Patient Intervention Protocols Unique to SUD

Current practices geared toward helping patients struggling with a substance use disorder still lack a clear understanding of some common protocols that can assist in planning for future considerations for care. Unfortunately it is still common for medical professionals to frequently “miss” opportunities to recognize and react appropriately to an SUD at their particular point of contact due to not knowing some of the experiences unique to an SUD patient. Knowledge of these experiences can improve decision-making and recommendations for follow-up care.

Early Detection

It is important to be able to detect when SUD has developed and symptomatology began during adolescence. When dealing with an adolescent, these patients will lack some of the overt medical symptoms associated with SUD and are often masked by other mental health-related concerns. Baler and Volkow²⁶ (2006) reported that patients with diagnosable SUD are known to have decreased executive functioning, low behavioral and emotional control, poor decision-making, and greater levels of deviant behavior and impulsivity. These symptoms are observably more pronounced when patients report initial use of substances in early adolescence. Knowledge of patient initiation of substance use is often associated w'ith increased addiction severity when faced with an acute medical crisis. There is evidence of a relationship between accumulated adversity and addiction risk—the greater the number of stressors an individual is exposed to, the higher the risk of developing a greater addiction severity.

Understanding a “Moment of Clarity”

When a patient’s use gets interrupted, it is medical professionals that wall often be the first person they come in contact with. Patients will often be in a state of despair, but w'ithin that despair many will experience something called a moment of clarity—a period of mental and emotional reflection where they recognize the intersection of past and present and may be willing to take action. This experience provides opportunity, albeit sometimes briefly, to “decide” rather than “react” to the pain, emotional dysregulation, and fear they will describe as overwhelming. There is a deep understanding and power surrounding the moment of clarity, and many might choose the path of recovery if treatment opportunities are immediately available. If treatment opportunities are not immediately available, it is likely they will return to active use once the acute episode is resolved.

This power to decide, rather than react, begins the process of healing. However, the fear of emotional and physical pain w'ill return shortly after the healing process begins. The emotional consequences tied to extensive and frequent relapses instill little hope of initiating recovery. Remember that it w'ill not take long for the patient to experience extreme depression where their feelings are more intense, their negative moods and emotions seem more severe, and their suicidal ideations more frequent. Survival during this period often depends on support from parents, siblings, and helping professionals. Lacking the skills of emotion regulation, they have to depend on others to help stabilize their lives.

Understanding Relapse Potential

Historically, this population has been documented as having a high risk and relapse potential. In many cases, medical professionals will have multiple experiences with the same patient related to overdose and withdrawal. Many patients who are addicted are looking to be understood and for medical professionals to understand what is motivating their use. Previous research has demonstrated that those addicted require additional support and attention to motivation to ensure improved outcomes.²⁷-²⁸

Understanding Patient “Reservations”

Reservation is a term universally used in the 12-step recovering community. Reservation refers to holding back a complete willingness to put full effort and internal and external energy into initiating and maintaining sobriety. Reservations are the belief that they should put some effort into getting sober but would still rather continue to use.

Most patients will come into an acute medical situation experiencing reservations, most frequently connected to feelings of fear or connected to feelings of anger/resentment, which result in previous failed attempts and a lack of full commitment to sobriety. The most common reservations can include serving jail time, losing a stable residence, needing to work, or the loss of a significant relationship. These reservations will be frustrating to the professionals attempting to triage the patient and assist them in finding treatment or recovery-oriented services. However, it is important to work with the patient in areas in which they are not showing reservations and connecting them to the treatment or services they require without gap or delay. Otherwise, emotional dysregulation will recur, and the patient may decide to not receive any assistance other than becoming medically stable.

Treatment Experience and Recovery Attempts

Many SUD patients will have experienced more than one treatment episode by the time you see them in a medical crisis. Many will have had near-death experiences and previous treatments during their lifetime. According to the Substance Abuse and Mental Health Services Administration (SAMHSA 2012) it is estimated that the number of adults who will need treatment for substance abuse has tripled since 2000.²⁹ Patients with diagnosable SUD typically will experience more than one treatment episode during their lifetime. Treatment experiences generally benefit patients with SUD even when the outcome isn’t immediately successful. Current research does not support the relationship between treatment engagement and patient increases in motivation at this time. However, treatment experiences often can provide resources, support, and time away from active SUD which can extend a patient’s life when properly diagnosed and placed.

Recovery Attempts

Previous recovery attempts can provide some benefit to patients as they will have some experience and knowledge. However, previous attempts at recovery can also be experienced as deflating or unattainable. Patients may describe their drive or motivation (often referred to as ambition) toward attempting recovery as lost once they become addicted and have experienced setbacks. Loss of motivation, to them, may instead look like a progressively deteriorating situation. Therefore, despite being in extreme crisis patients may appear unmotivated to accept help. Patients may recount decreased feelings of ambition to remain abstinent and decreased hope for the future. Motivation for change may appear as described as an external experience only, driven by fear of loss.

Aversion

Patients will likely experience aversion to withdrawal (dope sickness). This can be viewed as potential internal motivation for abstinence. Spitsbergen" (2017) reported that the term withdrawal and the aversion to it was frequently associated with other terms or phrases like “depression,” “wish I would die,” and “I would do anything to make this stop,” and patients acknowledged the psychological anxiety or fear of getting sick. Aversion is potent and impactful, even more than the thought of death when in an acute crisis. Aversion is helpful and attractive to a patient only when there are options to avoid withdrawal in lieu of recommencing the use of substances. This includes immediate detoxification services, residential SUD treatment, medically assisted treatments (MAT), and peer recovery coaches.

External Motivation

For patients struggling with an SUD, increased motivation toward abstinence will more likely occur when external pressure is applied. Spitsbergen" (2017) found several indicators central to external motivation, including parental influence, worrying about disappointing their parents, losing the financial resources, loss of employment, jail or prison, or having nowhere to go once they ran out of money. In the same study participants most frequently reported attempting abstinence for the sake of their children, avoiding jail time, or losing a relationship with a significant other as the primary reason to attempt sobriety. Observable lack of motivation can be summarized by looking at fear of withdrawal (aversion), motivation likely influenced by consequence (external), and lack of full commitment to change (reservations).