Effect of Door-Locking Policy on Inpatient Treatment of Substance Use and Dual Disorders

Abstract

Objective: Substance use treatment is often performed inside locked wards. We investigate the effects of adopting a policy of open-door treatment for a substance use treatment and dual diagnosis ward. Methods: This is a prospective open-label study investigating 3-month study periods before opening (P1), immediately after (P2), and 1 year after the first period (P3). Data on committed patients, coercion (seclusion, forced medication, absconding events with subsequent police search), violence, and substance use was collected daily. We applied generalised estimating equation models. Results: The mean daily number of patients with ongoing commitment changed from 2.64 (P1) to 2.12 (P2) to 0.96 (P3), corresponding to a reduction of relative risk (RR) for having an ongoing commitment by 20% in P2 (RR 0.80; 95% CI 0.66-0.98) and 67% in P3 (RR 0.33; 95% CI 0.25-0.42). The mean daily number of coercive events was 0.29, 0.13, and 0.05, corresponding to a risk for undergoing coercive measures reduced by 56% (RR 0.44; 95% CI 0.22-0.90) and 85% (RR 0.15; 95% CI 0.05-0.45). Substance use, violence or ward atmosphere did not differ significantly. Conclusions: Our results support findings from general psychiatric wards of reduced coercion after adopting a primarily open-door policy. However, coercive events were rare during all periods. The widespread practice of restricting the freedom of inpatients with substance use disorders by locking ward doors is highly questionable.

Substance-Use Disorders and Violence

“…MI was originally developed as a technique for motivating substance abusers to change (Miller and Rollnick, 1991). MI/brief intervention techniques have been proposed as well for the treatment of aggressive behaviour in dual diagnosis (McMurran, 2009;López-Castro et al, 2019), including adolescent (Cunningham et al, 2012;Zatzick et al, 2014), populations albeit conflicting results have been reported (Steinauer et al, 2017).…”

Opening the Doors of a Substance Use Disorder Ward—Benefits and Challenges From a Consumer Perspective

“…Simpson et al (33) did not report a consistent relationship between substance use and exit security features, intensity of drug/alcohol monitoring and the locking of the ward door. In another study, our research group found no relevant change of substance use on a specialized SUD and dualdiagnosis ward (not the ward under study here) comparing the time period when the ward was closed to the period when the same ward was open (34). As substance use was screened for by urinalysis and breathalyzer testing in the study mentioned above, there may indeed be no increase in substance use after introduction of an open-door policy.…”

International research into 22 years of use of chemical restraint: An evidence overview

“…The earliest enquiry was published in 1999, investigating the effect of a token economy on patient behaviour . The majority of papers in this theme were written from 2014 onwards, reporting on changed ward practices and their influence on coercive practices (such as open and closed wards); regulations and guidelines for practice; and different service configurations …”

“…This may reflect increasing international interest since the mid‐2000s in de‐escalation of violent behaviours by changed ward cultures as first line management strategies . There were a small number of studies which compared coercive practices pre‐post changes in ward policy or management (for instance the effects of change from closed to open wards; whether prioritising enforced medication over seclusion led to a decrease in aggressive incidents and coercive measures; or whether the frequency of seclusion and forced medication altered over 6 years of changing policy) …”