Addiction Therapeutic communities: residents’ retention, early dropout, and their correlates over fourteen years

Long-term retention is a reliably well-studied factor associated with enhanced outcomes in addiction therapeutic communities (ATCs). Staying no less than three months is considered to be a critical time for program effectiveness. I plan to estimate retention rates of Saudi AATCs for three months, completion of therapy (stay at least six months), and early abandonment and investigate its correlations in this study. A cohort retrospective study where data of all residents admitted to all Saudi ATCs since their establishment in 2000 through September 2014 were collected from their AATCs les. At the time of the study, there were ve AATCs, two of them in Dammam, one in Riyadh, one in Jeddah, and the fth one was in Taif. Date of admission, date of discharge, socio-demographic variable, and type of drug used of all of the ve ACS were reported. Retention rate at 3 and 6 months and dropout in the rst week were calculated. which may require further exploration to determine the factors related to these disparities.


Methods:
Population and data source The study included records data of all ATCs discharged residents in Saudi Arabia since ATCs establishment until September 2014. The reason for discharge could be related to completing the treatment program, discharge against treatment advice, dismissing from the program due to breaking the roles, or any other cause. We exclude only admissions with missing data due to incomplete records. At the time of study conduction, there were only ve addiction ATCs in the Kingdom of Saudi Arabia, and all of them were included. Two of the ATCs were in Dammam city and the others located in Riyadh, Jeddah, and Taif cities. Addiction ATCs establishments were recent. First Addiction TC was operated in 2000 and belonged to Alamal complex for mental health in Dammam. However, it takes almost a decade to establish the next addiction ATCs. The other four addiction ATCs operated between 2009 and 2013. Three of these ATCs were governmental, while the other two operated by non-governmental societies [39]. All of them are traditional addiction therapeutic communities with almost similar treatment and rehabilitation program [40]. The usual recommended length of stay is six to nine months. So, those who stayed six months or more were considered to be treatment program completers. All of these ATCs were for males and not accepting age less than twenty nor compulsory admissions.
Two paramedical staff collected data under the author's supervision from the patients' charts and records using comprehensive forms that include demographic information, number of admissions, diagnoses, admissions dates, lengths of stays, and addicted substances. We collected the data between September and January 2015. The author visited each TC, assigned two paramedical staff in each TC, and trained them on collecting data from resident les and records and ll in previously structured forms. We included all les in the study and excluded those with missing admission and discharge dates. The project's ethical approval was issued by the Institutional Review Board of the College of Medicine at Al-Imam Muhammad Ibn Saud Islamic University HAPO-01-R-010.

Statistical analysis
Data were recorded into the Microsoft excel sheet and exported into SPSS v21.0 for further analysis. Descriptive statistics used to represent the data. Quantitative variables were expressed as mean, standard deviation, median, and range, while categorical data were expressed as frequency and percentage and analyzed using the Chi-square test. P-value <0.05 was considered signi cant, and variables with p-value <0.05 were entered into multinomial binary logistic regression analysis. Therapeutic communities were labeled by numbers rather than their names for convenience.

Results:
We collected data of 2003 patients out of 2050 les that were discharged before the end of September 2014. General characteristics of them have been shown in table 1. All of the residents are adult males since there was no addiction ATCs for females or adolescents in Saudi Arabia at the time of the study. More than two-thirds of patients are younger than 40-year-old. Forty-three percent belonged to therapeutic community number three. The majority were single (64%), unemployed (68%), have intermediate or secondary school education (73%). Forty-six percent of patients reported Opioids use, 36% hash, 34% amphetamine, and 19% reported alcohol misuse. Most of the patients admitted once (92%), 6.7% admitted twice, and only 1.4% admitted more than two times.
Since the program's minimum duration was six months, 28% of the patient considered treatment completers. Dropouts in the rst week were 8.3% of all admissions, and almost 45% stayed for more than three months. The median duration of stay was 77 days. The rst-week dropout was associated with age, residency, occupation, and type of drug used. However, all these associations were insigni cant when adjusting for other factors. Furthermore, Age, residency, employment, social status, and drug users were signi cantly associated with retention for three months on univariate analysis. Though, these associations were insigni cant after multiple regression analyses except residency in TC 1, TC 2, and TC 4, which were less likely to stay for more than three months. After adjusting for other confounders, multivariate regression analysis excluded age and con rm unemployment and students to be associated with treatment completion. On the other hand, Admission to TC 1 and TC-2 prove to be signi cantly associated with treatment program incompletion. (Table 2, 3 and 4)    Three-month retention rates of 45% in Saudi addiction ATCs are acceptable and match with the documented rates worldwide and consistent with previous [13], [24], [41]. Most studies of long-term addiction therapeutic communities reported a three-month retention rate between 30% and 50% [41]. Gossip and his colleagues studied retention rates in eleven long-term residential programs in England and reported a 40% retention rate for the same period. In some other studies, the retention rate for three months was 25%, 31%, and 32% among intravenous drug injectors [42], amphetamine users, and all other drug users, respectively [43]. On the contrary, Mulder et al. reported a rate of 57%; however, the study population was small in size, and 71% of them were come to treatment due to court orders and not on their free well as in our study population [35]. Furthermore, the program completion rate was 28%, which lay in the middle of other studies, 9-56% range [10].
Fortunately, our study population is more or less similar in age, employment, gender, and marital status to those mentioned earlier. Most of the drugs used are opioids, as in not a little of them [13], [26]. The median of stay was 77 days compared to 70 days reported in English long-term residential treatment facilities [13] and 39 days in a prospective Australian study [24] . Although Saudi ATCs followed the same program structure and showed no differences in essential ATCs treatment elements [40], there were signi cant differences in retention rate, which need to be explored.
Being a student associated with treatment completion while the residency site was found to drop out before completing the program. Interestingly, the type of drug used was not associated with dropout and retention at one week, three months, or six months matching with other studies ndings [30], [35]. This may stress the addiction therapeutic community view of addiction as an illness of the person rather than the drug itself [4].
The rst-week dropout was 8.3%, which is better than most similar studies where dropout may exceed 17% to 20%, although high dropout makes these few days critical, requiring more intentions and a specially tailored approach. As in other periods, the site of residency is associated with dropout in the rst week, which means different approaches or applications in dealing with that among the different ATCs.

Conclusion:
Reported retention and dropout rates are good indicators for the effectiveness of Saudi ATCs. However, non-addiction specialized people may consider these numbers as humble ones due to their lack of experience about the nature of addiction disorder and about ATCs, which deals with the most severe cases. Performances of the ve ATCs were not the same though they apply the same program concepts and tools. These signi cant rates differences may need further study to explore and determine the factors that may play roles in this gap.

Declarations:
*The project's ethical approval was issued by the Institutional Review Board of the College of Medicine at Al-Imam Muhammad Ibn Saud Islamic University HAPO-01-R-010. *Availability of data and material: available upon request * Competing interest: Author has no con ict of interests, and the work was not supported or funded by any drug company.