General Issues in Substance Abuse Counseling. 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
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
DemonstrationAssessment of Use: Self Report
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 observedAssessment of Use: Objective Measures
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
Introduce the collection of screens into the treatment contract and discuss it up front
“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 positiveMore ways to address UDS issue
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 themWhat if you can’t observe?
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 useWhat if you can’t do random?
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
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…
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?
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