We always accept pregnant women into our program when referred. We realize that it is critical for SUD pregnant women to be in a medication assisted treatment program. We have helped start a community wide program with Waldo County County General Hospital using the evidence based program CHARM: Children and Recovering Mothers Collaborative. This well researched model provides superior case coordination of services to assure that a mother and infant receive the support they need to succeed.
Having individuals develop a realistic and practical plan to stop the cycle of behaviors leading to relapse is a primary goal of treatment. We often ask: “Who are three people you could call if you felt like using?” Sadly, some members respond with: “I do not have any sober friends, everyone I know is using.” We stress the availability and use of the State of Maine sponsored, Warm Line – for serious, but not crisis, assistance. (1-866-771-9276). Several program members have shared in group how helpful this resource has been to avoid a relapse. The Warm Line is staffed 24 hours a day, 7 days a week by mental health professionals.
This is a common and tricky problem. Many of our program members have used marijuana for years to address a number of emotional/physical issues. We try to be thoughtful and compassionate but firm in our belief that individuals can learn new skills/coping strategies, and ultimately they must eventually be off marijuana to remain in our program.
- Acknowledge any visible marker of adulthood and accountability. Keeping a dosage graph of an actively tapering patient can be a great incentive. Paying off fines on a suspended license deserves a group cheer.
- Invite mentoring peers. Mentors can set an example of success and hope. Starting a formal Peer Leadership program, and/or identifying and inviting specific program graduates who inspire and encourage others can be a great help.
- Try to mention specifics of “small positive things.” For example, a member supported her child’s efforts in school, sports, or teacher conferences: a mother was thrilled when her child wanted to do homework on the second day of school; a father went to a child’s sports event; a mother attended a child’s parent teacher conference; a member was able to refrain from saying or doing something that would cause offense to others. Ask how were you able to do this? Were you able to do this in the past? Why not?
- Mention in Group something positive discussed in individual sessions if not confidential and if this will help the patient’s Group status. For example, a non-worker starts part time summer work with his wife, which generates income and renews camaraderie with his wife which he would not have mentioned on his own.
- Ask: “How would that be different if you were not in Recovery?” For example, having enough money to buy Christmas and birthday gifts; making home or car repairs; being “present” for family events, birthdays, children’s school activities. This allows all group members to participate and collaborate on how they were unable, uninterested, and unaware of much of this in the past and how ‘good’ it feels to be able to do so now. These are questions no one else in their life can ask them.
- Acknowledge fears. Tactfully ask other Group members how they might handle a difficulty a member is having. Ask what worries them about tapering, staying on suboxone, relapsing, or being able to maintain relationships and jobs. Or are they afraid of just not being able to progress in life? Group members will often be more helpful than therapists or providers about member’s fears and anxieties.
- Mention Group confidentiality periodically. Talk about confidentiality in general: fear of family, coworkers, supervisors, community knowing about their SUD and their Recovery.
- Ask about relapse prevention plans. What specific plans do you have when you get cravings? Do you have 3 or more phone numbers or people you can call anytime? What about getting exercise, getting out, going for a walk, stepping away, taking a breath. Ask why you think you won’t relapse next time?
- Acknowledge remorse. At some point most Group members will want to talk about their regrets. Some will bring to Group their tentative plans to talk with family or those they harmed. Ask for specifics: what do they regret having done; what harm do they think they caused. No one else in their life will ask them to talk about this. Consider writing but not sending a letter or role playing in Group what each might say/write to family, friend, or other, acknowledging harm and offering apology.
- Ask each member to list an attribute of other Group members, one member at a time. This exercise fosters camaraderie, honesty and openness. Group members never have the opportunity to offer constructive insights to others or to hear good things about themselves.
- Encourage and acknowledge Group support. Group members know how helpful Group is. Providing a chance to express this encourages accountability and helps in preventing relapse. They deserve to acknowledge they are important to each other and that forming new friendships and relationships is difficult for everyone. No one else will ask them to talk about this.
By and large, our Recovery Program members are no different from the rest of our patient panel. Occasionally we have problems with inappropriate conversations occurring in the waiting room. By addressing these patterns in group, a useful discussion about what represents “Recovery” can happen. We do note a problem with recovery program members smoking in the parking lot or near the building. We remind members about this regularly. As expected, this pattern ebbs and flows.
This is a constant source of frustration for the treatment staff. We make a point to repeatedly remind people in group about working cell phones. Notes and letters are often mailed to program members reminding them of this treatment agreement.
Pill and film count are an attempt to address the diversion potential for program members selling their prescriptions. Seaport has the advantage of an on site pharmacy, and we strongly encourage our program members to fill their Suboxone prescriptions at our pharmacy. Pill and film counts are done per our Count Protocol.
Program members are told that they must have a working cell phone with the capacity to leave a message available at all times. We inform them that pill/film count calls happen between 7:00-8:00 AM, with most often a medical assistant leaving the message that a pill count has been ordered. Program members have until the 5:00 pm (sometimes later depending on pharmacy hours) that same day, to present their prescription to the Seaport Pharmacist. We sometimes also ask the program member to provide a urine screen at the time they arrive for a pill count.
We acknowledge that pill/film counts happening as outlined have been a source of frustration as most patients fail, possibly because of widespread diversion but more likely because of impoverished and chaotic lifestyles. Problems with non working cell phones, voice mail boxes being full or not set up and messages not being being listened to are common. Nevertheless the act of doing counts is an important factor in accountability for many and meets our DEA (Drug Enforcement Administration) requirements to curb diversion. If a program member fails repeated pill counts they are “put on warning” that they must have a working phone with voicemail and to check daily for the call that will be coming.
Our Medical Assistants are trained to conduct urine screens according to our UDS Protocol. A group member is asked to empty their pockets and be down to one layer of clothing before using a specially modified restroom. Program members are asked to come to appointments ready to provide a sample if asked. If a provider requests a urine screen, and the person responds, “I can’t; I just used the restroom,” a prescription is not provided unless the screen has been obtained. It is not uncommon for a program member to be drinking a glass of water during group to provide the screen before leaving the building. If a patient tests positive, does not declare this in group, and a relapse is suspected, it is useful for the provider to be informed of positive test results and discuss the issue as soon as possible while in group. Significant change more often occurs with feedback that is immediate, supportive, and constructive.
Per our Treatment Contract, members can miss up to one group a month. Two misses a month is considered a breach. Usually a warning letter is mailed, sharing that the program member has forfeited their option to miss one group a month for two months, and prescriptions (or prescription refills) are then written on a weekly basis to ensure compliance.
The SCHC recovery program is not a pain management program. We are a tapering program for those interested in acquiring the skills to live a drug free life. We work with individuals to find non opioid solutions to cope with pain concerns. That said, we do have many patients with chronic pain who value their continuing presence in our program.