We encourage our patients to pay their bill for services at each appointment (if insurance does not cover the complete cost). However, there are times when that is not possible for all of our patients and they may begin accruing a balance. In that circumstance we will give them a Payment Assistance Letter to remind them of expectations, and of the fact that we can help them with their medical finances if they ask.
Warning letters are sent out when rules are broken. Remediation sessions are scheduled when red flags continue to appear. The purpose of the session is to reinforce accountability and explore other possible factors inhibiting the process of recovery that may need to be addressed preventatively. Remediation sessions can be scheduled with the therpaist, the provider, or in a joint session with both to prevent triangulation. Remediation sessions are scheduled for:
- Missed or failed pill/film counts.
- Repeated drug-positive urines.
- Missed recovery group sessions (more than one per month).
- Repeated missed individual counseling sessions.
- Unwillingness to heed our recommendations for more intensive treatment.
Grounds for immediate discharge include threatening/harassing/assaultive behavior, confirmed breach of confidentiality, and confirmed sharing/selling of prescriptions. Often additional counseling is required. If an individual cannot stabilize in outpatient therapy, a higher level of care is indicated. We routinely refer individuals to “The Farm” (28 day residential program in Aroostook County), Wellspring in Bangor, and Crossroads which has the capacity to welcome mothers and their children. We notify everyone of discharge with a formal discharge letter.
Relapse is part of recovery. Every week an individual is asked: “How is your recovery going?” Because “honesty is the cornerstone of recovery,” the expectation is that one would report if he/she has been struggling with cravings, had a slipup, or experienced a major relapse. The purpose of the group is to provide a safe environment to explore patterns, sources of cravings, triggers etc. and to develop an adaptive strategy to support sobriety. Individual relapse prevention plans are actively discussed within the group, for each group member. If a person is continuing to use, a remediation session is scheduled to discuss a strategy for change.
It is our experience that cravings have more to do with a patient’s heightened anxiety or fear than they do with unsaturated receptor sites. Rather than agreeing with the request to increase the dose of buprenorphine, we try to explore the source of the anxiety and explore alternate approaches for dealing with it. Here, a peer support phone tree or the technique of mindful meditation can be very helpful. Rarely is an increase in dosage helpful; it only reinforces the addict’s belief that narcotics alone can make him or her whole and well.
We have learned that the best resource for informing the direction and development of our program is the participants themselves. Patients are our most effective teachers because they are living the process of recovery. We encourage peer leadership and feedback within groups. We value the honest feedback we have received from program members and have tried to adapt accordingly. We often seek immediate advice during group sessions, from the “consultants” or “jury of peers” themselves, when a situation arises that warrants careful and wider consideration. We feel that soliciting feedback and monitoring treatment outcomes, as well as looking at our own and our colleagues’ attitudes toward treatment, are the best ways to judge and monitor the success of a recovery program. Two valuable techniques for seeking feedback are:
- distributing an anonymous patient survey to all participants, seeking their honest feedback. We leave the room, allowing five to ten uninterrupted minutes to fill this out and place in a sealed box, only to be opened later.
- distributing a professional survey on attitudes of the professionals who work within our program, to better understand which of our attitudes are helpful and which are not.
Maintaining the civility, cohesiveness, and engagement of the group is one of the primary responsibilities of the two co-facilitators. All can be disrupted when patients arrive habitually late, use offensive language, hijack the check-in for their purposes, or initiate “drug talk” (the language of drug seeking and getting high). Facilitators will weigh the need to intervene versus allow the group to police itself (the latter is related to group maturity and trust).
Groups are 90 minutes, 5-12 participants, co-led by one social worker and the provider who also prescribes the buprenorphine for the group members, usually in individual sessions before or after the group.
The group starts with 2-5 minutes of a simple mindfulness meditation breathing exercise. Because of this it is important that all members arrive on time. This is followed by a 3-15 minute psycho educational Youtube clip on recovery-related skill building topics. Other groups show the video clip while inevitable stragglers arrive, followed by the quiet mindfulness session. Video topics include:
- Relapse prevention skills
- The importance of and how to quit smoking
- Urge surfing
- Animated clips of great books such as Viktor Frankl: “Man’s Search for Meaning, (Youtube channel: Fight mediocrity)
- “How mindfulness meditation redefines pain, happiness and satisfaction”Tedx Talk by Dr. Kasim Al-Mashat,
- “The Struggle Switch” Acceptance and Commitment Therapy by Dr. Russ Harris etc. Sample list of videos are available
Check in: Following the mindfulness session and short video clip, each group member “checks in” by sharing important elements of their past week. Individuals are asked directly: “How is your recovery going?” and share if they have had any relapses, cravings or difficulties. Individual check-ins vary from being thoughtful and profound to perfunctory. Group members often share feedback with us about check-in: “This is the only time during the week when anyone cares about how I have been doing.” We are aware of an individual’s greater goals and the group serves as a source of accountability, support and critical feedback. “Wait a minute Simon, you are thinking of going back to Maureen after you spent six months getting out of that relationship because she continued to use? Do you think that is a good idea?”
We openly discuss that Suboxone is a tool to stabilize and that true recovery revolves around creating positive and supportive relationships. Relationships, stability in housing, employment and having worthwhile life goals are stressed as the primary work of recovery.
We define our recovery groups as a supportive environment of peers and providers who share the very human journey of recovery. We strongly believe in the healing power of relationships and structure our program with that in mind. We include them in program development and actively seek their input in establishing program protocols. For example, we might ask them the following: “We need you all this evening to be our consultants. Please give us your feedback. Several of you who are farther along in recovery have shared that most individuals do not need more than 8 mg of Suboxone a day to feel fine. What are your thoughts?” or “Dental pain is a huge issue for some regarding pain medication, what are your thoughts? These open and honest exchanges have resulted in recovery program members feeling valued and respected and our policies being shaped by our program members needs and feedback. What seems an apt metaphor for our approach is that they are driving the “car” of their recovery; we staff are the backseat drivers, and the car happens to be ours.
Goal setting: To support the notion of being in the action stage of change, each group member defines a goal they will achieve before the next group. These goals can be as simple and pragmatic as: “getting the oil changed in my car” to “apologizing to my grandmother who I stole from while I was using.” The social worker records the weekly goals. Interesting patterns develop regarding what is revealed about a person’s life by the weekly goals they set.
During subsequent check in an individual reports back if they completed their weekly goal. Goal setting also allows the group to be involved in celebrating/affirming successes. We can also humorously chide or encourage the individual who has had the same goal (“I will go to the career center to get an updated resume) for several weeks to hopefully go forward.