[Prospective study of favorable factors in follow-up of drug addicted patients—apropos of 257 patients of the Cassini Center in Paris]

J L Goeb, J Coste, T Bigot, I Ferrand
L'Encéphale 2000, 26 (6): 11-20

UNLABELLED: Assessing the effectiveness of treatment is one of the main concerns of any medical process. The different ways proposed for assuming the responsibility of drug addicts and their efficacy are greatly heterogeneous since drug-abusing takes on diverse forms. Thus, in order to closely target the request of drug addicts and adjust their follow-up, we undertook to study prospectively, for 3 months, a population of drug addicts taking medical advice for the first time at the Cassini center in Paris, with the assumption that some predictors may forecast outcomes.

METHOD: Data were obtained at the admission with a structured interview about socio-economic and demographic status, psychiatric disorders (assessed clinically according to DSM III-R and with HAD and MADRS scales), substance use and prior treatment history, environmental data (as well as familial substance use or support lending). Medical and paramedical referents have been interviewed after their first contact with the patient about his expectations and his motivation. Familial attendance at this first contact was noted as well as its implication in the programme. At the end of the study, we noted length of stay, regularity of follow up and clinical changes with a last interview of the staff.

RESULTS: Half the time, patients' follow up doesn't last a month, drug abuse doesn't change in 6 out of 10 cases, and we only note 14% of durable abstinence. Polydrug abuse (over 80%) is not linked, here, with pejorative outcomes, in opposition to the usual literature. Heroin is the main substance used by our population (over 80%), other opiates, sedatives and alcohol are associated by more than 30% of these patients; cocaine is associated in a quarter of the cases. More than 10% of the patients are concerned by ecstasy and LSD. Cannabis use is common. Medical complaint (mainly viral diseases) at the beginning of the programme, concerns one of two patients. Only a few are initially known as being HIV positive, suggesting a great lack of information. Over forty percent of the patients are given a DSM III-R diagnosis at the end of the first medical advice, when a doubt subsists for a third of the other patients. Major depressive disorder for the first axis and borderline personality disorder for the second axis are the main disorders we founded. We also noted a large ratio (n = 13.5%) of schizophrenic disorders. Univariate analysis: length and regularity of the programmes are key factors of their efficacy. A long follow-up is also required to improve patients' socio-economical status. Initial psychiatric disorders are linked, in our study as well as in literature, with longer stays in therapeutic programms. By revenge, psychiatric disorders at the third month (over 10%) are linked with poorer outcomes. We noted with interest that, in our sample, neither imprisonment in the past (over 40%, but we noted several imprisonments in a case out of two), or intraveinous route at any moment of the patient's life time (40%), or else a programm caused by a court (a quarter of the patients) are of wrong prognosis. Relatives' implication in the programm is linked with favorable outcomes. Multivariate analysis draws 3 independent clusters about the length of stay. One concerns patient's motivation as assessed by medical staff. An other one concerns patient's relatives' implication in the care. A third one is about the begining of the treatment: an initial medical prescrition and a psychological help are linked with favorable outcomes. About the efficacy, multivariate analysis isolates 4 independant clusters. Prior drug abuse programmes (one out of three patients) are associated with poorer outcomes, when, by revenge, familial relationship initially seen by the patient as (very) satisfying, patient's motivation, and, again, an initial medical prescription are linked with better outcomes. The study of those of the patients whose programme lasted more then 3 months but without any appreciable benefit shows that a long follow-up is successful when it is regular, when it provides a socio-economical status improvement and when the patient is given access to insight. For these patients, the (old) age is associated with better outcomes. By revenge, such a 3 months follow-up is not able to reduce drug abuse when a psychiatric disorder exists at the third month. Patients whose treatment was referred by a court don't differ from the others: their length of stay and outcomes are the same.

DISCUSSION: Our study confirms our initial hypothesis according to witch subgroups in our population of drug abusers should be isolated and that some predictors of outcomes should be described. Three points seem important to be discussed. First, a medical prescription appears to be important to initiate the relationship between the patient and his practicioner. We have never see any report about this particular point. (ABSTRACT TRUNCATED)

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