels of dependence. They also reported
being used in high income countries (as evidenced by
the following structural barriers: lack of appropriate
the numerous community detoxification guidelines
remuneration (considering the time consuming
available, e.g. http://www.southwestyorkshire.nhs.uk/
nature of home detoxification), lack of specialised
documents/953.pdf, there are hardly any RCTs to
training and fear for personal safety in making home
examine the cost effectiveness of home detoxification
visits [22].
compared to inpatient detoxification. Furthermore,
almost all of the evidence that is available on the var-
ious aspects of home detoxification has been gener-
ated before the year 2000. So, there is limited cost
Discussion
effectiveness evidence and there is limited recent ev-
Despite some variability in eligibility criteria and de- idence about home detoxification. In the absence of
toxification procedures in the included studies, the such evidence it does appear that community detox-
current review demonstrates that community detoxifi- ification guidelines are informed by extrapolation of
cation has good rates of initiation and completion, is evidence from inpatient detoxification, even though
safe, leads to improved drinking outcomes, is cheaper the former might have its own specific contextual re-
than inpatient detoxification and is generally feasible quirements different from the latter. Furthermore,
to deliver and acceptable to a range of stakeholders. even in this existing limited literature about home
However the variability in eligibility and detoxification detoxification, only one study is based in a LMIC
and the nature of the study designs preclude the syn- [18]. LMICs have distinct contextual characteristics
thesis of the available evidence into clear evidence compared to high income countries, e.g. shortage of
based clinical recommendations. In fact, in our opin- specialist human resources. The lack of cost effec-
ion, the biggest outcome of this review is to highlight tiveness evidence from such settings is a major gap
the large gap in the evidence base and the need to in evidence as such evidence from low resource set-
generate high quality evidence, because the prelimi- tings could potentially be used to inform community
nary evidence does demonstrate the potential utility based services for AD in LMICs thus helping to
of home detoxification in reducing the treatment overcome the barriers to access posed by facility
gap for AD, which exists even in high income coun- based care in such settings.
tries [39]. Some lessons to be learnt from the limited There are some methodological limitations of this
evidence we have is that a safe and effective commu- systematic review. The review was focused only on
nity detoxification program should be characterised published literature and grey literature was not ex-
by clearly defined eligibility criteria, non-ambiguous plored. Also, the literature search was restricted to pa-
medication protocols based on objective measure- pers written in English, and most of the identified
ment of withdrawal symptoms, at least daily struc- studies were based in high-income countries, thus
tured monitoring of the patient’s progress and impacting the generalisability of findings to non-
linkage with continuing psychosocial care after com- Western settings. However, it is inconceivable that all
pletion of detoxification. of the addictions research literature from LMICs on
© 2016 Australasian Professional Society on Alcohol and other Drugs398 A. Nadkarni et al.
this particular topic would be published in non-English that decision it is important to build the capacity of
language journals when in fact a lot of other addictions primary care personnel to identify different severities
literature from such countries is published in English of AUD. Finally, policymakers, especially those in
language journals. This systematic review has its low resource settings, should focus efforts on
strengths, the primary one being the systematic ap- de-centralising services for detoxification from spe-
proach of literature searching and the strict adherence cialist services to a stepped care model where detox-
to a study protocol. Furthermore, the approach that ification is managed in primary care in the first
was followed in extracting data on a range of domains instance with referral of complex cases to specialist
(e.g. effectiveness, feasibility, safety) resulted in mak- services.
ing this review a comprehensive synthesis of the re-
search literature on this topic. There have been no
such reviews of home detoxification in the past. The Acknowledgements
reviews published on this topic have been limited by Daniela Fuhr is funded by the National Institute of
the non systematic nature of the search strategy [12], Mental Health (1U19MH095687-01). Abhijit Nadkarni
or a focus on discrete steps of the home detoxification is supported by Grand Challenges Canada. The
procedure, e.g. eligibility criteria [41]. Besides the funders had no role in study design, data collection
limitations of the review process the studies included and analysis, decision to publish or preparation of
in the review themselves have limitations which need the manuscript.
to be taken into account when interpreting the data.
One such limitation is the outcome of ‘abstinence’
measured in some of the studies. Detoxification is References
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