Drug and Alcohol Review (1995) 14, 125-129

BRIEF COMMUNICATION

Changes in die characteristics of clients admitted to an Australian therapeutic community, "The Buttery", 1980-92

W A Y N E HALL, R O S E M A R I E C H E N & BARRY EVANS 1

National Drug and Alcohol Research Centre, University of New South Wales, and 1The Buttery, Lismore, NSW,, Australia

Abstract

Data are presented on the characteristics of clients admitted to an Australian therapeutic community, The Buttery, between 1980 and 1992. The typical client was a 28-year-old male with a primary opioid drug problem complicated by polydrug use, particularly of alcohol and stimulants. Prior treatment experience was common, with one in three having been enrolled in methadone maintenance treatment. The average age of clients increased by about 7 months per year, and there was an increase in the prevalence of alcohol, stimulant and polydrug problems over the period of study. There was also an increase in the exposure of clients to methadone maintenance treatment prior to admission to the Buttery. Overall, the characteristics of patients in this drug-free treatment programme were strikingly similar to those observed among patients in methadone maintenance treatment over the same period. [Hall ~V, Chen R, Evans B. Changes in the characteristics of clients admitted to an Australian therapeutic community, "The Buttery", 1980-92. Drug Alcohol Rev 1995; 14: 125-129.]

Key words: Polydrug abuse; heroin dependence; treatment; therapeutic community; client characteristics.

Introduction

Therapeutic communities have provided drug-free treatment in Australia for more than 20 years. Such communities provide a non-medical residential set- ting that encourages personal growth by changing the life-style of drug-using individuals with social deficits, including criminal behaviour. Some of the common features of such communities include a drug-free environment, clear rules to govern the behaviour of all members, the development of prob- lem-solving skills, encounter groups and behaviour

modification through a hierarchical social system with the goal of re-entry into society [1,2].

Surprisingly little is known about the clientele of therapeutic communities in Australia by comparison with what is known about the clientele of metha- done treatment programmes [3]. There is limited information on the number, demographic character- istics, drug use and treatment history of their clients (eg [4,5]). This report partly remedies this lack of knowledge by describing the characteristics of clients

Wayne Hall, PhD, Professor and Director, Rosemarie Chen, MA, Research Assistant, National Drug and Alcohol Research Centre, University of New South Wales, Sydney 2052, Australia and Barry Evans, The Buttery, Lismore 2480, Australia. Correspondence to Wayne Hall.

Received for publication July 2nd I993, in revised form September 27th 1993. Accepted October 18th 1993.

0959-5236/95/010125-05 0 Australian Professional Society on Alcohol and Other Drags, 1995

126 Wayne Hall et al.

at one such therapeutic community, the Buttery, over the period from 1980 to 1992.

The Buttery

The Buttery is a residential centre for the treatment of chemical dependence which has operated as a therapeutic community since 1978, after beginning as a drop-in and outreach centre for youth in 1973 [6]. It is situated at Binna Burra on the Far North Coast of NSW, in an old butter factory (hence the "Buttery"). It caters for a maximum of 24 single adults living in three separate households in an effort to maintain as "normal" a non-institutional setting as possible by providing an extended house- hold concept which maximizes opportunities for interaction and the acquisition of living skills through the shared responsibility of managing a house. A strong emphasis is placed on indMduals being active participants in the recovery process by accepting responsibility for the personal application of insights gained (see [7] for a detailed account of the treatment philosophy of The Buttery).

Methods

Procedure

An admission form was filled out for each admission which collected data on the clients' age, gender and postcode of residence at the time of admission; their drugs of choice, the source of referral, participation in detoxification and methadone maintenance treat- ment programmes prior to the index admission to the Buttery; the date of admission; and the date on which the client left the programme.

Data analysis

These data were tabulated by year of admission for the study period. There were only 37 admissions in 1978 and 1979 when the programme was being developed so statistical analyses on changes over time were performed only on data for the period 1980 to 1992 inclusive. Descriptive statistical, anal),- ses were used to summarize the characteristics of clients by gender, age, drug use, treatment experi- ence and year of admission. A simple index of polydrug use was calculated by summing the number of different drug types for which a client sought help. Drug problems and polydrug use have only

been reported for the period 1980-1991 because of changes in the way in which this data were collected in 1992 (data on length of stay are reported in [7]).

Multivariate statistical analyses were undertaken to examine changes in age, prior exposure to metha- done maintenance and drugs of choice over the period of study. When the outcome variables were continuous (eg age, polydrug index) linear multiple regression analyses were performed. When the out- come variables -were categorical (eg an alcohol prob- lem or not) logistic multiple regression analyses were conducted. All analyses were performed using the SYSTAT package [8].

Results

Client characteristics

There were 1219 admissions to the Buttery- in the years 1978-1992. Excluding 89 readmissions, these represented 1130 persons of whom 69.7% were male and 30.3% were female. The average age of the sample was 28.1 years (SD = 5.6 years), with males being older (28.8 years) than females (26.5 years) (t[df= 737] = 6.84, p < 0.001).

Information on place of residence was available on 64% of admissions in the form of the postcode of their address prior to admission to the Buttery. The remainder either did not have a fixed address or did not provide one. The majority of these dients (82%) came from New South Wales, with 13% coming from Victoria and 5% from Oueensland. In New South Wales, 14% came from the inner city suburbs such as Darlinghurst, Surry Hills and Newtown, which are well known centres for illicit drag use.

Among the 15 listed referral agencies the largest source of referrals were the Langton Clinic (16.0%) and Wisteria House in Sydney (3.0%), the Rich- mond Clinic in Lismore, New South ~VYales (2.9%) and the Pleasant View Centre in Victoria (2.8%). Unspecified sources of referral comprised 61.6% while only 1.0% were self-referred.

The majority of clients had some previous ex- posure to treatment services. All clients had been detoxified prior to the index admission to the But- tery. In addition, 75% of clients had undergone detoxification on at least one occasion prior to the treatment episode that preceded their admission to the Buttery, and (30% had also been in methadone treatment prior to seeking help at the Buttery).

The most frequently nominated drug of choice

Client characteristics at an Australian therapeutic community 127

Table 1. Buttery Data 1980-92

% Mean % % % % Mean Year n Male age MM OPI ALC STI poly

1980 62 66 24.6 15 67 26 2 t.6 1981 68 73 24.2 24 71 21 10 1.5 1982 82 74 25.8 24 89 12 4 1.3 1983 78 64 26.6 32 89 14 8 1.6 1984 108 64 27.1 19 84 29 I7 1.9 I985 105 67 27.7 27 83 44 14 2.1 1986 116 72 28.9 35 91 40 24 2.3 I987 97 79 29.8 34 86 41 22 2.2 I988 97 7I 29.3 38 86 25 26 2.0 1989 105 72 30.1 38 78 42 26 2.1 1990 104 69 29.1 37 77 61 39 2.5 1991 97 77 30.9 30 63 53 32 2.2 1992 58 64 32.1 * * * * *

% OPI = % with an opioid drug problem; % ALC = % with an alcohol problem; % STI = % with a stimulant drug problem; Mean poly = mean score on the polydrug index.

*Not reported because of changes in the method of data collection introduced in 1992.

was an opioid (85%), primarily heroin (78%), with the remainder using synthetic opioids. Other addi- tional drug problems were common: 37% had a problem with alcohol, 20% had a problem with stimulants, 11% had problems with benzodiazepines and 52% had problems with a variety of other drugs. One-third of the sample (33%) reported problems with three or more drug types. With the exception of benzodiazepines, males outnumbered females by more than 2:1 for each category of drug, the ratio by which they were over-represented among the But- tery's clients.

Changes over time

The most striking change in client characteristics over the period of study was a steady increase in average age from 24.6 years in 1980 to 32.1 years in 1992 (see Table 1). An analysis of variance indicated that there was a significant linear trend in average age across these years (F[1, 1066]=176.63, p < 0.001), with the average age increasing by ap- proximately" 7 months per year. Although there was some variation in the proportion of males over time (from a low of 64% to a high of 79%) this did not increase and the variation was not statistically significant when examined by a logistic regression analysis.

There were a number of changes in the drags of

choice among the Buttery's clients between 1980 and 1990 (see Table 1). The proportion with opioid problems showed a slight decrease over time ( O R = 0.91 per year [95% CI: 0.86, 0.95]) while there were small increases in the proportions report- ing problems with alcohol (OR = 1.14 per year [95% CI: 1.09, 1.18]) and stimulant drags such as cocaine and amphetamines (OR = 1.16 per year [95% CI: 1.10, 1.21]). There was no consistent change in the proportion reporting problems with benzodiazepines (OR = 1.01 per year [95% CI: 0.95, 1.07]).

There was also an increase in the prevalence of polydrug use among clients over time, as indicated by a statistically significant increase in the average score on a polydrug index calculated by adding the number of different drug types nominated as a problem (see Table 1). This index has consistently increased between 1980 and 1991, a result confirmed by a test of linear trend over time (F [1, 922] = 164.50, p < 0.001).

The proportion of clients who had prior experi- ence with methadone maintenance treatment on one or more occasions prior to the index admission also increased over the period from 1980 to 1992 ( O R = 1.08 per year [95% CI: 1.04, 1.13]). The major change in the proportion with previous methadone exposur e was before and after 1985, the year in which the provision of methadone treatment was expanded under the National Campaign Against Drug Abuse (OR = 1.58 [95% CI: 1.19, 2.08]).

128 Wayne Hall et al.

Discussion

The main findings of this analysis of the data on clients admitted to the Buttery between 1980 and 1992 can be briefly summarized as follows. First, the typical Buttery client during the period of study was a 28-year-old male with a primary opioid drug problem complicated by polydrug use, particularly of alcohol and stimulants. Secondly, prior treatment experience was common with three of four of clients having been detoxified (other than as a condition of entry to the Buttery), and one in three having been enrolled in methadone maintenance treatment. Thirdly, the average age of clients increased by about 7 months per year over the period of study. Fourthly, there was an increase in the prevalence of alcohol and stimulant problems and of polydrug problems among the Buttery's clients over the period of study. Fifthly, over the period of study there was an increase in the exposure of clients to methadone maintenance treatment prior to admission to the Buttery.

The validity of these trends in the Buttery clien- tele depends upon the quality of the data collected by a variety of different treatment personnel over a long period of time. Although the data quality may have varied (eg with variations in the criteria that different staff used in deciding which drug types an individual had a problem with), we are confident that the overall trends are valid because similar changes have been reported among the clientele of methadone maintenance treatment programs [6,9] and clients admitted to We Help Ourselves thera- peutic community between 1985 and 1991 [5]. In all of these studies there has been an increase in the prevalence of polydrug use, and an increase in aver- age age of clients.

The time trends in average patient age and in- creasing polydrug use probably reflect changes in the population of people who are dependent on heroin and other illicit drugs. The consistency in these trends across both methadone and drug-free treat- ment populations suggests that heroin users seeking treatment over the past decade in Australia have constituted an ageing cohort. A similar phenomenon has been observed among American methadone maintenance patients [3]. The most likely expla- nation of these trends is that the number of new recruits to opioid drug use has declined over the period.

The increased prevalence of polydrug use indud-

ing stimulants among illicit drug users has also been noted in the United States [2]. The shift towards greater stimulant use in the Buttery's clients has been much less dramatic than the much larger shift to cocaine use among injecting drug users in the United States [2], reflecting differences between Australia and the United States in the availability of cocaine [10].

The increased exposure to methadone mainte- nance treatment reflects changes in treatment pro- vision in Australia. Methadone places in Australia have steadily increased from less than 3000 places in 1985 to more than 10 000 in 1992 [3].

Although there are reassuring similarities between the trends in patient characteristics at the Buttery and W e Help Ourselves [5] it would be premature to conclude that the Buttery's clients are representa- tive of drug users in therapeutic communities throughout Australia. It is hoped that the results obtained from this analysis of patient records may encourage other therapeutic communities, and drug- free treatment centres, to undertake similar analyses of changes in their clientele over this period. Such analyses may expose information that has been missed when treatment providers have their noses pressed to the treatment grindstone, as occurred in the present case with the increase in average age going unnoticed by Buttery staff. They may also contribute to a national picture of patient character- istics, treatment content and programme duration that will enable drug treatment and education to be better tailored to client needs.

References

[1] Luger M. The Odyssey experience: A therapeutic community. Aust J Alc Drug Depend 1979;3:80-83.

[2] Gerstein DR, Harwood HJ. (Eds) Treating Drug Problems Volume 1: A study of effectiveness and financing of public and private drag treatment sys- tems. Washington, DC: Institute of Medicine, Na- tional Academy Press, 1990.

[3] Ward J, Mattick R, Hall W. Key Issues in Metha- done Maintenance. Sydney: University of New South Wales Press, 1992.

[4] Didcott P, Flaherty B, Muir C. A profile of addicts in residential treatment. Sydney: Directorate of the Drug Offensive Monograph Series No 2, 1988.

[5] Swift W, Darke S, Hall W, Popple G. Who's Who? A Report on the Characteristics of Clients seen at We Help Ourselves 1985-1991. Technical Report No. 14, Sydney, National Drag and Alcohol Re- search Centre, 1993.

Client characteristics at an Australian therapeutic community 129

[6] Hall W, Bell J, Hay A. Characteristics of patients and programs in three private prescriber methadone maintenance programs (in preparation).

[7] Hall W, Chen R, Evans B. Clients admitted to "The Buttm3?', a therapeutic community, 1980-1992. Na- tional Drug and Alcohol Research Centre Technical Report Number 20. Sydney, National Drug and Alcohol Research Centre, 1993.

[8] Wilkinson JL. SYSTAT: The System for Statistics. Evanston, Illinois: SYSTAT Inc, 1987.

[93

[1o]

Caplehorn JRM. A comparison of private and public methadone maintenance patients. Drug Alcohol Rev 1992;11:43-49. Hall W, Hando J. Patterns of illicit psychostimulant use in Australia 1985-1991. In: Burrows D, Flaherty B, MacAvoy M. (Eds) Psychostimulant Use in Aus- tralia. Canberra: Australian Government Publishing Service, 1993.