Substance abuse and psychiatric conditions frequently co-exist. According to NAMI, most mental health services are not adequately equipped to address both conditions. This makes treatment and prevention of substance abuse in the presence of mental illness a challenging task due to several moving parts.
Firstly, there are two separate bodies that regulate treatment guidelines. The Office of Mental Health (OMH) and the Office of Alcoholism and Substance Abuse Services (OASAS) have different regulations. Patients with dual diagnoses frequently have difficulties obtaining the appropriate services they need to attain and sustain stability and end up bouncing back and forth between emergency rooms, psychiatric hospitals and addiction rehabilitation units.
Secondly, clinicians in the trenches know that it has become increasingly difficult to secure coverage for these services as different insurance carriers have specific criteria for what they consider medically necessary care.
Other important factors include an aging population with complex medical presentation in addition to the ever-changing, highly addictive and toxic street drugs. This does not exclude overuse and diversion of prescribed tranquilizers, analgesics, hypnotics and others which have become easily accessible given rapidly advancing technology and a world that no longer has borders.
This article will review what we have been implementing at NewYork-Presbyterian Hospital to assist those in recovery achieve the best possible outcome. We begin with a comprehensive diagnostic assessment that takes into consideration the psychological, neurological, medical and addiction issues which ultimately guides treatment and the discharge plan. Our treatment team is run by a psychiatrist and consists of addiction professionals from psychology, nursing, pharmacy, social work, addiction counselors, psychosocial rehabilitation and psychiatric mental health workers as well. This multidisciplinary treatment team frequently meets with patients to review their progress during their inpatient treatment and makes the necessary changes to medications and other interventions.
Evidence-based clinical guidelines influence the treatment approach. The essential components to successful outcomes include a respectful approach when treating patients afflicted with addiction and/or mental illness because stigma is rampant in this population. While our program is abstinence-based, an individualized approach is often used to move patients from the pre-contemplation to the action phase. The use of cognitive behavioral therapy, motivational interviewing techniques, individual, group and family therapies is essential to achieving the patients’ ultimate goals of stabilization, sustaining sobriety and remission from both ailments. Additional emphasis that includes relapse prevention, coping skills and ways to develop a sober network is woven into every aspect of the therapeutic program by all disciplines. These modalities are supported by nightly AA and/or NA meetings.
Paying attention to the medical co-morbidities is essential and requires the internal medicine, neurology and pharmacy teams to work hand in hand with the treatment team in order to optimize care. This partnership is also instrumental in the complex treatment of pain management, which is also on the rise and complicates addiction treatment in general.
Discharge Planning
Due in part to the reality that the covered length of hospital stay is decreasing, the importance of carefully crafted discharge plans is increasing. Once the treatment team has determined the complete diagnostic picture, they begin to partner with patients and families around the discharge plan, which needs to factor in a whole host of variables including the patients’ motivation to maintain sobriety, financial resources, available aftercare and supports.
Aftercare is essential to the life-long recovery process and can be simplified into two main options: intensive outpatient programs or residential therapeutic communities. Choosing a pathway depends upon the constellation and severity of the dual diagnosis. The reality is that despite the best efforts from treatment teams and families, some patients require longer or more intensive programs.
In summary this article does not claim to cover all treatment and prevention, rather it opens an opportunity for a genuine dialogue to improve the care of a growing population that affects the community at large. As a society, we can no longer turn a blind eye while this topic continues to touch each and every individual in our country. Recent tragedies, which affected every family all over the United States, mandate us to have honest, serious and well-informed discussions.
