Compliance, adherence, Stump the Shrink on treatment courts, Biopsychosocial

savvy, skills, & stump the shrink

• The first two questions/comments are follow-ups from the June edition of Tips & Topicsand 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.

• 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 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.

• 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.

• “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”.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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?

• 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.

soul