Contributor: Yvette McBride Thomas

Dimension 2: Biomedical Conditions and Complications

Problems (need)

• Patient has a medical condition (e.g. high blood pressure, asthma, diabetes, etc.) and has not consistently participated in recommended medical care.
• Patient has a serious illness and needs to continue medical care with his/her primary care physician/specialist
• Patient is pregnant and needs to engage in regular high risk prenatal care
• Patient is in need of dental treatment
• Patient is in need of prophylactic for treatment /prevention of active TB
• Patient is in need of healthcare information on HIV/AIDS, TB, and Hep that include the effects of illicit drugs on the body.
• Patient is in need of CXR after positive PPD (TB)
• Patient is in need of HIV education as part of preventive care
• Patient needs to engage in regular preventive medical care
• Biomedical condition may be exacerbated by illicit drug/alcohol use.
• A positive test for HIV/AIDS
• Patient has a history of neglecting his/her physical and medical health

Goal (I will)

• Secure medical care
• Engage in regular medical care for management of chronic medical condition
• Continue specialized treatment for serious medical condition
• Secure high risk prenatal care
• Secure dental care
• Receive screening and/or treatment for prevention of active TB
• Learn effects of illicit use on medical condition
• Participate in regular prevention medical care
• Ensure coordination of care including primary medical provider and treatment provider
• Medically stabilize physical condition
• Accept chronic medical condition with proper medical attention given to it
• Take responsibility for maintain physical health and well being
• Establish chemical dependency recovery that leads to improved physical health

Intervention (objective)

• Patient to secure medical appointment with primary care physician to follow up on abnormal labs within one month or earliest available appointment
• Patient to discuss in counseling session the benefits of complying with recommended medical care; monitor on going medical compliance
• Patient to verify available coverage and report back to staff: verify medical coverage as needed and offer patient appropriate referrals based on source of coverage.
• Patient to become aware of negative effects of illicit drug use on biomedical condition after reviewing in counseling: address ongoing through course of treatment.
• Patient to register all prescription medication and update prescription verification throughout course of treatment
• Patient to use referral list and call for dental appointment: target date one month or first available appointment
• Patient to bring verification of attendance at high risk prenatal clinic: monthly throughout the course of pregnancy
• Patient to be able to name benefits of regular prenatal care: address in counseling throughout period of pregnancy
• Patient to become aware of illicit drug/alcohol abuse/use on pregnancy: address in counseling session throughout period of pregnancy
• Patient to receive HIV/AIDS as well as TB risk reduction education: target date within six(6) weeks of entering treatment and update as needed throughout the course of treatment
• Patient to attend post-partum medical appointment within eight (8) weeks of delivery or first available appointment
• Treatment staff to consult with patient primary medical doctor as needed to ensure ongoing appropriate care
• Patient to discuss importance of preventive medical care for self and family
• Patient to bring in verification of TB screen (PPD)
• Patient to bring verification of prophylactic treatment for prevention or treatment of active TB

Diagnostic Suggestions (taken from DSM-IV codes associated with presenting problems)

• Axis 1

303.90 Alcohol Dependence

304.20 Cocaine Dependence

304.80 Polysubstance Dependence

Behavioral Definitions

• A positive test for HIV/AIDS
• History of neglecting his/her physical and medical health
• Medical complications secondary to chemical dependence

Long Term Goals

• Accept chronic medical conditions with proper medical attention given to it
• Take responsibility for maintaining physical health and well-being
• Establish chemical dependence recovery that leads to improved physical health

Therapeutic Interventions

• Make any necessary arrangements required for patient to obtain the medical services needed
• Refer patient to physician for complete physical
• Help patient understand his/her medical problem and the need to cooperate with doctor’s recommendations
• Monitor treatment effectiveness and document patient’s follow-through on doctor’s orders; redirect when patient is failing to comply
• Consult with physician and review doctor’s orders with patient
• Provide patient with any appropriate  literature that will increase his/her understanding of medical condition
• Arrange for consultation with dietitian to explain proper nutrition that will enhance medical recovery
• Explore and assess the role of chemical abuse/dependency has on medical condition
• Refer patient to public health of physician for STD and/or HIV testing, education and/or treatment
• Help patient identify and express his/her feelings connected with medical condition
• Assign patient to make a list of things he/she could do to help maintain physical health; process list

Progress Note:

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

• The patient presented with serious medical problems that are having a negative impact on his/her daily living
• The patient has pursued/refused treatment for his/her medical condition
• The patient has not sought treatment for his/her medical condition because of a lack of insurance and financial resources
• The patient’s serious medical condition has been under treatment and is showing signs of improvement
• The patient reports that he/she has tested positive for HIV/AIDS
• Patient has been HIV positive for several months but has had no serious deterioration in his/her condition
• The patient is obtaining consistent medical care for his/her HIV status
• The patient has refused medical care for his/her HIV-positive status and tends to be  in denial about seriousness of this situation
• The patient’s HIV-positive status has resulted in the development of AIDS
• Because of the patient’s chronic chemical dependency history, he/she has developed medical complications
• The patient has accepted that he/she has deteriorated medically because of his/her chemical dependency pattern and has terminated substance abuse
• The patient is in denial about the effects of his/her substance abuse and continues this self-destructive pattern
• The patient’s medical condition has improved subsequent  to termination of substance abuse
• The patient described a history of neglecting his/her physical and medical problems
• The patient continues to refuse medical evaluation and treatment for physical problems
• The patient agrees to seek medical treatment and has followed through on this recommendation
• After receiving medical treatment, the patient’s physical and medical condition has improved significantly.

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

Suggested Reading

Substance Abuse Treatment for Persons with HIV/AIDS. Treatment Improvement Protocol (TIP) Series, No. 37.

 INFORMATION SOURCES

• The National AIDS Treatment Information Project – http://www.natip.org/index.html

• The Measurement Group – www.themeasurementgroup.com

• JAMA HIV-AIDS information center – http://www.ama-assn.org/special/ hiv/hivhome.htm

• Critical Path AIDS Project – http://www.critpath.org/critpath.htm

• HIV/AIDS Treatment Information Service (ATIS) – http://www.hivatis.org

• AIDS Clinical Trial Information Service (ATCTIS) – http://www.actis.org

• Centers for Disease Control and Prevention (CDC) – http://www.cdc.gov

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