Kick out or Keep in?; Therapeutic action, not Discharge ; Germany
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.”
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.
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:
“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
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.
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.
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 problem is 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. Explain what 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 crisis and an acute exacerbation of their addiction; and that honesty is the best policy to face their mistakes and learn from them.
- They would learn that 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 like someone 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 back on 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 they knew 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 place for him is to continue treatment with the staff with whom he has formed a therapeutic alliance.
- In outcomes literature, the therapeutic alliance accounts 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 alcohol and 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 transfer or 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.
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.
- His speedometer only went up to 180 km/hour on the display and we were hitting 160 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. No customs 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 your liquids, 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 an empty 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 my trip 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.