Sunday, December 6, 2009

Economics and the Management of "Dual-Diagnosis" Alcohol-Drinking Clients: How Murky!

A patient is self-medicating if alcohol is used to reduce symptoms of emotional or physical pain regardless of whether the diagnosis of alcoholism exists. Unfortunately, this definition of self-medication often alters from one clinician to the next. And, of course, we know that some mental health professionals do this for the sake of economics, or maintaining their unshakable model of addiction, regardless of validity.

It is tempting to use "self-medicating" as an exclusionary term to decide the patient isn't simply an alcoholic or not an alcoholic at all. This helps justify the current course of therapy that may not meet the needs of the patient, especially if he or she continues drink. The incentive is usually preventing the loss of client or patient to a traditional course of treatment for addictive disease.

Alcoholics without dual-diagnoses drink to ward of withdrawal symptoms, however. So, as the AAMCO car transmission spokesman says on TV, "How can you tell which is what without mistaking one for the other?"

Why not use the National Council on Alcoholism and Drug Dependence and the American Society on Addiction Medicine's definition of alcoholism. No less that 20 or so authorities labored for a consensus and have amended the definition at least twice. 1990 was the last - 20 years ago. (Can't believe it, geez, time flies.) If you are not using it, why not? Goodness, I hope you know it! Click here!)

Digression: Many people were upset over the finality of the definition and deliberation of this well-credentialed group. Someone went as far to create a dummy website about the definition to load harmful viruses on people's computers who visit it. Talk about resistence. (Google has a warning on the Internet link to keep people away from it. You'll see it if you surf the web.)

A self-medicating patient is alcoholic if tolerance to alcohol as emerged during the course of the patient's drinking career and symptoms of withdrawal exist (even ones subtle enough to be certainly overlooked by non-medical professionals.)

Pathologic organ changes may be present or may coexist, and some of these may be undetectable without a meaningful liver functions work-up.

Obviously, based upon this description, you would need help in deciding for sure if the patient was only self-medicating, and not alcoholic, right? Definitely, especially if you were seeing adaptive and earliest stages of addictive disease.

Of course, it gets murkier.

There is the possibility that your patient is in the early stages of alcoholism. A dual-diagnosis might exist. (Dual-diagnosis was an behavioral health insurance-saving discovery rapidly popularized by mental health professionals, and very quickly, within few years of the explosive thrust to treat alcoholism as chronic disease in the early 70's.)

But here is the punchline: Regardless of why a patient drinks, abstinence is required to properly treat depression or any mental illness, especially if medication is involved, and even if it is a dual-diagnosis.

So this means the patient needs to acquire motivation and a sense of urgency to remain abstinent if he or she does not have it already. And what if you can't get that from your patient? Any non-alcoholic client wouldn't give it a second thought to acquire better mental health functioning. And, of course, an alcohol-using client wanting to stop drinking would be qualified for AA. (And you should use motivational counseling to help him or her do it.)

Consider the following:
  • 1) Refer the patient or client to an addiction medicine (certified) physician for the differential diagnosis who will work with the official, and most rigorously formulated understanding of alcoholism that exists.

  • 2) Do not accept without question or qualm the patient's explanation for why he or she drinks. I still can't believe how many professionals actually accept a patient's own well-intellectualized conclusions, even as they explain it with alcohol on their breath.

    It is natural to begin a diagnostic impression on what is conveyed by patients, but remember, alcoholics are well-practiced at explaining their drinking using the same misconceptions and misunderstandings as the general public. Some may even rely upon explanations provided to them by other health professionals who have attempted to treat in the past. The preferred definition of the actively drinking patient is always the one that will permit continued drinking or offer hope of doing so again one day.

  • 3) Be prepared to feel anger and resistance at losing your client to traditional alcoholism treatment, because without sobriety, and a stretch of time to overcome protracted withdrawal symptoms and the normal symptoms of recovery (remember those?), you may not be able to determine what you have sitting in front of you in the clinical setting.

In the end, you may have to fight yourself, the law of economics, and your model of alcoholism at the same time.

A drug and alcohol training program with effective and non-confusing language for use in business and industry can be found here.