January 2017

Vol. 14, No. 10
In this issue


Enduring principles as healthcare changes
Customer & team values
Marchers’ messages

David Mee-Lee M.D.


(more…)

Vol. 11, No. 12

In This Issue
  • SAVVY, SKILLS & STUMP THE SHRINK : A combined “conversation” on working with mandated clients
  • SOUL : Changing the context to avoid droughts and storms in helping people

Welcome to all new readers to the March edition of Tips and Topics.  Thanks to all for reading this month.

David Mee-Lee M.D.

SAVVY, SKILLS & STUMP THE SHRINK

This month, I presented a webinar on The ASAM Criteria and DSM-5.  A participant wrote to me with some follow-up questions.  We ended up having an email “conversation” as we clarified questions and responses to the initial questions.

(If you want to hear the Addiction Technology Transfer Center (ATTC) Network webinar, you can access it at www.ASAMcriteria.org.  Click on News & Events and you’ll see it there).

So forMarch, here’s a combined SAVVY, SKILLS and STUMP THE SHRINK. I will share with you the “conversation”.

My Webinar Point- about “doing time”

I made a point that treatment providers, especially when working with mandated clients, are responsible for making sure that clients are “doing treatment” not “doing time” in the program – i.e. not just going through the motions.

Question #1:

Howcan you tell if a person is just “doing time, not treatment”?

Hi David,

What other specific criteria should providers gauge to determine whether a client is just “sitting in the program” or “doing time”?  For example, say the client just wants to get a job and maintains that attitude throughout treatment – in effect, turning treatment into a vocational training program. Would you consider this one example of merely “sitting in treatment?” What should be done, in “treatment” or not? 

Response #1:

Youcan turn “doing time” into active treatment.

“Doing time” is when a person is not taking responsibility for their treatment and their treatment plan.  If your client just wants a job but is in a treatment program, it is fine to make the goal of treatment: to get a job.  That’s what he wants and is a good place to start to engage him in treatment.  Presumably however, he has been referred to an addiction program or mental health because he has an addiction and/or MH problem. Say he doesn’t see that and thinks he just has a job problem, then the treatment plan focus would be: do motivational work around helping him get a job.  At the same time examine with him how has not had a job; or when he does get a job he loses it due to addiction and/or MH problems.

Even with the focus on getting a job, he is not just involved in a vocational training program, because he would be assessing why he doesn’t have a job or can’t keep one. Treatment will emphasize:

*      His examining how he is going to keep a job if he does not address the addiction/MH problems.

*      His sharing in group why he thinks he does not have a behavioral health problem, yet he has not had a job.  OR he shares how he lost his job because he was not showing up, or was hung-over.  OR he shares that due to mental health problems he got fired, or that he couldn’t make it through a job interview because he was so depressed or unstable.

*      Executing a “discovery” plan not a “recovery” plan – discovering any connections between addiction/MH problems that interfere with getting or keeping a job.

*      Active and meaningful participation and working on a collaborative plan. This is “doing treatment”, involving stages of change work to see if the client can connect the dots: that if he is to going to land a job, at some point he will need to address his addiction and/or MH problems.

Say your client just sits there and doesn’t participate in collaborative treatment planning. Then he is not doing treatment, he is “doing time.”  We shouldn’t continue treatment.  If he is not changing his treatment plan in a positive direction, he is essentially choosing not to do treatment, and has a right to leave.

My Webinar Point – DSM-5 SUD and Homelessness

In the new DSM-5 criteria for Substance Use Disorder (SUD), there are 11 criteria with a requirement for at least 2 of the 11 to diagnose SUD.   Some of these relate to how substance use interferes with meeting life expectations like work, family and social obligations.

Question #2:

Are the homeless exempt from certain SUD criteria?

 

In working with a homeless population it seems the degree of social isolation obscures the impact of their substance use disorder given the extent and degree of social isolation. In effect, the degree of social functioning required of them is much lower in light of the lack of role obligations that they must fulfill. Does this make them “exempt” from some of the DSM-5 substance use disorder criteria?

Response #2:

Many homeless will still meet sufficient criteria to qualify for an SUD.

As you suggest, a socially isolated homeless person may not have work, family or social obligations.  Thus they may not meet the social obligation criteria. However, such a homeless person could meet the other criteria – only 2-3 of 11 are needed to have mild SUD.

Here are the first 4 they could meet:
1. Substance is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

3. A great deal of time is spent in activities necessary to obtain substance, use, or recover from the substance’s effects.

4. Craving or a strong desire or urge to use the substance. (DSM-5, SUD, criteria 1-4 of 11)

I hope this helps,

David

 
My Webinar Point- about “Graduation”

When I discuss program-driven treatment rather than person-centered, outcomes-driven treatment, I encourage participants to move away from “graduation” as aconcept and practice in the treatment of addiction (and actually any illness).

Question #3:

What did you mean about ‘graduating’ from the program’s policies and procedures?

Yes, this helps! If ever there was a critical thinker, it’s you, David.  I enjoyed tracking your logic and appreciate your way of explaining.

 

One last thing – in response to the question of why its erroneous to use the term graduation in the realm of addiction, you said something about clients’ graduation, but only satisfying graduation of the program’s policies and procedures…or something along those lines. This point grabbed my attention. I was hoping you could articulate it once more and perhaps expand upon it. On that point, I read your piece on RCA Ceremonies and don’t recall coming across it. (March 2011 edition of Tips and Topics)

Thank you for responding to my e-mail and making yourself accessible.

Response #3:

Focus on functional improvement not program compliance.

Thanks for your nice feedback.  Take a look at Tips and Topic (TNT) – February 2013 edition.  I raised concerns that an overemphasis on compliance to program rules, norms and assignments overshadows a person-centered, assessment-based, outcomes-driven approach. Progress in a person’s function based on their individualized treatment plan determines when they transfer to another level of care, not compliance with the program’s policies and procedures, or phases.

I think this addresses what you want, but let me know if not.

Thanks,

David

Question #4:

How do you work with a client who says the “right things”?

OK,I have one more question in response to your answer in regards to “doing time” in treatment.  Say, the legally-mandated client takes a compliant-orientated stance and “gives in.” Or perhaps he feeds the treatment staff what they want to hear by apparently acknowledging the connection between drug use and employment within the first several week ofIntensive Outpatient (IOP) treatment.  It’s not a unique or peculiar situation to have this kind of mandated client then say they have a job problem and that their drug problem is now under control. They remain “dug in” to that position by posturing as if “everything’s all good” and “I got this” type of mentality with respect to all other aspects of “treatment.” Thus would the treatment plan still be a “discovery plan” focused on the client’s need to obtain employment?

 

Would you please tell me how you might work with such a client.

Response #4:

Give your client the chance to follow his plan first. Closely monitor outcomes.

Take a look at the following editions of Tips and Topics, especially the difference between “compliance” and “adherence”.  We don’t want any client to be “compliant” and say what we want them to say (“feeds the treatment staff what they want to hear or not”).  Webster’s Dictionary defines “comply” as follows: to act in accordance with another’s wishes, or with rules and regulations.  It defines “adhere” as: to cling, cleave (to be steadfast, hold fast), stick fast.

Perhaps your client believes he has it all under control (“everything’s all good” and “I got this”.)  At that point, we can share with the client anything we see in his behavior and/or thinking and/or relationships we think would threaten his getting or keeping a job.  What if he doesn’t agree?  Then you develop a plan to track how he is doing with his job or job hunting.  Help him identify what would be the first sign(s) to recognize that he is heading in a direction of losing the job, or not even getting the job. If you track this closely with him, he/you can discover if indeed he has everything under control, or whether his plan is starting to unravel.  Close monitoring is vital.  We don’t want to wait until it all blows up before he changes his treatment plan.

For example:
If he still wants to hangout with substance-using friends, not go to AA or other support groups, and still thinks he can get or keep a job, then agree to have him try his plan: i.e. the plan to “keep hanging out with using friends; not attending AA” ‘treatment plan.’ See if his plans work.  Keep close tabs with him on recognizing the first signs that his plan is not working.

Say his treatment plan is actually working- i.e. the  “keep hanging out with using friends; no AA” treatment plan.   Maybe he’s either getting a job or keeping one. Understandably from your experience, you doubt that he will be able to sustain that stance/decision.  So what do you say in your sessions with him?  You agree to keep going with his plan; but with him you carefully watch what happens. With humility, you express that you hope you are wrong but you think his plan is a risky one.  If his plan starts to unravel, then he will be more open to trying a plan that incorporates your ideas, because his plan didn’t work.  What you did give him is the chance to make his own discoveries and decisions.

November 2007:

January 2004:

December 2006:

Hope this helps.

David

Question #5:

When do you finally discharge a person?

Thanks! David that helps. So in developing a plan to track how she/he is doing toward job obtainment this might include listing jobs of interest; applying to X number of jobs per week; listing potential barriers to employment; practicing job interviewing skills, etc?  AND what if the client consistently fails to successfully follow through–at what point would it merit a discharge?

 

You’ve shared this excellent example of MOTIVATIONAL ENHANCEMENT technique and what comes to mind is the consent forms which used to state the purpose ofthe consent to Adult Client Services was to ‘monitor compliance’.   Ever since hearing the compliance vs. adherence story, I STOPPED using the word compliance in my consent forms.

 

In speaking with Probation Officers and Intake Workers from criminal justice services who ask if a client is being compliant, I ask them if they are sure that is what they want from a client.  I then offer the explanation of how temporary and superficial “compliance” is.

Response #5:

Discharge when the person is not making positive changes in the treatment plan.

Thanks for that interesting update on your use of “compliance” versus “adherence”.  A person could be in “compliance” with a court order to do treatment, with which the person agrees to do.  But once they get to treatment, you don’t want “compliance”, you want “adherence” with the collaborative treatment plan in which the person had an integral part in developing.

Regarding:

So in developing a plan to track how she/he is doing toward job obtainment this might include listing jobs of interest; applying to X amount of jobs per week; listing potential barriers to employment; practicing job interviewing skills, etc? 

Yes, correct, as these are strategies that are Specific, Measurable, Achievable, Realistic and Time limited (SMART).  If the person does whatever they agree to do, then treatment keeps going.

Regarding:

AND what if the client consistently fails to successfully follow through–at what point would it merit a discharge?

If the person does not do what they agreed to do, assess why not.  Perhaps they said ‘yes’ too quickly when they meant ‘maybe’.  Or they really want to follow through, but it was harder to do.  Or they found a better way to get to their goal and so did that instead.  Whatever is revealed when you assess the lack of follow-through, if your client agrees to change their treatment plan in a positive direction, then continue treatment.  There is no need to discharge.

For example:

If a person did not follow through with a job interview they thought would be easy, practice role-playing the job interview process.  If they now agree to practice role-playing to prepare better for a job interview, this is a positive direction. Keep going in treatment.  (You can tell the Probation Officer that your client is in “compliance” with the court order to do treatment and is “adherent” to the collaborative treatment plan.)

What if your client does not want to adjust the treatment plan in a positive direction using role-playing or another acceptable strategy?   At that point, the client is choosing no further treatment.  This is their right and they can leave treatment.  You are not kicking them out – they are not doing treatment.  If you let them stay, then you would be “enabling” – allowing them to “do time” not “do treatment”.  They would be non-adherent (not following through) to the treatment plan they created collaboratively. But they also would be out of compliance with the court order to do treatment.  Hope you see the distinction.

*******

The decision flow makes perfect sense, David.

Thanks again for taking the time to put forth a thorough response.

References:

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Arlington, VA, American Psychiatric Association, 2013.

Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013).The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City,NV: The Change Companies.

SOUL

I am an avid reader of weather.com and the Weather page of the local newspapers.  This is not because I am finding the latest facts to have an intelligent weather conversation with the next person I meet.  It is because of two realities facing me at home and at work.

*      California had its driest year in history in 2013. This year we have so far received less than half the rain we should have by now.  We are in a drought. We have been doing our best to cut water use – collecting water in the shower while waiting for the water to warm up and using it to water the plants; not turning on garden sprinklers; and “if it’s yellow, let it mellow; if it’s brown, flush it down” (sorry for the bathroom talk).

*      At work, my commute is often an airplane ride into potentially snowy or stormy airports.  It is not good to be scheduled for a workshop or keynote presentation and be stuck at an airport in another state!  So I am always anticipating a Plan B if there is bad weather predicted en route or for my destination.

 

So this year there has been a strange phenomenon where I check every day hoping to see the weather prediction of either 100% precipitation or 0% precipitation – depending on whether I am home or on the road.

 

If I am at home, I rejoice to see 100% rain predicted because that means we are one step closer to breaking the drought.

 

If about to go on aroad trip, I want to see 0% rain or snow predicted, so I am not stressed about getting to the conference on time.

 

It’s funny how the context can totally change what we want by 100%. It’s a bit like when working with mandated clients.  You can either side with the victim-side of the client (“They made me come”) by saying something like: “Iknow you don’t want to be here, but you have to be, so suck it up and see if you can get something out of the program.”

 

Or, you can change the context and say: “Thank-you for choosing to work with me, so I can help you get people off your back and help you keep your job, or get your children back, or stay out of jail.”

 

I don’t want to be in an unproductive drought or a stressful storm.  By changing the context, you can avoid droughts and storms in your work with people too.

 

I hope it rains…well not next week when I’m traveling.

Until next time

See you again in late April.

David

Vol.12 , No. 4

Welcome to the July edition of Tips and Topics. If you are in the northern hemisphere, I hope your summer is fun. If not, stay warm!

David Mee-Lee M.D.

SAVVY

This month, there was a vigorous discussion amongst some members of a relatively new and small group of Addiction Medicine Physicians called “Like Minded Docs”.

 

“We Like Minded Docs are a group of compassionate physicians who support efforts to improve the quality of care for persons with addiction. We seek to put more “heart and soul” back into all aspects of the practice of addiction medicine. As we strive to achieve that shared goal, we will continue to work with the American Society of Addiction Medicine (ASAM) and other organizations toward a comprehensive, integrative approach to addiction treatment.”

www.likemindeddocs.com 

 

We Like Minded Docs don’t actually walk lock step on a variety of issues in addiction treatment, as I discovered full well this month. A discussion began about people who use alcohol or other drugs while in residential or inpatient treatment, and what to do about that. It was fascinating to see how this group of committed physicians, all of whom firmly believe addiction is a disease needing chronic disease management, varied in their views on what to do when a patient has a flare-up of addiction and uses substances while in treatment.

 

In the 1980s, I established and directed an inpatient addiction treatment unit. There we had a zero tolerance policy and discharged patients who used while in treatment. I have long argued, since then, about a zero tolerance policy. It is not consistent with viewing addiction as a chronic disease characterized by loss of control of use, and prone to relapse or acute exacerbation of addiction illness.

I have written on this several times before. You can read more in the October 2012 and November 2012 editions of Tips and Topics.

http://www.tipsntopics.com/2012/10/

http://www.tipsntopics.com/2012/11/

 

TIP 1

Consider these steps when a person uses substances while in treatment.

 

1. View such a flare-up as a poor outcome, which needs assessment and a change in the treatment plan.

2. Collaborate with the patient to discover: What went wrong? What is s/he willing to do differently in their treatment plan that is in a positive direction?

3. Call a crisis patient community meeting.   Highlight the dangers of use in the treatment community and address any triggering or even actual use by others.

4. Work with any patients affected by their fellow patient’s flare-up. Help them learn from this and change their treatment plan accordingly.

5. Discharge the person who used only if s/he is not interested in treatment and just wants to “do time” in a treatment program and continue using trying not to get caught.

 

Now not all my Like Minded Docs agree with these steps. It was interesting to note different approaches by some addiction medicine specialists. Here are some excerpts and my commentary on their approaches:

 

Comment #1

I had a patient once who took meds brought in by another, and I did not ‘kick out’ the one who used in treatment who had been given the drugs by the ‘smuggler’. She was forever grateful that we let her stay and process her use. But the person who brings drugs in and violates the safety of the milieu, is a ‘vector of disease’ and this person must be removed, for his/her own good, and to protect the integrity of the environment….

 

If someone brings drugs into a residential environment, for WHATEVER reason, is that ‘enough’ of a ‘violation’ that even if it is ‘predictable addiction behavior’ we need to transfer them to another location? I argue that it is……and this isn’t ‘punitive’ to the person, but it’s necessary for the care of the OTHERS in treatment…bringing drugs into a residential setting is assaultive to the community….it’s one of the expellable offenses that makes the treatment environment unsafe and “untherapeutic.”

 

My Commentary #1

The patient you did not “kick out” is an example of good therapeutic action and results: retaining in treatment the patient who used and this becoming a learning experience for which she was eternally grateful.

 

The patient who was the “smuggler” should have been discharged if he did so because he was willfully not interested in treatment. If he figured he would just hang out in a program because he was mandated, continue to party, use substances and pull others down with him, then discharge fits the assessment of his not being”in treatment”. It is assaultive to the community and expellable if the person has no interest in looking at or working on his addictive behavior.

 

However- if your “smuggler” was a patient in crisis, whose addiction was acutely flaring up with use, then that patient is in need of the same assessment and process to change the treatment plan as the patient who was not “kicked out”.  I would argue that the treatment environment is strengthened and made more therapeutic by embracing the crisis of this patient’s acute exacerbation of addiction, which is not willful misconduct. The community is strengthened by helping this patient who (there but for the grace of God) could be any one of the other patients. Furthermore it addresses the needs of anyone else who also used with him or her.

 

And why are we even using terminology like “kicked out” and “smuggler” anyway when we are talking about a chronic disease?

 

 

Comment # 2

“Patients come into treatment in a residential setting and are extremely vulnerable whether they are in detox, just finishing, or after detox. They come into residential treatment with the hope and expectation that the environment is safe and drug-free. I cannot allow someone to bring drugs into the community and not do anything. If their using jeopardizes the community, then they need to be removed from that community by going to a different level of care within the current system or transfer to another system. We move them to an increased structure.”

My Commentary # 2

A zero tolerance policy prioritizes keeping the treatment community safe.Equally important is the patient in crisis AND keeping the treatment community safe. “Doing something” is equated with discharging or transferring the patient. However it IS”doing something” to take the following actions:

  • Call an emergency community meeting with all patients. Have the patient explain what happened in their flare-up and substance use.
  • Mobilize the community to take care of anyone who is triggered, not least of which the person who just had an acute exacerbation of addiction.
  • Assess what went wrong to get a poor outcome of substance use. Change the treatment plans of all affected by the crisis. Change level of care only if the new treatment plan cannot be delivered and provided in the current level of care.

 

When there is an acute exacerbation of addiction illness, it is not therapeutic action to discharge or transfer someone out of the milieu. Psychiatric patients also enter an inpatient unit very vulnerable. If we discharged every patient who cuts themselves, attempted suicide, became psychotic, angry, loud and violent in order to keep the inpatient community safe, we’d have no patients.

 

When someone physically attacks other patients, commits sexual predatory behavior, then that is behavior which “jeopardizes the community”. If the program is unable to help the patient contain those behaviors, a safer place may be needed. All addiction patients must learn how to deal with triggering situations. Addiction flare-ups create triggering situations. Treatment must address both the patient in crisis AND others in the therapeutic milieu. Good therapeutic results can occur for the patient in crisis in their hour of need; and the others affected by his addiction flare-up.

 

 

Comment # 3

“The bringing in of drugs should be assessed and if there is no “correctable cause” found then the risk of it happening again is too great to continue in the current level of care. If the cause is found but the patient won’t engage to correct it and decrease risk, same thing, transfer or discharge is needed.

 

However, like any other symptom of the illness, if a correctable cause is found and corrected so that one can say that risk of recurrence is no greater than someone else bringing in a drug, then there should be no contraindication to the patient staying.”

 

My Commentary # 3

This physician’s approach parallels what is done with other signs, symptoms and flare-ups of any illness or disease. Bringing in or using substances is a sign and symptom of a flare-up of addiction illness for which a correctable cause is assessed and treated.

For example: Did the person get into an argument with his partner, which triggered drug use? Were cravings to use overwhelming so all he could think of was to buy and use drugs? Did he attempt to self-medicate anxiety or depression by using? Is the patient still hanging out with using friends?

 

Once a correctable cause is discovered with the patient, treatment continues if the change in the treatment plan addresses the problem:

e.g., “OK I won’t hang out with those friends anymore. Help me know how to say “no” to them.”
Or “when I get upset, depressed or anxious, I’m now ready to practice reaching out to someone for support and practicing my progressive relaxation exercises.”
When/if the patient is not interested in addressing the correctable cause of their substance use, they have a right to choose no further treatment and leave.

 

 

Comment # 4

“In our setting we identify relapse as a symptom of addiction, and if the patient self- reports we would dissect his relapse as a community process, and so far we have not seen relapse occur as an epidemic….our patients will soon enough be in a real world setting where relapse is the experience of many peers, especially in opioid recovery. Helping patients, and the patient who relapsed, have a process for understanding the chronicity of addiction and how to return to recovery following relapse can save them from saying “F- -k it, I relapsed, I failed – I’ll just stay high” and then fatally overdosing.”

 

My Commentary # 4

This resonates with the physician in Comment #3.
When a person uses substances while in treatment, it is a reminder to everyone that addiction is a chronic illness that can easily flare up.  Our job is to assess and help them get back on track, rather than do anything that makes them feel defeated and give up.
I wonder how many of those patients I discharged for using (back in the day) felt like a failure, perhaps resumed active addiction and maybe even overdosed.

The unintended negative effects of a zero tolerance policy include:

  • The effect on the rest of the patients: “I better keep this to myself if I see someone else BUDDING (Building up to a drink or a drug) or actually using, if I don’t want to be the rat who turns my fellow patient in.”
  • This sets up an environment where substance use in treatment goes underground. People can’t openly confront and deal with any triggering that may be happening to them by someone else’s BUDDING.
  • The message to patients is: Substance use by an addicted person is willful misconduct for which you will be sanctioned, removed, discharged or transferred away from your treatment environment.
  • This makes it very hard for patients to be honest about any use, especially if they want to “complete” the program to keep their job, gets their kids back or get off probation.

SKILLS

One of the Addiction Medicine physicians shared a case. It provided a great illustration on what taking action and doing something means…..other than the often-usual transfer or discharge of  the person who used substances while in treatment. For confidentiality reasons, I have altered the case. As well, I have excerpted clinical case material and interspersed my comments and suggestions on how to take therapeutic action.

 

TIP 1

What does taking action look like when a person uses while in treatment?

 

This week one of the patients admitted to the staff and other clients that he got some vodka at an Alcoholics Anonymous (AA) meeting and drank it.”

  • The fact that the patient let staff and other clients know that his disease had flared-up is huge, especially if you hope to have an honest program. First this must be acknowledged as it’s so hard to admit powerlessness over this disease.
  • The fact he drank is not a good outcome. However he got honest, and this is something to be positively reinforced, not suffer a transfer away from continuing care in the program.
  • Poor outcomes in treatment leads next to an assessment of what went wrong; then a collaboration on how he will change his treatment plan. Stu Gitlow, M.D., President of ASAM uses the metaphor of being in a locked room desperate to escape: “Addicts feel like they’ve been in the locked room for too long and that they must do something. It’s not a choice once they reach that point. What is a choice is whether they use other methods to escape the room prior to reaching that point. ”
  • Once addiction flares up and a person uses, Like Minded Docs seem to be in disagreement. Is this willful misconduct or out-of-control disease? I agree with Stu that “it is not a choice once they reach that point.”
  • Also I agree with: “What is a choice is whether they use other methods to escape the room prior to reaching that point. ” If patients knew how to do that perfectly, they wouldn’t need treatment and wouldn’t be severe enough to need a residential treatment level of care.

 

Andrea Barthwell, M.D., Founder, Two Dreams Outer Banks and Director, Encounter Medical Group approach referenced William E. McAuliffe in a National Institute on Drug Abuse (NIDA Research Monograph 72, 1986) about recovery training. According to Andrea, McAuliffe described treatment as complete when:

(a) the patient acknowledges addiction,
(b) commits to recovery, and
(c) reduces or eliminates inducements to use.

 

“When I apply that to where a patient is” Andrea said, “substance use is not “relapse” unless those three simple criteria have been met:
(a) acknowledge – knows the disease and understands he has it;
(b) commit- heartfelt acknowledgement and willingness to follow lead of peers and professionals without resistance;
(c) reduce/eliminate- follows assessment of untreated issues and takes care of them (risky peer group, drug dealing boyfriend, untreated bipolar disorder, etc.).”

 

Dr. Barthwell continues: “So, I look to keep building on the gains made in treatment until these three criteria are met and thus look at substance use as really just “continued” use and not ‘relapse’.”

  • So now that this patient has told staff and clients about his continued drinking this is a crisis for both him and the treatment community.
  • For him,it is critical to build on his honesty that he drank vodka. We must now assess and make changes around how he failed to “use other methods to escape the room prior to reaching that point.” Or, as Andrea says: “assessment of untreated issues and takes care of them (risky peer group, untreated bipolar disorder, etc.).”
  • Here are questions to explore with the patient: “What happened when you were at the AA meeting and got vodka? What could you have done before you even looked at the vodka? Before you drank it? Or even before that, what could have done for your BUDDING signs (Building Up to a Drink or Drug)? Do you even know what your BUDDING signs are? Are you in a risky peer group? Do you still stay in touch with drinking friends? Is there an untreated co-occurring mental disorder? What stopped you from reaching out BEFORE you even looked for alcohol?”
  • A good assessment will help this patient in his acute exacerbation of his disease and will help all the other clients, some of whom might even have drunk with him. That must be opened up before the community becomes toxic.

The case continues:

I wanted him out and transferred to a higher level of care, being a traditional inpatient program. He clearly needs a more structured program.”

  • Why do we want to transfer patients out when they get honest about an acute flare-up of addiction, and are clearly in a state of crisis? They need help, now, with staff and clients who already know them and can immediately build on whatever treatment has already started.
  • Good things have apparently already happened in treatment so far – the patient was honest and shared about his alcohol use. That action is to be positively reinforced, not punished, especially if we believe addiction is an illness where it is common for people to lose control.
  • In any poor outcome of any illness, the next step is to assess what is the problem(s). What services are needed? The intensity of services needed determines the level of care – not automatically “up” the intensity ladder.
  • The patient may not need a more structured program- if he now sees that he needs more names and numbers, OR a sponsor, OR to call people before he picks up a drug, OR to have a psychiatric evaluation, OR to stay away from certain friends OR to be on an anti-addiction medication….or whatever the problem and treatment needs are.
  • In no other disorder do we automatically think a person needs a more intensive level of care when there is a poor outcome or deterioration in progress. Why do we treat addiction differently from other chronic diseases?

The problemis it was Friday at 5 pm before the weekend. We were not able to make it happen until Monday. If we streeted him he probably would immediately relapse and of course risk continued heavy drinking. If we kept him we worried about what the other clients would think: “I guess it is okay to drink and use in rehab and nothing happens“.

  • Yes, if this patient was “streeted” for having an acute exacerbation of his disease, that would increase his chance of further deterioration and risk of further heavy drinking and even death.
  • The next step: Call an emergency community meeting with the patients, staff and program community. Explainwhat needs to be done to re-assess this patient and anyone else who got triggered. Then continue treatment if the patient (and anyone else affected) is willing to change their treatment plan in a positive direction.
  • The patients will learn that it is not OK to use; that this is a crisisand an acute exacerbation of their addiction; and that honesty is the bestpolicy to face their mistakes and learn from them.
  • They would learnthat a flare-up of addiction and drug use is like a flare-up of mental illness- feeling suicidal or psychotic.  In the physical arena it is likesomeone who has another asthma attack. The flare-up must be shared immediately with staff and patients so they can get quickly back on track.
  • They will learn the program is here for their support so long as they are making commitment to progress in their recovery; and that they don’t have to be perfect.
  • The patients will learn they need to be vigilant for themselves and for their fellow patient who just used, to help each other get backon track ASAP. It is a crisis.

 

The compromise we made was he can’t stay in our program but we will keep him until Monday. This was discussed with all the clients at a community meeting so theyknew we were taking action. Had he given or offered alcohol to any other client I probably would not have let him stay in the program until Monday.”

  • If the patient indeed wants treatment (but is not perfect) then the best placefor him is to continue treatment with the staff with whom he has formed a therapeutic alliance.
  • In outcomes literature, the therapeutic allianceaccounts for a greater impact on the outcome than even the evidence-based practices used.

 

The Bottom Line

Even among Addiction Medicine physicians there are mixed feelings about:

 

1. Whether alcoholand other drug use in people with addiction is willful misconduct and a choice, which requires expulsion for being assaultive to the treatment community; or whether it is out-of-control addiction where “choice” is no more relevant than “choosing” a heart attack.

 

2. Whether the highest responsibility of providers in inpatient and residential settings is to the other patients to keep the community drug-free and therefore transferor discharge the person who used substances; or whether the milieu can be kept therapeutic by actually dealing openly with the patient whose addiction flared up and with those affected by the patient in crisis.

 

3. Whether zero tolerance policies are effective in keeping an environment safe and therapeutic; or whether the unintended negative effects are for substance use to go underground, encouraging dishonesty and non-confrontation of BUDDING and actual use.

 

Even criminal justice is coming around to the futility of just removing drug users from the community to keep the community safe from drugs.

SOUL

July is Germany’s month…..if you were into the World Cup for soccer or “football” (depending what country you are in.) Germany won it all.

 

For me personally though, July was also my Germany month. “Das ist sehr gut” = that is very good. Not because I spent so much time traveling the country, but because I do love foreign travel. I had the opportunity to conduct a training in Mainz, not far from Frankfurt. No – I didn’t have to do the training in German,”Ich spricht nicht Deutsch” = I don’t speak German… or is it “Ich nicht spricht Deutsch”? It was for adolescent addiction counselors throughout the USA military bases and schools in Japan, Korea, Europe and Hawaii.

 

What was fun was simply noticing the differences in how other countries approach a variety of everyday things:

  • I confess I like driving fast on the highway, however I had to close my eyes several times while my taxi driver sped along the German autobahn that has no Federally mandated speed limit.
  • Hisspeedometer only went up to 180 km/hour on the display and we were hitting160 km/hour or more at times…..over 100 miles/hour.
  • Another taxi driver reported he had tested out his car when he first bought it. He pushed it to 230 km/hour…about 143 miles/hour. My daring 80 mph is chicken feed compared to that!

Then there was getting into and out of the country. No forms to fill out arriving or leaving. Nocustoms declaration of goods brought in or taken out. No inspection of bags. Passport control was over in about 30 seconds with a simple stamp in my passport.

 

The security checkpoint for boarding the plane in Frankfurt was very civilized. In the USA, you often have to search for the cart of plastic trays into which to place yourliquids, gels and toothpaste. (The Transportation Security Administration (TSA) personnel have not yet moved the empty trays stack back up to where the passengers are lining up.)

 

In Frankfurt, the trays arrive on a smooth-flowing conveyor belt exactly where you need them.  It slots the next empty tray into place as soon as you remove one to use.  If you happen to need two trays, you simply reach down and retrieve the next one. No frantic pushing and shoving to grab the last tray on anempty cart, or calling out to a TSA person to bring more trays.

 

One more thing: the stores were closed on Sunday to allow for a more relaxed weekend for people and their families. Not good for an American tourist who wanted to shop, but a reminder that consuming and shopping should take second place to life-work balance.

 

Now for August and mytrip to Australia. That is the opposite extreme and I don’t just mean driving on the left hand side of the road. There, you had better stick strictly to the speed limit or risk a camera-tracked speeding ticket of hundreds of dollars. No 5 to 10 miles/hour grace margin.

 

But at least the US dollar gets me a healthy Aussie dollar exchange rate compared with the dollar-busting exchange rate for the European Euro.

 

Happy travels!

Until next time

Thanks for joining us this month. See you in late August.

David

Vol.12, No. 9

Welcome to the September edition of Tips and Topics (TNT). I’m glad that we have many new subscribers to join our longtime TNT community.

David Mee-Lee M.D.

SAVVY

It is difficult to work in the mental health and addiction treatment field without interfacing with clients involved in the criminal justice system. Some addiction treatment programs receive 90% or more of their clients from the criminal justice system.

 

“In a 2006 Special Report, the Bureau of Justice Statistics (BJS) estimated that 705,600 mentally ill adults were incarcerated in State prisons, 78,800 in Federal prisons and 479,900 in local jails. In addition, research suggests that “people with mental illnesses are overrepresented in probation and parole populations at estimated rates ranging from two to four time the general population” (Prins and Draper, 2009). Growing numbers of mentally ill offenders have strained correctional systems.”

http://nicic.gov/mentalillness

 

Here’s another headline from the Bureau of Justice:

 

STUDY FINDS MORE THAN HALF OF ALL PRISON AND JAIL INMATES HAVE MENTAL HEALTH PROBLEMS

“More than half of all prison and jail inmates, including 56 percent of state prisoners, 45 percent of federal prisoners and 64 percent of local jail inmates, were found to have a mental health problem”. This was according to the 2006 study published by the Justice Department’s Bureau of Justice Statistics (BJS).

http://www.bjs.gov/content/pub/press/mhppjipr.cfm

 

And now, note this headline on addiction and criminal justice:

 

NEW CASA REPORT FINDS: 65% OF ALL U.S. INMATES MEET MEDICAL CRITERIA FOR SUBSTANCE ABUSE ADDICTION, ONLY 11% RECEIVE ANY TREATMENT

NEW YORK, N.Y., FEBRUARY 26, 2010

 

The National Center on Addiction and Substance Abuse at Columbia University, a

drug policy organization, found that “of the 2.3 million inmates crowding our nation’s prisons and jails, 1.5 million meet the DSM-IV medical criteria for substance abuse or addiction, and another 458,000, while not meeting the strict DSM-IV criteria, had histories of substance abuse; were under the influence of alcohol or other drugs at the time of their crime; committed their offense to get money to buy drugs; were incarcerated for an alcohol or drug law violation;or shared some combination of these characteristics, according to Behind Bars II: Substance Abuse and America’s Prison Population. Combined, these two groups constitute 85% of the U.S. prison population.”

http://www.casacolumbia.org/newsroom/press-releases/2010-behind-bars-II

 

Any way you cut it, in clinical work it is increasingly important to understand Drug Courts, Mental Health/Behavioral Health Courts, other Problem-Solving Courts, and how to interface with Probation and Parole officers, Judges and their court teams.

 

TIP 1

What Are Problem-Solving Courts?

 

Here’s how the Center for Program Evaluation and Performance Measurement explains these courts:

 

“Problem-solving courts began in the 1990s to accommodate offenders with specific needs and problems that were not, or could not be adequately addressed in traditional courts. Problem-solving courts seek to promote outcomes that will benefit not only the offender, but the victim and society as well. Thus problem-solving courts were developed as an innovative response to deal with offenders’ problems, including drug abuse, mental illness, and domestic violence. Although most problem-solving court models are relatively new, early results from studies show that these types of courts are having a positive impact on the lives of offenders and victims and, in some instances, are saving jail and prison costs.

 

In general, problem-solving courts share some common elements:

  • Focus on Outcomes Problem-solving courts are designed to provide positive case outcomes for victims, society and the offender (e.g., reducing recidivism or creating safer communities).
  • System Change Problem-solving courts promote reform in how the government responds to problems such as drug addiction and mental illness.
  • Judicial Involvement Judges take a more hands-on approach to addressing problems and changing behaviors of defendants.
  • Collaboration Problem-solving courts work with external parties to achieve certain goals (e.g., developing partnerships with mental health providers).
  • Non-traditional Roles.These courts and their personnel take on roles or processes not common in traditional courts. For example, some problem-solving courts are less adversarial than traditional criminal justice processing.
  • Screening and Assessment Use of screening and assessment tools to identify appropriate individuals for the court is common.
  • Early identification of potential candidates Use of screening and assessment tools to determine a defendant’s eligibility for the problem-solving court usually occurs early in a defendant’s involvement with criminal justice processing.”

https://www.bja.gov/evaluation/program-adjudication/problem-solving-courts.htm

 

 

TIP 2

Access “A Technical Assistance Guide For Drug Court Judges on Drug Court Treatment Services

 

The Justice Programs Office, School of Public Affairs at American University, Washington D.C. http://www.american.edu/justice has published a very useful guide that helps judges understand what is addiction treatment. It helps treatment providers understand Drug Courts. You can Google the guide (paste in “A Technical Assistance Guide For Drug Court Judges on Drug Court Treatment Services“)and it should come right up.

 

There is even a small section on The ASAM Criteria (2013) which I was privileged to contribute.

SKILLS

In May this year, I gave a presentation on The ASAM Criteria at the National Association of DrugCourt Professionals in Anaheim, California. It was such a learning experience for me to be around so many judges, attorneys, court team professionals and treatment providers. In a session I attended on Judicial Leadership principles, I was struck by something one of the judge panelists said when speaking of client outcomes (sorry, I didn’t note which judge it was):

 

“People don’t failDrug Court, Drug Court fails them by not meeting their needs.”

 

Problem-Solving courts are focused on outcomes. But knowing how easy it is to blame the offender and participant in Drug and other Problem-Solving Courts for any poor outcome, that statement really got my attention………and got me thinking:

  • How should Drug Court, the judge, court team and treatment provider work together to meet the needs of participants?
  • How do we collaborate to get the outcomes of increased public and community safety and decreased legal recidivism and crime that we all want?
  • When client outcomes are not going well, what is the balance between client accountability and the treatment provider’s responsibility to improve assessment and treatment planning?
  • What is the role of court sanctions and incentives in holding offenders accountable for treatment adherence?
  • What is the role of treatment providers to keep the court informed about the participant’s threat to public safety?

Some judges are rightly concerned that treatment providers are not watching public safety closely enough.  Not sure that they trust treatment providers’ reports, judges sometimes take treatment into their own hands. This can result in judges working outside their scope of practice and issuing sanctions or mandates that are not clinically assessment based.  Here are some examples:

  • Mandating 90 days of residential level of care
  • 90 Alcoholics Anonymous meetings in 90 days
  • Ordering sanctions that may be ineffective in producing improved treatment engagement and real client functional change.

 

TIP 1

Consider these thoughts on how to deal with sanctions and incentives in Drug Court (and other Problem Saving Courts)

 

Drug court participants are varied and can present with addiction, mental health and physical health complexity. These diverse clinical presentations highlight the need for individualized approaches to sanctions that are:

 

1. Based on assessment of each client’s multidimensional needs as per The ASAM Criteria six dimensions (I’m biased of course, and there are other assessment tools and parameters that address high risk and high need).  So assessing if a person is developmentally disabled and suffers from an intellectual developmental disorder (previously called Mental Retardation) is important compared with a person who has antisocial personality disorder or lifestyle and is very institutionalized and used to incarceration. The intellectually developmental disordered person has deficits in reasoning, problem solving, abstract thinking, judgment, learning from instruction and experience etc.  The institutionalized antisocial person experiences sanctions like water on a duck’s back.

 

2. Based on treatment engagement and good faith effort of the client in treatment. Participants with co-occurring mental and addiction issues will have more difficulty with engagement and have needs that require awareness of their multiple vulnerabilities. Treatment plans need to be assessment-based and person-centered not program and compliance based. Because of different client learning styles and their array of needs, any manualized and evidence-based curriculum may require adaptation to fit each client’s problems and progress/outcomes.

 

This calls for a level of clinical sophistication to use Evidence-Based Practices (EBPs) in a person-centered and outcomes driven manner rather than a compliance and one-size-fits-all manner.  Interactive Journaling is an evidence-based method to facilitate self-change using Motivational Interviewing, stages of change work and CBT.  The Change Companies has a Drug Court journal that can be used along with other journals designed for criminal justice populations used by Federal Bureau of Prisons and many others.

 

3. Based on outcomes in treatment.  Is the client making progress in real accountable change? Are they demonstrating improved functioning that will increase public safety, decrease legal recidivism and crime and increase safety for children and families?  Active credible treatment is not just about compliance with attendance and negative drug screens.  Is the client invested in a change process at a pace that fits their assessed abilities and vulnerabilities? Or is the client merely passively complying, which does not translate into lasting change and increased safety?  How do we impact the revolving door of repeated episodes of treatment and incarceration, which wastes resources and does not produce the outcomes we all want?

 

TIP 2

What is the “bottom line” on how to move from punishment to accountability for lasting change – implications for sanctions and incentives?

 

A. Sanction for lack of good faith effort andadherence in treatment based on the clinical assessment of the person’s needs, strengths, skills and resources.  Don’t sanction for signs and symptoms of their addiction and/or mental illness in a formulaic manner that is one-size-fits-all.

 

B. The treatment provider is responsible for careful assessment and person-centered services and to keep the court apprised of any risk to public safety. The court should be informed about the client’s level of good faith effort in treatment; and whether the client is improving in function at a pace consistent with their assessed needs, strengths, skills and resources. The provider should not just report on passive compliance with attendance and production of positive or negative drug screens….passive compliance is not functional change.

 

C. If the client is not changing their treatment plan in a positive direction when outcomes are poor e.g., positive drug screens, attendance problems, passive participation, no change in peer group activities and support groups like AA etc., then the client is “doing time” not “doing treatment and change.” Providers need to then inform the judge that the client is out of compliance with the court order todo treatment.  The client consented to do treatment not just do time and should be held accountable for their individualized treatment plan. If the client is substantively modifying their treatment plan in a positive direction in response to poor outcomes; and adhering to the new direction in the treatment plan, then the client should continue in treatment and not be sanctioned for signs and symptoms of their illness(es).

 

D. Incentives for clients can be explored and matched to what is most meaningful to them.  For example, incentives that allow a client to choose a gift certificate or coupon for a restaurant may be meaningful for some clients.  But others may find assistance in seeing their children; or receiving help with housing; or advocacy to change group attendance times to fit better their work schedule to be more meaningful incentives to be used.  This requires an individualized approach recommended to the court by providers who should know their client’s needs, skills, strengths and resources.  It is too much to expect the judge can work all this out in a busy schedule of court appearances.

 

E. A close working relationship between the client, judge, court team and treatment providers is needed to actualize this approach.

 

These ideas come from my clinical bias and experience, but they are offered with awareness:

  • That we need more discussion to make this work in the world of courts and criminal justice.
  • That to achieve the public safety outcomes we all want, we have to move treatment from a passive compliance and a ‘jumping through the hoops’ mentality that allows many clients to “do time” in treatment instead of “doing treatment and change”.
  • That treatment providers will need to rise to the occasion and improve assessment and person-centered treatment planning that values outcomes-driven services.
  • That judges and court personnel can expect treatment providers to design and deliver individualized care; and to keep them well-informed on any threats to public safety. Reports need to be on functional improvement not just compliance with attendance and drug screens.

SOUL

Recently a colleague was to meet up for dinner but had to cancel because he strained his back and was in a lot of pain. I know what that is like. Over 20 years ago, I reached up to place my roll aboard suitcase in the overhead bin on the plane only to be shocked by a sharp back pain that left me walking like a 120 year old.

 

Hopping out of a car is a quick turn to the side, swinging your legs to the outside and rising out of the car seat….right? Not when you have back pain. Even in slow motion, each of those maneuvers can be excruciating. If you think back pain is mind over matter, let me know after you get your first attack.

 

On the other hand, it is true that people can milk back pain for all kinds of advantages: “I’d help you move those tissue boxes, but I have a bad back.” “Sorry I can’t come to the volunteer community park cleanup, I have a bad back (and by the way, the game is on TV).” I’d help with the dishes, but you know my back is bad today.”

 

Twenty years ago, I had almost crippling back pain in Greece on vacation, in Australia on vacation and when I moved to California. But I haven’t had an acute episode in nearly 18 years!

 

Lucky streak of good health? I don’t think so. On that bad back attack in Australia, I saw a musculo-skeletal physician who was quick to prescribe not narcotic analgesics,but rather muscle strengthening exercises. They take less than five minutes a day and I swear by this preventive remedy.

 

Here’s the three sets of exercises the Aussie doctor taught me:

1. Modified windshield wipers – I lie on my back with knees bent and feet flat on the floor. Arms are by my side and I sway my legs back and forth like windshield wipers. This seems to loosen up the back and spinal muscles.

 

If you want to do the real thing, you can check out:

How to do Windshield Wipers

http://www.health.com/health/video/0,,20732158,00.html

http://workouttrends.com/how-to-do-windshield-wipers

 

2. Next, do Pelvic tilt exercises. Same position on my back, feet flat on the floor, arms by my side. Then I tilt my pelvis up and down repetitively.

 

If you want to see a professional teach this, go to:

How to Do Pelvic TiltExercises -YouTube

https://www.youtube.com/watch?v=lTX15Qk1xTM

 

3. The third exerciseinvolves abdominal crunches. Same position on my back, but this time, I raise my legs and rest my feet on a stool or chair. Keeping the neck in line with your spine, not bent forward with chin touching your chest, do some crunches to strengthen abdominal muscles. I cross my arms across my chest butyou can check out a couple of ways here:

How to Do Crunches

https://www.youtube.com/watch?v=Xyd_fa5zoEU

http://www.wikihow.com/Do-Crunches

 

How many repetitions of these are necessary? I don’t know what works for you, but at first, if the back pain is still acute, just do a few to get the idea…maybe five each. But I have worked up to do 3 sets of 20 windshield wipers and pelvic tilts and 2 sets of 20 crunches in sequence: wipers, tilts, crunches to tilts,wipers and crunches and ending with tilts and wipers.

 

I talked to another colleague today. He is going for an MRI in preparation for back surgery, hopefully to fix his chronic back pain.

 

I feel bad for him and I know I don’t want to get anywhere near that. I better do my wipers, tilts and crunches.

Until next time

Thanks for joining us this month. See you in late October.

David

Vol. 13 , No. 4

Welcome to the July edition of Tips and Topics. I hope your summer is going well for our northern hemisphere readers. Stay warm Down Under.

David Mee-Lee M.D.

SAVVY & STUMP THE SHRINK

Earlier this month, I received a question prompting this combined SAVVY and STUMP THE SHRINK.  This is especially relevant if you work in a program that focuses on rules and regulations, consequences for breaking the rules, and behavior contracts.

 

Even if it is the treatment plan that focuses your work with the client, it is easy to become distracted by behavior which disrupts the group and treatment milieu. Here is what Bob Fox of St. Paul, Minnesota wrote:

 

Question

Dr. Mee-Lee:

“I work in Level 2.1 Intensive Outpatient, mixed gender group. What is your view on policies about treatment peers forming exclusive, romantic relationships, or plain old sexual intimacy (hooking up) in treatment?”

 

Bob gave me three multiple choice options, but as you can see further below, I waxed eloquent and expanded way beyond the offered choices:

 

“a.   Should the relationship be prohibited and one or both clients be discharged (referred to another program?)

b.   Should the relationship be allowed, but the involved clients be separated into different groups? And then a focus of treatment is learning about healthy relationships, boundaries, etc.?

c.   Or some other option?”

 

TIP 1

Think about how you deal with emotional, behavioral and cognitive issues that are potentially disruptive to the group and treatment milieu.

 

My response

In general, my view is to see all emotional, behavioral and cognitive problems as treatment issues needing to be dealt with in the context of an individualized treatment plan.  That plan should be frequently and collaboratively changed depending on what is working well (or not working well) in the client’s progress in treatment.  

 

So in this case…. if peers are forming relationships and hooking up, that is behavior which is going to happen while a person is in treatment and certainly occurs when people are not in treatment.  I suspect that for many clients in treatment the relationships and sexual behavior they engage in has created problems in their lives previously – both substance-related and non-substance-related.

 

In outpatient and residential treatment, we have an opportunity to create:

  • A safe, therapeutic environment.
  • A therapeutic milieu which seeks to engage and attract people into an exploration of what has worked well for them before and what has not worked well.
  • An opportunity allowing clients to develop and practice new and healthier ways to deal with their behavioral health problems.  

In addiction treatment and sometimes in mental health as well, we have had a tradition of creating a safe environment by having rules, policies and consequences if clients break the rules: like behavioral contracts; set back a level or phase in residential settings; loss of privileges; writing tasks; separating people into different groups; discharge etc.

 

We need to rethink our attitudes about what treatment is meant to do:

  • Meet people at the stage of change they are at. (What is the person at Action for? Identify their issues. Are they possibly still in a Precontemplation, Contemplation or Preparation stage of change?).
  • Help them self-identify and own the issues that keep “shooting themselves in the foot.” What behaviors are counterproductive to recovery and getting them what they want? Is it health and wellness? Maybe getting their children back? Getting off probation? Keeping a job? Retaining a relationship? Keeping their housing? Being sober and embracing recovery? Whatever it is that brought them to treatment- find it out.
  • Work compassionately with them to facilitate a self-change process using a collaborative, accountable treatment plan.
  • Fashion with them an updated treatment plan whenever progress stalls or new issues arise e.g., exclusive relationships and sexual behavior. The new strategies should move in a positive direction.

TIP 2

Help clients assess and evaluate the “differential diagnosis” of their emotional, behavioral and cognitive issues and the effect on their lives.

 

The answer to the STUMP THE SHRINK question centers around having a talk with the clients in the exclusive relationship. In addition, talk with all their peers in group regarding the dangers of becoming distracted by exclusive relationships and sexual behavior. Explore with all the clients about how this type of situation has distracted them in the past, how it distracts now in the present setting. Converse about how it can ‘de-focus’ people from recovery, from attending to their “work” of embracing new ways of being and doing.  

 

1. Engage the group in talking. Where has this been an issue in other peers’ lives? What have they learnt from those experiences?

2. You can also discuss the dangers of forming intense new relationships early in recovery, especially if the new “love of my life” is also new in recovery and may even be less interested in recovery than I am.  

3. How easy it is to turn to relationships and sex as a way to deal with pain e.g., regrets of past mistakes, lost relationships and jobs, mental health issues? Discuss this angle.

4. Pose this question for discussion: How can sex or a new relationship avoid the hard work of recovery? Can people avoid taking “a searching and fearless moral inventory of ourselves” (Alcoholics Anonymous 4th Step)? Looking at your life, whether in addiction or mental health treatment, can be a very hard thing to do.

5. Identify if certain mental health issues are contributing to such behavior e.g., unresolved issues with parents; or trauma or sexual abuse.

 

In other words, there is a whole “differential diagnosis” of what forming relationships and sexual behavior can mean.  These are assessment and treatment issues to be opened up for the clients involved.  There is also a rich opportunity for the other peers in the group to explore these issues for themselves for “there but for the grace of God go I.”  

 

TIP 3

Consider what happens to treatment if the focus is on rules, consequences and discharge.

 

You can “prohibit” the exclusive relationship and sex, but are you also going to “prohibit”:

  • Substance use and relapses (we still do this often and I have written before about discharging people for having the symptoms and signs of their addiction illness).
  • Angry outbursts.
  • Cravings to use with irritability and isolating behavior.
  • Disrespectful talking and interactions with peers and staff.
  • Hanging out with drug-using friends.
  • Telling war stories about drugs etc. etc.

Treatment is not about us making people behave. It is about helping them make the right decisions in the dark of night when nobody is watching.  If people do the right thing only when in our program, have we helped them to help themselves when we are not around?  Have we facilitated a self-change process which enhances sustainable recovery? Or have we externally imposed compliant behavior that too easily falls away after “graduating” from treatment?

 

TIP 4

When is it appropriate to discharge people for their behavior?

 

A. There may be mandated clients who say they want treatment, but end up just “doing time”.  They occupy and distract themselves by forming relationships and hooking up. They are not, in good faith, looking at the meaning of their behavior, the negative effects on their life and on others.   Just sitting in a chair is not doing treatment. They are not choosing the work of treatment. At that point, you can talk about discharge.  

  • So you would be discharging them not because of bad behavior or breaking rules, but because they are not being open and willing to change their treatment plan in a positive direction. They have a right not to do treatment. As the clinician, you have a right to keep the treatment milieu therapeutic and “discovery” and “recovery”-focused.

B. If you ascertain someone is a sexual predator focused on disrupting treatment for themselves and others through forming relationships and hooking up, then discharge is appropriate. Why? Because you run a treatment place, not a dating place.  

  • Let’s say you determine a client’s behavior is part of their biopsychosocial-spiritual illness with implications for addiction, mental health and physical well-being. Then these are important treatment issues to pursue with further assessment and treatment. Do not discharge and hope you can just prohibit human behavior. If the person is willing to deal head on with this behavior and attitudes, then treatment is what they need. To discharge them for having problems to work on doesn’t fit my vision for treatment.

A friend and colleague recently said this:

“My mantra is, ‘this is the place where you don’t have to be at your best.’ If people are out of sorts or have a bad hair day, all the more material for the staff to work with.”  

Andrea G. Barthwell, MD, FASAM

Oak Park, Illinois

708-613-4750

www.twodreams.com

 

If we expect people to behave and be at their best, then they probably don’t need treatment and have nothing important to change.

SKILLS

In June 2003, the 3rd edition ever of Tips and Topics, I wrote about “Discovery, Dropout” (D/D) prevention plans for people in early stages of change, those not yet interested in recovery. I also wrote about “Recovery, Relapse” (R/R) prevention plans for people at Preparation and Action for recovery.  In 2015, you still find most treatment providers in general health, mental health and addiction treatment creating treatment plans which assume the client/patient is committed to recovery and relapse prevention.

  • The doctor or nurse writes a prescription for the patient expecting adherence and healthy living. Actually medication non-adherence is widespread with rates ranging from 25% to 50%. Between $100 and $300 billion annually of avoidable health care costs in the US have been attributed to non-adherence.

(Aurel O Iuga and Maura J McGuire: “Adherence and health care costs”. Risk Management Health Policy. 2014; 7: 35-44. Published online 2014 Feb 20. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934668)

  • Psychiatrists and mental health clinicians document problem #1 as “Psychosis” and problem #2 as “Medication Compliance” in the treatment plan.  However the patient thinks they are not mentally ill, it’s a conspiracy and the medication is poison and part of the plot. No wonder the patient doesn’t take their medication nor show up for sessions.
  • The addiction counselor documents strategies of abstinence, AA meetings and changing drug-using friends when the client simply just wants to cut back, hates AA and sees nothing wrong with his friends. No wonder he drops out of treatment.

What patients and clients actually need is a Discovery, drop-out prevention:

  • To discover for themselves (with our help) that what they are doing with their emotions, behavior and thinking is not getting them what they want.
  • We need to do all we can to prevent them from dropping out of services, so we have a chance to attract them into recovery.

TIP 1

Consider these Sample Strategies for Treatment Plans

  1. List three reasons the court sent you to treatment (D/D).
  2. Write down the most recent incidents involving alcohol and other drugs (D/D).
  3. Identify what happens if you don’t comply with probation requirements and report to group (D/D).
  4. List the positive and negative aspects of substance use (D/D).
  5. Attend at least one AA meeting and see if you can identify with anyone’s story (D/D).
  6. In group, verbalize what things need to change in your life or not (D/D).
  7. Discuss the positive and negative consequences of continued substance use (D/D).
  8. Explore early childhood history of violence through individual therapy once per week. Focus on what kind of role models the client had then, and how this affects relationships now (R/R).
  9. For the next incident of rage and anger, track it. Fill in the date, trigger, physiological signs and your behavior. Then discuss how you could have de-escalated the incident (R/R).
  10. In group, share what has been working to prevent relapse and obtain other suggestions (R/R).

For more on Discovery plans, see SKILLS in the March 2006 edition.

https://www.changecompanies.net/blogs/tipsntopics/2006/03 

 

Related past editions explain aspects of this too if you want to take a look:

February 2013

https://www.changecompanies.net/blogs/tipsntopics/2013/02 

 

November 2012

https://www.changecompanies.net/blogs/tipsntopics/2012/11 

  

TIP 2

Treatment Plan Strategies for Working on Relationships and Hooking Up

 

Referring back to Bob’s question: if the clients are interested in treatment, they will be willing to change their treatment plan in a positive direction using such strategies as:

  1. Talk with a counselor about where relationships and hooking up has affected their life and addiction in the past. Share that in group to receive feedback.
  2. In group, explain what is so great about the new, exclusive relationship. Obtain feedback on whether this relationship will help, hinder or jeopardize recovery.
  3. Have a trial of staying away from the other person for a week. Then have each person in the relationship talk in group about what that experience was like.
  4. In group, talk about examples of past relationships and sexual behavior they got into quickly. Examine how that contributed to problems in their life, both addiction-related or not.  

Once you have done more assessment, there would be many other strategies that might fit better for this client. If they are willing to do this work, treatment continues. Don’t separate them or discharge them. Use the power of the group to implement these strategies.

 

Note of Caution:

You’ll notice that I define good faith working in treatment as “being open and willing to change their treatment plan in a positive direction.” Or as they say in AA “progress, not perfection”. We would like every person from Day 1, to be:

  • perfectly sober, with no cravings or impulses to use and no actual use
  • perfectly delaying gratification for relationships and hooking up and totally focused on recovery
  • perfectly non-depressed, non-psychotic; non-anxious; non-manic
  • perfectly non-angry, irritable and isolating
  • perfectly non self-mutilating, suicidal or impulsive etc. etc.

But if our clients and patients could do all that, they wouldn’t need our help in the first place! So if you have a notion to change their treatment plans by inserting: “Bob and Jane will end this inappropriate relationship and sexual behavior and focus on recovery” and then discharge Bob and Jane when they break their treatment plan, that is “perfection” not “progress”. It is not changing their treatment plan in a “positive direction”, it is expecting perfection and the final outcome immediately.

SOUL

I just have to tell you my Medicare story. (So now you know I’m a senior citizen.) Last year when I joined Medicare, I was looking forward to that much lower monthly premium for health insurance…and yes, it was quite a bit lower. But then new notices came informing me that the bill was going to be higher because of my income. (So now you know I’m not a minimum wage senior citizen.)

 

I was OK with that, because I don’t mind contributing to the greater good if I can afford it. But then the amount I owed kept changing and I dutifully paid what the monthly invoice said. Here’s where the story gets interesting (or is a better word “frustrating”).

  • Invoices would come late with a due date that had already passed; or were so close to the date I received the bill, that it was bound to be delinquent.
  • You can’t pay online, so by the time snail-mail arrived, it was surely late, plus the three weeks it takes for their department to process the payment.
  • So now, each monthly invoice was showing either delinquent amounts owed and/or unprocessed payments I had already made.
  • Then I didn’t receive any invoices for two months. Had I already paid too much in advance, so they didn’t send me a bill? Or did it get lost in the mail? Or had I lost my Medicare? Who knows, because you can’t check your account and payments online – like every other business.

Time to call and talk to someone at Medicare. I called on a whim one night to see what hours they were open and amazingly you can talk to a “live” person- they are open 24 hours a day, 7 days a week. And it is not someone in the Philippines or India. Sounded like a regular ole American.

  • Nice helpful man, but after 7 PM he can’t check the computer records to see what I owe or not. I could call back the next morning and then find out what I owed. But he did tell me I could sign up for Medicare Easy Pay where the payments would come directly out of my bank account. That sounds more like it in the 21st century.
  • But not so fast. He would have to mail me the form to fill out, and that could take 3 weeks; then it could take up to 8 weeks to process my application for Easy (or not so Easy) Pay. Faster, he said, to sign up with my bank for online payment directly.
  • Went to my bank website and in 5 minutes I had signed up and paid a couple months’ premium just to be sure I wasn’t behind. “I’ll check in the morning to see where my account stands”, I said to myself.
  • Next morning at the Medicare call center, there was a nice helpful lady and not a long wait to get to her either. However, she can see what premium I am being charged, but has to send a special request to another department to tell me whether my account is ahead or behind and what has happened to my monthly bills.

“Is there no way that I can go to a website, see my payments and what I owe, just like I do with my credit card, electric and phone bill etc.?”

 

No, I’m sorry, we can’t even see that. I have to send a request to another department and they will call you to let you know where your account stands.”

 

“Could they not send me an email, because what if I miss their call?”

 

Oh, well if they don’t reach you, they will send information in the mail.”

 

“You mean, regular snail-mail, not email?”

 

You get my drift. Now I think it is great that Medicare is open 24/7 and the hold time was very reasonable. BUT I spent at least a half an hour or more with people who receive more than minimum wage and nice government benefits only to find out that they can’t help me. The information I need will take much more time being spent by more government workers who will use last century’s methods to communicate with me.

 I better stop here and recite the Serenity Prayer. But if any of you have the courage and wisdom to make government more efficient, please step forward. This old guy feels a bit hopeless.

Until next time

Glad you could join us this month. See you in late August.

                           

David

March 2016

Vol. #13, No. 12


In this issue

Criminal justice reform; treatment and functional change; sanctions and incentives

David Mee-Lee M.D.


(more…)

Upcoming conference; 14 minutes at Longwood University; Stump the Shrink

Vol. #14, No. 7

David Mee-Lee M.D.

SAVVY AND CONFERENCE ANNOUNCEMENT

Upcoming Conference:

If you’d like to come to sunny California soon for the 7th Western US Journal Training Conference October 24-26 2016, in Newport Beach, CA, The Change Companies is featuring a “Justice Services Track” for all those who work directly within the Justice System. I will be speaking and attending. And there is much more – take a look at

http://www.usjt.com/Conferences/2016/7th-Annual-Western-Conference-on-Behavioral-Health-and-Addictive-Disorders/ 

Hope to see you there.

David

Earlier this month, I got an email from Kevin Doyle, Ed.D., LPC, LSATP., who is a “longtime counselor in substance use disorder treatment, now Assistant Professor in Counselor Education at Longwood University in Farmville, Virginia. If “Longwood University” sounds familiar, but you aren’t quite sure why you remember the name, it is because it was the site of the October 4 Vice-Presidential Debate.

Kevin was asked to give one of about 10 faculty talks that afternoon as part of Longwood University’s debate-related activities. He talked about “Addiction and Public Policy” and covered many topics that I have written and spoken about before – only he covered them not in a day’s workshop, but in 14 minutes. You can see his presentation at: https://youtu.be/5UP5njyders

Since the Presidential election is heating up to a fever pitch, I thought a summary of Kevin’s points would keep us in the election mood, since he was up close and personal to at least the VP candidates. And by the way, Kevin is an “avid reader of Tips and Topics, which I enjoy very much.”

TIP 1

Review how attitudes and terminology about addiction, perpetuates stigma

Kevin reviewed many points about stigma and the way the public, payers and providers view addiction treatment. Here is his list with some comments I added:

1. How we perpetuate stigma – we talk of “addict” and “alcoholic” instead of saying “a person with addiction or a substance use disorder” – Use person-first language

The most recent Tips and Topics on this is September 2015:

https://www.changecompanies.net/blogs/tipsntopics/2015/09/

2. When a person goes for help for treatment, we say they were “sent to rehab” instead of “they are seeking help for a condition or a particular problem.”

The public, payers and policy makers and even treatment providers think addiction treatment is doing a set length of stay in “rehab” – a residential program from which the person will graduate and complete. Some insurance benefit plans then limit the number of “rehab” admissions to two, 30-day episodes a year, instead of understanding an addiction treatment continuum of care.

3. Families and clients sometimes say “We tried treatment and it didn’t work”. But if a cancer patient tried chemotherapy and the cancer recurred, most would try it again or certainly not give up on treatment and dismiss it.

With addiction, families and even physicians feel that if treatment hasn’t cured the person, then treatment doesn’t work and it’s no use going back to treatment.

4. “Treatment is a waste of time unless the person really wants it” – few people wake up and spontaneously say this is the day for recovery. Most people getting into addiction treatment have some external pressure or loss that prompts them to seek treatment and may even say “I don’t need this. I’m no worse than anyone else. I can stop any time I want.”

Expecting people to show up fully ready for recovery from day one before treatment is available, is a good way to decrease case loads and not help people. Treatment’s job is to attract people into a change process and recovery by using motivational enhancement methods.

5. “We need to lock those people up and they can learn their lesson that way” – Society responds to addiction with a criminal justice, punishment perspective.

Happily there is a bipartisan recognition and effort to see addiction treatment as a cost-effective way to increase public safety and decrease legal recidivism and crime rather than to just incarcerate those with addiction.

 6. When a person gets a urine drug screen result that is positive for a substance(s), we say they have “dirty urine” – We would never say a patient had “dirty cholesterol” and scold or sanction them for their laboratory result.

If a person’s urine is “dirty”, what does that imply? They are “dirty” too and we perpetuate stigma and discrimination.

 

TIP 2

Note how payers perpetuate stigma by policies that don’t see addiction as a disease

Payers’ policies often don’t treat addiction as a chronic disease process needing treatment.

1. “We can’t pay for residential treatment until there has been an outpatient treatment failure.” Instead of allowing a person to go immediately into a level of care that is needed, such a “fail first” policy expects a clinically inappropriate level of care to be used first.

We would never expect a person with diabetic coma to try outpatient diabetic dietary changes before admitting them for a diabetic crisis. We would never expect a patient with a heart attack to try weight loss, exercise and stopping smoking before admission to the cardiac care unit. It is true that if a person is safe to do treatment in an outpatient setting, that level of care should be tried first rather than residential care. But if they need residential treatment from day 1, then they should not need a “treatment failure” in outpatient first.

2. “Sometimes people are penalized for doing well”.  If a client is progressing well, payers expect the person to be transferred to a less intensive level of care and limit further reimbursement for care. Providers feel it is then necessary to play games by reporting their client is not doing well in order to assure ongoing payment for treatment. 

The solution is to explain honestly, the progress a person is making. But then the provider has to convey what clinical severity still exists that needs services that can only safely be delivered by more time in the current level of care before transferring them.

3. “Burdensome processes for accessing benefits that lead to longer waiting times and put barriers in place to get someone into treatment.” When someone is ready to access treatment, waiting lists and appointments several days and even weeks away work against treating addiction as the disease it is.

 

TIP 3

Now note how providers perpetuate stigma by policies that don’t treat addiction as a disease

1. “Length of stay is not individualized according to the needs of the client.” – 28 day programs based on insurance coverage, not based on severity of illness and progress in treatment. Adolescent treatment program design has added 2 weeks for a 42 day program because adolescents can be difficult to treat; and cookie cutter programing expects all clients to need and do the same interventions e.g., everyone has to go to Alcoholics Anonymous. For some it might not be the best fit for a mutual help group as powerful and effective as it is for others. 

2. “Kick people out for violating the rules and boundaries of the program.” For example discharging people for using substances on a pass when addiction is characterized by loss of control of use – that is what addiction is that needs more treatment, not discharge. 

3. “Inappropriate contact between clients can get clients thrown out because of a moralistic sense instead of this being a disease process” e.g., clients found holding hands – “Should we discharge them?” Kevin’s staff once asked. 

4. “Treatment programs may be only open from 9 -5 in OP; or only open Monday-Friday.” This doesn’t fit the needs of people with addiction who are using at all hours of the day and week. This is another example of how providers do not adhere to a therapeutically-based approach.

5. “Even people in recovery can perpetuate stigma by using terms like “sober”, “clean” or “straight.” These are “good and bad” and “positive and negative” stigmatizing moralistic terms rather than empowering terms like “I am a person in long-term recovery” (“Anonymous People” film). Such terms work against a public health and treatment approach to addiction.

 

TIP 4

Consider these Addiction and Public Policy Issues

Public policy implications:

1. Be aware of these stigmatizing terms and avoid using them.

2. Treat addiction like the chronic disease that it is and compare with what we do for other chronic diseases like diabetes, asthma, heart disease and hypertension. Some say “but addiction is different because there is choice involved in using substances.” But with other chronic diseases people make diet and lifestyle choices all the time that affect the progression of their disease and their recovery. For example, 70% of cardiovascular disease can be prevented or delayed with dietary choices and lifestyle modifications (Forman D, Bulwer BE, Curr Treat Options Cardiovasc Med. 2006;8:47-57) 

For more facts and figures on lifestyle change, see the October 2015 edition of Tips and Topics:

https://www.changecompanies.net/blogs/tipsntopics/2015/10/

3. Individualize treatment for the variety of needs that people present with.

4. Eliminate waiting lists.

5. Respond to relapse from a treatment perspective not punitively. 

6. Negative consequences can motivate change e.g., an encounter with the legal system can motivate a person to seek help, so there is no need to pamper people or not hold them accountable for their behavior. But treatment is the response for someone who has addiction that results in illegal or bad behavior, not punishment.

“From uncomfortability comes change” said one of Kevin’s mentors. 

SKILLS AND STUMP THE SHRINK

More and more states are looking to The ASAM Criteria to help reorganize their addiction treatment system. I wrote about these changing forces in the August 2015 edition of Tips and Topics

https://www.changecompanies.net/blogs/tipsntopics/2015/08/

TIP 1

Understand ASAM Criteria Level 3.1 and 3.5 and Moving from Program-Driven Services

Here are some excerpts from questions about New Hampshire’s residential levels of care and my response about the true content and spirit of The ASAM Criteria levels of care.

Dr. Mee-Lee,

Hello, my name is Paul Kiernan. I am the clinical services specialist at the Division of Behavioral Health for the State of New Hampshire. You and I had exchange emails some time ago regarding helping us better define the clinical requirements for level 3.1, Clinically Managed Low Intensity Residential, a level of care provided by several agencies that are contracted with us. We are having a bit of difficulty that I was hoping you could shed some light on.

The contracted agencies we work with are required to provide services consistent with ASAM Levels of Care. The problem we are encountering is determining what services fall under the scope of the level of care (these issues are being encountered in levels 3.1 and 3.5 primarily) and what services are above and beyond this and therefore can be billed as separate services. Many of the agencies are providing Recovery Support Services with groups such as Smoking Cessation, Managing Anxiety, Importance of Self-Care, Money Management, jewelry Making, Designing a resume and Self-Empowerment to name a few. Recovery support services are listed under both levels of care but frequency is not defined.   The contracts state that the contractor will provide services in accordance with ASAM Criteria, which leaves us with a bit of ambiguity. Any support or direction you could offer would be greatly appreciated.

Paul Kiernan, LADC Clinical Services Specialist

Division for Behavioral Health

Bureau of Drug and Alcohol Services

Clinical Services Unit

Concord, NH

Email address: paul.kiernan@dhhs.nh.gov

 

My response:

In Level 3.1, the person is getting at least 5 hours of clinical services per week. Since 3.1 is more of a 24 hour living support level, I can see that any formal individual or group clinical services could be charged separately because a person could be living in 3.1 but getting services in an outpatient (OP) agency separate from the 3.1 site.

The kind of 24 hour counseling support that is part of 3.1 would be provided under the 3.1 daily fee, because there should be trained staff there on a 24 hour basis, who can handle informal counseling support to someone who is having, for example, cravings to use at 11 PM or 2 AM and needs someone to talk to. But if there are formal clinical services like a group or individual session in 3.1, then that can be provided onsite or in collaboration with another OP service agency.

Recovery support services are not referring to Jewelry making. Helping with money management, resumes and vocational counseling if needed by the client on their treatment plan could qualify as a clinical service for Dimension 6, Recovery Environment, needs and be counted in the five hours or more of clinical services.

The daily fee for Level 3.1 would be lower than 3.5, Clinically Managed High Intensity Residential, which is for people who need 24-hour services because of imminent danger and instability. Sessions like Money Management, Jewelry making, Designing a Resume would not be in a Level 3.5 treatment plan that should be focused more on stabilization of imminent danger and preparation for continued care in less intensive levels of care. Because 3.5 is 24 hour care, the daily fee should be higher and include any formal individual and/or groups clinical sessions in the daily fee and not unbundled as in Level 3.1.

So the frequency of clinical services is not defined in the ASAM Criteria book for either level 3.1 or 3.5 as in 3.1, it depends on the severity and function of the person and the needs in their individualized plan. In 3.1 it has to be at least 5 hours/week to distinguish 3.1 from a general recovery home, halfway house or Oxford House. 3.1 clients are more severe needing the availability of 24 hour living and counseling support plus at least five hours of formal clinical services.

In 3.5, clients need 24-hour care and therefore formal and informal counseling sessions and supports all included in the daily fee. Again, frequency of sessions in 3.5 depends on the level of instability of the client and what they need to be stabilized sufficiently to continue care in a less intensive level.

Paul’s Reaction to my Response

You helped clarify a misconception I had about the 3.1 level of care and also got me thinking about what patients are appropriate for what residential levels of care and what interventions are appropriate for those patients.

We have really been trying to move to a more patient-driven system of care and have specific language in the contracts stating that patient stays are treatment plan/patient driven. Treatment plans have to be personalized and the levels of care must follow ASAM guidelines. The reality is that these are, and continue to be, program-driven with arbitrary assignments and Evidence-Based Practices (EBPs) implemented with no real evidence that they are clinically appropriate for the particular client.  

In the past year I have really immersed myself in understanding ASAM clinically but also in philosophy. One of the things that I will be working on is development and implementation of a comprehensive plan to help our contracted agencies become patient-driven. Any support along the way we be greatly appreciated. I find it very difficult to articulate how grateful I am for your input.

Thank you

TIP 2

ASAM Criteria Level 3.3 and Dealing with Behavior Problems

Another question from Paul

On another note I would like to pick your brain on Level 3.3, Population Specific High Intensity Residential Level of Care. We have none in our great State of New Hampshire and this seems to be a level of care a lot of folks who “fall through the crack” may benefit from. Patients who are not meeting criteria for psychiatric admission, but cannot function in a typical patient milieu. Patients who have behavioral problems who end up getting discharged for rule infractions (throwing things at staff, cursing at staff, stealing from other patients, stealing medication and hiding it in there room etc). For now, we have been trying to get folks set up with Co-Occurring enhanced 2.1, Intensive Outpatient or 2.5, Partial Hospitalization where there are less restrictions and it is easier for them behaviorally. Obviously problems arise when dangerousness and lethality are high. Wondering if you have any suggestions of other states that are doing this well or what a good 3.3 would look like? Also if the interim solution I mentioned is a good idea for now.

My response:

I know 3.3 is tricky and I don’t have a mecca state for you to go to. But I would make the distinction that 3.3 is for people with cognitive difficulties and Traumatic Brain Injury (TBI) that makes it hard for them to be in a typical milieu. In contrast, patients who have behavioral problems may or may not be having those because of cognitive issues like TBI. Rule infractions can be caused by multiple reasons including, but not limited to:

1. Programs that are more focused on phases in a program-driven system where patients advance by being compliant with rules. “Breaking rules” is seen a behavioral problem requiring behavioral contracts, rather than assessing why the person “broke the rule” and making this part of an individualized treatment plan.   It may help to look at Tips and Topics, Volume 10, No. 11 February 2013

https://www.changecompanies.net/blogs/tipsntopics/2013/02/

2. A patient may be mandated to a program and is not really doing treatment and just “doing time”. If the program is not skilled in Motivational Interviewing and stages of change work, they are going to be more focused on rule breaking and compliance instead of engaging the person in a “discovery” plan rather than a “recovery” plan for which the patient may not be ready. Such a person would be better treated in OP levels unless in imminent danger and then in 3.5 only for the time they are unsafe and unstable. Working with a person who is more interested in getting off probation than in getting into recovery and using residential levels for that work is a setup for rule breaking and the revolving door of discharging people for bad behavior.

3. If there are issues in Dimension 3, Emotional, Behavioral or Cognitive Conditions or Complications, that are causing a person to “break rules”, then the focus should be on assessing what the Dimension 3 problem is and what to do about it, not discharge. If it is an issue in Dimension 5, Relapse, Continued Use or Continued Problem Potential, and the person is willing to change their treatment plan in a positive direction, treatment continues as stealing medication and trying to get and use drugs is normal for people with addiction.

This behavior is not about rule breaking, but about the cravings of addiction. If the person is not interested in treatment, and just thinks they can have fun while “doing time” then discharge or court sanctions are appropriate, not for having used, but because they are not interested in treatment, as evidenced by not participating in a reassessment of what went wrong and changing their plan in a positive direction to get a better outcome next time they get a craving to use. In other words “rule breaking” should be assessed as a bad outcome needing a new treatment plan.

(See Appendix B on Dimension 5 in The ASAM Criteria (2013).

4. It may be that a program has too many rules trying to control behavior rather than assess six dimensional needs and do individualized treatment. Residential levels should focus on preparation of people for OP services not seen as a place for a total life makeover in residential.

Yes, there should be more OP levels that can take people with co-occurring mental disorders and addiction (COD) and for those in early stages of change who need motivational services. We should use residential only for people who need 24-hour services to be imminently safe. So developing levels 1, Outpatient, 2.1 and 2.5 that can be more enhanced and complexity capable is not an interim solution, it is an important solution in an array of approaches.

Paul’s Reaction to my Response

Dr. Mee-Lee,

You helped clarify some misconceptions I had about the 3.3 level of care. During the Quality Assurance (QA) of the treatment plans, these are exactly the types of things I am encountering. On one treatment plan the goal was actually “the client will reduce feelings of shame and improve self-esteem”. I don’t think that goal is Specific, Measurable, Achievable, Realistic, or Time-Limited (SMART)

One of the many obstacles we deal with is clinicians’ knee jerk reaction to treat cases as imminent danger. So many people are dying that folks ignore or misinterpret imminent danger criteria C (“the likelihood that such adverse events will occur in the very near future, within hours and days, not weeks or months.” – The ASAM Criteria 2013, pp 65-68; 420) and are treating their own anxiety. As a result, patients end up in what appears to be an inappropriate level of care. So we have been engaging our providers in a community of practice to help them sharpen their ASAM skills and in a lot of cases teach them a basic understanding.

I have to be honest, prior to the newest edition I was one of those who just did the 1 page checklist! We have done 2 webinars consisting of an overview of the 6 ASAM Criteria dimensions, severity rating, withdrawal management, levels of care, treatment planning and a special Paul Kiernan soap box lecture on what really constitutes imminent danger. 

A point I stressed during these is that just because two patients have a high severity rating in dimension 5 for example, does not mean that they are going to have the same treatment plan. One patient may be using because they do not like dealing with negative emotions and another patient may just really like getting high. Another patient may have absolutely no internal dialogue prior to using (perhaps a red flag to revisit dimension 4, Readiness to Change) where the other person has a real internal struggle. 

These are some of the things that we are working on in hopes of moving providers to a patient-driven model.

Again I am so grateful for your correspondence.

Cheers,

Paul

Reference:

Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.

For more information on the new edition: www.ASAMcriteria.org

SOUL

Warning: The following is an unpaid, unsolicited, political opinion. If you are definitely voting for Donald Trump as President of the United States of America, please stop reading. I do not want to argue with or alienate you. I value you as a Tips and Topics reader and more. 

But if you are undecided, you may be interested in my thoughts and concerns. These are not academic political science observations, but just my opinions that you could rightly take with a grain of salt:

1. President of the United States and leader of the free world requires intelligence, integrity, political experience and knowledge of how political systems work. While it is understandable to think career politicians are the problem, I have always favored change from within, rather than blowing things up and radical change from without. It is easy to see solutions when on the campaign trail, but much harder when faced with the real negotiations and issues when in actual office e.g., Barack Obama declared he would close down Guantanamo Bay and meant it. But easier said than done.

2. For any job, especially a highly complex position that requires interfacing with many systems, countries and personalities, I would only consider candidates who have some demonstrated experience in the duties, dilemmas, challenges and complexities of the position. Hilary Clinton apparently delivered on a consensus, collaborative and across-the-aisle style when she was a Senator; and slogan or not, I favor “Stronger Together” than “Build a Wall” type politics.

3. How a candidate has defined their life’s mission and occupied their actual work energies, tells me whether there is a consistency in what they stand for and believe in. Have they demonstrated a commitment to public service or to causes that are consistent with public service? Has their work and systems experience encompassed the kinds of challenges they will face as President? Do the values of their life’s work speak to compassion, integrity, honesty, and fair play; or to materialism, adversarial power plays, bullying and self-centeredness? Is there a value of “it takes a village” or “I alone, can make things great again”?

4. Finally, you have almost certainly heard about the infamous audio and video of Donald Trump bragging about kissing and groping women because as a star, you can do whatever you want. If you don’t know what I’m talking about, see the link:

http://talkingpointsmemo.com/livewire/trump-lewd-comments-women-2005-hot-mic

I give many workshops and keynotes and have often been the featured speaker at a conference. What would you think of my integrity and values; my leadership and presentation content if I were to say that because I’m the keynote speaker I could kiss or grab any woman I wanted at the conference; and then say that if I didn’t do that, it was the woman’s fault that she wasn’t attractive? I am no star and I am not running for President. But I am mystified that millions are not fazed by Donald Trump’s demonstration of distorted values, lack of respect, abuse of power and failure of integrity.

I rarely speak my mind about politics, but in this case, I felt compelled to speak up. I hope you will vote – for whomever your conscience says has the skill; compassion and integrity; and knowledge, character and values to be President of the United States.

Until next time

Thanks for joining us this month . See you in late November with President Clinton or President Trump.                                                                                                                                               

David

Compliance, adherence, Stump the Shrink on treatment courts, Biopsychosocial

Vol. #15, No. 4

Welcome everyone to the July edition of Tips & Topics (TNT).  Glad you could join us.

David Mee-Lee M.D.

SAVVY, SKILLS & STUMP THE SHRINK

You may have heard people described as either “lumpers” or “splitters”. Lumpers look at a certain topic and like to lump information together into as few categories as possible to keep it simple. Splitters like to dive deeply into a topic and tease apart more of the details into a variety of split categories.
Usually in Tips and Topics, I split apart SAVVY, SKILLS and STUMP THE SHRINK to tease apart some knowledge content, assessment, treatment and administrative skills, and challenging questions readers have sent. This month however, I lumped them all together because the comments and questions that drive the content for this edition encompass all three categories.
  • The first two questions/comments are follow-ups from the June edition of Tips & Topics and the article on rethinking discharge categories in substance use disorders treatment. If you missed it, here is the link:  Tips & Topics June 2017
  • The second set of questions/comments arose from the recent Annual Training Conference of the National Association of Drug Court Professionals (NADCP) held in National Harbor, Maryland July 9 -12, 2017.
TIP 1
Distinguish compliance from adherence when considering discharging people from treatment.
Compliance:
  • Merriam-Webster’s dictionary defines ‘comply’ as follows: “to conform, submit, or adapt (as to a regulation or to another’s wishes) as required or requested.”
  • Compliance names and labels participants based on participant behavior.
  • Compliance and following the rules assumes that actual treatment and change is happening. It also assumes that increasing compliance by the person means a good prognosis and successful long-term recovery.
  • However compliance often means “doing time” in a treatment setting rather than “doing change.” It doesn’t necessarily mean treatment has actually been successful.
Adherence:
  • Adherence has quite a different meaning from compliance in various dictionary definitions. According to one dictionary, adherence is to “stick as if glued, maintain loyalty, as to a person; or follow without deviation” (Ogden, 1999, p. 221).
  • Merriam-Webster’s defines “adhere” as “to hold fast or stick by or as if by gluing, suction, grasping, or fusing; to give support or maintain loyalty; to bind oneself to observance.”
  • Treatment adherence allows for treatment plans to be individualized to the specific needs and strengths of the client, not tied to a “one size fits all” program rules and phases.
  • If the treatment plan makes sense to the participant and helps them get what they specifically want, they will more likely stick to it and hold fast.
  • Compliance (versus adherence) with treatment allows a participant to “go through the motions” in a program, not being held accountable for working on whatever is needed to change attitudes, thoughts and behaviors to advance public safety.
 
Question No. 1
David-
I read your TNTs all the time and I definitely agree with you about not discharging patients from treatment. When we have discharged patients, sometimes they die from overdoses.   But what do you do with the person who cannot stop using alcohol, cocaine or illicit benzodiazepines? We offer further treatment but they don’t cooperate. They miss appointments. Do you discharge them then?
 
Judy Dischel, M.D.
Stanley Street Treatment and Recovery
386 Stanley Street
Fall River, Massachusetts
My first response to Judy
Hi Judy:
Thanks for writing and it is a dilemma when patients are hard to engage into treatment. If the person is in imminent danger of overdosing then you have the right and obligation to commit them against their will until stable e.g., someone who has intense cravings, will not agree to treatment . You assess they are very likely to continue to use in a dangerous life-threatening manner over the next few hours and days (not weeks or months, as that is not imminent.)
But if there is not imminent danger, and they are not interested in treatment, then the next intervention to try is to see if there is any leverage from family, significant others or anyone who has power in the person’s life e.g., supports them financially or in their living situation; or an employer; or partner and love relationship.
By working with any significant others, it might be possible to intervene and get a person into treatment to receive motivational enhancement therapy backed up by the leverage of the significant other. If there is no leverage, then basically you have to “Serenity Prayer it” as there is only so much you can do. We are dealing with a deadly disease that sometimes wins, even when we have done all we can.
Hope this helps a bit. No magic answers I’m afraid.
David

 

Judy’s first response
Still, would you kick them out of treatment while you’re saying the Serenity Prayer?
My second response to Judy
Judy, it isn’t a matter of kicking them out of treatment. If the person isn’t changing their treatment plan in a positive direction, even if in tiny steps, then they are not doing treatment, just “doing time” and are choosing not to accept treatment.
Think of it this way: if the patient is not interested in changing their treatment plan in a positive direction when their outcomes and progress are poor (e.g., using substances but not interested in doing something different to learn from that use), then the person is not doing treatment and is “kicking themselves out of treatment”. So you would discharge them (if not in imminent danger) since they are not interested in treatment.
If patients just sit there and don’t do anything different, then you are, in effect, saying to people that it is OK to sit in a program and not do treatment. So I wouldn’t want them to blame you for “kicking them out”, but rather they have decided they are not interested in doing an improved treatment plan. They have a right to be uninterested in treatment and so leave.
It may sound like semantics, but it puts the responsibility on the person to do treatment or choose not to do treatment, which is their right and OK for them to leave.
Hope this helps, but let me know if not.
David
Judy’s final response
Perfect, David, I hate letting people go from treatment, given the dangers, but they do seem to have an adverse affect on others. I really appreciate your time in responding to me.
Judy
Comment from Scott Boyles, LAC, MINT Trainer
Scott Boyles is a long time colleague and friend and is a licensed addiction counselor and the National Training Director for Train for Change Inc. His career has included inpatient and intensive outpatient counselor, clinical director and director for over three decades in the behavioral health field. Scott has passion and expertise in system change approaches to support implementation and use of evidence-based practices. For over two decades, he has been a consultant and trainer, with a focus on the ASAM Criteria, individualized treatment planning, clinical documentation, and motivational interviewing strategies.
His comment relates to the June article on rethinking discharge categories in substance use disorders treatment.
Hi David,
Great article! Raising awareness around Discharge Category (DC) terminology seems like a unique and powerful lever in driving systems change, amongst other things. One of the other classic DC terms, “Received Maximum Benefit,” was the ultimate in implying poor compliance, but not poor enough that we could use “Discharge at Staff Advice”.
 
Or sometimes “Received Maximum Benefit,” actually meant “we kept them for the whole program and they just never changed”, cool part is we got paid anyway…
Thanks,
Scott
My response to Scott
Thanks, Scott. Yes, we thought about putting in Received Maximum Benefit, but wondered if that was still in wide use. Your explanation was quite apt (and funny/cynical) because it captures the all-too-often practice that treatment is all about getting clients to comply with the rules, regulations and phases of the program.
David
Scott’s response
A program reacted to my comment about the Maximum Benefit discharge category when I was training a couple weeks ago in Oregon. The provider explained to me their Criminal Justice contract measured and expected an 80% completion rate based on a fixed length of stay in the program. This is a legitimate and unfortunate truth in their argument for the impossibility of having a variable length of stay (LOS).
 
Contracts and business models are another prong of the system that also drives the “old” measures and discharge categories. Maybe you could do a future piece in TNT on contracting (what’s the product and how is the quality measured?); and business models to support the variable length of stay, person-centered, partnership model.
Take care,
Scott
My Further Comments
Scott is right. Even if counselors and clinicians recognize the need to move to person-centered, collaborative and individualized treatment, the system issues often work against what we know creates lasting, sustainable, positive change.
Here are a few examples:
  • Administrators more focused on filling beds or treatment slots to stay profitable.
  • Contracts and so-called quality measures which require an 80% completion rate.
  • Such expectations perpetuate a program, fixed LOS model rather than expecting measures to track engagement across a flexible continuum of care, with a focus on improvement in function, rather than compliance with program behavioral rules.
TIP 2
Recognize that sanctions and incentives, punishment and reward belong to a narrow behavioral modification approach to addiction treatment.
Here are three questions arising from the NADCP conference earlier this month. They point to Drug and other Treatment Courts’ focus on behavior modification as the primary treatment approach in addiction. The American Society of Addiction Medicine (ASAM) describes addiction as a brain disease that certainly has behavioral manifestations. But behavior modification is just one possible tool in what should be a wide variety of recovery-oriented treatment tools to attract participants into lasting positive change.
Question No. 1
Hi,
I just attended the NADCP Conference with Dr. Mee-Lee and after reviewing my notes I never got a chance to ask him a question – if you could pass along this email to him that would be helpful, thanks.

We talked a lot about sanctions, discharge or suspending – as well as individualized treatment plans and the difference between “doing time” and “doing change.” I think individualized treatment is crucial to the client getting anything out of treatment (I won’t say success because I am aware that treatment doesn’t necessarily correlate with success from this disease)…. But for a while, our court was doing general sanctions (for example: missed therapy = 1 day in jail, missed urine screen = positive test and loss of clean time, missed curfew = 8 hours of community service, etc.).  
 
Then, it started to shift more towards individualized sanctions (for example: person X was late for a urine screen but ended up taking one later so the judge said it was confirmed negative so no loss of clean time, when person Z lost their clean time with the same scenario…. Or person X relapsed for the 4th time but because they are honest and upfront about it they don’t go to jail. But person Z had a positive screen and won’t admit to use so they will go to jail for lying).
Do you think this damaging? We previously tried to remain consistent with sanctions for specific things but then it became more individualized and then the group compares themselves out to one another. Or they say “It’s not fair because I’m telling the truth that I didn’t use, the cup was just positive” and it’s hard to verify this so we have to go by the lab…. Any thoughts?
Also, you mentioned Discovery, Dropout Plans… I am really interested in seeing some examples of these and how they differ from Recovery, Relapse Prevention plans. Since you mentioned that some folks never stopped using long enough for a Recovery, Relapse Prevention plan, I feel like this might be a really great thing to incorporate for folks who are more ambivalent.
 
Thanks for addressing this. I think it’s really important discussion to bring to my team.
Lanier Meeks Yi, MA, NCC
Arlington County Drug Court Therapist
Phone: 703-228-5214
My response to Lanier
Thanks, Lanier for these more in-depth questions. Here are some thoughts and suggestions:
1. When you were doing the “general sanctions” that were more formulaic, standardized and predictable (e.g., missed therapy = 1 day in jail) it can seem to be fair and consistent rules. One problem is that this places all the emphasis on compliance with rules and regulations predicated on a behavior modification approach to “treatment”.
2. If the goal of treatment is to improve attitudes, thinking and behavior and address all of the specific aspects of a participant’s functioning which interferes with public safety and reoffending behavior, then treatment is more complex than reward, punishment and behavior modification.
3. You may remember the importance of assessment of biopsychosocial severity and function using the common language of six ASAM Criteria dimensions to determine needs/strengths in behavioral health (The ASAM Criteria 2013, pp. 43-53).
1. Acute intoxication and/or withdrawal potential
2. Biomedical conditions and complications
3. Emotional/behavioral/cognitive conditions and complications
4. Readiness to Change
5. Relapse/Continued Use/Continued Problem potential
6. Recovery environment
4. When you recognize each person has different strengths and vulnerabilities, then it’s obvious each participant needs an individualized treatment plan to achieve successful outcomes.
E.G. if one person has post-traumatic stress on Dimension 3 and chronic pain on Dimension 2, their treatment needs will be different from another person’s priorities. E.G. Another person may have great difficulty with cravings to use on Dimension 5 and no supportive friends on Dimension 6. Their plan is quite different. A one-size-fits-all behavioral modification sanction plan doesn’t translate into lasting change.
5. Your shift to “individualized sanctions” seems like the right direction, however the “individualization” is based on criteria such as, complying later with a missed drug test, or admitting a mistake and being honest etc. This type of individualization can be too subjective leaving the team vulnerable to sanctioning one participant because they weren’t honest enough or fast enough. This then sets a tone of having all participants focused on who can get around the system more craftily than the next person.
6. Effective individualization is based on the specific unique needs of each participant. Each person is responsible for good faith effort in working on their own treatment plan with adherence, rather than focused on compliance with rules and regulations.
What then is fair for every participant? It is not what sanction they receive for the rule they broke. Rather fairness is that everyone is sanctioned for the same reason. That reason? When a person is not working in good faith on their individualized treatment plan which is designed to improve function and public safety. That is the distinction.
7. If there is a missed therapy day or drug screen, right away you assess what went wrong (e.g, participant overslept or used a substance and was afraid to be tested.) Learning from that poor outcome, the person fashions a new and improved treatment plan to wake up on time, or how to resist cravings to use. If they work to make changes in a positive direction, then no sanction is necessary. Only when someone is not interested in changing their treatment plan in a positive direction, is it then that they receive a graduated sanction.
8. The focus now is not on comparing one individual’s sanction with another, looking for uniformity and “fairness. ” Rather the attention is on what the participant is working on with effort and accountability.
9. Lanier asks if it is “damaging” to have “individualized sanctions” metered out in the the way she described? For example: person X was late for a urine screen but ended up taking one later so the judge said it was confirmed negative so no loss of clean time, when person Z lost their clean time with the same scenario…  I do think both “general sanctions” and your new direction draw attention away from holding participants accountable for adherence to their own treatment plan. It keeps participants’ focus on rules and regulations, compliance and concern with sanctions rather than on demonstrating real change in attitudes, thinking and behavior and pro-social functioning.
10. As regards Discovery, Dropout Plans for a start look at Tips & Topics June 2003:
A “discovery”, dropout prevention plan can use strategies like:
  • “Ask two old timers at an AA meeting why they think you may have an alcohol problem simply because you got two DUIs. Report back to group” or….
  • “Keep a log of all the times you are late with your curfew. See if you parents are on your back more or off your back when you are late”.
Also, see Tips & Topics February 2010:
Tips & Topics February 2010
Question No. 2
Dr. Mee-Lee;
This is a follow-up to our discussions at the “Meet the Expert” ASAM Criteria roundtable last day at the NADCP annual conference.

By way of re-introduction, I am a former prosecutor who is currently working on a project to determine compliance with the requirements of Pennsylvania’s DUI statute. That law requires that each DWI offender undergo a preliminary screening and, if warranted [repeat offender, BAC > .16], a full drug and alcohol assessment prior to disposition of the underlying criminal case. In the course of the review, we reviewed the process of collaboration/consultation between the criminal justice and treatment systems.

During our discussions, I raised concerns expressed by both judges and probation/parole officers present at the table, regarding the quality of status reports provided to them by the treatment providers. Our statute provides that the sentencing order require the defendant to “participate in and cooperate with drug and alcohol addiction treatment”.   The statute also requires the treatment program to report periodically to the assigned parole officer on the offender’s progress in the treatment program. The treatment program shall promptly notify the parole officer if the offender: (1) fails to comply with program rules and treatment expectations, (2) refuses to constructively engage in the treatment process, or (3) without authorization, terminates participation in the treatment program.  

Our state also has confidentiality provisions that provide that information released to the criminal justice system [judges, probation officers] Is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following”: (1) whether the client is or is not in treatment; (2) the prognosis of the client, (3) the nature of the project, (4) a brief description of the progress of the client and (5) a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
These regulations are given as the reason for the very general descriptions in treatment providers’ status reports such as “client is compliant with the treatment plan.”
You indicated that you may be interested in further discussing the issue in a future edition of your “Tips and Topics”.

If you need any additional information, please don’t hesitate to ask.
All the best,  
Jerry Spangler
Pennsylvania Department of Drug and Alcohol Programs.  
My response to Jerry
Yes, Jerry, I have heard from many judges and probation/parole officers their dissatisfaction with the quality (or lack of quality) of status reports provided to them by the treatment providers.Regarding your confidentiality provisions list and its 1-5 criteria, here is more detail on what treatment providers could provide which would not violate confidentiality, yet provide more meaningful status information:
Our state also has confidentiality provisions that provide that information released to the criminal justice system [judges, probation officers] Is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following”:    
“(1) whether the client is or is not in treatment”
  • This should encompass a report as to whether the client is actively adhering to an individualized treatment plan designed to improve attitudes, thoughts and behaviors that increase public safety and enhance lasting accountable change.
  • Just sitting in groups or handing in an AA attendance log is not being “in treatment”.
  • The status report can indicate if the participant is working in good faith on doing treatment and change or just “doing time” complying with rules, phases and program-driven behavioral expectations.
  • If a treatment provider works with a client to engage them, yet the client continues to passively comply instead of actively work on changing, then a graduated sanction should be discussed with the participant and the treatment court team.
” (2) the prognosis of the client”
  • The status report should indicate if the client is changing in attitude and function, working on that person’s unique mix of strengths and vulnerabilities.
  • If the participant is not working in good faith on actual positive, lasting change, then the prognosis is shaky.
  • This should be discussed with both the participant and court team. This expresses that the client has not yet demonstrated sufficient change in function to decrease public safety risk.
  • If the participant is working hard on improved function, this predicts a better outcome. That information should be shared in a status report also.
“(3) the nature of the project” 
  • Does “nature of the project” refer to the highlights of the treatment plan without the need for intimate confidential details? If so, then the status report should outline those highlights – e.g., the client is working with his ambivalence about the severity of his substance use; or the client is exploring how strong are her parenting skills given she wants to get her children back.
” (4) a brief description of the progress of the client” 
  • Progress is measured not by the client attending all groups and complying with urine drug testing. Progress is measured by whether the client is actually changing in function, attitudes, thinking and behavior towards recovery and public safety.
  • Details on every up and down of a client’s progress is not necessary or useful. But the status report should be clear about whether the client is making progress towards positive change that is sustainable.
“(5) a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse” 
  • If flare-ups of addiction have occurred (like any poor outcome in any illness) the next step is assessment as well as a change of the treatment plan in a positive direction, learning lessons from the relapse.
  • If the client has learned what went wrong, changed their treatment plan in a positive direction, then that information is what the status report should reflect.
  • If the client is not interested in changing in a positive direction and learning from the flare up, the client is now not doing treatment. This should be in the status report and be discussed for a possible graduated sanction.
I hope it is clear that providers’ status reports such as “client is compliant with the treatment plan” are inadequate, incomplete and need improvement. Concerns about confidentiality does not explain, justify or excuse such flimsy status reports.
Question No. 3
Hello Dr. Mee-Lee,
I was lucky enough to attend two of your wonderful workshops at the National Association of Drug Court Professionals conference and got so much out of each. I’m a therapist in a Drug Court.
I have a few questions for you if you have the time and I certainly understand if you don’t.
My first question is about our policy with high and low creatinines. We changed labs a few years ago and now every random urine drug screen has creatinine levels. We’ve been told the normal range is 20-300 mg/dL. For a level below 20, we give a warning letter for the first time and consider the second and all subsequent lows a positive drug screen test, which can mean jail, returning to a lower phase, change of sober date, 60/60 (60 AA meetings in 60 days), etc. For a high, above 400, we give a warning on the first test result; do daily urine drug screen tests for a week on the second test result above 400; and consider a third and all subsequent highs positives with the typically tough sanctions.

I’ve read and attended workshops and corresponded with Paul Cary, the major proponent of creatinine sanctions. As far as I can tell, he cites only one study for the lows and none for the highs. We certainly have clients who water-load to avoid detection of use and may have clients who supplement with creatine. However, many of our clients with highs and lows have no positive urine screens before or after the highs or lows.
 
Do you have any thoughts on this problem? I have many clients who appear to be really working a recovery program who are terrified about getting highs or lows. I also wondered if you have a toxicologist who you’d recommend my corresponding with on this subject?
My other question is about Vivitrol (trade name for extended release, injectable naltrexone), which we use with many of our alcohol and opioid clients. Sometimes the judge orders the client to take it-for a year-when the client doesn’t want to. What do you think about that?

All my best and thanks again for your extraordinary service on behalf of clients everywhere.
TD
Therapist in a Drug Court
My response to TD
Before I respond to TD’s important questions, here is some information on creatinine levels. Since I am not expert on urine drug screening tests and interpretation, I turned to Dr. Google. If you are an expert and I got it wrong, please let me know.
  • Creatinine is a waste product of creatine, an amino acid contained in muscle tissue and found in urine in relatively constant quantities over a 24-hour period with “normal” liquid intake. It is filtered out of the blood by the kidneys and some amounts are normally secreted into the urine.
  • Therefore, urine creatinine can be used as an indicator of urine water content or as a marker identifying a specimen as urine.
  • A normal result is 20-300 mg/dL in urine.
  • Creatinine level varies based on a person’s size and muscle mass. Below normal creatinine levels indicate that a person has been drinking excess fluids. Such a reading is a red flag in drug tests because it signifies that the person tested has attempted to tamper with the results by disguising other active by-products that would have otherwise been detected.
  • In other words, the creatinine levels determine whether or not a person is trying to cheat on a urine drug test. Most laboratories now perform advanced screening procedures that verify whether there has been adulteration or dilution. In the case of the latter, when the urine sample is too diluted, the results are normally labeled as “inconclusive.”
  • Why Is Creatinine Being Analyzed in Urine Drug Tests? The accuracy and reliability of urine drug test results depend heavily on the validity of the urine specimen.
  • When the specimen is pure and free from adulteration or substitution, those who rely on the results of the analysis can be assured the reported outcome is precise.
  • Adulteration or tampering with the specimen in order to alter the drug test results to produce a false negative is a known practice among drug users. A common way to do is by adding some products such as bleaching agents or detergents to the urine sample.
  • Another method is to conceal the metabolites or by-products of the ingested drugs by consuming excessive amounts of fluids or taking diuretics in an attempt to “flush” out the metabolites and “dilute” the urine.
  • The best way to check for “dilution” is to analyze some urinary characteristics such as creatinine levels.
Another resource:
ASAM has developed the “Appropriate Use of Drug Testing in Clinical Addiction Medicine” document to provide guidance about the effective use of drug testing in the identification, diagnosis, treatment and promotion of recovery for patients with, or at risk for, addiction.
 
TD, here are some thoughts and suggestions:
1. Urine drug screens and creatinine levels are laboratory tests for addiction, like any other lab test in assessing the severity and treatment for any health condition.
2. Lab test results have to be interpreted in the context of the participant’s history, gender, current health conditions and signs and symptoms. Lab test results do not stand alone, and should not be the final answer on a person’s health and well being.
3. Creating sanctions based solely on a lab test result is against good clinical practice in tracking the progress in any disease and health condition.
4. When you say “I have many clients who appear to be really working a recovery program who are terrified about getting highs or lows.” This is a good example of what happens when the focus is on compliance, rule breaking and sanctions rather than on demonstrating positive, sustainable and lasting change (recovery).
5. Even if a client does attempt to tamper with a drug test, the treatment provider should look as much at themselves as the client.
  • What type of culture and treatment atmosphere have we created such that clients feel the need to play games and cheat, rather than be honest about any flare-up or relapse?
  • Do we offer this explanation? While substance use in treatment is never good, if it does happen, it is important to raise that and get help. This is exactly like a depressed person who becomes suicidal. We teach them to reach out rather than hide the depression flare-up.
  • Have we created a ‘gotcha’ attitude to urine drug testing and a ‘police state of affairs’, rather than a treatment healing environment where we expect progress in treatment rather than perfect abstinence?
6. For a toxicologist with expertise about lab tests and addiction recovery, I suggest you contact the American Society of Addiction Medicine and contact any of the members of the Expert Panel who developed the “Appropriate Use of Drug Testing in Clinical Addiction Medicine”.
7. As regards Vivitrol – “Sometimes the judge orders the client to take it-for a year-when the client doesn’t want to.”
  • This is an example of a judge or any court personnel working outside their scope of practice.
  • In addition, the best predictor of good outcomes is the quality of the therapeutic relationship. This means agreement on goals and agreement on strategies and methods, within the context of a safe, trusting working relationship.
  • What if the participant doesn’t agree with the goal of abstinence or the method (medication)? You do not have an alliance. The likelihood of a good outcome is very low.
  • Thus the problem is not only the wrong treatment strategy for the wrong participant, but it is assessed and prescribed by the wrong person working outside their scope of practice. Good intentions don’t produce good outcomes if the alliance and treatment are out of alignment.
References
Adherence. (n. d.). In Merriam-Webster online. Retrieved from https://www.merriam-
American Society of Addiction Medicine (ASAM) “Appropriate Use of Drug Testing in Clinical Addiction Medicine” https://www.asam.org/quality-practice/guidelines-and-consensus-documents/drug-testing
Compliance. (n. d.). In Merriam-Webster online. Retrieved from https://www.merriam-
Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.
Ogden, J. (1999). Compliance versus adherence: just a matter of language? The politics and poetics of public health. In J. D. Porter & J. M. Grange (Eds.), Tuberculosis: An interdisciplinary perspective (pp. 213-234). London: Imperial College Press.
Williams IL, Mee-Lee D (2017): “Coparticipative Adherence: The Reconstruction of Discharge Categories in the Treatment of Substance Use Disorders” Alcoholism Treatment Quarterly. Vol. 35, Issue 3, June 2017 Pages: 279-297. Published online: 16 Jun 2017, Pages 1-19 http://dx.doi.org/10.1080/07347324.2017.1322432

SOUL

Forty years ago this year, psychiatrist George Engel introduced his Biopsychosocial model as a holistic alternative to the prevailing biomedical model that had dominated industrialized societies since the mid-20th century.
Earlier this month, I watched two tennis players in the finals matches of Wimbledon who by tennis standards are “old” – Venus Williams at 37 going for her sixth win and Roger Federer at 35 going for his 8th championship.
I watched Federer win the all time record of 8 Wimbledon tennis tournaments and accomplish his 19th Grand Slam title. I also saw five-time Wimbledon winner, Venus Williams, lose the second set of the finals 6 – 0. Watching them both, “biopsychosocial” crossed my mind.
Although Venus worked hard and was so close to winning the first set and looking like she was headed for victory riding with confidence, she couldn’t win even one game in the second set.
Both players work hard with their physical fitness (Bio). Both have disarmingly calm temperaments and positive outlooks (Psycho). Both have very supportive families and loved ones (Social).
What was the difference between those two champions with such longevity and success in tennis? Who could blame Venus for the impact of two psychological blows?:
  • A month earlier on June 9 an officer at the scene of a fatal car accident was seen telling Venus Williams: ‘You kind of violated his right of way’.
  • The tennis star was at an intersection in Florida when she apparently caused a crash. Jerome Barson, 78, was killed; his wife Linda left with ‘disfiguring injuries’ in the accident.
  • After losing the first set, this same physically fit, socially-nurtured and supported champion could not muster the psychological confidence to win a single game.
The power of the emotions and psychological vulnerability, I suspect, undid Venus that day.
Federer: “Previously I always thought it was just tactical and technique, but every match has become almost mental and physical – I try to push myself to move well. I try to push myself not to get upset and stay positive, and that’s what my biggest improvement is over all these years. Under pressure I can see things very clearly.”
(“Five lessons in success from tennis champion Roger Federer”)
Finding the right balance of bio-psycho-social goes a long way to a happy healthy life – even if you don’t win at tennis.

Until next time

Thanks for joining us this month. See you in late August.