Addiction Medicine

We are approaching our third year of providing full time addiction medicine services at Caron Renaissance.  Our effort continues to focus on integration of these services into the fabric of the Caron Renaissance philosophy. We have come to recognize that Caron Renaissance is a unique culture. It is organic, fluctuant and complex. As a relatively new department, our capacity to integrate and evolve increases as our appreciation of this unique culture deepens. We continue to explore ways in which we can best translate our knowledge and skills to the individual departments.

During the past year we have implemented training for the Community Living managers on medications: overview of classification, indication for use, common dosages and side effects, and medication errors. We have presented suboxone use in greater detail. In addition, we have developed a presentation on mental status assessment, and will continue to explore other opportunities for in-service training.

Our interaction with the admissions department has continued to evolve. We review incoming patients, particularly those with complex medical or psychiatric diagnoses; we function in a supportive role with referring physicians and psychiatrists when a greater understanding of addiction medicine is needed, and in ongoing patient management; we actively participate in gathering clinical information. This helps to connect the medical and psychiatric community with the Caron Renaissance staff so that coordinated care can be rendered.

We have been participating in monthly private practice supervision and have attended weekly supervision groups with the clinical staff.

We have arranged our schedules to make it possible for both of us to attend and participate in the morning treatment team meetings. This has provided us with an opportunity to participate in the application of the clinical philosophy in decisions around interventions and treatment planning. Further, we are able to respond immediately to questions and concerns about emotional and behavioral issues, medication, and medical problems. In so doing, we are able to discuss Axis I, II and III diagnoses, the impact of family of origin and trauma within the context of addiction medicine.

We use the definition of addiction medicine as presented in the preface of the second edition of the textbook Principles of Addiction Medicine, and it reads as follows:

"Addiction Medicine is an interdisciplinary practice specializing in the identification and treatment of persons whose disorders are caused, or worsened, by their use of addictive substances.  These substances have the unique property of promoting continued use in a compulsive manner despite adverse consequences to the user.  In our society, the most notable offending substances are nicotine, alcohol, opiates, stimulant drugs and marijuana.  The most common services offered by specialists in Addiction Medicine are:

• Prevention
• Diagnosis
• Detoxification
• Consultation with other physicians concerning identification, intervention and management of patients in hospital or office whose disorders are directly related to the use of these substance
• Facilitation of patient engagement in treatment programs designed to reduce the progression of the patient's substance-related problem
• Development of outcome-based treatment programs for such patients
• Treatment of medical or psychiatric complications and relapse
• Environment modifications that attempt to alter the social, behavioral and psychopharmacological inputs that support the continuation of substance abuse and dependence
• Research into the genetic and neurobiologic aspects of addition with the ultimate goal of developing improved treatments (behavioral and psychopharmacologic) for addictive disorders."

Our ongoing efforts is in continuing to develop an interdisciplinary practice that is designed to address the complex issues that characterize patients and families who are typically treatment-resistant and relapse-prone.  Key among these issues is the presence of co-occurring disorders, particularly DSM Axis II disorders.  The Caron Renaissance model addresses these disorders directly.  Many patients have never had these diagnoses identified or managed.  The inclusion of Axis II diagnoses in the treatment continuum is what makes this model unique and at the same time challenging to our discipline.  Much of the addiction medicine and western medicine practice, contrary to claims otherwise, is heavily invested in the short-term medications and procedure interventions.  The integration of behavioral therapies and techniques that motivate individuals to embrace self-care that includes mind, body and spirit is difficult to achieve in the quick - fix environment of the dominant culture. Experience has shown that the practice of holistic integrated care, though labor and time intensive, provides the basis for permanent, meaningful change.

A principle framework that guides our assessment of patients and serves as the lens through which we review psychiatric and medical diagnoses is drawn from the growing body of neurobiological research. The current literature supports our belief that emotional experiences are encoded throughout our nervous systems, woven into the fabric of our physical and mental being. Negative experiences, whether consciously remembered or not, carry an emotional charge. These experiences affect our whole being, and when triggered by everyday events, will manifest as a host of affective and physiological symptoms.

The inclusion of the attachment continuum in our assessment of patients has added an important dimension to the assessment and treatment approach at Caron Renaissance. Recognition of the role played by Attachment Disorders in the treatment resistant/relapse prone nature of our patients and families has enhanced our understanding of Axis I and II disorders.

The clinical model at Caron Renaissance is led by a primary therapist and family therapist who, in concert, help patients and families find their way into recovery.  This pathway is often cluttered with old DSM diagnoses and medication regimens that have not served the patient well or have been poorly utilized because of unaddressed Axis II disorders.  One of the roles played by addiction medicine on the clinical team is to help with the understanding of the pathophysiology of addiction, post-acute or protracted withdrawal, and the ways in which these factors interact with, and are influenced by, co-occurring disorders.  This is not only helpful to us as a treatment team; it has helped our patients and families make sense of the baffling and painful process of early recovery. Defining the role of addiction medicine in a setting that is driven by the clinical staff rather than the medical department was initially challenging. In remaining sensitive to the collaborative nature of working relationships at Caron Renaissance, our role is continuing to evolve.

Since joining Caron Renaissance in early 2006 one of our goals has been to cultivate good working relationships with medical specialists and services within the local community. Finding specialists who provide good quality care, have some understanding of addiction and are willing to communicate and work with us in a collaborative manner has been a challenge. The addition of our medical services coordinator, Jill Kind, has allowed us to make some important strides in this area. Jill has taken over the management of our department, communicating with outside services and providers, arranging patient appointments and meetings with local physician groups. She has researched prescribing patterns at Caron Renaissance over the years, monitors patient responses to satisfaction surveys, records and quantifies themes in medication non-compliance among our patients. Her presence has allowed us to focus more completely on patient care and participation with the treatment team.

The development of telemedicine/teleconferencing has grown significantly over the past year. The importance of this capability cannot be overstated.  The admissions department has grown accustomed to utilizing this service in meeting with potential admissions and referents at Caron, Caron Bermuda and Maine. We have been able to attend medical staff meetings at Caron via teleconferencing, which has enhanced our understanding of each other, the difficulties and clinical challenges we both face. It has had an indirect impact on the quality of our communication regarding specific patients being transferred to our facility.

Our move to our new office building allowed us to expand our private addiction medicine service. We hope to see continued interest in teleconferencing. As the Caron Renaissance clinical services grow, we anticipate a need for additional addiction medicine staff.  Developing these new professionals so they can contribute to the Caron Renaissance model will be a continuing challenge, one that we anticipate with enthusiasm.

-Stanley J. Evans, MD, Medical Director, Caron Renaissance