When I was working in New York I was case managing a patient who needed continuing care in another state. I called a colleague and explained that I had a “dually disordered” patient seeking continuing outpatient care. My patient had primary diagnoses of alcohol dependence and major depression. The onset of depression occurred before he began to abuse alcohol and thus appeared to be independent of the alcohol dependence diagnosis. I asked the person with whom I was speaking if there were any MICA (Mentally Ill Chemical Abuser) support groups available. He had absolutely no idea what I was talking about. I told my patient that he would have to make do with regular 12-step recovery groups. The plan seemed to work.

When I checked on my patient a few weeks later I found out that he was in treatment with people who were clearly polysubstance dependent but were not coping with a co-occurring mental health disorder. And there lied the problem. In the state in which I was working, we used the term “dually disordered” to refer to patients with a substance abuse and a mental health disorder. My patient moved to a state where “dually disordered” referred to people who had used a number of different drugs during active addiction. So my patient wound up in the wrong program.

Not only that, but my patient told me that there were plenty of support groups around him that helped people cope with an addiction and a mental health disorder. They were called “Double Trouble.”

The story above is close to being true. The names have been changed to protect the not so innocent.

Terms that have been used to describe people with a simultaneous substance use and mental health disorder include:

MICA, CAMI, MISA, SAMI, MICD, ICOPSS, Dual Diagnosis, Dual Disorders, Co-existing, co-morbid, concurrent, multiple vulnerabilities.

Even the term many professionals use when referring to their patients as their clients can be confusing to the general public who often think of themselves as patients, and clients as people generally represented by lawyers, not doctors.

You keep calling me your client . . . I thought I was your patient?

“Co-occurring Disorders”

The American Society of Addiction Medicine (2013) and the Substance Abuse and Mental Health Services Administration (SAMHSA) recommend that substance abuse and mental health professionals both use “Co-occurring Disorders” to refer to individuals having “at least one mental disorder as well as an alcohol or drug use disorder. While these disorders may interact differently in any one person, at least one disorder of each type can be diagnosed independently of the other (SAMHSA, 2005).”

It makes sense that we all comply with this simple recommendation; but even that becomes complicated because the general public still refers to “co-occurring disorders” as “dual diagnosis.” This can be easily seen when searching on Google for “co-occurring disorders” and you will get less then 100 thousand results, but if you search for “dual diagnosis” Google shows you almost 3 million results.

“Withdrawal Management”

Another reason to change the terminology we use is that new, universally accepted vocabulary that better describes a process.

The reality is that we have never actually been detoxing people; we were born with a liver that does that quite well. Sometimes, when considering patients who have had multiple admissions for withdrawal management, we may have to say “it used to” do that quite well. In any case, we have never detoxified anyone. The term we should be using is “withdrawal management” (ASAM, 2013).

Patients arrive to treatment with complex withdrawal management needs. New drugs are on the street. How these drugs react with others is difficult to tell. More seniors with very long substance use histories are presenting for treatment. In some cases it is difficult to obtain accurate information or it may be difficult to know how a patient will react to withdrawal management. Levels 1 & 2 allow for longer periods of observation. These are likely to be among the reasons that the ASAM 2013 Criteria advocates for five levels of withdrawal management.

The Five Levels of Withdrawal Management are:

• 4.0 Medically Managed Inpatient
• 3.7 Medically Monitored Inpatient
• 3.2 Clinically  Managed Residential
• 2.0 Ambulatory extended onsite monitoring
• 1.0 Ambulatory without extended onsite monitoring

Level 4.0 (Medically Managed Inpatient) requires physician staffing 24 hours each day. We currently provide level 3.7 (Medically Monitored Inpatient) that requires 24/7 staffing by a nurse and 24/7 access to a physician. Level 2.0 (Ambulatory extended onsite monitoring) can best be provided by partial hospitalization. Level 1.0 (Ambulatory without extended onsite monitoring) can be provided in a physician’s office or by home health care. All levels below 4.0 need access to the next higher level of care.

It needs to be mentioned that the diagnostic criteria for all levels of withdrawal management are the same. Patients need to meet DSM 5 Criteria for a substance withdrawal disorder. All dimensional criteria are used to determine placement.

There is also recognition that a patient who has completed the objectives of level 3 or 4 withdrawal management still needs to be monitored. This can take place while their treatment needs are being met at any level of care.

For a more complete description of each of the five levels of withdrawal management see the ASAM 2013 Criteria.

The stated mission of ASAM includes “to advocate” and “to educate.”  To advocate and to educate is also the responsibility of treatment professionals. Five levels of withdrawal management make sense. Short-term protocols do not.

In any case, it would be nice if professionals and their patients could all speak the same language.

NOTE: There have been some changes with regard to providing treatment to patients with opioid use disorders. For the most part, these changes do not impact Behavioral Health of the Palm Beaches. The umbrella term for providing all services to patients with opioid use disorders is Opioid Treatment Services (OTS). The term Opioid Maintenance Therapy (OMT) will no longer be in use. For a full discussion of OTS see the ASAM 2013 Criteria.