Continuing Care Issues for Recovering Professionals
Presented by Wally Cross, RPh, MHS, CADC
Transcript of Presentation:
What we’re going to talk about today are continuing care issues for recovering professionals, probably from the perspective of a professional either nearing the end or out of a treatment program that treats healthcare professionals.
Here’s how we’re going to do that. What we’ll talk about and cover are some issues like: When do you start continuing care planning? What does continuing care planning actually involve? Some of these topics you already know, so for some of you this is going to be more of a review than brand-new information. We’ll cover what types of recommendations should we be considering when we have a professional in treatment. Addressing back to work issues which can be critical especially if it’s a high risk healthcare professional like an anesthesiologist or a pharmacist. We’ll talk a little bit about what constitutes an aftercare program and the dynamics of an aftercare program. We’ll spend actually a little time on relapse prevention strategies. We’ll talk about addressing new problems that come up post-treatment or just prior to discharge. Problems like being terminated from your job just before you leave treatment. When our aftercare planning had been predicated on this person returning to work, so now everybody is scrambling – the patient, the therapist – and we have to make a new plan. When do you start continuing care planning? What do you think? The answer is right on your handout. [Laughs] We start early. Really early.
Generally, after you have some type of reasonable feel for the patient, usually that’s about a week or so. Some of the reasons for starting early are some of the recommendations that we might be thinking about giving that patient may take actually [take] some time to set up. For instance, the best example I can think of is if the patient is an opioid addicted individual and he’s going to return to his work setting and have access, you’re probably going to want to start that patient on regimen of Vivitrol. So everybody familiar with what Vivitrol is? Vivitrol is a narcotic antagonist, and its once monthly injection. If an individual uses a narcotic, it just simply won’t work. We use that all the time in narcotic addicted people. Also in alcohol addicted people, it helps reduce the severity of cravings, but in order to set up this regimen of Vivitrol and work with an insurance company because it’s very expensive, that takes three weeks at least. If we want that person to return to work on Vivitrol, we have to start early.
I think it’s important to remember that continuing care planning is actually an ongoing process although the individual’s treatment. For me, that’s always included permission to change my mind. I’m going to try and give examples from my experiences as I go through this lecture. I had a doc who is a cardiac surgeon/heart surgeon. My initial feeling was that he would return to work right after treatment. Five or six weeks into treatment, his hands were still very shaky and he had some cognitive deficits still. He was getting better but he even had difficulty finding my office which was right across the hall from our group room. That was a plan that I had to change. Ultimately, what happened was that individual took a month off and it was okay with him because he understood that he was kind of shaky and that it was taking him a while to get back to his true self. He took a month off and then returned to work and returned to work really just doing office work for two or three weeks and then started doing surgery. Occasionally, you make an initial plan and then when you gather more information you may need to change your mind.
What does continuing care planning actually involve? Some of the considerations that we would be thinking about would be things like – and I’ll come back to almost all these things – appropriate post-treatment recommendations, you know what the heck are those things? What should we be thinking about? Relapse, prevention strategies like Vivitrol, for instance, would be a relapse prevention strategy. We’ll get into more depth with that though. Thinking about specific workplace recommendations, things that you might be able to setup before the patient leaves that would help keep them safer in their workplace, a weekly aftercare group, addressing new problems that have developed – I’ll give you some examples, some more examples of new problems that can potentially arise that we would need to make a new plan for. Setting up a urine monitoring schedule, it’s really important to set up a specific schedule. For instance, the patients in our aftercare program, it’s a two-year aftercare program. So a urine screening schedule should go out at least two years. For instance, for the first three or six months the patient does one urine screen a week. Then, reduces that to urine screens a month for the duration of the two years, but it should be pretty specific and spelled out. Working with referral sources. I’ll spend some time on that because they can be an excellent source of information regarding some of the other recommendations that we might make, like the individual therapist, psychiatrist, that type of thing.
These are some of the things that we would consider, some of the recommendations that we would be thinking about making. Individual therapy: That sounds simple, right off the bat. But what type of individual therapy would best fit this patient? In other words, if we have a borderline personality disorder patient, we might be thinking of a DBT therapist, dialectical behavioral therapy therapist. If the individual has serious trauma issues or posttraumatic stress disorder, we might be thinking of a therapist who’s adept at doing EMDR, that type of thing. If you start early enough, you can find a therapist that not only does DBT or EMDR, but that fits the patient well also.
Then the thing we would have to consider would be psychiatric follow through. For instance, we would want to pick a psychiatrist who really understood addiction for patients that we had that might have depression or bipolar disorder or generalized anxiety disorder. In other words, we would want an addiction psychiatrist, someone who for our generalized anxiety disorder wouldn’t be prescribing valium or xanax or something like that.
Medical follow through occasionally is also critical sometimes especially for individuals with chronic pain issues. We might be looking for a pain doc. I had a patient who had out of control diabetes. We had to find a physician who is really pretty good with patients with out of control diabetes. Family therapy — for instance if your patient has come in to treatment with a history of serious marital conflict and stress associated with that that may have even driven their addiction to some extent, then obviously we are going to have to be thinking about family therapy for that patient.
An aftercare group is something that we nearly always recommend but what type? It gets kind of interesting for us because we get patients from different states. Some of the states that we get patients from have an aftercare group, they call it caduceus aftercare, but really it’s a caduceus AA meeting. The patients are required to go but there is really not a lot of accountability there. I’ll come back and talk a little more about aftercare. If we had a patient with a co-existing AID issue, addictive interactive disorder issue, like gambling addiction or sexual addiction, we would want to be picking an individual therapist who is adept at both chemical addictions and a gambling or sexual addiction. Workplace restrictions or recommendations would be something that we would have to be thinking about. Just examples of those might simply be the individual works a maximum of 40 hours per week, does not work shift works especially late night shift work.
In urine monitoring, what type and what frequency are things that we have to consider? Some of our patients do urine screens through different entities. It’s important for us to check within. For instance, I had an alcoholic patient in my aftercare group who is doing urine screens through his hospital but they weren’t doing ethyl glucuronide urine screens which I think we had on the patient’s contract. He relapsed and it went undetected. So being sure that the right types of urine screens are being done is really pretty critical. Some urine screens, for instance, don’t screen for hydrocodone which is a pretty common drug of choice around here. It’s really important to make sure that the urine screens that the patients are doing covers their drug of choice.
Is it possible to overload a patient with recommendations? Absolutely! It’s possible to overload a patient. The best example I could think of was having a medical resident who may be working 70 to 80 hours per week and doing shift work. This isn’t a choice for them. In other words, we couldn’t say we don’t want you to work more than 40 hours per week because the residency program would just likely let them go. So this is something that an individual has to do and it may literally be impossible for that patient to follow through with anything other than individual therapy, 12-step meetings and an aftercare group. Occasionally, that may be difficult for them to do it.
One of the things that’s really important for us to keep in mind is that with some of our referral sources, the patient literally has to do everything, everything, that we put on paper. If our mindset is “Gee, there are some other things I’d like them to do, maybe they’ll have time. I think I’ll just write them on here.” We really can’t do those kinds of things. We really have to think this through and figure out if this patient can really do what we’re recommending.
Aftercare programs at a minimum, they really should include counselor-facilitated chemical dependency and, as I mentioned, in some states, they’re really AA meetings which is helpful for them but there is really no accountability there. They should be two years in length, hopefully, fairly lengthy. They should have a relapse prevention focus. That’s where the accountability comes in to effect, in other words this counselor is checking to make sure that people are actually following through with the recommendations, with what they are out there supposed to be doing. An aftercare program should involve frequent random urine screens and hopefully it’s an aftercare program that does outcome studies.
Dr. Angres has done a number of different outcome studies. I did one on pharmacies that I’ll talk about a little bit later. I see in the promotional material from some treatment centers information about studies but there are no real references backing it up. For me, unless it passed the test of scientific scrutiny, I’m skeptical about the results. Problems that arise post-treatment and some examples are if the patient is terminated shortly after leaving treatment or just prior to leaving treatment. These are examples of things that have had happened. Unfortunately, the person I’m thinking of was terminated just two days before I was going to go home and our aftercare was predicated largely on that person returning to work. Now, this person is going to have an awful lot of time on their hands. Obviously, we needed to change the plan. The patient discovers that he/she has been reported to IDFPR, the Illinois Department of Financial and Professional Regulation, that happen sometimes with our healthcare professionals, and maybe they find that out just prior to leaving treatment. We can make somewhat of a plan for that because that’s just incredibly anxiety provoking and very scary for patients, when in the end, if they just simply do what they are supposed to do and march in there with an advocacy letter from us, they are probably going to be okay.
This is a tough one: The patient’s husband or wife asks for a divorce just prior to treatment. Your aftercare was predicated an awful lot on this person returning home, but the patient’s wife is saying “I don’t want him to return home.” So now, we’re scrambling — the therapist, our treatment team and the patient – okay, what happens? Where is this person going to live? Often the answer is a recovery residence but unfortunately that takes some while to set up sometimes, so we have to have a plan in effect for that patient to keep them safe at least until they get into a recovery residence or move in with their brother or parents or a safe place.
A close family member dies just post treatment, these are situations where we may be thinking about changing the individual therapist we have in mind. For instance, finding a therapist who is really adept at grief issues, that type of thing. The patient’s child is diagnosed with a serious illness. For a parent there aren’t a lot of things worse than that, or more anxiety provoking or scary. So we would have to add something to their continuing care plan like help them find–obviously in our aftercare group, in an individual therapy they could talk about that–but they may need something extra like, for instance, a parent support group for children that are seriously ill, things like that.
Working with referral sources. This is really very important especially if the patient is an out of state patient and were not as — if the patients leaving our treatment program and they live right around here and they are going to go to our aftercare program, that’s fairly easy for us. We have all sorts of sources around here but out of state, on the other hand, it gets a little more difficult. But referral sources can be really further grown for getting good information about an individual therapist in appropriate aftercare group, even a psychiatrist that understands addiction or legal representation like an attorney. Sometimes even if the patient lives around here, one of the reasons it’s important to start early with an individual therapist is the individual therapist we had in mind might not be covered under their insurance program or maybe they can’t afford to pay the therapist’s fee, so referral sources are often in really close touch with individual therapists and psychiatrists that would be covered under their insurance plan. I was told by a referral source a long time ago that – she did this is in a really nice way–that the patient is ours for eight weeks, this was an out of state referral source, but the patient is theirs for five years, so please give me an honest appraisal of what I’m looking at with this patient. Because there is a tendency, if the patient makes some strides during treatment, to say, “Wow! He’s just doing really really well.” But it’s important to keep the patient’s history in mind. For instance, if they have a history of relapse and/or history of not following through. That’s one of the things you have to keep in mind when you talk to a referral source about what they can expect from the patient. You just simply say “You know what? This fella did really well in our program, maybe even much better than we expected, but he does have that history, so that’s something to keep in mind.”
It gets complicated because some patients are very adept at saying precisely what we want to hear. We call that blowing sunshine. But then upon returning home they failed to follow through with recommendations. One of the things – Well, actually, probably the smartest day I ever had in this field was the day I figured out that I would know where they were at. Most of the time, yes. But what I used to do was I paid attention to what they were saying, but I paid more attention to what they were doing. Were they doing all the little things?
I’ll give you an example. I had a patient who is exceptionally shy. She had very poor social skills. She had a history of isolation and she was just very comfortable when she was by herself, but not very comfortable when she was around other people. She was a really serious alcoholic so I was really pretty concerned about her and her ability to first of all, meld in the community here, and then, especially connect with 12-step program. So what I had her do – she was actually very motivated – what I had her do is introduce herself to someone that she didn’t know in an AA meeting every night, and then come back and talk about it in group the next day. So it was exceptionally hard for this woman, but somewhere – I just wonder and I kept thinking, is she going to be able to follow through with her recovery program? Somewhere along the line keeping my ear reasonably close to the ground, I heard that she had volunteered to do and had lead at an AA meeting. Now, for most people this would be some sort of an event, but for this woman this was huge, just huge. It gave me a pretty clear indication, it made me really feel pretty good. Wow! I think she is going to be able to follow though. As it turned out, she did.
Workplace considerations for high risk healthcare professionals like anesthesiologist, pharmacist. One of the things that we have to keep in mind when we’re considering workplace considerations or restrictions or just recommendation is how well is this patient doing and how motivated are they. Some of the examples of things that we might do or that we might recommend is — there are a million of them, this is just a few of them: Working no more than 40 hours per week, not having access if it’s a narcotic addicted individual like some of our nurses, not having access to narcotics for a period of one year, finding some other physician in a hospital,l for instance, beginning a regimen of monthly Vivitrol shots, not working late night shift work – the reason for that is twofold actually. Late night shift work often involves working by yourself a lot of the time, and that’s not necessarily a good thing for people returning to work or they had access early. The other reason is that it really messes with your sleep cycle. Another thing we might consider if this is a high risk health professional is recommending that they live in a recovery residence for the first six months after returning to work. It tends to add a layer of safety to their recovery. Just doing other things like hair analysis every three months or if we’re really concern about the patient, every month. We have to be careful about these things because some of these things are expensive. But for some people, if doing some of these things is the only way we feel comfortable returning them to work at all, then the fact that they’re back at work and making money, sometimes they really just kind of have to make do [with] not working in a situation where they work strictly by themselves. It is not always easy to set up, especially for pharmacists, but sometimes it is. Our mindset, of course, needs to be that we make these recommendations not to be punitive but because we really want to make their work setting a safer place for them.
Advocacy and support. This would be beyond our department of financial and professional regulation. One of the things I used to do with healthcare professionals that were in trouble when they came into treatment was to tell them that if they follow through with absolutely everything that I recommended, I would be very, very supportive with the department of professional regulation when they left, and write a very good letter – but that they had to do everything that I suggested. Some of the things that an advocacy letter should include would be things like the dates of treatment plus successful completion of treatment. It should include our recommendations for the patient so that the department can see that these individuals are really doing a lot of stuff, there’s a lot of stuff set up to keep them safe in their recovery. Then finally that we feel the prognosis for this individual is really pretty good.
Actually, going to the patient’s informal hearing is a possibility. Counselors are welcome to attend. I’ve gone to an awful lot of hearings. A counselor’s function would just merely be to support the patient to explain our recommendations and that we feel those recommendations were made to keep the patient safe and that we feel very good about the patient’s ability to follow through with the recommendations. Advocacy and support for legal issues like a court appearance just generally involves writing a letter of advocacy and support which includes what the patient’s done to this point, our recommendations. It’s really important that the court see what the recommendations are, that the court see that this person’s really doing a lot right now, and that we feel good about the prognosis for continued success. The letter should be completed early enough for the patient’s attorney to present it to the judge prior to the court appearance because if you’ve ever gone to court and had the attorney hand judge the judge the letter during the court appearance, they scan it a little bit but the body of the letter really doesn’t register well, so it’s really important that the judge get the letter early if at all possible.
Addressing relapse. I’m sorry. I love these freaky images. They are in most of my stuff. Okay. So what happens if a patient relapses and they are in our aftercare program? For instance, what action should we be considering? I supposed we see somewhat of a difference between a slip and a real relapse. What we would call a slip which is still relapse, but that would be an individual who has a quick return to use like drinking one night, gets up the next day, feel awful, calls their sponsor, tells their wife, and contacts us. Often that’s a patient who’s not looking like they necessarily need to come back into treatment. These things are all individualized, however, because sometimes even with a slip, we would have a patient come back for what we call a two-week relapsed focused sort of tune up which can be very, very helpful. If on the other hand, the patient’s relapse involves us finding out about it through a positive year-end screen, then the patient admits to it, these are the options that we have: The two-week relapse focused tune up, coming back into our program in living down here for two weeks, or having the patient do a full treatment. For instance, if this was a nurse who is found in the bathroom with a needle on her arm and unconscious, we’re going to have her come back for a full treatment. This is not going to be a two week tune up. That’s a pretty life threatening event. It’s individualized and it really depends on the severity of the relapse. Sometimes we have a patient who has been through our program a couple of times and has done the two-week relapse focused tune up. This doesn’t happen very often but we would be considering at least sending them to a different treatment setting because they may be just way too comfortable in our treatment setting. So those are some of the things we’d be thinking about if an individual relapsed.
Relapse prevention. I listed six common reasons for relapse. There are a ton of reasons for relapse but these are some of the reasons that we hear over and over and over again. There are simply just some principles that recovering people really need to buy into. These are some of the things that is kind of critical for us to listen to, listen while the patient is still in primary treatment because if you listen hard enough you can hear these stuff. For instance, the patient doesn’t buy into the concept of abstinence from all mood altering addicting drugs. The patient is thinking my problem was a narcotic, was an opioid so maybe I could have a glass of wine. The patient doesn’t necessarily buy that this is a chronic disease. In other words, a disease that’s not going to go away. They get out there and work their recovery program but life gets good, gets really good and they are starting to think you know maybe I’m well, maybe I’ve beaten this thing. Then, after a period of time, they wind up back in treatment. This sometimes happens between the fifth and sixth year. That’s because they are not monitored any longer. Sometimes they have minimal acceptance of their disease and you can hear that if you listen closely enough. Sometimes they have a mistreated or undiagnosed psychiatric disorder or an uneducated family support system. A wife who’s saying, “Can’t you have a glass of wine with me?” Your problem was a narcotic. Or “Do you have to go to a meeting tonight?” That kind of thing.
I’m going to talk about this pharmacy study really quickly. I picked this study because it’s the one I know the best. You can look back and see the parameters of the study, but one of the reasons we did the study was to determine the outcome. What was our success rate? It was 87%, which is really pretty good in a population that is at high risk in the work setting like that. The other reason we did it was to study the folks that relapsed. Here’s what we came up with. These were the strongest predictors. We tracked about 14 different variables. These were the strongest predictors of relapse. An individual with personality disorder. This RRR stands for relative risk of relapse. So, in other words, a relative risk of two would make that person twice as likely to relapse. So relative risk of almost seven is really pretty big. An individual with a personality disorder was at greater risk for relapse. Minimal 12-step investment, 17.83. I mean that’s through the roof. Statistically, that’s just crazy significant.
There were nine pharmacists that didn’t invest in AA. All of them, every single one of them, was in the relapse group. And that was a surprise for us. So was this one: having a diagnosis of alcohol use disorder alone or in combination with some other drug, the relative risk was three times greater. If they weren’t on Naltrexone, it was eight times greater. No involvement in formal monitoring, ten times greater. In other words, formal monitoring for us would be like they are all in our professionals’ health program or other programs for pharmacists like PRN programs, they are known as pharmacist recovery network programs.
Having a prior history of relapse made people five and a half times more likely to relapse. Being single, almost three times more likely to relapse. Interestingly, in the study having a personality disorder and being single predicted nonparticipation in AA. So we learned a lot. At the end of your handout here I have some information about IDFPR, in boards, and the different types of hearings if you’re interested on those things.
So that’s it. Thank you very much.