General Issues in Substance Abuse Counseling

1. General Issues in Substance Abuse Counseling

2. Time Line Followback Make a calendar to track last 30 days of use For Alcohol, get sufficient description to determine standard drinks Cigarettes and pills can be counted Marijuana, cocaine, meth, probably dollar value is the way to go Assessment gives idea of frequency, severity of use and provides comparative baseline Demonstration Assessment of Use: Self Report

3. Natural tendency is to under-report, partly due to saving face in front of others, but also to oneself (ever try to accurately report weight or amount of food eaten?) Urine drug screens frequently used Most providers believe that urine drug screens should be random and observed Assessment of Use: Objective Measures

4. Who is going to be the “Pee Police”? • Who is going to collect it? • Who is going to observe it? (“Observe flow of urine from genitals”) • How can it be random if you see patient same time each week? • Sometimes outside services can collect and process, but this might not be an option for patients without insurance • Bottom line: Sometimes the providers have to observe and collect it themselves Logistical Issues of UDS

5. So you’re building a relationship where the patient trusts you and confides their vulnerabilities to you… …now you’re holding out a cup to them and asking them to let you watch them pee. How does this affect your “therapeutic relationship?” Clinical Issues of UDS

6. Introduce the collection of screens into the treatment contract and discuss it up front • Is UDS necessary? • Probably more so if patient is compelled to be in treatment (e.g. court order, PTI, or patient brought to tx by family member) • Probably more so if impaired sobriety introduces immediate risk Ways to address UDS issue

7. “Shy bladder” can occur when people are surprised with UDS… could be nervous because positive…or just nervous because they’re watched Possible solution: Invite patient to drink some (but not excessive amounts) of water and return later – also applicable for patients who say “I just went…” Do you have time to do this? You might have a rule that failure to provide urine will count as a positive More ways to address UDS issue

8. Patients run out when they see the cups being prepared • Have a rule to count missed urines as positive Ways to address UDS (3)

9. Screens do have a method to test for dilution (looks for levels of creatinine, a normal by product in urine), so if they try to put water in the test, the test can tell. This won’t tell you if they brought in urine, or got someone else to fill the cup for them What if you can’t observe?

10. Drugs (except marijuana) usually clear the system between three to five days Observed urines on Monday and Friday gives very little opportunity for use between visits, M-W-F Who will do it? Probably not you if seeing patient once per week, and can be a lot of work in an intensive program with 30+ Patients …BUT it is good advice for parents who have kids struggling with use What if you can’t do random?

11. It is my belief that parents have to be willing to either monitor their kids or take the kids to a lab, either randomly or frequently My very limited impression of parents dealing with kids with addiction is that they have to do a lot of the “policing” at home My job is to encourage them to consistently enforce consequences in an even-handed manner …and on the Topic of Kids on Drugs

12. For managing patients with chronic opioids, stakes are high Note: many opioid pain killers don’t show up for standard Opioid screens, need to order special screens Also note: people on opioids may try to have someone else provide urine, but if they are using meds as prescribed, they should be positive for the specific drug they are prescribed E.g. A patient can be negative for opioids but positive for oxycodone. If negative on both, where is the drug going? Diversion? For Opioid Users…

13. Clearly, we can’t give as much weight to UDS given unobserved or non-randomly …but there are some people who change their behavior when the sense it is being monitored Examples: Radar boxes on streets that display speeds, greeters at retail stores like WalMart Often patients will find a way out of those situations (can’t provide sample, disappear) But how can UDS be valid if not random or observed?

14. Providers are generally more uncomfortable about collecting pee than patients are about providing it – some long-term addicts are even proud to provide clean urine In advanced state of addiction, you might beat a drug screen, but the addiction will catch up to you If the consequence falls solely on the addict without collateral damage, one might argue that they only hurt themselves when they are dishonest Question: Are you comfortable with that? Where do you draw the line? Experience and Philosophy

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