Referral (How patients access the program)
An intake, scheduling, billing receptionist is available 8:30 4 daily for receiving calls made by prospective patients. Many calls reflect emergencies; persons using potentially lethal drugs or behaving in potentially lethal ways. Every effort is made to insure that these calls are responded to with a same-day appointment. However, this must be balanced by the outpatient nature of the service. Detoxification admissions must come in during the morning so that the psychiatrist can observe the nature of a withdrawal syndrome and the effects of prescribed medications. All prospective patients must have their insurance checked, and fill out some initial screening information before they can be scheduled.
The Sober Support Person (SSP) requirement might be viewed as a "barrier" to treatment. However, it is expected to actually provoke an improvement in engagement and efficacy of treatment. The nature of treatment without any effort by ill persons to enlist the help of caring individuals in their environment is often that the addicted person continues to make little effort and keeps their presence in treatment a secret from potentially helpful persons such as family or physicians. There is a clear distinction between "privacy" and "secrecy." The former is colloquial term for good boundaries that enable members of a household or group to function autonomously and yet interdependently. The latter is a common interpersonal form of denial; a way to protect the use of drugs or alcohol that would be more difficult if the secret was exposed. Treaters respect privacy but do not keep secrets about potentially lethal behaviors.
Intake and Admission
(include requirements and necessary medical evaluations when applicable)
All new patients are required to allow contact with all current physicians as a condition of admission and of continuing treatment. This requirement follows the above discussion of privacy/secrecy. Many addicted persons want "help" that allows them to continue to be actively addicted. Keeping secrets from physicians is viewed as an enabling behavior, and is not practiced by the staff. Patients who refuse to allow coordination of treatment between the Psychiatric Addiction Service and other treaters are referred for care elsewhere.
All new patients start with a psychiatric evaluation. Patients requiring detoxification also have a physical examination, blood and/or urine tests as ordered by the psychiatrist, and are referred for specialty medical treatment when that is indicated. The recovery plan is discussed with the patient and with their SSP.
The general concept is that an addiction psychiatrist is competent to provide basic primary care treatment such as management of diabetes or hypertension during the withdrawal period. Comprehensive primary care referrals are made for patients who achieve stable sobriety because it is impossible to treat any other medical condition effectively if the addictive disorder is active. (Trying to refer actively using persons for primary care usually results in missed appointments and/or negative interactions.) However, it is a goal of the program that all patients have a primary care physician and are being cared for by that physician within two months of entering treatment.
Evaluation, Assessment and Diagnosis
The psychiatric evaluation results in a 5-axis diagnosis, including comorbid psychiatric and medical conditions. Every patient has a Hamilton Rating Scale for Depression (HRSD) and Modified Mini-Mental Status (3MS-a brief but sensitive cognitive screen). This allows the HRSD to be followed prospectively as a measure of the efficacy of treatment of depression, and the 3MS facilitates planning the way psychotherapy should be adjusted for each individual patient; concrete for impaired patients, and more complex for intact patients. Copies of the HRSD are given to the patients so that they are clear on the target symptoms of antidepressant/psychotherapy treatments.
Extended Evaluation and Referral
Each person is an individual. Treatment is tailored to each particular patient, their SSP, and the conditions under which the person is living. We usually meet with patients daily for their first week of treatment. Further appointments are used to treat comorbid psychiatric disorders, work on denial, and help patients get into more definitive long-term treatment.