The following is adopted from a post by Dr. David Meelee (Addiction Medicine), and very much in line with the SunCloud Health treatment philosophy and community accountability model:
If a patient uses substances/eating disorder/self-harm behaviors while in treatment or brings them into a treatment center and you work in a program that suspends, discharges, transfers or does not allow the patient to stay so they can work through that addiction flare-up, in my experience there are versions of at least four reasons given for a zero tolerance policy and procedure:
- We can’t allow the patient to stay as it will trigger others to use.
- We can’t allow the patient to stay because it will endanger the whole community.
- We can’t allow the patient to stay because there “needs” to be consequences for using and patients need to know and experience consequences otherwise the patient using and other patients will think it is OK to use if they are not suspended, discharged, transferred. (Some programs even send someone to “detox” even if the patient drank a couple of beers or smoked or shot up once and certainly does not need withdrawal management).
- We will get a bad reputation as a treatment facility that is soft on use if there are no consequences for using and especially if bringing in alcohol and other drugs to the facility.
With a zero-tolerance policy and procedure, we, the treaters, are creating the “consequence” of suspension/transfer/discharge. Ask a counselor, administrator or physician why we need to transfer or discharge someone for use and I suspect “need for consequences” will come up somewhere in the rationale. Transferring a patient out of the treatment facility is a clinician-induced consequence not the natural history of disease consequences for out of control addiction. Discharge is a “consequence” we have control over as we evaluate with the patient in the midst of an acute exacerbation of addiction, whether they “can’t” or “won’t” follow the treatment recommendations. If the patient willfully won’t change their treatment plan in a positive direction after a thorough assessment of what went wrong in their flare-up, then the patient has a right to choose no further treatment with us. We can arrange transfer to whatever situation the patient wants if not in imminent danger. That may be to go home or the street or a shelter or to some other facility of their choosing.
If the patient “can’t” follow the recommendations on how to stay abstinent and embrace recovery because they have addiction that can flare-up and lead a patient to use substances against their better judgement, against their understanding of the rules and their values, then to me, that is an urgent assessment and treatment planning need that should continue with the same treatment team and place.
It would be wonderful (and I mean I would be full of wonder) if a patient new to addiction treatment could perfectly not use if and when:
- They get an overwhelming craving or trigger to use and now can somehow muster up skills out of nowhere to reach out to someone before they use.
- They get into an argument with their partner and now don’t reach for a drug to cope like they have done for years.
- They have a flare up of PTSD or some other mental health problem and now resist self-medicating with a drug like they have done in the past.
- They have a flare-up of chronic pain and now don’t try to find drugs to relieve the pain.
- They could immediately make all new supportive friends and stay away from using friends and situations.
- They could now make rational choices about how important it is to not use and endanger others rather than do what has happened to them in the throes of addiction for so many years – driving drunk, neglecting their children, spending resources so the family had no food or shelter etc.
Emily Long, Clinical Intern at SunCloud Health, describes the level of authenticity and care that patients can expect.
To me, addiction treatment is about helping people learn new ways to handle all these kinds of situations and co-occurring conditions that have perpetuated out of control use or addictive behaviors like gambling. This is especially urgent in the midst of an acute exacerbation of addiction with actual use.
So then what could we do about the concerns that seem so compelling as reasons to suspend/transfer/discharge a patient in the midst of their addiction flare up? Some suggestions concerning:
- We can’t allow the patient to stay as it will trigger others to use:
What better place to be triggered than in a treatment group or facility where there are trained counselors to support and help develop skills to deal with triggering, than to be triggered on the bus and get off at the next stop and use or call their drug dealer. We don’t want addiction flare-ups to happen when patients are vulnerable in a treatment group or inpatient facility, but if they do, because patients can’t be perfectly sober especially early in treatment, situations might arise when a patient uses and triggers others. We help the patient in the midst of their addiction flare up AND those triggered by it.
- We can’t allow the patient to stay because it will endanger the whole community:
Patients are exposed to dangerous situations all the time. Treatment should be helping them learn how to cope with those situations whenever those arise – on the street, at home, at work and yes, if they arise in a treatment facility. When I ran a program with a zero tolerance policy, we would discover someone using and discharge them to keep the community safe. The other patients would say after he was gone “I’m glad he’s gone because he’s been using for the past couple of days.” We would say “And you jeopardized your own safety and the treatment community by not confronting him and letting us know?” The patients would say “I’m not going to be the squealer to get him kicked out, that’s your job”. With zero tolerance in treatment, drug use goes underground and actually endangers the community more in my opinion, as it impedes both the person who is in the throes of an addiction flare-up and the rest of the community in being honest about substance use.
This is especially true when we say on admission, in essesence, that you have to be working on abstinence as a condition for coming into treatment; and you have to be perfectly about to stay abstinent as a condition for staying in treatment. And if you use while in treatment or get so overwhelmed that you even bring in drugs you will certainly be transferred or discharged. If a patient is trying to get their kids back or get off probation or keep a relationship or a job, why would they be honest about use if they know they will be discharged?
- We can’t allow the patient to stay because there “needs” to be consequences for using and patients need to know and experience consequences otherwise the patient using and other patients will think it is OK to use if they are not suspended, discharged, transferred. (Some programs even send someone to “detox” even if the patient drank a couple of beers or smoked or shot up once and certainly does not need withdrawal management):
The orientation we would give to patients and families on admission; and to referral sources is that for a person with addiction it is not OK for their own health and others around them to use substances or bring them into treatment. But if anyone gets overwhelmed with an addiction flare-up, then that is a potential crisis, just like a person with major depression who gets suicidal impulses and may even cut themselves before reaching out. The policy and procedure is to reach out before or during the flare-up and not hide it. Then we can assess what is going wrong and what needs to change in the treatment plan. So please come to group or talk to a staff person if you used or brought drugs in. We will first assess you are safe and not in imminent danger needing more intensive services; and make sure you are not so intoxicated that you can’t function. If you are safe and cognitively able to function, then you be asked to start off a group and tell everyone you used and get help in the group to revise your treatment plan in a positive direction.
If others used with you and have not spoken up, you will be asked to identify them so we can help them too in their hour of need. If this is a residential setting there will be an emergency community meeting with whoever used starting off the meeting explaining the reason for the emergency meeting and the need to get everyone who used with you back on track. If any patient is not interested in staying in treatment and working positively on learning from their mistakes, then they have a right to choose no further treatment and we will help them transfer to some other situation or home.
If anyone recognizes that they themselves or their fellow patients are building up to a drink or drug, it is the community members’ responsibility, if serious about treatment, to confront that person for your own safety and the community’s rather than have it go underground. This is so we can prevent as much as possible actual substance use by catching addiction flare-ups early and intervene.
- We will get a bad reputation as a treatment facility that is soft on use if there are no consequences for using and especially if bringing in alcohol and other drugs to the facility:
Such a policy and procedure above, increases accountability on each patient to be working on their own addiction cravings and triggers to use and to keep the treatment community safe. Being honest about substance use is approached as an assessment and treatment process for a bad outcome rather than willful misconduct requiring a consequence. The treatment facility gets known as a place that holds patients accountable for taking treatment seriously, that will not tolerate “doing time” in a treatment program; and that any use is taken seriously as an indication that treatment is not going well for the patient and needs a reassessment and treatment plan change. When patients are more focused on how to hide any use that overwhelms them, lie about use, blame the lab for getting their urines mixed up, return to criminogenic thinking and behavior that tries to get around the rules and scam the system, then the community is not safe. It should be an honest program.
Of course, if a person is not interested in treatment and just wants to party in a treatment setting and bring in drugs to gets others using with them, then discharge is appropriate as the person is thinking it is a party place not a treatment place. It would be “enabling” to give the message that you can use and nothing happens that the person needs to take responsibility for. But the responsibility is about improving the treatment and plan, not discharge consequences for use. If the patient is invested in treatment and is struggling with multidimensional issues that overwhelms them and their addiction flares-up and they use, that is a potential crisis needing treatment, not discharge.
A relapse represents a failure of the treatment plan. The treatment plan is a shared creation. So it is not the patient’s relapse, it is our relapse. Each relapse represents a chance for the patient and the treatment team to carefully examine what clues were missed. How could I have gotten the ideas across better? Was the treatment strategy I employed flawed? Both of us can learn more about this addictive illness, and both do better in the future.