Personal Experience as a Dentist in the California Dental Diversion Program

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2 Personal Experience as a Dentist in the California Dental Diversion Program

3 History of Treatment Early AA meetings, both the alcoholic and the wives attended meetings AA began in Treatment centers Hospitals Dr. Silkworth first AA program Duffy s Tavern 5 days in Hospital setting AlAnon formally begins in 1951 Minnesota Model 28 day which included a Family week Johnson Intervention placed more emphasis on family Systemic Intervention (Raiter Late 80 s) the focus became the family. Family health become the goal

4 Treatment Cont d 1980 s Extended Treatment Talbott et al 90 day programs dramatically increased outcomes Still limited to one 5 day family week Recommended AlAnon and therapy AMA s highest causation was enabling from family 1990 s Licensed Professional s were achieving outcomes approaching 90% Extended care treatment minimum of 90 days Long term monitoring 5 years Usually 5 day family week Home visit part of re-entry towards end of treatment stay

5 Since 2000 Many young adult extended care programs emerged. Did not experience the level of success as the professionals Parents were much more difficult to treat Massive Malignant Enabling. Enabling, poor limits, and boundaries was the main cause of failed treatment and young adults not completing treatment Year long treatment for young adults Improved outcomes Usually at least 3 family workshops were required Workshops usually educational in nature Main cause of AMA s: enabling parents After treatment, high risk of old family dynamics returning Many can not return home and remain sober

6 Public Treatment Outcomes >50% of outpatients drop out of treatment within one month. About 60% use drugs within 6 mos. following treatment discharge No difference between Brief and Intensive Treatments No difference between Inpatient and Outpatient Treatments

7 How about private addiction treatment? 1. NAATP Report 2. Included report on programs for people of means and prominence

8 Relapse Rates Still High 40-60% relapse within 6 mos. following treatment discharge No differences by: gender, age, profession, drug of choice

9 Improving Outcomes We now understand that we can improve outcomes by extending the duration of treatment 90 days or more Extended treatment combined with long-term monitoring can dramatically improve outcomes Urine Monitoring is critical When family member s focus on their own recovery: Outcomes improve Stephanie Brown research More patients complete treatment One family week during treatment is rarely enough Educational oriented programs often do not result in family beginning their own recovery process Families are under treated

10 Why Study Physician Health Programs, PHPs Doctors receive a different form of addiction treatment and follow-up than that received by most other patients To document what is actually received Outcomes are better (~75-96% 5-10 year abstinence) To verify outcomes Shore 1990, Domino 2003

11 What are Physician Health Programs? Most PHPs prefer to say they do not provide treatment services How PHPs described their function Manage physician rehabilitation Oversee treatment and monitoring Adequate Treatment 90 days 5-Year Monitoring agreement Case management Treatment supervision Contingency management Consequences for non-compliance defined

12 Components of a PHP? Provide education and information, Receive and investigate inquiries, Conduct interventions, Refer for evaluation and treatment, Develop monitoring agreements (contracts), Conduct monitoring (including customer svc), Report deficiencies, Advocacy Documents Recovery / Abstinence

13 Are there similar programs for others? Pain management drug test monitoring Drug testing for courts, probation, etc. Occupational medicine sites that do testing Parents encouraged to test their children Post addiction treatment monitoring ASAM policy statement: Urine drug testing is a key diagnostic and therapeutic tool that is useful for patient care and in monitoring of the ongoing status of a person who has been treated for addiction.

14 Relationship with Authority All PHPs have some type of relationship with Regulatory Licensing Boards All programs (100%) claimed some type agreement or letter of understanding with their state licensing board PHP-type monitoring and case management must have a relationship with authority Family Participant s employer

15 Long-Term PHP Drug Test Results Percentage of Positive Drug Tests 2% 1% 2% 3% 14% 78% None One Two Three Four Five or More

16 Barriers to CM for everyone Not currently part of addiction treatment culture Addiction counselor negative attitudes Cost Lack of understand of the importance of systemic focused case management

17 A New HIGHER Standard Total abstinence Long-term monitoring Defined immediate consequences for discontinuing monitoring or violating agreement The new paradigm has been successfully used in the criminal justice system a population entirely different than physicians

18 New Paradigm in the CJS Hawaii s Opportunity Probation with Enforcement (HOPE) and South Dakota s 24/7 Sobriety Project These programs uphold the zero tolerance standard through drug tests and immediate, brief, incarceration for any use Treatment is available but only required for individuals who demonstrate the need, using Behavioral Triage 12-Step participation is optional but encouraged

19 Are there similar programs for others? Post addiction treatment monitoring - rare Some treatment centers encourage monitoring and provide some services frequently without a leveraged contingency agreement Families are not included in the monitoring Companies providing PHP-Like Care Management services are few and are only focused on the Alcoholic/Addict

20 Families: The Missing Link Families need be included in long term case management Families need a PHP type program where the family is the main focus All family decisions need to go through the family case manager Under treated families are a large reason for post treatment relapse

21 Early recovery can be difficult

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23 You Don t have to Drink to Suffer from Alcoholism Entire family system is affected Measured by behavior Multi-generational legacy Compulsive behaviors

24 Do any of your relatives suffer from mental illness? No, they all seem to enjoy it.

25 What we expected

26 What we got

27 The Pink Cloud Families feel relief while the alcoholic or addict is in treatment It s the first time I ve been able to sleep in years. I m working my program and everything is wonderful High relapse rate when the addict/alcoholic returns home It is common for family members to revert back to old behavior Old alcoholic family dynamics re-emerge This can be the all too common result regardless of the duration of treatment

28 Trauma of Early Recovery Addicted Family System must collapse. Myth - Most expect the problem to be fixed when the patient returns home regardless of what they say Many families do not survive the disruption and turmoil caused by abstinence. Early recovery can be very difficult for children At times the addict cannot return home or they will not remain sober

29 Welcome Home Honey

30 I should have listened to the treatment team!!!!!

31 Trauma of early recovery

32 Couple s therapy in early recovery We recommend therapy for most couples after treatment Should be more educational type therapy to help couples understand that it will take time to develop a new recovering family system Help couples balance the responsibility of maintaining recovery and incorporate healthy parenting i.e., better parenting skills Assist them in seeing early recovery is difficult and that what they are experiencing is normal They are right where they are supposed to be

33 Current recommendations for families following intervention 3 Workshop type treatment experiences during a 6 month period Family week at the treatment center Onsite s Living Centered Program Week long intensive family of origin based experiential treatment in retreat setting Caron s Codependency Treatment Week Family Reintegration Workshop - Onsite Coupleship Onsite Long term family case management and monitoring

34 Treatment options for Families Onsite Retreat Setting Living Centered Program (LCP) Experiential based family of origin treatment and codependency Coupleship Program Family Intensives Family Reintegration Program Caron Codependency treatment week The Bridge 14 to 30 day codependency residential treatment Meadows Survivors Weeks Offers survivors level I & level II

35 Intensive Workshops Individual therapy can be slow and difficult early on Traditional couple s therapy can be counter productive if introduced prematurely educational therapy can be useful Couples are usually able to benefit from more intense therapy after completing an intensive workshop Workshops can be the equivalent to a year of therapy All end in resolution, hope, recommendations and treatment plans for future Always recommend to return home to therapist Referring therapists report that therapy is more productive after Onsite Experiential therapy proven to more effective

36 Family Treatment Recommendations Research recommends additional treatment and unlimited continuing care. We include family case management as part of our intervention service for the first 90 days. Recommend multiple treatment experiences in the first 6 months of family recovery LCP at Onsite, Family week at the treating facility and one additional family intensive workshop at the completion of formal treatment

37 Onsite Family Re-Integration Workshops Intensive 3-4 day family experiential workshop designed to: Improve family dynamic Develop a treatment plan for the entire family which could result in more extended treatment. Ideal for treatment centers as an additional family week to: Develop healthy limits and boundaries to reduce enabling Challenge myth that the patient is fixed after treatment and everything will be wonderful Create a longer range treatment plan which can enhance success Too frequently, families are doing well while their loved one is in treatment and seem to forget everything when they rejoin after treatment

38 Family Reintegration Workshops Can be offered as additional family week at treatment centers Offered at Onsite for a retreat setting Multiple family participation appears to be much more effective Most have similar stories and problems Helps reduce shame and break denial Is offered for single families in their area as a second intervention workshop

39 Aftercare and Case Management At the end of the initial 3 month agreement families have Attended Living Centered Program at Onsite Family week at the treatment center Family Reintegration Workshop at the end of treatment Engaged in Therapy Engaged in 12 step program for family, Al-Anon, Naranon, Coda etc Recommend Family Case Management for the family for at least 1-2 years minimum Urine monitoring and case management for the patient is critical As well as a monitoring program designed to be similar to health professionals

40 Family Recovery

41 References McLellan AT, Skipper GE, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ Nov 4;a2038, doi: a2038 White, W.L., DuPont, R.L., Skipper, G.E. (2008). Physician health programs: What counselors can learn from these remarkable programs. Counselor Magazine, June 27, 2007, DuPont, R. L., & Humphreys, K. (2011). A new paradigm for long-term recovery. Substance Abuse, 32(1), 1-6. DuPont, R. L., McLellan, A. T., Carr, G., Gendel, M., & Skipper, G. E. (2009). How are addicted physicians treated? A national survey of physician health programs. Journal of Substance Abuse Treatment, 37, 1-7. DuPont R. L., McLellan A. T., White W. L., Merlo L., and Gold M. S. (2009). Setting the standard for recovery: Physicians Health Programs evaluation review. Journal for Substance Abuse Treatment, 36(2), McLellan, A. T., Skipper, G. E., Campbell, M. G. & DuPont, R. L. (2008). Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. British Medical Journal, 337:a2038