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"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.
See link above.

More people over 65 are admitted to hospitals for alcohol-related problems than for heart attacks.
See link above.

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.



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 at

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 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 and outcome.



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 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.

Seventeen percent 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 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.

Providing 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?

While 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.

The problem with administratively discharging patients, is that you can't treat patients who are not in treatment to be treated!

Abstinence 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 more appropriate.

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.

What 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.

Aftercare/continuing care/maintenance 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 episode.


Since 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.

Documentation 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.


Three demographic predictors of poor outcome in addiction and mental health treatment are:
*under 25 years of age
*never 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 at



Never, never, never, never, never, never give up!

Alcoholics are just like other people but more so.

"Resistance" is "Ambivalence in Drag."

Substance abuse and substance dependence are different disorders, not merely different stages of the same disorder.

Alcoholism does not come in bottles, it comes in systems, e.g., families.

Uncounted numbers of people get sober in church.