ch. 4 - Treatment Modalities & Client Placement

Question 1

Detoxification Services

Answer 1

O The withdrawal process from some substances can be life threatening and must be conducted under close medical supervision.
O Regardless of detoxification location, it is imperative that detoxification serve as a prelude to treatment.
O Different substances require a different approach to detoxification due to the unique symptoms and severity of the withdrawal process caused by different substances.

Question 2

Alcohol Onset

Answer 2

§ Occur 6 – 24 hours
§ Heavy drinkers may experience withdrawal symptoms by only reducing their daily alcohol intake
§ Typically runs 2 to 3 days possibly upward to 10 days

Question 3

Alcohol Withdrawal Symptoms

Answer 3

§ Autonomic nervous system – sweating, rapid heart rate, tremors, insomnia, and hypertension
§ Gastrointestinal issues – Indigestion, nausea, and vomiting
§ Cognitive issues – vivid dreams, hallucinations, or delirium. Grand mal seizures, in about 5% of all alcohol withdrawal cases and can occur within 7 to 24 hours
§ Most severe symptom – delirium tremens (DTs) which may occur within 2 – 5 days after last drink. This is a medical emergency that may last anywhere from 3 – 14 days.

Question 4

Medical Treatment of Alcohol

Answer 4

§ Recommendations are to implement diazepam treatment as early as possible in the withdrawal process to prevent the client from regressing to a more severe withdrawal experience.
§ Withdrawal risk: Wernicke’s and Korsakoff’s
§ Wernicke’s neurological symptoms by biochemical lesions of the central nervous system after exhaustion of vitamin B1.
§ Korsakoff’s psychosis can produce permanent brain damage and result in memory loss

Question 5

Benzodiazepines Onset

Answer 5

§ Occurs 2 – 5 days

§ Maximum experience of symptoms between 7 – 10 days after last use

Question 6

Withdrawal Symptoms of benzos

Answer 6

§ Anxiety, insomnia, agitation, irritability, and poor memory or concentration
§ Nightmares, depersonalization, increased sensory perception, ataxia, panic attacks
§ Psychotic symptoms and cognitive confusion may also occur

Question 7

Medical Treatment of benzos

Answer 7

§ Like alcohol, a long-acting benzodiazepine such as diazepam is the preferred medical intervention to facilitate a healthy and safe detoxification process.

Question 8

Opioids Onset

Answer 8

§ Heroin occurs 6 – 24 hours, peak 24 – 48 hours resolves in 5 – 10 days
§ Methadone occurs 36 – 48 hours, withdrawal length 3 – 6 weeks.

Question 9

Opioids withdrawl symptoms

Answer 9

§ Restlessness, anxiety, piloerection, excessive sweating, rhinorrhea, muscle twitching, gastrointestinal issues, hot and cold flashes, and insomnia
§ Like a severe case of the flu
§ Not life threatening

Question 10

Opioids Medical Treatment

Answer 10

§ Methadone is administered in decreasing doses over a period not exceeding 30 days (short term) or 180 days (long term)
§ Buprenorphine: Subutex contains only buprenorphine and is intended for use at the beginning of treatment. Suboxone contains both buprenorphine and naloxone and is intended to be used in maintenance treatment of opiate addiction.
§ Maintenance treatment with buprenorphine consists of three phases: (1) induction, (2) stabilization, and (3) maintenance

Question 11

Stimulants Onset

Answer 11

§ Amphetamines 2 – 4 days, peak severity around 7 – 10 days and subside 2 – 4 weeks
§ Cocaine 1 – 2 days, peak severity around 4 – 7 days and subside 1 – 2 weeks

Question 12

Stimulants Withdrawal Symptoms

Answer 12

§ Fluctuation in mood or energy levels, disrupted sleep including insomnia and/or vivid dreams, general body aches, muscle tension, and the potential for paranoid delusions or hallucinations

Question 13

Stimulants Medical Treatment

Answer 13

§ Bromocriptine a dopamine antagonist at low dosages and an agonist at high dosages, reduce cocaine craving
§ Cocaine vaccine – helps the body immune system make antibodies against cocaine – basically inhibits the pleasurable effects of the substance

Question 14

Inpatient Treatment

Answer 14

o Medical Center
§ Ongoing treatment for medical problems (related and unrelated to substance abuse)
§ Group, individual, marital/family therapy programs
§ Psychoeducational programs and social service support
§ Minnesota model – entire staff works on make recommendations for clinical areas to focus on, does not determine length of treatment
§ Health care insurance now demands shorter stays, and refusing to pay beyond 28 days whether if the client needs it or not

Question 15

The old style of Therapeutic Community

Answer 15

§ 24-hour marathon group – all day/night intervention and group counseling with the purpose of moving the client toward recovery
§ “hot seat” – where a member was confronted by all group members regarding personality flaws that inhibit recovery

Question 16

Today’s style of Therapeutic Community

Answer 16

§ Host for varying programs, including short- and long-term residential and day treatment, as serving those with co-occurring SUD and psychiatric disorder
§ Views that substance abuse is a disorder of the entire person
§ Focuses on a lifestyle change without the need for substance use (1) developmental, (2) socialization, (3) psychological, and (4) community membership

Question 17

Longer-term TC programs

Answer 17

§ Stage 1 - orientation – lasts for approximately 60 days
§ Stage 2 – primary treatment – months 2 – 12 involves the principals that facilitate personal change
§ Stage 3 – reentry – months 13 – 24 more advanced treatment components, maintenance of changes achieved, development autonomous thought and behavior without substance use, acquisition of vocational and/or education skills

Question 18

Outpatient Treatment

Answer 18

o Nonresidential program focused on SUD treatment and recovery
§ Individual counseling, group counseling, marital/family counseling and psychoeducation
§ 60.1% of all SUD treatment admissions were in outpatient settings
§ More clients were admitted to a detox program than an inpatient treatment program
§ Integrates group and individual counseling with other services such as relapse prevention, anger or stress management, educational programs, job skills training and marital/family counseling

Question 19

Intensity levels of treatment centers

Answer 19

§ Partial hospitalization – most intense
§ Intensive outpatient – moderate
§ Outpatient – least intense

Question 20

Partial Hospitalization

Answer 20

§ Evening or day treatment
§ May or may not be hospital based
§ Intensity equal to an impatient program but less than a 24-hour basis
§ More than 20 hours per week
§ Medical/nursing, psychiatric evaluation and medication management, group and individual/family counseling, psychological testing, vocational counseling and relapse prevention
§ Used as a time-limited response to stabilize acute symptoms

Question 21

Intensive Outpatient Program (IOP)

Answer 21

§ Runs 3 – 4 hours per day between 3 – 5 days per week
§ Group and individual counseling coupled with urine toxicology
§ Referrals may be made for pharmacotherapy, psychiatric evaluation, and marital/family counseling services
§ May be used as transitional level of care and stand-alone level of care

Question 22

Outpatient Care

Answer 22

§ Time-limited and primarily designed mild to moderate clients
§ Approximately 2 times per week along with 12-step meeting engagement

Question 23

DUI/DWI Psychoeducation

Answer 23

§ Least intensive/restrictive care
§ Group and/or individual counseling coupled with urine toxicology
§ Component of a larger series of tasks and fees the violator must pay to reinstate their driving license

Question 24

Biopsychosocial Functioning

Answer 24

treatment is not one-size-fits-all and tailored to person and treatment starts with the six domains

Question 25

six domains of Biopsychosocial Functioning

Answer 25

§ Acute Intoxication or Withdrawal Potential
§ Biomedical Conditions and Complications
§ Emotional, Behavioral, or Cognitive Conditions and Complications
§ Readiness to Change
§ Relapse, Continued Use, or Continued Problem Potential
§ Recovery Environment

Question 26

ASAM Criteria (2013) Levels of Care

Answer 26

o Based on clients needs, treatment placement may occur in any one of 10 levels
§ Early Intervention (Level 0.5)
§ Outpatient Services (Level 1)
§ Intensive Outpatient (Level 2.1)
§ Partial Hospitalization (Level 2.5)
§ Clinically Managed Low Intensity Residential (Level 3.1)
§ Clinically Managed Population Specific High Intensity Residential (Level 3.3)
§ Clinically Managed High Intensity Residential (Level 3.5)
§ Medically Monitored Intensive Inpatient (Level 3.7)
§ Medically Managed Intensive Inpatient (Level 4)
§ Opioid Treatment Services (Level OTS)

Question 27

Multicultural Elements of Treatment Placement and Planning

Answer 27

Treatment programs must always consider whether the needs of a specific cultural group can be meet within a nonspecialized treatment program or if a specialized program may best benefit these clients

§ Combined with the general treatment program, these unique culturally relevant groups provide another outlet for individuals to shape their recovery (Muslim, African American, or Lesbian, Gay, Transgender, Bisexual and Queer)
· Holistic worldview
· Spirituality
· Community orientation
· Multidimensional learning styles
§ Counselors must be trained on certain cultures
§ May also include counseling in other languages
§ Counselors must engage in a meaningful dialogue around culture

Question 28

co-occurring psychiatric disorder basically results in one of which scenarios?

Answer 28

§ A co-occurring disorder
§ A disorder that exacerbates the SUD
§ A potential risk factor for relapse and treatment dropout

Question 29

Quadrants of Care

Answer 29

§ Any client can fall into a category of having high/low addiction symptom severity and high/low mental illness symptom severity
§ The question remains as to how well such a quadrant system would work when working with symptoms (and no diagnoses), which is typically the experience during an inpatient or outpatient SUD treatment intake session
§ Quadrant model needs to expand

Question 30

The Affordable Care Act

Answer 30

§ 32 million will receive substance abuse treatment for the first time
§ 30 million will see their behavioral health benefits expand
§ The ACA established 10 mandatory “essential health benefits” (EBHs)

Question 31

Drug Courts

Answer 31

A special docket within the court system designed to treat addiction via a close integration and collaboration
§ Judge leads team of professionals
· Court coordinator,
· the prosecuting and defense attorneys
· Treatment providers
· Case managers
· Assigned probation officer
§ Mandatory clients
· Treatment can be effective
· Do as well or better than those who entered voluntarily
§ More cost effective

Question 32

Adolescents

Answer 32

§ Only 1 in 4 programs offer services specially developed for the adolescent
§ Requires treatment tailored to their developmental needs
§ Misbehavior should be expected but the facility must also manage it
§ Adolescent diagnosis is fraught with potential misdiagnosis or underdiagnosis
§ Home life must be looked at to make sure the teen is safe

Question 33

Older Adults

Answer 33

§ Pharmacological treatment should follow up by treatment of adult population with appropriate dose adjustments for age-related pharmacokinetic and pharmacodynamic changes
§ Treatment must be age-specific with a focus on coping with depression, loneliness, and loss (death of spouse, retirement)
§ Must also have appreciation for the specific treatment placement needs
· E.g. Vocational and educational training are not appropriate placement

Question 34

Briefly explain the onset and risk of Wernicke’s encephalopathy and Korsakoff’s psychosis in the alcohol withdrawal process.

Answer 34

p. 89

Question 35

As per the chapter, what were the clinical considerations required when deciding between inpatient and outpatient detoxification services?

Answer 35

Pp. 92-95