Patient Pathways Study
People rarely present to alcohol and other drug (AOD) treatment services with only alcohol and other drug problems. More commonly, clients present with additional complexities such as physical and mental health, legal, housing, employment, and other problems. Moreover, alcohol and other drug 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 alcohol and other drug 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 alcohol and other drug services in Western Australia and Victoria, with questionnaires covering a range of issues including substance use; housing, employment, and legal problems; use of health, alcohol and other drug, and social services; quality of life; reasons for seeking alcohol and other drug 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 alcohol and other drug 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 three 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 one-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 alcohol and other drug treatment.
At the follow-up, 38 percent of participants had abstained from their primary drug of concern for the whole of the past month, and an additional 14 percent had significantly reduced how often they used their PDOC, meaning that 52 percent of participants were considered a “treatment success”. However, only 14 percent abstained from their PDOC for the whole one-year follow-up period, and only 30 percent 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 alcohol and other drug treatment system tended to have better outcomes. For participants with illicit or pharmaceutical drugs as their PDOC, those who completed their alcohol and other drug treatment, and had continuous referrals between alcohol and other drug 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 alcohol and other drug treatment system may be more important.
Turning Point team
Professor Dan Lubman, Associate Professor Victoria Manning, Dr Joshua Garfield, Professor David Best, Dr Tina Lam, Dr Belinda Lloyd, Ms Sharon Matthews, Dr Caroline Gao, and Mr Andrew Larner.
Professor Steve Allsop (Curtin University), A/Associate Professor Penny Buykx (University of Sheffield), Ms Janette Mugavin (La Trobe University), Dr Lynda Berends (Australian Catholic University), and Professor Robin Room (La Trobe University).
Learn more about this project
Turning Point publications:
- Lubman, D. I., Garfield, J. B. B., Manning, V., Berends, L., Best, D., Mugavin, J. M., Lam, T., Buykx, P., Larner, A., Lloyd, B., Room, R., & Allsop, S. (2016). Characteristics of individuals presenting to treatment for primary alcohol problems versus other drug problems in the Australian Patient Pathways study. BMC Psychiatry, 16, 250.
- Manning, V., Garfield, J. B. B., Best, D., Berends, L., Room, R., Mugavin, J., Larner, A., Lam, T., Buykx, P., Allsop, S., & Lubman, D. I. (2017). Substance use outcomes following treatment: findings from the Australian Patient Pathways Study. Australian and New Zealand Journal of Psychiatry, 51, 177-189.
- Berends, L., Garfield, J. B. B., Manning, V., Buykx, P., Lam, T., Mugavin, J., Larner, A., Room, R., Allsop, S., & Lubman, D. I. (2016). Social disadvantage and past treatment among clients entering public alcohol and drug services in two Australian states. International Journal of Drug Policy, 29, 88-90.
- Manning, V., Best, D., Garfield, J. B. B., Allsop, S., Berends, L., & Lubman, D. I. (2017). Money well-spent: Further evidence of improved outcomes for methamphetamine users following treatment. Drug and Alcohol Review, 36(2), E1-E3.
- Storbjork, J., Garfield, J. B. B., & Larner, A. (2017). Implications of eligibility criteria on the generalizability of alcohol and drug treatment outcome research: A study of real-world treatment-seekers in Sweden and in Australia. Substance Use and Misuse, 52, 439-450.
- Berends, L., & Savic, M. (2017). Using timelines to visualize service use pathways to alcohol treatment. The Qualitative Report, 22, 1964-1974.
- Foulds, J. A., Manning, V., Garfield, J. B. B., Allsop, S. J., Lam, T., Arunogiri, S., & Lubman, D. I. (2018). Prescribed sedative and other psychotropic medication use among clients attending alcohol and other drug treatment. Drug and Alcohol Review, 37, 738-742.
- Manning, V., Garfield, J. B. B., Lam, T., Allsop, S., Berends, L., Best, D., Buykx, P., Room, R. & Lubman, D. I. (2019). Improved Quality of Life Following Addiction Treatment is Associated with Reductions in Substance use. Journal of Clinical Medicine, 8, E1407.
- Best, D., Manning, V., Allsop, S., & Lubman, D. I. (2020). Does the effectiveness of mutual aid depend on compatibility with treatment philosophies offered at residential rehabilitation services? Addictive Behaviors, 103, 106221.
- Piercy, H., Garfield, J.B.B., Lubman, D.I., Lam, T. & Manning, V. (2020) Improved rates of treatment success following alcohol and other drug treatment among clients who quit or reduce their tobacco smoking. Drug and Alcohol Review 40, 78-82
- Garfield, J. B. B. & Manning, V. (2019). Homelessness among substance use treatment-seekers: Insights from the Patient Pathways National Project. VAADA Conference, 2019, Melbourne.
- Lessons from the Patient Pathways study in delivering evidence-based practice by Associate Professor Victoria Manning