Short Reports 234
Five-year
follow up for sobriety in a cohort of men who had
attended an Alcoholics Anonymous programme in India
P. K. KURUVILLA, K. S. JACOB
ABSTARCT
Background.
There are little data from India on the long term follow
up of patients with alcohol dependence who have undergone a
de-addiction programme. A cohort of patients who completed a
detoxification and de-addiction programme based on the
Alcoholics Anonymous model were followed up for a period of
5 years.
Methods.
A cohort design was used. A community outreach programme
of a de-addiction centre was the setting for the study. One
hundred and eighty-two patients who completed a
detoxification and de-addiction programme based on the
Alcoholics Anonymous model were followed up. Sobriety at 5
years’ of follow up was the outcome measure.
Results.
One hundred and fifty-one (83%) patients were followed
up at 5 years. The majority (90; 59.6%) did not change their
alcohol consumption and a small minority (25; 16.5%)
remained completely sober over the 5-year period. Sobriety
at 1 year was significantly associated with complete
abstinence at 5 years (c2=53.8; df=1; p<0.001). More
patients coming from distant places (RR 0.84; 95% CI: 0.71,
0.98; p<0.03) and those with health workers in their
localities (RR 0.81; 95% CI: 0.68, 0.96; p<0.01) were
completely abstinent. These variables were also
significantly associated with sobriety even after adjusting
for other confounders using logistic regression.
Conclusion.
The results of the 5-year outcome are modest. More
patients coming from distant places and those with health
workers in their localities remained completely abstinent
suggesting the possible role of the individual’s
motivation and the need for continued community support in
maintaining sobriety.
Natl
Med J India 2007;20:234ê6
INTRODUCTION
Different treatment packages have been used to treat people
with alcohol dependence with variable success. Though
different factors associated with favourable outcome have
been examined,1–3 definite predictors of favourable
outcome have not been conclusively
established.
However, the following factors favour abstinence: absence of
antisocial personality disorder, other substance use and
severe legal problems, and the patient staying the initial
full course (2–4 weeks) of rehabilitation.4 The duration
of use of disulfiram has also been associated with good
outcome.5
There
is a dearth of data on long term follow up from India.5,6
The details of the 1-year follow up of the present study
cohort have been reported previously6 and are briefly
summarized. Of the 187 patients recruited, 5 were excluded
due to the presence of major psychopathology, 1 committed
suicide and 7 could not be traced. Of the 174 patients
followed up, 58 (33.3%) remained sober (complete abstinence
for the past year) at 1 year of follow up. Patients coming
from distant places for treatment and those with community
health workers to follow up in their localities had better
outcomes. This study documents the 5-year outcome in people
who received a hospital-based detoxification and a
de-addiction programme based on the Twelve Step Facilitation
therapy of the Alcoholics Anonymous (AA).7
METHODS
The
details of recruitment and baseline assessment are
reported elsewhere6 and are briefly mentioned. The setting
for recruitment of the cohort was an inpatient facility for
alcohol treatment at Mochana, Manganam PO, Kottayam, Kerala,
which is widely known in the state of Kerala. The treatment
package included a medical detoxification programme
(supervised by a general physician and a psychiatrist). The
Twelve Step Facilitation (TSF) therapy of AA was
administered by a therapist trained in counselling and
psychotherapy. Patients were hospitalized for a period of 2–3 weeks and followed the AA 12-step programme. All
patients attended the AA meeting during the period of
hospitalization. Spouses were encouraged to stay with the
patients during hospitalization. The centre has a reputation
for strict discipline and patients unwilling to follow the
routine and rules of the hospital were allowed to leave the
programme. The patients were encouraged to attend the local
AA meetings after discharge and were followed up by
community health workers trained by the programme.
One
hundred and eighty-seven consecutive patients, who were
admitted to a medical detoxification facility and a
de-addiction programme based on the AA model for the first
time between February 1998 and January 2000, and who
fulfilled the DSM IV criteria for alcohol dependence,8 were
recruited for the study. The routine treatment package,
which included a detailed assessment, treatment programme
and follow up was offered to all patients attending the
facility. A verbal informed consent was obtained after all
details were explained to the patients. The baseline
assessment included details regarding the use of alcohol: (i)
familial alcoholism was assessed with Family history–Research
Diagnostic Criteria (FH–RDC);9 (ii) a semi-structured
interview was used to collect data on alcohol use. Age at
starting social drinking, age when the subject first got
drunk, age at onset of regular drinking and the age at which
a diagnosis of alcoholism was made, were obtained. The
duration of social drinking and problem drinking were also
established. The onset of problem drinking was obtained by
averaging the reported age at the onset of 4 milestone
events in the patient’s drinking career (i.e. age at first
regular drinking, age when
first getting drunk [or binge drinking] started to occur
regularly, age at which heaviest drinking began and age at
first reported diagnosis of alcoholism);10 and (iii)
sociodemographic details were obtained using a specially
designed proforma.
Complete
sobriety was the outcome measure used. The community health
workers participating in the study were trained at the
centre on different aspects of alcohol dependence and its
management including the nature of the problem, the
detoxification package, the 12 steps of the AA treatment
programme, motivational interviewing skills, skills related
to conducting regular AA meetings and follow up. Follow up
data were gathered by community health workers who visited
the patient’s home, spoke to them and their family. They
also spoke to people who regularly attended AA meetings at
various localities and the monthly meetings held at the
centre. The assessment of outcome and follow up was
discussed in detail with the health workers who reported to
the centre every month.
RESULTS
Of the
187 men admitted to the centre during the study period, 5
patients were excluded as they were diagnosed to have
co-morbid conditions at the end of the period of
hospitalization. These were patients who qualified for DSM
IV major depression (3), generalized anxiety disorder (1)
and atypical affective disorder (1). All the 182 patients
enrolled for the study were men; 169 were married (92.8%),
163 smoked tobacco (93.7%) and 160 did not abuse other
substances (91.9%). Their mean (SD) age was 40.6 (8.1)
years. The mean (SD) age of onset and duration of social
drinking were 22.9 (5.7) and 11.7 (7.4) years, respectively.
The mean (SD) age at onset of dependence pattern and the
duration of such drinking were 34.5 (7.7) and 6.1 (5.0)
years, respectively.
A
total of 151 patients (83%) were followed up at 5 years
after discharge. Follow up was not possible in 31 patients:
2 died of haematemesis, 2 committed suicide and 27 could not
be traced. The differences in baseline variables between
patients who were followed up and those who were lost to
follow up were not statistically significant.
The
5-year outcome showed that the majority (90; 59.6%) did not
change their alcohol consumption and a small minority (25;
16.5%) remained completely sober over the 5-year period.
Three patients (2%) had significantly reduced their alcohol
intake but
TABLE
I. Relative
risk and adjusted relative risk for characteristics among patients who
relapsed over the 5-year period
|
Characteristic |
At follow up |
Univariate
statistics |
Multivariate
statistics |
Sober
(n=25) |
Relapsed
(n=126) |
Relative risk
(95% CI) |
p value |
Adjusted relative risk*
(95% CI) |
p value |
|
Age >39 years† |
14 |
72 |
1.0 (0.5, 2.1) |
0.9 |
0.9 (0.4, 2.2) |
0.8 |
|
Marital status: Married |
24 |
118 |
0.7 (0.1, 4.3) |
0.7 |
1.7 (0.2, 14.8) |
0.6 |
|
Education status: >10
years |
12 |
69 |
1.3 (0.6, 2.6) |
0.5 |
0.7 (0.3, 1.8) |
0.5 |
|
Family history of
alcoholism present |
8 |
51 |
0.9 (0.8, 1.1) |
0.4 |
0.8 (0.3, 1.8) |
0.4 |
|
Age at onset of social
drinking >22 years† |
12 |
72 |
1.4 (0.7, 2.8) |
0.4 |
0.7 (0.3, 1.8) |
0.4 |
|
Duration of social
drinking >10.5 years† |
13 |
65 |
0.9 (0.4, 2.0) |
0.9 |
1.1 (0.4, 2.8) |
0.9 |
|
Age at onset of dependent
drinking >22 years† |
24 |
125 |
3.1 (0.7, 13.0) |
0.2 |
0.2 (0.01, 2.8) |
0.2 |
|
Duration of dependent
drinking >5 years† |
14 |
67 |
0.9 (0.4, 1.9) |
0.8 |
1.2 (0.5, 2.9) |
0.8 |
|
Distance of residence
from centre: Far |
16 |
48 |
0.84 (0.71, 0.98) |
<0.01 |
0.89 (0.36, 0.90) |
<0.05 |
|
Community health worker
present in the area |
16 |
43 |
0.81 (0.68, 0.96) |
<0.01 |
0.30 (0.17, 0.79) |
<0.02 |
* Adjusted relative risk calculated using logistic regression and
adjusting for age and educational status
† Median values of the sample used to divide sample into 2 groups
were drinking
regularly, 27 (17.9%) were sober for over half the period
while 6 (4.0%) were abstinent for less than 2.5 years. The
factors associated (Table I) with complete abstinence at 5
years were (i) greater distance from the centre, and (ii)
presence of a health worker in the area. These factors
remained statistically significant after adjusting for age
and educational status. The interaction between distance
from centre and the presence of a community health worker in
the locality was not statistically significant. Being
completely abstinent at 1 year after treatment was
significantly correlated with being sober for the 5-year
period (c2=53.8; df=1; p<0.001).
Other baseline variables did not predict outcome.
DISCUSSION
This study is
the first of its kind from India. Its strengths include the
fact that a cohort was assembled, treated with a uniform
treatment strategy and followed up for 5 years. The loss to
follow up was small and the patients lost to follow up did
not differ significantly from those who participated in the
study with regard to many of the baseline characteristics
evaluated. The psychiatric morbidity in the sample appears
to be low and this could be explained by the referral nature
of the centre and the fact that psychiatric morbidity was
assessed after detoxification to exclude alcohol
intoxication and withdrawal-related co-morbidity. The
limitations of the study were that community health workers
who were employed by the programme to motivate patients to
abstain from alcohol were also employed to assess the
outcome status. However, the objective nature of the outcome
measure (complete abstinence for 5 years) and the high
prevalence of relapse to alcohol use in the sample suggest
that the outcome assessment can be relied upon. Other
limitations of the study include (i) the absence of data on
attendance at AA meetings after going back to the community,
(ii) absence of data on contact with health workers, (iii)
assessment of other outcomes including social and
occupational functioning and parameters of health, and (iv)
failure to adjust for possible regional differences in
health and social resources and in the availability of
alcohol. Despite these limitations, we believe that our
study provides valuable information on the outcome of
alcohol dependence in India.
Our study
documents that 1 of 6 patients (16.6%) stayed completely
sober 5 years after treatment, although a quarter of them
had reduced the amount or duration of their drinking. It
documents that
the results of the treatment programme are modest. These
findings are comparable with those in the literature
reporting similar outcomes.4
Abstinence at 1-year follow up was associated with extended
periods of sobriety and have also been reported elsewhere.4
Our study shows that those who took the trouble to come from
distant locations (often undertaking tedious journeys) had a
better outcome and possibly suggests a greater initial
motivation to quit the habit. Other studies have also
mentioned motivation as a factor responsible for a good
outcome.11,12 An important finding of
our study is that those who came from areas where there were
community health workers who actively encouraged abstinence
fared better than patients who did not have such workers in
their localities. It is possible that these workers played
an active role in improving the attendance at AA meetings
and thereby increased the social and emotional support when
patients were back in the community. It highlights the
importance of continued support and follow up when the
patients are sent back to the community.
The dearth of
data from India on the ideal treatment package and the
course, outcome and prognosis of alcohol-related disorders
mandate the need for more research in the area.
ACKNOWLEDGEMENTS
We thank the
patients and staff of the centre for their cooperation and
help with the study. The outcome assessment was part of the
community outreach programme of the centre. No additional or
specific funding was obtained for this study.
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