TIPS & TOPICS
Volume 7, No.3
In this issue
— STUMP THE SHRINK
— SUCCESS STORY & SHARING SOLUTIONS
— Until Next Time
Welcome to the June edition of TIPS and TOPICS. I’m glad you could join us.
There is a lot of discussion in the USA right now about reforming health care. And there should be since there are 47 million Americans without health insurance. Whatever system eventually is established, the cost of health care has to come down because we spend proportionately more than any other country. Whether you are a consumer, counselor, clinician, administrator or payer, we all have the responsibility to be more efficient and effective with the mental health and addiction treatment dollars that are spent.
- Consider how you might be wasting precious resources, decreasing access to care and increasing the cost of care.
Either because of tradition, ideology, habit or lack of awareness of the research evidence, we waste or use inefficiently mental health and addiction resources. Here are some practices and policies where we are not good stewards of resources and some proposals for changing our ways:
Practice/Policy: If a client slips, relapses and uses alcohol or some other drug while in treatment, we withhold treatment for that day; we discharge the client; or transfer them to a detox whether the client needs detox or not.
Cost Implications: Without treatment, the client’s relapse easily continues and expands. It creates the need for more expensive acute services; new admission costs are generated when and if the client returns; detox days are used for clients who may have relapsed, but not to the extent of needing formal detoxification.
Proposal: Retain the client in treatment and address the recurrence of signs and symptoms of the addiction illness as you would a relapse of psychosis, suicidal behavior, panic and anxiety or mania. If the client chooses to continue treatment and chooses to improve his/her treatment plan based on an assessment of what went wrong, there is no need to transfer or discharge the client.
For more on this approach, read this previous edition of Tips n Topics.
Practice/Policy: The National Institute on Drug Abuse (NIDA) published the Second Edition of Principles of Drug Addiction Treatment – A Research-Based Guide (April, 2009). Principle #2 of 13 evidence-based principles: No single treatment is appropriate for everyone.
Despite this evidence, many outpatient and residential treatment programs continue to provide fixed length of stay services for all clients, ranging from weeks to months in the same level of care; they do not use a flexible continuum of care as outlined in the ASAM Patient Placement Criteria (ASAM PPC-2R, 2001).
Cost Implications: Whether the daily cost of a residential program is $65/day or $650/day or more, the cost implications of even a week’s worth of unnecessary care are enormous. The waiting lists generated by non-individualized care and lengths of stay decrease access to care, increase the severity of those who cannot access care and increase the use of acute resources.
Proposal: So what should determine when a person should be moved from one level of care to another? Answer: When their functioning has improved, so that they no longer need that service intensity. This is no different from how you would treat other chronic and potentially relapsing illnesses. The ASAM Patient Placement Criteria (PPC) provide guidelines for providers and payers of care to design and deliver services that promote individualized, assessment-driven and outcomes-driven care rather than program-driven and diagnosis-driven care. Give all the care that a client needs- at a particular level of care, but not more than is needed, because that wastes resources. Don’t give less than is needed because the client then deteriorates, and that is bad for their outcome as well as for costs.
For more on this approach, read this previous edition of Tips n Topics.
Practice/Policy: Some states, counties and other payers contract with providers to deliver detox services for only one level of care rather than a continuum of detox services. For example, a contract may be for Medically-Monitored Inpatient Detoxification (ASAM PPC Level III.7-D) which requires 24 hours nursing, physician availability, medication and medical monitoring and documentation on each of three daily shifts. Since the contract is for this one and only level of detox care, then the staffing and documentation must be in compliance with this intensity of service, regardless of whether all the clients need that intensity or not.
Cost Implications: Many clients may need this level of care for a day, but may not need this intensity for the next 3 or 4 days that people commonly stay in a detox program. Some clients amy not even need that intensity for 1 day, and could be admitted to a clinically-managed, “social” detox (i.e. a non-nursing and non-medical setting.) You can see that when the contract is for one level of care only, it does not allow for flexibility and savings in staffing, documentation and medical costs.
Proposal: Use the five levels of detoxification as in the ASAM PPC to develop a continuum of withdrawal management services. This way clients receive only the intensity of services they need. This would allow staffing, documentation and medical monitoring to be flexed and decrease nursing, medical and documentation costs that are now wasted on clients not needing that intensity.
For more on this approach, read this previous edition of Tips n Topics.
Practice/Policy: Most housing and supportive living options for people suffering from addiction and co-occurring disorders require abstinence as a condition for admission and continued stay. There is always the need for sober living options for people interested in recovery. However many clients, not yet ready for sobriety and recovery, burn up thousands of dollars in the revolving door of emergency rooms and acute services.
Cost Implications: One recent study reported on 134 homeless people with severe alcohol-use problems. They were placed into free housing without requiring abstinence or treatment. Here were the results on the costs of medical use, social services and criminal justice contacts:
- One year before receiving the free housing, the average cost was $4, 066 per person.
- One year after receiving the free housing, the average cost was $958 per person.
(“Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons with Severe Alcohol Problems”, 2009)
Proposal: Such Housing First programs can reduce overuse of crisis services and reduce alcohol consumption. At one year, the average daily alcohol use dropped from an average of 15.7 drinks per day to 10.6 drinks a day. That sounds like Progress, even if not Perfection.
References and Resources
1. “Principles of Drug Addiction Treatment: A Research Based Guide (Second Edition)”
NIH Publication No. 09-4180
Printed October 1999; Reprinted July 2000, February 2008; Revised April 2009
2. Mee-Lee D, Shulman GD, Fishman M, Gastfriend DR, and Griffith JH, eds. (2001). ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition-Revised (ASAM PPC-2R). Chevy Chase, MD: American Society of Addiction Medicine, Inc.
American Society of Addiction Medicine – 4601 Nth. Park Ave., Arcade Suite 101, Chevy Chase, MD 20815. (301) 656-3920; Fax: (301) 656-3815; www.asam.org; To order ASAM PPC-2R: (800) 844-8948.
3. “Health Care and Public Service Use and Costs Before and After Provision of Housing fro Chronically Homeless Persons with Severe Alcohol Problems”, 2009.
JAMA, April 1, 2009; 301: 1349 – 1357.
4. “Addiction Treatment Matching – Research Foundations of the American Society of Addiction Medicine (ASAM) Criteria” Ed. David R. Gastfriend- released 2004 by The Haworth Medical Press. David Gastfriend edited this special edition that represents a significant body of work presented in eight papers. The papers address questions about nosology, methodology, and population differences and raise important issues to continually refine further work on the ASAM PPC. (To order: 1-800-HAWORTH; or www.haworthpress.com)
Even though we know that implementing these evidenced-based practices could decrease costs, increase access to care, and more effectively use the limited resources we have, it is hard to overcome our convictions about what we do now and how we have done treatment, contracting and funding for decades.
Here are some excerpts from previous editions that address two vexing questions related to dealing with relapse.
Tip on Triggering:
- “But if I let a client who has used alcohol or some other drug come to group, won’t they trigger someone else?”
Excerpt from Volume 4, No.5, September 2006/ Things that don’t make sense- No.3
A clinician excludes an addiction client from group treatment when she shows with alcohol on her breath. There’s a fear she might trigger other group members. In contrast, many clinicians are quite comfortable with a mental health client talking about domestic violence or sexual abuse, even though that talk may trigger others in the group.
I have never heard of a therapist asking someone to leave group because their sobbing or severe anxiety disturbed another group member and made them feel uncomfortable or even angry. Yes we need to keep the treatment milieu safe and therapeutic.
However do not misunderstand.
I am not saying that if a person is severely intoxicated – slurred speech, cognitively unable to participate- that we continue to do group or psychotherapy with them. These are urgent needs that must be addressed. You would do the same with an acutely suicidal and impulsive person where establishing safety is also the top priority. Nor am I saying that if the client is intent on using substances and trying to get others to use with them that we just ignore that and continue treatment as usual. But if a person wants help, what better place to be triggered than in a group- rather than in a bus sitting next to a person who just used, tempting them to get off at the next stop and go to a bar. Better to be triggered in a therapy group with trained therapists right there to help both the client who has relapsed and any others who could identify with the same struggles and loss of control.
What to do about triggering?
Make it clear to all clients that recurrence of use is a treatment alert. Similarly recurrence of psychosis, mania, depression or suicidal thoughts and behavior are also significant events that need professional assistance. If a client is willing to reassess his treatment and change his plan in a positive direction, then treatment continues.
Tip on Consequences
- ” If there aren’t consequences for using, won’t this be “enabling” and send a message that it is OK to use and then everyone will start relapsing?”
“Enabling” is continuing to do the same strategies, behaviors or treatment plan even when the outcome and results are not improving. However if a client is willing to change his treatment plan in a positive direction to achieve a better outcome, that is “progress” even if not “perfection”.
Excerpt from Volume 4, No.7, December 2006
Here’s a question about substance use while in residential treatment.
“At my agency, we have been having some important discussions and would like your views, if possible. Our agency operates several 24 hour residential treatment programs. We have one that is specifically designed to be an integrated and comprehensive co-occurring treatment program and several that have specialized services for clients with co-occurring disorders but also serve substance abuse- only clients.
When a client relapses while in a 24 hour residential program, we continue to work with him/her to address the relapse etc. However, we have typically differentiated between someone who relapses and someone who brings drugs or alcohol into the program premises. When someone brings drug/alcohol into the building, we have seen this as a danger to other clients (and potentially the program). These clients have been discharged from the residential program and are not eligible for residential program services for 90 days. We continue to work with the client through case management services and emergency services at detox if necessary. We have seen this as important:
- for the client who needs to understand that his behaviors have impact and consequences
- for the other program clients who need a safe place to live and recover
- for the program which needs to maintain order and not be subject to NIMBY (Not-In-My-Backyard) issues, complaining neighbors etc.
Clients are aware of this upon admission to the program. Please let me know if you think this approach is reasonable. Do you think there is a difference between programs specifically for co- occurring clients and programs for both substance abuse and co-occurring clients? Do you see any difference between alcohol and drugs? We would appreciate any guidance you can give.”
Director, Residential Services
I agree that there are times when discharge is reasonable and necessary. Some clients are not invested in treatment and just want “three hots and a cot” (3 hot meals a day + a bed to sleep in). In that situation, if a client brings alcohol or other drugs into the facility and influences others to use too, then you discharge. The residential program is a “treatment place” – not a hotel, resort or “marketplace.”
On the other hand, a client might be doing treatment to the best of his ability. He/she gets a craving, and uses on a pass or on the grounds. In desperation, he may even arrange for someone to drop off drugs, and bring them to his room. While using, this might influence his roommate to use with them. This is when you “continue to work with him/her to address the relapse etc.” – as you do already. Like you, I would reassess and change the plan accordingly – not just automatically discharge.
You would do the same with a mental health problem. If a client has impulses to hurt himself or self-mutilate, in his desperation he may bring in a razor blade to the residential program, or use the kitchen knife to cut themselves. Obviously this is a danger to other clients and the milieu also. Again, I would reassess. Explore what the person is willing to do to try to prevent that behavior. If he recognizes this is not the best way to respond to his impulses, and is willing to try a more productive plan, you keep going. This process should be the same for addiction treatment in my opinion.
Clinicians can still achieve safety goals for clients and the milieu with a community meeting/group as soon as possible. This safety message is communicated: It is not OK for anyone to bring in drugs, razor blades, engage in cigarette-burning, using or cutting in the residential program. The person is expected to share/talk openly about his/her crisis. He is expected to apologize to those who might have been triggered by his actions.
The focus then moves to a positive treatment direction: 1. What does the client intend to do differently to deal with this craving or impulse? 2. How will he keep himself safe, plus other clients and the milieu?
This approach is important for all clients – whether addiction only or co-occurring disorders.
Excerpt from Volume 6, No.5, September 2008
- 21st century addiction attitudes and practices parallel those of the physical and mental health fields.
My vision for 21st century treatment is that we view addiction illness no differently from many other physical and mental disorders- especially regarding relapse possibilities, clients’ common non-adherence with their treatment, the chronic nature of many illnesses and frequent poor outcomes.
–> Whatever the illness, if a patient or client relapses, the first task is to make sure there are no immediate acute needs that are life-threatening. Assess what went wrong; and then what the new and improved, modified plan will be.
You wouldn’t want your physician to discharge you for your elevated blood pressure or blood sugar level; or your mental health professional to dismiss you from a treatment session for getting more depressed.
–> Whatever the illness, if a client does not stick to the collaborative treatment plan, outcomes will be poor most likely. This is an urgent situation. The goal is to re-engage the client and assess what can be done to retain them in treatment.
You wouldn’t want your physician to blacklist you from his clinical practice for your fourth diabetic coma or emphysema crisis, even if you were careless with your insulin or having trouble not smoking. You wouldn’t want your mental health clinic to ban you from their center because you became psychotic after not taking your medication.
–> Whatever the illness, if an individual is getting worse, this simply means that a broader array of services may be necessary. The system of care is designed to encourage illness management in an ongoing continuum of care.
You wouldn’t want your physician to blame you for your worsening hypertension or
diabetes; or to simply re-admit you for diabetic coma without managing your diabetes in a long-term fashion. You wouldn’t want your mental health therapist to blame you for getting obsessive-compulsive, or simply stabilize an acute crisis and neglect planning a long term strategy with you.
We can all share and learn from each other, no matter our fields.
The general public still largely views addiction as a self-inflicted problem. There is less tolerance for supporting treatment when compared with physical illness, and even for many mental disorders. What is even worse still is when addiction treatment also embraces policies which appear to view addiction relapse as willful misconduct, needing consequences and possible discharge.
Change is challenging. Think about the last time you promised yourself to lose twenty pounds or start daily aerobic exercise. How is that going? This month I was reminded of two life lessons that are easy for me to forget:
- Be optimistic about change
- Change begins with me
Have you ever found yourself complaining that your supervisor, administrator, co-worker or client is just “so resistant” and unwilling to change? A more optimistic, compassionate and effective re-frame would be to say: “Oh, so he is just at a different stage of readiness to change than I would like.” “She is just motivated for something that is more important to her than it is to me.” “How can I raise awareness about where we both are?” “How can I start where she is at and attract and inspire her towards a different goal?”
You have probably seen the Gandhi quote that I love: “Be the change you wish to see in the world”. Charity begins at home. Whoever feels he or she is more right than the other, that is the one to reach out and build bridges.
See SUCCESS STORY AND SHARING SOLUTIONS for a reminder on being optimistic for change and taking action. Brunie wrote: “All I know is that we saw this train coming and figured we’d better do something about it because no one else was going to. It has been REMARKABLY successful!”
Thanks for your success story. It gives me faith that adversity can bring people together rather than create my more pessimistic scenario.
STUMP THE SHRINK
Elizabeth Dosher, CSW raises important issues if you or your program decides to begin to use evidence-based practices and move away from tradition and “the way we have always done things”. It is not easy and needs to be planned for.
“Hi Dr. Mee-Lee:
I recently attended the training you facilitated at Valley Mental Health in Salt Lake City on May 20, 2009. You mentioned that you believe clients/patients should be able to attend treatment if under the influence of a substance or alcohol, noting that the treatment agency should be a safe place for support and an environment to talk about relapse, etc. You also stated that a client under the influence may be triggering to other clients but that this is an appropriate, therapeutic environment to process triggers for relapse, as they do not live in a bubble and may benefit from exposure to someone under the influence.
What I am wondering is how do you present to clients that they may indeed come to treatment groups under the influence? We are a dual diagnosis outpatient treatment center that offers ASAM levels .5 (Early Intervention), I.0 (Outpatient Services), and ll.1 (Intensive Outpatient treatment, IOP). Currently, we have an abstinence policy for clients entering treatment but want to allow clients to come to treatment under the influence if needed.
We are unsure how to convey this to clients, as we have experienced past difficulties with clients taking excessive liberties with a non-abstinence based program. Recently, a clinician informed an IOP group that they should come to group if they have used and the next day a group member showed up intoxicated. We do not want to open the flood gates for clients to attend treatment while actively using, however, realize we need to join clients where they are at with their substance use goals.
We have a large population of court ordered clients who have minimal motivation for treatment participation. How do you suggest tackling this issue? Are there specific protocols for handling this issue in the treatment agreement contract?
Elizabeth Dosher, CSW
Substance Abuse Team Leader
Valley Mental Health- Summit
I know it is tricky to make the transition. Here are some thoughts and suggestions:
1. All staff involved need to be on board about the change and have bought into this as a better clinical way to deal with relapse. In other words, staff should not just declare a change of approach to clients if they have significant ambivalence about this approach as that will show through.
2. Similarly, referral sources have to be prepared through education and discussion that this is an approach to increase the chance of honest involvement in treatment by the client. Also, it increases the likelihood of a client actually changing to be more responsible and accountable to decrease legal recidivism and increase public safety. If there is not buy-in from those who refer court-ordered clients, they will perceive this as being soft on clients and sabotage it.
3. Here is possible language to the clients:
“We believe you all have the illness of addiction and that for some, this is a relapsing illness. That doesn’t mean relapse or slips are inevitable and we would want to do everything to help you prevent relapse. This is how we would treat diabetes or asthma or hypertension.
But if it should happen that you slip or relapse, then we want you to know that can be a crisis, as it is easy to feel like a failure and give up. But there is no need to be hopeless or keep using just because you slipped. Make sure you reach out to AA members, your sponsor and also to come to treatment to get help to assess what went wrong and to work on how to change your treatment plan to prevent it getting worse.
We are not saying it is OK to go and use and see that as “no big deal” and just show up at treatment and blame your disease. What we are saying is that if your relapse prevention plan breaks down and you slip, then come to treatment even if you just used, so we can work with you to prevent it getting worse.
If you are so intoxicated that you can’t cooperate and collaborate in individual or group treatment, then we will help you stabilize until you can do some meaningful work on improving your treatment plan.. We’ll also make sure you are safe and don’t need detox or more intensive care.”
4. What I outlined above is for clients who are at Action for recovery. For the court-ordered clients who are at Action for getting off probation, or staying out of jail, there is a different approach. If they don’t think they have a problem with addiction, then a “discovery, dropout prevention” plan is needed rather than a “recovery, relapse prevention” plan. A “discovery” plan may be to work with the client to develop the data to prove the client does not have a substance use disorder. Part of gathering that data would be to see if they have consistently negative drug screens and abstinence.
If the client uses and can’t maintain abstinence, you would still want them to come to treatment to discuss how they must have more of an addiction problem than they think. They would be using the group to discuss how they believe they don’t have a problem and yet can’t stay abstinent plus to get feedback from the group.
Hope this makes sense but let me know if not.
SUCCESS STORIES & SHARING SOLUTIONS
In last month’s SOUL section, I suggested that when there is competition for scarce resources somehow “people of good will easily morph into people of ill will”. “Not so fast” was Brunie Emmanuel’s response!
Here is his SUCCESS STORY on how the Pensacola, Florida area handled shrinking resources. I appreciate his SHARING SOLUTIONS that can easily work across the country.
“Here in our little corner of northwest Florida, when we saw the economic crisis coming, we convened a group of leaders of the 40-50 key social service organizations into an “Economic Crisis Solutions Circle.” It was called by the regional Director of the state welfare department, and focused on expediting the unobstructed flow of those in need to services available, especially the BASIC needs of food, shelter, & clothing. Out of those meetings evolved a number of activities and workgroups focused on taking advantage of what resources we have in the community and not on what we did not have.
There were (and continue to be) a number of great synergies, additional focuses, some combined services, etc. One of the greatest results was a “Community Data Base” whereby we will soon be able to directly communicate between and among all of the key providers of social services, mutually accessing available services in a “real time” way through “bridged” data systems and a community data warehouse, thus providing the means to eliminate duplication, and in-the-not-too-distant-future, be able to make appointments for clients at each others’ places of work.
Yes, my Friend…sometimes things get competitive in a tough environment. Sometimes, too, people of good will find a way to tighten their bonds of mutual support and discover ways to do more with less.”
Brunie Emmanuel, Director
EscaRosa Coalition on the Homeless
Web site: www.ecoh.org
Until Next Time
Thanks for reading. See you in July.
DML Training & Consulting