5 Steps to Help Patients Achieve Sobriety

I have 5 steps I follow every time to help my patients struggling with substance abuse. Find out what they are!

Welcome back everyone and thanks for joining! I’m so excited to see so many new subscribers! Thank you so much for the support and I hope you enjoy the content!

Today let’s talk about how to treat substance abuse! I’m calling it “The Pathway to Recovery.” I find many psychiatric nurse practitioners shy away from treating addiction. I was weary of it in the beginning as well, but you know what? It’s a niche I just kind of fell into and I really enjoy it. It’s a wonderful subspecialty in psychiatry and understanding how to treat addiction can open up a whole new patient population to you! I’m going to give you 5 steps to treat substance abuse patients! If you follow these 5 steps you can’t go wrong! I use this approach with my patients and, guess what? It works! I’m attaching the patient handout portion and an explanation of how to use the handout. Below I will explain my methods in more detail!

Step 1: Assess Motivation

Assess whether the patient is motivated to get sober. Yes, patients will walk into your office and NOT be ready to commit to treatment! Their partner, friend, or relative convinced them to come and they are trying to appease them. When working with the unmotivated patient, you will feel their resistance throughout the assessment. They will often deny that their substance use is really a problem. They will also REALLLLLLY resist medication. When this starts to happen LISTEN TO YOUR GUT! Ask the patient right away, “Do you want to get sober?” Because this process is going to be hard. It’s going to take commitment. They must be ready and motivated! Some of your patients will be ambivalent (remember the Transtheoretical or Stages of Change model in nursing school… yup, here it is!). These patients may partially engage and be willing to do some of the treatment plan, but not all. Maybe they will take a medication but not go to therapy. Meet the patient where they are. When I have an ambivalent patient who is only partially engaged I like to say, “Okay, let’s try it your way first for a month. When you come back next month if you aren’t sober we will try it my way.” They usually agree! You must get the patient to buy in and build rapport and this is part of that. If your patient is ready and committed, you are ready to jump onto the pathway to recovery!

Step 2: Assess Whether the Patient Needs to Detox Inpatient

Always ask yourself, is it safe for this patient to detox and achieve initial sobriety in an outpatient setting? MOST of the time, the answer is yes. In three years, I can only think of a handful of patients I recommended inpatient detox for. What may be an indicator that a patient needs inpatient detox first? Lack of support at home, moderate-severe withdrawal symptoms, medically unstable (particularly if their blood pressure is elevated or they are high risk for seizure), or psychiatric instability (psychosis, mania, suicidal thoughts). All the patients I sent inpatient for detox were medically unstable and/or having moderate-severe withdrawal symptoms. Blood pressures were sky high, they appeared extremely unwell, and had severe tremors. If your patient appears unwell and you are concerned for their physical health DO NOT IGNORE YOUR GUT! Patients detoxing from alcohol or benzodiazepines are your most medically high-risk patients. Opioid detox is uncomfortable, but not deadly. Alcohol and benzodiazepine detox can be deadly. If I am concerned and really feel strongly the patient needs inpatient detox first, I am very straightforward about how serious the detox process is. I say, “Detoxing from alcohol (or benzos) is extremely serious. You can have seizures, hallucinate, and be very ill. If you go inpatient you will be prescribed medications that will make your detox a lot safer and more comfortable.” If your patient is hitting close to 48 hours without alcohol they know what you’re saying is true and often they will take your advice. Once they detox, they can return to you and resume outpatient care.

I have found inpatient detox to be the fastest, safest, most reliable way to get patients to detox. They have no access to alcohol or other substances, they are medically monitored, and they are getting introduced to group therapy and support groups. Going inpatient is a significant event for most patients and leaves a major impact on them which also provides good motivation not to relapse in the future.

Step 3: Prescribe Relapse Prevention Medication

Your primary role in this treatment plan is 1) Get your patient to the right treatment setting and 2) Make sure your patient is on the right medication. If they go inpatient to detox they may come back to your office on the right medications, but you need to be sure! Substance abuse patients are more likely to stay sober with medication to prevent relapse. I like to explain to my patients “Medication is a very small, but important part of the treatment plan. The right medication can give you the foundation to move forward.” Take a look at the corresponding handout to see more about when to use each medication. In the handout I don’t go in depth on how to treat benzodiazepine abuse. That is a whole other topic that I have a really great handout for. You will most commonly treat alcohol, opioid, and cocaine dependence. Marijuana dependence is extremely common, but there are no medications studied or approved for marijuana dependence at this time. Some BIG KEY POINTS to keep in mind are DO NOT START NALTREXONE UNLESS THE PATIENT HAS BEEN OFF OPIATES FOR 7-10 DAYS and DO NOT START ANTABUSE UNTIL 24 HOURS AFTER THEIR LAST DRINK. Be sure to give your patient a list of products and foods to avoid while taking Antabuse. On that note, though, let me add that I have NEVER had a patient say, “Oh man I accidentally used too much aftershave and had the worst reaction” or “I ate chicken marsala and got so sick.” It doesn’t usually go that way. So, reassure your patients that as long as they avoid alcohol and do their best to avoid the things on the list they will be just fine. Antabuse takes 1-2 weeks to completely leave the body. So, having your patient on Antabuse provides an excellent long-lasting safety net.

Be sure to assess for comorbid psychiatric conditions. In my experience, 20% or less of patients presenting with a substance abuse disorder ONLY have a substance abuse disorder. The other 80% of patients have a comorbid psychiatric disorder. Make sure you prescribe the appropriate medications for these co occurring psychiatric disorders as well.

Step 4: Refer the Patient to a Substance Abuse Counselor

This part is so important. First, this adds an additional layer of accountability. Your patients need as many points of accountability as possible. Second, your patient doesn’t know it yet, but they are going to experience multiple phases during their recovery. The first phase (we call it the “pink cloud phase”) everything feels so wonderful and the patient is over the moon they are sober. That phase eventually evolves into a more ordinary phase where reality settles in and the excitement of sobriety has worn off. Patients need a lot of help working through this phase and onto the next ones. Patients who don’t have a therapist and aren’t anticipating this get caught off guard and are very high risk for relapse during this time. A good therapist will help the patient anticipate this new phase and can give your patient the tools to navigate through it.

Step 5: Pick a Support Group and Start Attending ASAP

Here is another layer of accountability. I am a big advocate of “90 in 90” which means a patient will attend 90 meetings in 90 days. These meetings keep their sobriety at the forefront. There are different types of meetings for everyone. The corresponding handout lists the most common support groups, their websites, and the theoretical basis for each group. If your patient attends meetings they are significantly more likely to stay sober. Also encourage your patient to get a sponsor! If your patient can only see a therapist OR go to meetings, I would encourage them to go a support group every time! This part of the puzzle is absolutely critical. Best of all, the meetings are free.

Now you are ready to treat substance abuse patients like a pro! Don’t shy away from it! Follow these steps and you will be able to have the joy of helping so many people achieve sobriety and change their lives! Now I need your feedback. The attached handout is a sampling of the type of handouts I plan to make in the future. My goal is to make a blog post that explains a concept in detail and make a handout you can use in an appointment with the patient (that will hopefully save you time explaining things) and a quick reference sheet you can put in a binder. Does this handout have too much information? Too little? Is this post too in depth? I want to provide you with the most practical information and tips to give you confidence in your practice. Let me know how I could make this information better for you! I’m looking forward to your feedback! I probably won’t leave this handout up permanently if I decide to include it as part of the Psych NP Resource File. So download it now!!

“Can I have time off work?” How I handle requests for extended leave of absence

Today we will discuss how I handle requests for an extended leave of absence as a psychiatric NP.

Welcome to post two! I’m so excited to see more people joining today! This one is going to be a doozy! But here we go… If you have been practicing as an NP (or PA – let’s include PAs here!) for any length of time, you have encountered it. A patient comes in for a first time appointment and as you go through the evaluation every question comes back to work.

“How have you been sleeping?” “Oh horrible, I’m so exhausted at work.”

“How is your concentration?” “Terrible, I can’t get anything done at work?”

“How’s your mood?” “Terrible, I can’t stand to be around my co-workers.”

You know what’s coming next. You get a lump in your throat as you attempt to finish the evaluation and the patient says, “Oh one more thing, can you fill out these forms for me? I need time off work.” AHHHHH!! You KNEW it was coming! You KNEW it! Nonetheless, the tension in the room mounts as you try to figure out what to do next…

There’s a couple of different scenarios that led to this moment. By the time the patient makes it to a psychiatric NP, it’s possible someone in primary care already saw them, gave them a few weeks off, and when they were not ready to return to work referred them to psychiatry for more intensive treatment. Or primary care referred them to psychiatry immediately. Or they have missed a lot of time at work for mental health symptoms and now they are seeking treatment for the first time since they have used up all of their sick leave and need to apply for FMLA and/or short term disability. Now the patient fully expects for their leave of absence (whether through FMLA or a short term disability claim) to be extended and for the time between their primary care referral and the time they made it to your office to be covered as well. WHAT?? Where in the world did they get this idea??

At this moment I am thinking SO MANY things. Why would you stop working prior to receiving this recommendation from a medical provider? How in the world would I be able to cover time off you missed before you were even my patient? WHY are we meeting for the first time and things are now so serious that your mental health concern is cause for “disability???”

You can say this sounds heartless. That’s okay. Once you have been faced with this situation 101 times you have to be start being a bit more objective. Don’t get me wrong, if an established patient needs medical leave, like REALLY needs medical leave, I am your number one advocate! If a new patient is truly ill enough to impair their ability to work, I’m here for you. If a patient needs time off work to seek more intensive treatment, I will absolutely go to bat for you. But let’s be honest… 95% or more of our patients seeking medical leave (at least in psychiatry or for psychiatric purposes) are not sick enough to merit taking an extended leave of absence from work.

So, what do I do next? First I have to shut down my personal feelings. My personal feelings are work is good for people. A busy and productive mind is a happy mind. I believe my patients need to be working, volunteering, doing something that gives them the opportunity to contribute to society (if at all possible) which will have a huge positive impact on their mental health. For this interaction I have to place these thoughts in the back of my mind.

Once I can shut down my personal feelings I start to EDUCATE. I have found education to be the savior in MANY difficult situations. I educate the patient on the purpose of FMLA and short term disability. I educate the patient on the process of applying and advise that MOST times the short term disability claims in mental health are denied so they may end up never getting reimbursed for their time off. I say, “Insurance companies approve or disapprove your time off, not your provider. I can make a recommendation, but ultimately it’s in the insurance company’s hands.” Then I dive into discussing the best way to treat their mental health concern (which is the whole reason they are in my office, right?). At this point, the patient believes the best way to treat their mental health concern is to take time off work. This thought has to be reframed and again we EDUCATE about what will REALLY help their mental health. We discuss medication, therapy, and more intensive treatment options. When I need to be VERY direct I say, “If your mental health concerns have become severe enough to merit a disability claim, then we also need to discuss inpatient treatment (or partial hospitalization treatment at the very least).” Treating a patient who is so severely mentally unstable that they cannot perform their job functions and need an extended leave of absence means that they are likely not a good candidate for traditional outpatient psychiatric services at this point in time. Outpatient treatment offers you a 15-20 minute visit with the NP/PA/MD biweekly or monthly and then weekly therapy (if a therapist is available, they can afford it, and/or their insurance will cover it). That is just not enough. If someone is seeking a leave of absence for medical reasons the person is likely having surgery, doing physical therapy, birthing a baby. They are doing something that requires their time and energy be invested in the healing process. Why should psychiatry be any different? Taking a leave of absence and dedicating only one hour a week (or less) to mental health treatment is simply not productive.

What happens next? Once I have given the patient all of this information the end result varies widely. If the patient was only seeking an extended leave of absence, they usually leave upset. If the patient is in need of help and ready to work toward recovery, I provide a list of partial hospitalization programs and my patient starts making calls that same day to start treatment. At the start of my career I had a VERY hard time saying no or delivering news people wouldn’t want to hear. So, on several occasions I gave in to patients who requested an extended leave of absence and let them refuse more intensive treatment. Do you know what happened? The patients met with me once every other week for the length of their time off, reported no change in their symptoms, and at the end of the leave of absence we were in no different shape than at the start. They requested another extension on their leave of absence over and over again. Most of the time these claims were denied and sadly once the leave of absence was over, so was the patients willingness to attend office visits. I quickly realized that telling the patient what they wanted to hear was not helping them at all. So, my methods changed. Once patients started engaging in partial hospitalization programming they raved about how beneficial it was and were more ready to return to work with new coping skills and a much better frame of mind. One patient even told me, “Everyone should have to go through this program when they start mental health treatment. It changed my life.” That’s when I realized that to really help people I might have to ruffle some feathers along the way.

So, now the patient has gone through treatment, they return to work, and they come back to you two weeks later and they are decompensating again? What then? It’s very important to decipher between a patient who has a mental illness that prevents them from working and one that dislikes their job. If a patient dislikes their job or their boss they won’t like the answer… find a new job.

What are your thoughts on handling short term disability claims in psychiatry or other specialties? How often are you faced with this? How do you handle it? Leave a comment below! I can’t wait to hear your thoughts! As always, thanks for joining!