I.  Provide Episodic Attention To Substance Use; Reassess Periodically

 

OBJECTIVE

 

Encourage the patient to engage in ongoing care while addressing urgent concerns.

 

ANNOTATION

 

Some patients refuse to engage in any type of ongoing care with any provider (e.g., medical, psychiatric, or addiction).  These patients may require substantial emergency care and stabilization and may repeatedly present in crisis, but are not willing to return for outpatient visits or engage in alcohol and/or drug treatment.

 

Episodic attention to substance use may be accomplished by the following:

1.      Provide crisis intervention, as needed.

2.      At any contact initiated by the patient:

§         Assess current substance use.

§         Recommend that the patient accept ongoing care in the most appropriate setting.

3.      Designate a single provider to coordinate care for patients who repeatedly present in crisis.

4.      Consider involving supportive family members or significant others, if the patient agrees.

5.       Initiate involuntary treatment procedures, if imminent threat to safety occurs (e.g., suicidal, violent, or unable to care for self).

 

DISCUSSION

 

The approach to episodic care can be individualized and cover the areas that are of concern for that patient.  All patients will require education and counseling on:

1.   How to decrease the use or alter the route of administration in order to slow the progression of medical illness and decrease the risk to the public health.

2.   Maximizing their present health and decreasing their own, and if appropriate, family members’ suffering. For example, a patient who routinely comes to the emergency room for gastritis after a bout of drinking may require education on the issue of alcohol irritating the stomach and the eventual development of gastrointestinal (GI) bleeding and ulceration.  In addition, an emergency treatment plan may need to be developed so that the patient is not admitted every time he or she comes to the emergency room (ER) with exacerbation of gastritis.

3.   Understanding the issues of alcohol and family violence.  The family should be furnished with an appropriate referral, if safety is an issue.

4.    Brief motivational counseling to encourage the patient to accept more addiction-focused treatment in a specialized substance abuse treatment program, if necessary.

 

This is a pragmatic approach that delineates the management of a group of patients who present serious challenges to clinicians and agencies.  The goals are to decrease morbidity, mortality, and inappropriate use of intensive services, while motivating the patient to accept addiction treatment or─at least─regular medical or psychiatric care.  Although currently untested in rigorous studies, it is likely to be an improvement over a less systematic approach, with little if any added risk or expense.