Often, primary care professionals and their clients have a profoundly adversarial relationship, when it comes to substance abuse and addiction.
Two recent studies prove this point quite well. In the first, published in the journal Addiction, 47 percent of abusers of anabolic-androgenic steroids claimed that they trusted the information they received from their dealers as much as they trusted the information they got from their doctors. In the second, also published in Addiction, 38 percent of general practitioners and family physicians reported that they didn’t discuss smoking cessation with their clients, as they felt the conversations were ineffective. Put these two studies together and they paint a picture of clients and doctors who are often unwilling or unable to discuss substance abuse openly.
It’s possible that some of this conversational lull occurs due to the nature of addiction care itself, particularly in people who have Dual Diagnosis concerns. Once the issues have been disclosed, the patient likely needs some kind of specialized care, and that might not be an issue a medical professional has researched extensively in medical school. In fact, unless that medical professional has taken a number of CME courses on addiction, it’s likely that the advances in care have passed by unnoticed, and that medical professional might not know much about how these issues are even addressed via modern, research-based techniques.
This guide is designed to help. Here, we’ll outline some of the broad strokes of addiction care in our modern era, along with techniques doctors and other professionals can use to both discuss issues openly and provide appropriate follow-up care for their needy clients.
Much of the information presented in this guide cites research. Statistics and formal findings can make difficult concepts move from the realm of opinion into the terra firma of fact, and as a result, they’re of vital importance to each and every person who works in the medical field. However, research conducted on addiction can be slightly complicated, and it’s worth taking a moment to discuss those issues in advance.
Addictions can manifest in different ways in different people, particularly if the patients in question have complicating factors such as schizophrenia, eating disorders, anxiety or conditions on the autistic spectrum. At times, it can be difficult to untangle the knot of competing types of causation, which can make attributing symptoms to their proper conditions a little difficult. In a perfect world, scientists would have access to monozygotic twin studies, so they could determine how one new factor determined the course of a disease, but at the moment, most researchers are content to compare two sets of addicted clients with one another, or they might compare addicted people with sober controls. It may not be perfect but it is the tool that’s available. As always, individual results may vary.
With words about research out of the way, it’s appropriate to turn the discussion to the forms of treatment that have the scientifically proven ability to assist people with serious cases of addiction, even if those people have complicating mental illness. Getting the right kind of care matters for these clients, as accessing the wrong form could mean placing these vulnerable clients in a revolving door form of treatment. They might enter a program, stay for a few months, and then drop out in order to return to their old habits. This kind of pattern can lead to all sorts of undesirable outcomes, including:
Those facilities that want to stop this cycle might begin by ensuring that the therapies they provide have a sound footing in scientific principles. Among the forms of therapy that have decades of research behind them, Cognitive Behavioral Therapy (CBT) may be the most widely known, and some might argue that it’s also the most widely successful.
No matter the type of therapy a patient might receive in an addiction treatment program, research suggests that longer stints in care tend to be more effective than shorter bursts of therapy, particularly for people who have Dual Diagnosis issues. Typically, referring professionals are encouraged to perform some sort of assessment on the severity of the addiction when a client presents for care, and the result of that testing should be used to determine the length and the course of care. Unfortunately, as yet another study in Addiction demonstrates, few of these assessment conversations go as planned. In the study, less than 25 percent of patients were properly evaluated and placed based on severity.
In general, since addictions are defined as chronic conditions, and many mental illnesses share that same designation, it’s best to refer to programs that have at least the capacity to provide long-term solutions for clients in need.
Assessments can then take place within the walls of the treatment facility, and the proper course of action could take place based on that assessment. By referring to facilities that can provide comprehensive long-term care and extensive monitoring, referring professionals might be closing the revolving door for good.
Medication management is another hot topic among addiction treatment professionals, and primary care physicians may have their own concerns about the pharmaceutical treatment of both addiction and mental illness in their vulnerable patients. As an article in the Journal of Psychoactive Drugs aptly points out, physicians may be concerned about providing specific medications, such as benzodiazepines, for fear of triggering further episodes of abuse. Clients might also resist the use of medications, for fear that they’re still leaning on drugs.
These concerns aren’t easily resolved but the fact remains that some mental health conditions simply require pharmacological solutions. Those with schizophrenia, intractable depression or bipolar disorder may need a chemical alignment in order to improve, and without that assistance, they may return to drugs in a desperate search for a do-it-yourself solution. For these reasons, it’s advisable to refer Dual Diagnosis clients to those facilities that can and do provide medication management.
Any article about scientifically demonstrated addiction treatment would be remiss without a mention of the 12-Step movement. In a study in the Journal of Substance Abuse Treatment a whopping 80 percent of respondents supported the idea of increased use of these types of interventions, which seems to suggest that most providers have at least a passing understanding of the concepts of this spiritual movement. The idea behind the groups, for the unfamiliar, is to encourage addicted people to link to a group mentality and reach out to a higher power in order to stay sober. The long-term aspect of the movement can be vital for some people, as joining a 12-Step group provides them with ongoing access to the world of recovery that they can access for no fee and with no planning. This kind of supportive and long-term care can keep them on the right track for decades.
While all of this research might help to illuminate the necessity of care, along with the forms of treatment that tend to be most successful, it can be difficult for providers to start the conversation with addicts and their concerned family members. Sometimes, opening with an expression of hope can be vital.
These are hopeless, helpless statements that can keep people out of the programs that could bring relief. Physicians who share their knowledge about the addiction treatment program and who sprinkle statistics into their talk may help to convince addicted people and their families that there are hope and help available, and that working toward a solution is neither silly nor fruitless.
In addition to speaking, however, physicians should be certain to spend an appropriate amount of time just listening and expressing sympathy. Often, people who have addictions spend a significant amount of time hiding their despair, and their families can become unwilling participants in this deception. Opening up the conversation can mean punching through a wall of silence for the first time, and that might release an intense stream of thoughts, feelings and fears that have previously never been discussed. Allowing the talk to unfold naturally could allow the family to take their first furtive steps toward healing.
Unfortunately, a physician’s hands may be tied when it comes to providing care for the unwilling due to confidentiality rules. Families may not be able to learn more about what an addicted person says in a closed-door appointment, and the addicted person may never even agree to an appointment in the first place.
Thankfully, there are professionals who are equipped to help families hold these delicate and fraught conversations, and transition those expressions of concern into actions that can help an addiction to abate.
Interventionists, as these professionals are often known, specialize in helping families talk openly about addiction with the person who has the addiction. In these structured conversations, families have the opportunity to express their feelings about the progression of the disease while the interventionist stands at the ready to provide information about treatment. The interventionist can even transport the person to a professional treatment facility in some cases.
Some interventionists use the so-called Johnson Intervention model in which the family reads a set of prepared statements and pressures the person to attend treatment. Typically, these interventions are held on a surprise basis, and a slightly confrontational tone is common. These interventions can be effective but families may balk at the idea of openly criticizing the addicted person. Thankfully, there are other intervention modalities that can also be helpful, and these alternate forms might be best for those who have mental illnesses complicating their recovery. The CRAFT Intervention model, for example, relies on a series of non-confrontational education sessions the addict can also attend, with conversations becoming more and more intense until a formal Johnson Intervention is held, if the person won’t accept care.
In a study of this type of intervention, published in the Journal of Consulting and Clinical Psychology, researchers found that Johnson Interventions resulted in admission to addiction care in only 30 percent of cases, while 64 percent of those who participated in a CRAFT Intervention were willing to attend rehab. Since this study looked specifically at addicts who had resisted prior suggestions of care, this is a remarkable accomplishment, and it demonstrates the value that an interventionist can bring to a discussion regarding addiction and therapy.
Reading up on how addiction care works and how clients might benefit can be helpful but as a referring professional, you might have targeted questions about how the programs should help your clients and how you can best prepare them for the work that’s to come. If so, we’d like to help.
At Foundations Recovery Network, we have access to some of the most intense Dual Diagnosis research available, and we have decades of experience in dealing with intractable cases of addiction complicated by mental illness. We’re happy to discuss individual cases with you or link you to our medical staff members who can share their expertise and understanding. We can also help to smooth the admissions process for your clients, should you deem that step necessary. Please call us to find out more or to take any of the steps mentioned above. We have admissions coordinators available around the clock to take your call and provide assistance.