Bookmark and Share
Share

 

3. Followup Sessions (15 to 25 minutes)

3.1. Overview

 

 

At each followup session, make these three assessments (they need not be made in this order), explained in detail in the sections below:

 

1. Perform a brief check on the patient’s medical status, including general functioning, BAC, vital signs, weight, concurrent medications, laboratory data (when applicable), medication side effects, and medication compliance.

 

2. Ask about the patient’s drinking status.

 

3. Make recommendations for the upcoming week(s).

The length of the visit depends on the patient’s progress, side effects, and compliance with prescribed medications. Most visits will range from 15 to 25 minutes, but they can be as long as 30 minutes.

3.2. Medical Status, Medication Safety, and Compliance (5 to 10 minutes)

 

Check out the following areas:

  • Take the patient’s BAC, vital signs, and weight if this was not done just before this visit, and record the results on the Vital Signs and BAC form (Form A–2).

  • Ask the patient if he/she experienced any medication side effects or adverse events, and inquire if he/she has taken any concurrent medications.

  • If the patient has had laboratory tests performed, review the results with him/her; reinforce the concept that improvements in drinking and/or laboratory data are linked with the patient’s decision to remain abstinent or drink less.

  • Go over the events listed on the Modified SAFTEE form (Form A–7) to see if the patient has experienced any of these adverse effects (if necessary, use the SAFTEE Guidelines, Parts 1 and 2 [Forms A–8 and A–9] for more information about the events listed on Form A–7).

  • If the patient is female and of childbearing potential, inquire about regular use of birth control and her menstrual cycle, and complete the Menstrual Calendar (Form A–10).

  • Use the Concurrent Medications form (Form A–3) to record any medications the patient is taking in addition to the target pharmacotherapy, including over-the-counter medications and herbal supplements.

  • Ask the patient if he/she has any questions or concerns about the pharmacotherapy.

  • If the patient describes a serious adverse event, complete the Serious Adverse Event Report (Form A–11) and process the reporting of these following U.S. Food and Drug Administration (FDA) guidelines and, in the case of research studies, Institutional Review Board (IRB) guidelines.

REFERENCE
Form A–2: Vital Signs and BAC
Form A–7: Modified SAFTEE
Form A–10: Menstrual Calendar
Form A–3: Concurrent Medications
Form A–11: Serious Adverse Event Report

3.2a. Pill-Taking. If the patient brought the blister card, inspect it for any evidence of missed medications. Even if there are no pills on the card, inquire if he/she took all medications following the prescribed schedule because there could be other reasons for an empty blister card that would indicate noncompliance. If so, you may need to address this in the session.

Record the patient’s pill-taking on the Pill Count sheet (Form A–14). To record accurate information on the Pill Count sheet, list the number of pills you prescribed to the patient. If the patient did not return the blister card, check off “No” in the “Patient Report” section. If the patient brings in the blister card at a later visit, change the “Pills taken” information on the sheet and check “Yes” in the “Patient Report” section.

REFERENCE
Form A–14: Pill Count

If the patient took the medication as prescribed, praise him/her for adhering to the treatment regimen. If he/she skipped any doses, inquire about the reasons. Most patients say that they skipped a dose because they forgot to take the medication. Although this is true for some patients unaccustomed to taking medication, some patients say this because it is the easiest reason to explain. If the patient tells you that he/she “forgot” at other sessions, probe further into the circumstances (see Chapter 4, “Medication Compliance and Treatment Session Attendance,” for other common reasons for not taking pills). Try to determine why the patient skips his/her doses so that you can provide helpful advice for complying. For example, if the patient tells you he/she didn’t take the medication because he/she was drinking, determine if the patient skipped the medications and then drank or if he/she drank first and then missed the dose. If the latter, determine if the patient drank and just forgot to take the medications or if he/she decided to skip a dose after drinking because he/she didn’t want to mix alcohol and the medications. Point out that regardless of the specifics, the patient’s drinking was related to missing doses.

3.3. Drinking Status (5 to 10 minutes)

Ask the patient about his/her drinking status since the last visit as well as about illegal drug use and attendance at mutual-support groups. In this part of the session, allow for some open-ended discussion of the patient’s current concerns about drinking or the medications. Reward any positive steps the patient has made toward achieving recovery. Continue to provide the patient with optimism that he/she can recover.

The examples below suggest questions to ask about different aspects of the patient’s drinking status:

CLINICIAN: How have you been since our last visit?

  • What was difficult?

  • What went well?

  • How well were you able to keep from drinking?

  • (If the patient did drink) What were the circumstances? Remember, change occurs in small steps; keep trying, don’t get discouraged.

  • How great was your desire to drink?

  • (If the patient did drink but found his/her desire to drink was greatly diminished) Reductions in your desire to drink may be the first sign of change for you.

  • (If the patient’s desire to drink was strong but he/she didn’t drink) Congratulations on choosing not to drink when you really wanted to. You have taken an important step toward your recovery!

  • (If the patient didn’t drink) Did you observe an increase in any other problems (e.g., illegal drug use)?

  • (If the patient continued with abstinence) Congratulations for staying abstinent. You are demonstrating your determination to change. You are making great progress toward your recovery!

If your patient is also receiving concurrent therapy, provide as much support as possible. Ask if he/she is attending the therapy sessions and if there are any practical problems such as coordinating the schedule of visits so the patient can attend both treatments. If this is a problem, work with the patient to ensure he/she can continue to attend both types of treatment.

3.4. Recommendations/Troubleshooting for the Four Possible Outcomes (5 to 10 minutes)

The results of the brief assessments described in sections 3.2 and 3.3 dictate how you should spend the remaining time in the session. There are four possible outcomes: the patient is not drinking and is medication compliant; the patient is drinking but is medication compliant; the patient is not drinking and is medication noncompliant; and the patient is drinking and is medication noncompliant. The scenarios below describe ways to handle each outcome.

3.4a. Scenario 1: The Patient Is Not Drinking and Is Medication Compliant. Many patients will take the medications faithfully and discontinue drinking. Some will be compliant early in treatment; others will become compliant midtreatment; some will not reach this point until treatment is almost over. When the patient has achieved this outcome, use the following guidelines:

  • Reinforce the patient’s ability to follow advice and stick to the plan. Discuss how most patients have trouble achieving abstinence and being medication compliant. Ask the patient to tell you specifically how he/she did so well.

  • Address the common but incorrect belief that the patient can stop the medication compliance plan you constructed together at the initial session as soon as he/she feels successful in treatment. Focus on the fact that if the patient completes treatment as prescribed, it may better ensure his/her continued recovery after treatment is over. Explain that even when things have been going well for some time, his/her sessions with you serve as “booster shots” or extra insurance that his/her successful compliance and response to treatment can continue past formal treatment.

  • Review the benefits of abstinence in general terms (e.g., improved health, fewer drinking-related problems) and the benefits of the medications.

  • Finish the session with positive, supportive statements such as, “It sounds like things are going well. Keep up the good work!”

3.4b. Scenario 2: The Patient Is Drinking but Is Medication Compliant. This is one of the most difficult situations. It can occur early in treatment, at midtreatment, or at the end of treatment. If your client is in this situation early in the treatment process, encourage him/her by saying that the medication has not had a chance to work fully yet. This statement is not effective for patients who start drinking later in treatment.

Encourage these patients to go to mutual-support groups such as Alcoholics Anonymous and SMART Recovery. Although some patients will inform you early on that they have no intention of attending these meetings because of previous negative experiences or a fear of groups, encourage them to try these groups by stressing that a different type of group could be helpful (e.g., going to SMART Recovery instead of AA or attending smaller AA groups, same-sex AA groups, or AA groups in a different location).

The following is a list of additional strategies. Note that these are responses that a primary care clinician (not necessarily an alcoholism treatment specialist) would likely employ in such a situation.

  • Review with the patient the data on his/her Clinician Report from the initial MM session to remind him/her why he/she originally sought treatment.

  • Review the benefits of abstinence in general terms (e.g., improved health, fewer drinking-related problems) and the benefits of the medications. Encourage the patient to give abstinence a chance. Tell him/her you know that starting the process of abstaining from alcohol is the most difficult time but that if he/she can get the process started, it should get easier as time goes by.

  • Praise any small steps the patient has taken toward abstinence and/or reductions in desire for alcohol. Reassure your patient that recovery is a gradual process and that occasional returns to drinking sometimes occur along the way.

  • Review the benefits of any other aspects of the treatment course helpful to maintaining abstinence that the patient seems reluctant to try.

  • If the situation occurs early in treatment, remind the patient that the medications work slowly and may not have begun to yield their full effect on reducing drinking.

  • If the patient appeals to you for advice on how to become abstinent, find out if he/she has been drinking at home or at a bar or another regular place. If at home, encourage the patient to get the alcohol out of the house. If at a bar or with specific people, suggest not associating with drinking buddies and not going to bars.

  • Ask if there is a particular time of the day that the patient drinks. If so, suggest that he/she find some other activity to distract him/her at that time.

3.4c. Scenario 3: The Patient Is Not Drinking but Is Medication Noncompliant. Some patients will discontinue drinking but report difficulties in routinely taking the medications. This can occur early in treatment, at midtreatment, or at the end of treatment. At the point when this happens, do the following:

  • Congratulate the patient for not drinking.

  • Review the benefits of abstinence in general terms (e.g., improved health, fewer drinking-related problems) and the benefits of the medications.

  • Probe further about why the patient is not taking medications regularly, because this is something you can help the patient change, such as if the noncompliance is related to side effects.

  • Tell the patient that he/she may significantly improve his/her chances for sustained improvement by taking the medications.

  • Revise and reconstruct the Medication Compliance Plan.

3.4d. Scenario 4: The Patient Is Drinking and Is Medication Noncompliant. Some patients who continue drinking will also frequently report difficulties in routinely taking the medications. This can occur early in treatment, at midtreatment, or at the end of treatment. At the point when this happens, do the following:

  • Review the benefits of abstinence in general terms (e.g., improved health, fewer drinking-related problems) and the benefits of the medications. Encourage the patient to give abstinence a chance. Say that you know that beginning the process of abstaining from alcohol is the most difficult time but if he/she can get the process started, it should get easier as time goes by.

  • Encourage the patient to give the treatment a chance.

  • Explain that although it is very difficult to give up drinking, it is a lot easier to routinely take medications as prescribed. To this end, go over the following:

    • Briefly evaluate reasons that the patient failed to comply with taking medications.

    • Review the common reasons why people fail to regularly take their medications.

    • Reconstruct the Medication Compliance Plan with the patient and add new ways to circumvent obstacles to medication compliance.

If your review reveals that the patient is no longer motivated to stop or reduce drinking, follow these steps:

  • Remind the patient of the specific reasons for which he/she sought treatment (as discussed in the initial session).

  • Review the information you gathered about consequences of the patient’s recent drinking behavior prior to the initial session.

  • Repeat the points you made in the initial session about the general benefits of abstinence.

  • Review the benefits of attending as many mutual-help group meetings as possible to maintain abstinence. If the patient had negative experiences before, suggest a different type of group (non–12-step instead of 12-step meeting, and/or a different type of AA meeting [e.g., same-sex, smaller]).

  • Find out if the patient has been drinking at home or at a bar or another regular place. If at home, encourage the patient to get the alcohol out of the house. If at a bar or with specific people, suggest not associating with drinking buddies and not going to bars.

  • Ask if there is a particular time of the day that the patient drinks. If so, suggest finding some other activity to distract him/her at that time.

  • Review the benefits of any other aspects of the treatment course helpful to maintaining abstinence that the patient seems reluctant to try.

3.5. Family Education/Social Service Referrals

Feel free to encourage the patient to bring a family member or significant other to an MM session to ask questions and discuss medication and/or treatment issues. Depending on the patient’s relationship with his/her significant other, this person may help the patient be compliant with MM treatment principles. For example, the patient may benefit from a companion who will remind him/her to take medications and attend MM treatment visits or who will accompany him/her to AA or other kinds of mutual-support group meetings. This session may be up to 15 minutes longer than a normal session.

During the course of treatment, a patient may tell you about a problem such as loss of a place to live, unemployment, or lack of health care. If such a situation arises, make referrals to the appropriate social service agencies as you would likely do in your clinical practice.

3.6. Emergency Crisis Intervention

If your involvement in crisis intervention exceeds two sessions beyond those planned for the patient’s MM treatment, it is likely that his/her urgent needs require more attention than MM treatment alone. Use your clinical judgment to determine what action is warranted and whether you should refer him/her for more intensive treatment.

If at any time you feel that the immediate welfare and safety of the patient or another person is in jeopardy (e.g., impending relapse, the patient is acutely suicidal or violent), intervene immediately and appropriately for the protection of those involved.

3.7. Psychosocial Issues

If the patient is concurrently receiving therapy and brings up psychosocial issues at the MM treatment sessions, refer him/her to his/her therapist. If the patient is receiving psychosocial intervention through the MM treatment sessions only, encourage him/her to consider seeing a therapist; start attending AA meetings or, if he/she is attending AA meetings, increase the number of meetings he/she attends; or seek other support mechanisms (e.g., family, friends, minister).

3.8. If Patients Request Additional Treatment

Use MM treatment strategies for dealing with problematic patients, such as suggesting they attend more AA or other kinds of mutual-support group meetings. If your patient requests additional formal help, advise him/her that it is not uncommon for ancillary problems such as marital or parenting issues to arise during the course of treatment, and he/she may eventually resolve or reduce these problems if he/she maintains abstinence. Tell him/her that you will review these ancillary matters again at the end of MM treatment. If the patient is struggling with problems outside the scope of the MM treatment intervention, refer him/her to other formal treatment(s). This can help provide the necessary foundation to support ongoing abstinence.

Address clinical deterioration immediately. Refer the patient to a more intensive, structured treatment program.

3.9. Preparing for the Final MM Treatment Session

As soon as you feel certain that you have effectively involved the patient in the treatment and that he/she has had several productive sessions (this usually happens after six to seven visits), you and your patient need to begin anticipating what will occur at the end of the MM treatment course. Well before the last MM visit, start to plan with the patient how he/she will establish an effective long-term maintenance treatment plan.