Patient Pathways National Project

Summary

People rarely present to alcohol and other drug (AOD) treatment services with only AOD problems. More commonly, clients present with additional complexities such as physical and mental health, legal, housing, employment, and other problems. Moreover, AOD treatment often involves more than just simply accessing one type of treatment at one service resulting in one’s problem being permanently solved.

The Patient Pathways National Project, which was a collaboration between Turning Point, Monash University, and Curtin University’s National Drug Research Institute, sought to examine the complexities of AOD treatment – both the complexities of the problems faced by clients, and the complex pathways and combinations of treatment and other services they access, and how these factors relate to treatment outcomes. It was the first multi-site outcome study in Australia to compare clients seeking treatment for various types of drugs. We surveyed 796 people accessing various types of treatment from 20 AOD services in Western Australia and Victoria, with questionnaires covering a range of issues including substance use; housing, employment, and legal problems; use of health, AOD, and social services; quality of life; reasons for seeking AOD treatment; social support; stigma; and others. 555 of these participants were followed up one year later.

The baseline questionnaires confirmed the complex and marginalised characteristics of the AOD treatment-seeking population. Half of the participants had a chronic medical condition. Only half had completed either high school or another educational or trade qualification. Only one third had participated in paid employment in the past 3 months, and nearly half were on unemployment benefits. One quarter had current legal problems. Half had been to an emergency department within the past year, and nearly half were engaged with mental health services in the past year.

However, there were differences between groups seeking treatment for different types of drugs. Those whose primary drug of concern (PDOC) was alcohol tended to be older and more educated, and less likely to have legal problems, multiple drugs of concern, or to be tobacco smokers, compared to participants whose PDOC was an illicit or pharmaceutical drug. However, those with alcohol as their PDOC had particularly high rates of emergency health service use, compared to the other groups, suggesting a high rate of accidents or acute health problems. Those with opioids or amphetamines as their PDOC had the highest rates of legal problems and unemployment. Those with opioids as their PDOC appeared to be particularly marginalised and clinically complex: they had the highest rates of recent homelessness and imprisonment, were the most likely to have multiple drugs of concern and most likely to have problems with benzodiazepines, and scored the lowest on several quality of life scales.

We observed high rates of AOD service use in both the year before the baseline interview, and the year after. However, there was a shift in the types of services accessed before and after treatment. Participants’ rate of admission to withdrawal management services (i.e. “detox”) decreased, while attendance at residential rehabilitation increased, as did attendance at mutual aid groups (e.g. 12-step programs, SMART Recovery, etc.). This suggests a shift from services addressing the acute effects of recent drug use towards services and other resources focused on more long-term recovery. Indeed, attending rehabilitation was associated with increased rates of  abstinence from the PDOC at the 1-year follow-up, and mutual aid attendance also improved treatment outcomes in those whose PDOC was alcohol. There were also significant declines during this time in the proportion of participants accessing emergency health services and legal aid, suggesting reduced physical health and legal problems following AOD treatment.

At the follow-up, 38% of participants had abstained from their primary drug of concern for the whole of the past month, and an additional 14% had significantly reduced how often they used their PDOC, meaning that 52% of participants were considered a “treatment success”. However, only 14% abstained from their PDOC for the whole 1-year follow-up period, and only 30% abstained from all their drugs of concern (i.e. both PDOC and any secondary drugs of concern as well) in the past month at the follow-up. Interestingly, rates of treatment success were highest in those whose PDOC was methamphetamine, and lowest in those whose PDOC was alcohol, suggesting that alcohol may be particularly difficult to quit.

We also found a difference between those with alcohol as the PDOC and other participants in terms of the factors were associated with treatment success. For participants with alcohol as the PDOC, those who attended mutual aid groups and accessed additional social services outside the AOD treatment system tended to have better outcomes. For participants with illicit or pharmaceutical drugs as their PDOC, those who completed their AOD treatment, and had continuous referrals between AOD treatment services tended to have better outcomes. Thus, when alcohol is the PDOC, seeking additional support outside the formal AOD treatment system may be particularly important, while for those with other drugs as their PDOC, what happens within the AOD treatment system may be more important.

The findings of this study have been reported in a variety of formats:

An analysis of the baseline interviews, including comparisons between those seeking treatment primarily for alcohol and those with other primary drugs of concern, is freely available at:
https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-016-0956-9

Analyses of participants’ drug use outcomes, and the factors associated with these outcomes, were published in this paper:
http://journals.sagepub.com/doi/abs/10.1177/0004867415625815

A short report specifically looking at the outcomes for participants whose primary drug of concern was methamphetamine can be found at:
https://onlinelibrary.wiley.com/doi/abs/10.1111/dar.12410

The following paper examined which factors were associated with accessing AOD services in the year prior to the baseline interview:
https://www.ijdp.org/article/S0955-3959%2815%2900371-0/abstract

The following paper used data from the Pathways project to examine ways of visualising treatment pathways:
https://nsuworks.nova.edu/tqr/vol22/iss7/14/

The following paper analysed prescribed medication use among participants in the project:
https://onlinelibrary.wiley.com/doi/abs/10.1111/dar.12841

Papers reporting on other analyses are still being prepared.