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

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.