November 2012

Last month’s SAVVY TIP 2 was: “Consider whether even the term “relapse” has no useful clinical meaning.” In case you missed last month, here’s the link:
October 2012 Tips & Topics

The focus of November’s edition comes out of comments and suggestions from one of our Tips and Topics readers, Ray from Cape Cod, Massachusetts. He shares his tip and raises a common concern about the impact of substance use on the residential treatment milieu. I’ll tackle that concern in SKILLS this month.

Now for Ray’s Tip:
TIP 1
If you stop using the term “Relapse”, try on for size, some alternate words.

“On the ‘relapse’ term, I have stopped using it and this really came home to me while doing training with medical staffs and trying to get them beyond their stigmatized perceptions of addiction patients. I decided to use the terminology they are familiar with:

• “remission”
• “a recurrence of acuity”
• “extending remissions”
• “shortening acute periods”
• “re-stabilizing the patient after acute symptoms recur”
• “improving functioning during periods of remission” etc.

It got them. Also avoiding use of the word “addicts” or “alcoholics”. In concert, this use of new terminology fits into their model and it is changing how our own addiction treatment staff thinks about patients.”……………

Raymond V. Tamasi, M.Ed
President/CEO
Gosnold on Cape Cod
www.gosnold.org

You may not yet be ready to drop the term “relapse”. However, when you reflect on it , I don’t think we use “relapse” for many, if any, other disorders, even in mental health. If someone becomes depressed and suicidal, I don’t say they’ve had a depression or suicide relapse. Same if someone becomes manic, psychotic or anxious. Same if a patient’s blood pressure flares up or their blood sugar spikes.

TIP 2
Even ASAM’s definition of “Relapse” raises more questions than it solves.

The American Society of Addiction Medicine (ASAM) has long defined “Relapse” as “a recurrence of psychoactive substance-dependent behavior in an individual who has previously achieved and maintained abstinence for a significant period of time beyond withdrawal.”

• Is the “recurrence of psychoactive substance-dependent behavior” drinking a couple of beers or using marijuana or crack cocaine once or twice in the past few weeks? Or does it mean daily or frequent heavy use with impacts on family, friends and co-workers? Or somewhere in between?
• How long is “significant period of time” for the person to have achieved abstinence? 3 months, 6 months, a year or two?
• Anyway is “abstinence” the only goal of treatment? What happened about a goal of “recovery” and isn’t recovery way more than just abstinence?
• Some individuals have never had a significant period of time being abstinent. If they now show up to treatment but having used on their way to group, is that considered a “relapse,” or just someone continuing to use, as is common for people with addiction illness?
  You can read more about this in Principles of Addiction Medicine (Reference is below).

The Bottom Line:
What words you use for relapse is important. But more importantly is the need to assess the reason(s) for the recurrence of signs and symptoms. After that comes the collaboration with the client- i.e. to change their treatment plan in a positive direction to get a better outcome.

Reference:
Appendix 1. ASAM Addiction Terminology in “Principles of Addiction Medicine” (2009) Eds Richard K. Ries, Shannon Miller, David A Fiellin, Richard Saitz. Fourth Edition. Lippincott Williams & Wilkins, Philadelphia, PA.,USA. Page xxix.

Douaihy A, Daley DC, Marlatt GA, Spotts CR (2009): “Relapse Prevention: Clinical Models and Intervention Strategies”, Chapter 65 in Section 5, Special Issues in Addiction Medicine in “Principles of Addiction Medicine” Eds Richard K. Ries, Shannon Miller, David A Fiellin, Richard Saitz. Fourth Edition. Lippincott Williams & Wilkins, Philadelphia, PA.,USA. pp 883-898.

Here’s the common concern Ray highlights:

“On the issue of resumption of use while in residential treatment, the reference to “kick ’em out” or discharge is a no-no at Gosnold. We do transfer the patient to a higher level of care (that being detox) not necessarily because they need detox, but in the current configuration that is the available next level of intensity.

While in detox then, both detox staff and residential staff consult to modify the treatment plan, meet with patient, etc., before a return to residential care or, in some cases, if we feel the patient’s presentation dictates a service that we don’t have, arrange for transfer to a more suitable program.

The missing piece in Miller’s model is the impact of in-program drug/alcohol use on the residential milieu. We cannot factor that out for the sake of devotion to the ideal model. Using in a residential/rehab program has significant impact on the patients and, while it enables discussion with them about the power of this disease, their own moralistic view in judging the patient who uses, etc., the sanctity of abstinence as a foundational residential/rehab program principle must be upheld.”

TIP 1
Reconsider your “relapse” policies if you automatically transfer a person to a more intensive level of care.

My response to Ray’s concern expands on my answer to a STUMP THE SHRINK question in December, 2006. It’s about what to do with substance use in residential treatment. You can look back at that question and response: December 2006 Tips & Topics

My response:
A recurrence of signs and symptoms of any illness and in this case, addiction, warrants an immediate reassessment of what went wrong, with a goal to improve the outcomes by changing the treatment plan in a positive direction. This should be true in an outpatient setting as well as a residential setting. Once the assessment and new service plan are agreed upon, the next decision is where can that plan be safely and efficiently delivered? The new plan may be able to be provided in the current level; or may need a less intensive or more intensive level. But the level of care decision is driven by the individualized treatment plan, not a predetermined policy to always move the person to a more intensive level of care.

Here’s some examples:

• Transfer to a less intensive level of care:
  Your client uses while in residential or intensive outpatient treatment, because after a period of abstinence, he now believes he is not really addicted. He is sure that recent substance use problems were caused by a lot of stress with family and work difficulties. He feels he was able to be abstinent with little difficulty, therefore he believes he can safely return to social drinking. That explains why he consumed a couple of beers when having dinner with friends on a recent transitional therapeutic pass. (Or if an outpatient, at a recent birthday party.) While the clinical team is sure he has addiction illness, they agree to transfer him from residential to outpatient services, or from intensive outpatient to once-a-week outpatient sessions to do “discovery, dropout prevention” work using motivational strategies.
• Transfer to a more intensive level of care:
  Your client has had increasing cravings to use. She is reluctant to reveal that fact and to process it with her counselor and peers. She fears her treatment stay will be lengthened. As her urges to use become almost unbearable, she hopes she can secretly get her old drug dealer to drop off some heroin, which she could use to get some relief. She succeeds in smuggling some heroin into the residential setting and is found slumped over in the bathroom having overdosed with the needle still in her arm. She is transferred to intensive care. In an outpatient example, this same type of transfer to a more intensive level would occur if, for example, a client was discovered overdosed by her roommate at home.
• Continue in the same level of care:
  Your client again experiences increasing cravings to use; she’s reluctant to process that with her counselor and peers. She arranges for some friends to bring oxycodone pain pills and some marijuana; she uses this while in residential treatment. Some peers notice this flare-up of addiction; when confronted, your client owns up to this return to substance use. In group, she processes this flare-up; she realizes she needs to sever all contact with old drug friends; she is willing to do that. Peers promise to support her; in group, she role-plays with them what to say to end her relationship with old drug-using friends.This treatment plan is best continued in the current level of residential care. There she has the support of peers who can also learn from her flare-up of addiction, even while living in a more protected environment. (There but for the grace of God, go I).
  
  In an outpatient setting, a client with 2 weeks of abstinence from methamphetamine and pain pills is genuinely excited about his recovery process. On the weekend, he visits friends who are still using methamphetamine. He wants to attract them to join him in recovery. Overwhlemed, he ends up using. Thankfully, he talks about that in group the next day. He realizes his mistake of visiting with using friends too early in his recovery; he determines to stay away and instead go to more Narcotics Anonymous meetings.
  
  This treatment plan is best continued in the current level of care where his updated treatment plan can safely be provided. To transfer him to a more intensive level of care would be wasteful of resources and break the continuity of care.

When is discharge reasonable?
When a client is NOT invested in treatment – doing time, not treatment.
…You can tell they just want a place to stay and “three hots and a cot” as a respite from being homeless.
…When a client agrees to treatment to get out of jail sooner, but is actively sabotaging the treatment milieu by bringing in alcohol or other drugs into the facility, influencing others to use with him/her.
The residential program is a treatment place, not a hotel, resort or marketplace.

When is discharge NOT reasonable?
When a client is trying to do treatment to the best of his/her ability.
These clients might still experience cravings and even use when on a pass, or on the facility’s grounds. They might even persuade a friend to drop them off drugs; they might bring them inside their room and use there; they may even get a fellow resident to use with them. I would still reassess and if they are willing to change their plan accordingly, treatment continues. This is about progress, not perfection- not just automatic discharge or transfer to a more intensive level of care.

Compare with a response to a mental or physical health flare-up
Consider how you would deal with a mental health problem. If a client deliberately copes with suicidal or self-mutilation impulses by bringing in a razor blade to the residential program or using a kitchen knife to cut themselves, what do you do?

This calls for an immediate reassessment. What is your client willing to do to try to prevent that behavior? If she acknowledges this is not the best way to respond to her impulses, if she gains some insight into what’s going on inside her, if she’s willing to try a more productive plan, then keep going in the same level of care. Transfer to a more intensive level is not necessarily the automatic response. Patients have flare-ups of their conditions frequently- their angina, asthma, hypertension or diabetes. It is not always necessary to immediately transfer a patient to the intensive care unit just because of a flare-up. The approach should be the same for addiction treatment.

On “the sanctity of abstinence as a foundational residential/rehab program principle must be upheld”
You can still achieve the goals of safety for the other clients and the milieu. Have an emergency community meeting and/or group as soon as possible. This message is delivered: It is not OK, nor safe, for the identified client or the other clients and the milieu to bring in drugs, razor blades, cigarettes to burn themselves. It is not OK nor safe to use, cut or be violent in the residential program. At this emergency community meeting, the client in crisis is front and center. Their task is to openly share what went wrong; to talk about what was going on for them that led to this crisis. He/she apologizes to others if the behavior triggered things for fellow residents. Apologies done, the focus is then on what he/she is going to do in a positive treatment direction to deal with this craving, or impulse etc. What explicit actions are they going to take to keep themselves safe, as well as the other clients and the milieu? This approach is important for all clients, whether addiction only or co-occurring disorders.

Ray’s final comments:
“The whole “cast the patient aside” issue in our field needs more discussion. We cannot draw comparisons to other chronic illnesses when it’s convenient (compliance rates, etc.) and contradict ourselves by discharging if the patient regresses. The old way needs to be challenged at every turn. Keep up the good work. ”

My response:
This is the dilemma that faces Ray and many others. More and more providers are becoming comfortable dealing with recurrences and flare-ups in outpatient settings and not sending people away. However when it comes to residential settings, we still treat acute addiction crises differently from mental and physical health flare-ups. As Ray says, “We cannot draw comparisons to other chronic illnesses when it’s convenient (compliance rates, etc.) and contradict ourselves by discharging if the patient regresses.”

Remember when you were on the playground. Everyone was lined up; the two captains were choosing teams for that volleyball game. If you were like me, I dreaded being picked last. It’s embarrassing and humiliating to be passed over each time a name is called. You know each captain is rolling his/her eyes when they see you still standing there. Please pick me!

Well this week, I had this same problem….. in reverse.

Have you ever been called up for Jury Duty? Now I am all for fulfilling one’s civic and constitutional duty, but when you have an all day workshop to teach in four days time to 150 people at a conference that’s been arranged for nine months, loyalty to them overrides my civic duty.

The juror information packet stated , if selected for the jury, most trials are over in two days. Or that’s what I thought I read. So in my head, I ‘allowed’ three days before I would have to fly to my workshop. (When I checked later… it actually stated most trials last two to five days. A bit of selective reading there on my part.)

So now the judge is explaining that the criminal case for which a jury will be selected will be relatively short…just four days. I have three days max before I have to be out of there. So now a mild panic starts in my gut. But wait, there is a hardship plea you can apply for and I raise my hand:

“I’m a psychiatrist. I do fulltime training and consulting and have a workshop that has been arranged for nine months that I must teach.”
Judge: “Will you be in economic hardship if you serve on the jury?”

“Well I won’t get paid, but I’m more concerned about my loyalty to the conference and attendees, your Honor; and I am willing to come back soon and leave more time available next time.”
Judge: “Well they won’t get to hear you, but you can cancel your plane.”

Now the panic is rising more. How can I call up and cancel a workshop where 150 people are planning to come and the venue has been booked and and…?

Judge: “Request for hardship denied.” I sit down.

They call the first 18 names. This is where the reverse problem starts – please don’t pick me! My name is not called. Panic recedes a little. Surely they can select 12 jurors and two alternates from 18 people. Ah, but the case involves scores of counts of alleged sexual molestation of a minor stepdaughter. It is clear the defense attorney plans to use alcohol use as part of the defense case. And it seems every other person has been a victim of, or has a close relationship with, someone who has been molested or involved with alcohol.

After much questioning a number of potential jurors are dismissed by either the prosecutor or defense attorney. Another seven names are called. The reverse problem again –
please don’t pick me. Panic is back up. My name is still not called. Panic recedes. Surely now, they will get the jury.

No such luck. More victims of sexual abuse or alcoholism. Another seven names are called. Now I’m sweating it. Any second now, I’m going to be picked. Phew! I’m still not called. Now they
have to be able to get a jury. Panic way down.

Success. They have 12 jurors and two alternates and I’m home free, as if I was just released after doing 10 years in State prison. The judge thanks us all for our time and civic duty. I stand to leave.

Then I hear the judge: “Dr. Mee-Lee…” Panic is back up. “….your name was the next to be called.” I smile and yell back: “I better buy a lottery ticket!”

Please don’t pick me.

Thanks for reading. See you in late December.

David