Contributor: Yvette McBride Thomas

Dimension 1:  Acute Alcohol and/or Drug Intoxication

Problems: (need)

• Patient presents with opiate withdrawal symptoms
• Patient reports continued opiate dependency for ____ years and urine toxicology confirms opiates in system
• Patient reports pattern of acute  cocaine intoxication
• Patient reports/evidence episodic alcohol intoxication
• Patient reports pattern of THC abuse or dependency
• Patient is opiate dependent and in need of continued outpatient methadone treatment
• Patient has been maintained in OMT and patient in consult with staff have determined he/she is ready for therapeutic detoxification
• Patient shows  signs of continued opiate use on current methadone dosage

GOALS (I will)

• Stabilize on methadone maintain dosage
• Cease use of illicit opiates as evidence by urine screen results
• Cease use of alcohol
• Cease use of non-narcotic illicit drugs as evidence by urine results
• Successful therapeutic detoxification from methadone/methadone
• Continued stability o OMT

INTERVENTION (objective)

• Medical review of history and physical by MD: target date within 72 hours of admission
• Begin induction of methadose and monitor for needed dose adjustments. Patient to be observed at dosing 6x per week initially and patient to report any symptoms of intoxication or withdrawal to medical personnel: target date for dose stabilization: three weeks and monitoring ongoing
• Patient to be randomly breathalyzer for monitoring due to history of ETOH abuse: target randomly breathalyzer throughout the course of treatment
• Patient to have a urine toxicology screen within six (6) weeks of treatment to monitor for evidence of illicit drug use/pattern of intoxication and random urine screens per FDA regulations throughout treatment
• Counselor and medical team to consult MD to order appropriate therapeutic detox plan
• Patient to monitor self during therapeutic detox and report any symptoms to staff for MD review
• Counselor to discuss possible need for increase in meth dose with patient and document on medical review
• MD to review patient urine screens and symptoms for possible meth dose change per medical review

DIAGONOSTIC SUGGESTIONS (taken from DSM-IV codes associated with presenting problems)

• AXIS 1

303.90 Alcohol Dependency

305.00 Alcohol Abuse

304.30 Cannabis Abuse

304.20 Cocaine Dependence

305.60 Cocaine Abuse

304.80 Polysubstance Dependence

BEHAVIORAL DEFINITIONS

• Consistent use of alcohol or other mood-altering drugs until high, intoxicated, or passed out
• Inability to stop or cut down use of mood altering drug once started, despite the verbalized desire to do and the negative consequences continued use brings
• Denial that chemical dependence is a problem despite direct feed-back from spouse, relatives, friends and employers that the use of the substance is negatively affecting them and others
• Amnesiac blackouts have occurred when using alcohol
• Increase tolerance for the drug as there is the need to use more to become intoxicated or to attain the desired affect
• Continued alcohol/drug use despite experiencing persistent or reoccurring physical, legal, vocational, social, or relationship problems that are directly caused by the use of drugs/alcohol

LONG TERM GOALS

• Accept chemical dependency and begin to actively participate in a recovery/support program
• Establish a sustained recovery, free from the use of all mood-altering substances.
• Establish and maintain total abstinence while increasing knowledge of the disease and the process of recovery
• Acquire the necessary skills to maintain long-term sobriety from all mood-altering chemicals
• Withdraw from mood-altering substance, stabilize physically and emotionally, and then establish a supportive recovery plan

THERAPEUTIC INTERVENTIONS

• List recreational and social activities and places that will replace substance abuse related activities
  • Assist client in developing insight into life changes needed in order to maintain long term sobriety
  • Assist client in planning social and recreational activities that are FREE from association with substance abuse
  • Write a good-bye  letter to drug of choice telling it why it must go
    • Direct patient to write a good-bye letter to drug of choice; read it and process related feelings with counselor/therapist.
    • Ask client to make a list of the ways substance abuse has negatively impacted his/her life and process it with therapist

PROGRESS NOTE

Note: each note is in the order of the therapeutic intervention

Consistent abuse of alcohol/drug

• The patient described a history of alcohol abuse on a frequent basis and, often, until intoxicated or passed out
• Family members confirmed a pattern of chronic abuse by the patient
• The patient acknowledges that his/her alcohol abuse began in adolescence and continued into adulthood
• The patient has committed him/herself to a plan of abstinence from alcohol/drugs and to participate in a recovery/support program
• The patient has maintained total abstinence, which is confirmed by his/her family

Inability to reduce alcohol/drug abuse

• The patient acknowledges that he/she frequently has attempted to terminate or reduce usage of the mood/mind altering substance, but has found that once use has begun, he/she is unable to follow through.
• The patient acknowledges that in spite of negative consequences and a desire to reduce or terminate the use of drugs/alcohol he/she is unable to do so.
• As the patient has participated in a total recovery program, he/she has been unable to maintain abstinence.

Denial

• The patient presented with denial regarding the negative consequences of his/her substance abuse, inspite of direct feedback from others about its negative impact
• The patient’s denial is beginning to breakdown as he/she is acknowledging that substance abuse has created problems in his/or life
• The patient now openly admits to the severe negative consequences in which substance abuse has resulted

Amnesiac blackouts

• The patient has experienced blackouts during alcohol abuse, which have resulted in memory loss for periods of time in which the patient was still functional
• The patient stated that his/her first blackout occurred at a young age and that he/she has experienced many of them over the years of his/her alcohol abuse
• The patient acknowledged only one or two incidents of amnesiac blackouts
• The patient has not had any recent experiences of blackouts, as he/she has been able to maintain sobriety

Increase tolerance

• The patient described a pattern of increasing tolerance for the mood-altering substance as he/she needed to use more of it to obtain the desired affect
• The patient described the steady increase in the amount and frequency of the substance abuse as his/her tolerance for it increased

Continued alcohol/drug use

• The patient has continued to abuse alcohol/drugs in spite of recurring physical, legal, vocational, social, or relationship problems that were directly caused by the substance use
• The patient has denied that the many problems in his/her life are directly caused by alcohol/drug abuse
• The patient acknowledged that alcohol or drug abuse has been the  cause of multiple problems in his/her life and verbalized a strong desire to maintain a life free from using all mood-altering substances
• The patient is now able to face resolution of significant problems in his/her life as he/she has begun to establish sobriety
• As the patient has maintained sobriety, some of the direct negative consequences of substance abuse have diminished

REFERENCE USED: Jongsma, A.E. Jr and Peterson, L. Mark The Complete Adult Psychotherapy Treatment Planner 2^nd edition

SUGGESTED READING

Alcoholics Anonymous (1975). Living Sober. New York: A.A. World Services

Alcoholics Anonymous (1976). Alcoholics Anonymous: The Big Book. New York: A.A.  World Services

Carnes, P. (1989).  A Gentle Path Through the Twelve Steps. Minneapolis, MN: CompCare.

Nuckals, C. (1989) Cocaine: From Dependency to Recovery. Blue Ridge Summit, PA: TAB Books