July 14, 2016 | Continuing Ed with Ed Baker
"Continuing Ed" with Ed Baker: Role of Drug Testing in Treatment
By Ed Baker, LICSW/LADC
Burlington Labs Addiction Education Specialist
Treatment for severe substance use disorder has come a long way over the past few decades. There have been profound advances in the way Counselors understand and engage people with this disorder.
Certainly, the work of Prochaska and DiClemente regarding the process of change and its stages, and the contributions of Miller regarding counseling techniques geared toward maximizing client motivation, have propelled the field forward.
In addition, the groundbreaking work of David Mee Lee, developing a matrix to determine the best level-of-care for clients, has provided a common reference point for important decision making regarding appropriate intensity-of-care decisions.
Finally, the conceptualization and movement toward the adoption of Recovery Oriented Systems of Care, advocated by William White, is revolutionary, as is the social component of this movement, the Recovery Network Movement.
Never before in this field have we seen so much social and political attention and support for investment in treating these disorders as we do today. It seems both national and local governments, health care, law enforcement and the general public are coming together to face what has become a profound health crisis affecting us all.
Added to this we have both Opioid Agonist and Opioid Antagonist medications available for individuals with Severe Opioid Use Disorder, combined with a general trend to increase the number of providers dispensing these important medications.
While the knowledge base of the field itself has matured over time, and the social and political environments supporting this particular segment of health care have begun, and continue, to move forward in very significant ways, the nature of the disease, and the ways the disease manifests itself in the personal psychology and interpersonal relationships of the person with addiction, have remained largely unchanged.
Basically, for the most part, people with the brain disease of addiction are likely to be ambivalently motivated in therapy, and perhaps prone to engage in inaccurate self-reporting regarding drug-use.
There are a myriad of reasons for this seemingly irrational behavior.
Among these is the likelihood of the client’s having, over the course of the disease, developed unconscious defenses to protect themselves from the emotional discomfort of facing the unattractive reality of their self-harming behaviors. Facing this truth is uncomfortable for two reasons: it is not within the person’s perception of themselves, what we call ego-dystonic. It is uncomfortable, unacceptable, to say the least. And, secondly, if faced and dealt with, a whole series of corrective behaviors will be necessary, including abstinence from the use of a drug which has begun to serve a purpose in the person’s life -- a purpose usually related to the relief of inner suffering.
The individual will unconsciously resist these changes by employing defenses, such as:
While these defenses are unconscious, and employed to protect the person from realizing the uncomfortable truth about themselves regarding the progression of addiction, they will manifest themselves interpersonally in counseling, appearing as argumentativeness and deceit.
In addition to these, the effects of the severe substance use disorder itself are likely to stand in the way of motivation and progress toward health and recovery.
The person may feel ashamed of their behavior, and therefore be motivated toward defense. Or guilty, or disgusted with themselves.
They may fear consequences, sometimes with some base in reality, sometimes because of shame, guilt and their own inner anticipation of punishment.
As long as these defenses predominate, trust is not possible, and the truth necessary for personal motivation and forward movement remains unavailable.
Now, a trained and skilled Counselor or Physician will succeed in creating a safe place for the client. Certainly confidentiality and true empathy are invaluable. Unconditional positive regard for the client is indispensable. There cannot be any judgmental attitudes operating in the relationship. Add to this a respect for the client’s right to self-determination, and a professional commitment to provide ongoing support without threat of abandonment, and the stage is well-set for the therapeutic work to come.
But still, because of the nature of this disease we call addiction and its incredible ability to cause the person to withhold important information, another ingredient has to be added to the treatment protocol.
This ingredient is Substance Use Testing.
There are basically three indispensable parts to this ingredient: reliable collections, accurate testing, and clear and timely results reporting.
The first leg of the triangle is collections.
For a test to be accurate, the collection must be reliable, meaning the specimen must be from the donor, unadulterated or tampered with in any way. The best way to guarantee this is by conducting random, observed collections. This is best practice.
Next is the accuracy of the testing process itself. There is no debate concerning laboratory-based immunoassay screening being the most dependable method for presumptive testing. The rates of both false-negative and false-positive screening results are significantly lower with this method, as compared to point-of-care (POC) or instant-read cup tests. As far as definitive testing, GC/MS and LC/MS/MS are the most reliable scientific testing methods available for confirmation today. Again, there is no debate, this is best practice.
The third leg in our triangle regards timely and clear results reporting. It goes without saying that drug test report results need to be available to the provider in time to be utilized in a therapeutic manner during a session. Many times providers will time their tests to occur between sessions, with the results then being available for the next session’s review. The availability of laboratory scientists for discussion is crucial here, so that unclear or complex results can be discussed and clarified.
The ultimate value is the Provider’s confident presentation of a reality the client may be attempting to disguise, because of the defensiveness and fear noted above.
Much like the three sides of a triangle, these three elements will provide a rock-solid process providing information, the truth, with which the Counselor or Physician will be well equipped to either affirm a client’s self-report, or significantly clarify a client’s self-report, in both cases creating inner motivation to move forward.
In the first example, where the Substance Use Test results indicate forward movement toward therapeutic goals, or adherence to medication protocols, the information provided by the test confirms the client’s progress. These are important moments in treatment, reinforcing moments, affirming moments. Besides signaling forward movement into health, and strengthening commitment and motivation, these results are often required by processes external to the counseling relationship, such as license reinstatement, continuation of employment, matters affecting child custody, and so on.
In the latter example, the substance use test report will differ from the client’s self-report. Very often, a supportive confrontation based on a reliable substance use test, with empathy rather than consequence, will elicit a more accurate self-report, and perhaps a modification of the treatment plan or a deeper understanding of some of the personal dynamics involved in recovery and relapse. These learning experiences are the building blocks of healthy recovery, and they also strengthen the therapeutic relationship.
That being said, it is these moments of truth, sometimes impossible without reliable substance use testing, that eventually accumulate to a critical mass sufficient to tipping a client’s motivation in a way that literally changes their life. This aspect of treatment is the very beginning of the process we call recovery, the embracing of a lifestyle supportive of ongoing health.
If you have thoughts to share or questions to ask regarding the use of SUT in therapy, please contact me at [email protected]. And if you have suggestions for future blog post topics, those are always appreciated!