Cost-effective treatment matters!
"Pearls to Ponder"
Jerry has listed comments, ideas, "pearls"
and other tidbits reflecting his beliefs and biases, some with recommendations for further information, which may be of interest
to people who have accessed this web page. He invites your responses, including disagreement, if any.
In contrast to younger patients, the most important sources of motivation for older adults with substance
use disorders in order of increasing importance are their finances, physical health and independence. For what may be the
single best source of information about older adults with substance use disorder, order TIP #26, "Substance Abuse Among Older
Adults" at no cost from The National Clearing House for Alcohol and Drug Information
or at (800) 729-6686.
For some populations, case management may be as, or even more inportant than the treatment itself.
These include dually diagnosed, public welfare, criminal justice, child welfare, older adult, severely and persistently mentally
ill, and other diadavantaged or severely impaired populations.
Treating an older adult in a mainstream adult treatment
program is as inappropriate as treating an adolescent in an adult program.
See link above.
The group most at risk
for suicide in terms of race, gender and age are white males over 65 years old.
See link above.
One third of older
adults with alcohol disorders who exhibit "late onset" alcoholism are less likely to manifest physiological dependence.
More people over 65 are admitted to hospitals for alcohol-related problems than for heart attacks.
Contrary to popular belief, cognitive deficits severe enough to interfere with activities of daily living
are NOT the result of aging alone.
Adolescents are NOT short adults.
ASSESSMENT and PATIENT PLACEMENT
The quality of treatment
delivered can never rise above that of the quality of the assessment on which it is based. For a very good source of assessment
instruments, contact: Evince Clinical Assessment
Assessment is an ongoing process that takes place at the beginning, the middle and the
end, and at all points in between.
It is more important to understand the person who has the disease(s) than the diseases(s)
the person has.
Treating patients in more intensive levels of care than are appropriate, not only wastes resources
but is likely to result in poorer outcomes.
Screening is a process that is "cheap, quick and easy" and is designed
to rule prople "in" or "out".
The ASAM Patient Placement Criteria is the most effective system
for performing comprehensive assessment, determining appropriate level of care, and providing the basis for treatment planning.
For more information contact: ASAM
at www.asam.org or (301)656-3920.
For many clients in the public sector, ASAM Dimentions 3 (Emotional, Behavioral
and Cognitive Conditions and Complications) and 6 (Recovery Environment) should be expected to contribute most heavily to
addiction severity and recovery obstacles.
Anything less than a five Axis DSM IV assessment is clinically inappropriate.
Patients should always be treated in the least intensive level of care in which their treatment plan goals and objectives
can be SAFELY met.
Waiting lists for treatment programs can be managed to increase and enhance readiness to change
Persons with co-occurring substance
use and mental health disorders constitute a heterogeneous group of individuals. It is usually the case that without simultaneous,
integrated treatment for both, the chances for recovery from either is very much diminished. To raise clinical questions,
learn what other clinicians are doing, and have a forum for discussion, consider joining the Dual Diagnosis Listserve
at firstname.lastname@example.org operated by CSAT.
Mental health problems exist on a continuum of severity from none to
very severe. Just because there are not sufficient symptoms or traits to meet the diagnostic threshold, does not mean the
patient is "O.K." For example, the patient with impulse control and anger management problems alone will not warrant a diagnosis
of Antisocial Personality Disorder, but these problems will likely interfere with recovery efforts.
of patients with Bipolar Disorder commit suicide.
Chronic pain is as much a threat to recovery than is pain medication.
Dual Diagnosis is an expectation, not an exception. Look for a new TIP, a revision of the older dual diagnosis TIP,
which should be available shortly, without cost from The National Clearinghouse for Alcohol and Drug Information at www.health.org
or (800)729-6686. See link above.
For some patients, the issue is not
rehabilitation but "habilitation."
The longer individuals remain in a treatment system, the better the treatment outcome.
appropriate "wrap around" services IS part of treatment.
When the only tool in your toolbox is a hammer, everything
looks like a nail.
In abstinence-based treatment, is abstinence the goal of treatment or a requirement for treatment?
not "the answer" to addiction problems, there are a large number of pharmacological interventions that can be of help and
sometimes make a critical difference in recovery. These include psychiatric medications such as mood stabilizers, antidepressants,
anxiolytics, ADHD drugs and neuroleptics; anti-craving drugs such as naltrexone (ReVia for alcohol, acomprosate (for alcohol
craving), and bupropion or nicotine replacement (for nicotine craving); aversive drugs such as disulfiram (Antabuse for alcohol);
opioid maintenance/substitution drugs such as methadone and buprenorphine (Suboxone and Subutex); opioid antagonist drugs
such as naltrexone (Trexan for opioids) and naloxone to reverse overdose (Narcan for opioids); and withdrawal management drugs
benxodiazepines and other sedative-hypnotics for ETOH withdrawal as well as other medications for symptom relief for withdrawal
from other drugs.
Skill building activities in treatment yields better change results than information alone.
problem with administratively discharging patients, is that you can't treat patients who are not in treatment to be treated!
and reducing intake/changing use patterns are both harm reduction strategies, appropriate to different subsets of persons
who have experienced alcohol-related problems. For the DUI offender who is diagnosable as alcohol dependent, abstinence is
the only goal likely to bring about a change in the target behavior. However, for the offender who does not meet diagnostic
criteria for either dependence or abuse, other harm reduction strategies related to the pattern of drinking and driving are
Self image and treatment outcome are positively related.
The most common reasons why alcohol
and drug patients are administrative (non-routinely) discharged, are the same reasons why they were admitted.
distinguishes "habilitation" treatment from "rehabilitation" treatment is greater emphasis on skill-building in the former.
The better the practitioner or program manages the care of their patients, the less difficulty they will have with
external managed care entities.
Resistance responded to with confrontation results in more resistance, responded to
with more controntation, ad infinitum.
Care should be managed. In fact, the hallmark of quality treatment is the management
of patient care.
Relapse or continued use may be as much a result of inadequate assessment and treatment as the patient's
lack of readiness to change.
Motivational interviewing provides us with a mechanism for dealing with patients with
low readiness to change but is not in and of itself the treatment for addictive disorders.
care must be of a minimum length of service, which varies by population, in order to be effective.
While Twelve Step
groups like Alcoholics Anonymous, may arguably be the best support for ongoing recovery, it is incumbent upon us to use what
the patient will accept and what will work.
Contrary to popular belief, patients can and should stop smoking as they
begin recovery from other addictive substances.
The statement that "insanity is doing the same thing repeatedly and
expecting a different result" applies not only to chemically dependent patients and the substance abuse behavior but also
to treatment services which readmit patients with no plan for doing anything differently than during the previous treatment
TREATMENT PLANNING and DOCUMENTATION
the treatment plan is the patient's own, write the treatment plan objectives as "I will...." instead of "the patient/client
will..." or "John will..."
Some of the most important items on a treatment plan, are NOT treatment, e.g., literacy
training, child care, housing.
Treatment plan objective should be "BAM": Behavioral, Achievable and Measurable.
remains one of the greatest deficits in addiction treatment. If a clinical record cannot show linkage between the assessment
and the treatment plan with measurable and behavioral objectives, and linkage between the treatment plan objectives and the
progress notes, there is no way to measure patient progress nor determine the appropriate time for discharge or transfer.
In order to assess documentaion, take ten closed clinical records and after removing identifying data, copy the assessment,
the treatment plan, and the progress notes, sort them in three piles and ask the staff to reassemble them.
demographic predictors of poor outcome in addiction and mental health treatment are:
*under 25 years of age
married or having lived as married
*no high school diploma or GED
Case mix must be taken
into account when deciding on outcome measures. For example, if abstinence is a selected outcome measure, commercial airline
pilots should be expected to have much higher rates of recovery than homeless alcoholics.
Aftercare services may contribute
more to treatment outcome than the treatment itself.
Public and private purchasers of insurance benefits for substance
use disorders are less interested in "Treatment Works" than they are in the answer to their question, "What is the return
on my investment?" or asked another way, "What am I getting for my money?" Recommended link is to:
Committee for Outcomes Based Benefits
Never, never, never,
never, never, never give up!
Alcoholics are just like other people but more so.
"Resistance" is "Ambivalence
Substance abuse and substance dependence are different disorders, not merely different stages of the same
Alcoholism does not come in bottles, it comes in systems, e.g., families.
Uncounted numbers of people
get sober in church.