6. Medical Attention

6.1. What Is Medical Attention (MA)?

Some patients receiving MM, either with or without psychotherapy, will be unable to continue taking medications after starting them. The most common reasons for this are intolerable side effects and a medical or psychiatric contraindication, such as elevated liver function tests or pregnancy.

In addition, patients may temporarily discontinue pharmacotherapy for various reasons during treatment but may have the goal of restarting medications at some later time during treatment.

Medical attention (MA) is an intervention that has been derived from MM for patients who want to continue seeing their MM practitioner but are not able to take medications. Medical attention consists of medical monitoring (e.g., checking BAC, vital signs, and weight, and administering the SAFTEE), and a discussion of drinking according to the principles of MM.

6.2. Frequency of MA Visits

MA visits should be held as frequently as MM visits in the first month. Thereafter, the frequency of MA visits should be decreased (e.g., to monthly) until patients restart medications or until the end of treatment. MA visits typically will last about 15 minutes, although they can be as brief as 10 or as long as 20 minutes, depending on each patient’s medical status and progress in maintaining recovery.

6.3. Treatment Overview

The goal of MA is to promote recovery from alcohol dependence by encouraging patients to continue in their MA visits, supporting patients’ efforts to stop drinking, and making recommendations for changing drinking behaviors. MA treatment should be delivered by a medical professional who will follow the patient throughout the treatment. Your role as the medical practitioner is to provide expert assessment, support, and direct advice to patients in their efforts to achieve recovery from alcohol dependence. When talking with the patient, appeal to reason and common sense, particularly in relation to the overall goal of preserving or restoring health. It is important in expressing concern for the client to be nonjudgmental. Always be friendly, supportive, and optimistic about recovery.

MA visits include a medical check on BAC, vital signs, and weight; a review of health status; a brief assessment of drinking; review of attendance at mutual-support recovery groups; and recommendations for the patient to follow until the next visit.

6.4. Pitfalls to Avoid When Using MA in a Research Context

6.4a. Non–MA Therapeutic Strategies.

Many professional therapies utilize techniques and strategies that extend beyond the scope of MA treatment, such as the following:

• Conformation
  
  
• Skills training approaches
  
  
• Client-centered counseling
  
  
• Family therapy.

Although these methods might complement MA treatment in a clinical setting, they are not part of the MA intervention per se, and most medical staff will not have training to deliver these methods. These approaches were not used by MM clinicians during the COMBINE project.

6.4b. Nonabstinent Goals.

Typically, patients are encouraged to be abstinent throughout treatment, if possible. This was the case also in the COMBINE project. Do not tell patients in advance things such as, “Expect slips—they are a natural part of recovery,” or “Some reduction in the amount you are drinking is an acceptable goal.” However, when patients do drink during treatment, it is important to avoid expressing disapproval or disappointment. Praise any improvements or steps toward achieving recovery. If patients do slip, reassure them that slips are common and are not signals that recovery is unattainable.

6.5. Brief Assessment: Functioning and Drinking Status Review (5 minutes)

Ask the patient about his/her drinking status since the last visit. You should also allow for some open-ended discussion so that the patient can tell you his/her current concerns about drinking. Reward any positive steps he/she has made toward achieving recovery. Continue to provide the patient with optimism that he/she can recover.

Before determining the content of the discussion for the rest of the visit, ask the patient any other questions that will provide you with information you feel you need, including whether or not he/she has been attending mutual-support groups.

Below are some questions you could ask during the status review:

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 that 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 had a strong desire to drink but did not do so) Congratulations on not drinking, even though you really wanted to! You have taken an important step toward your recovery!

• (If the patient remained abstinent) Congratulations on staying abstinent! You are demonstrating your determination to change and are making great progress toward your recovery!

6.6. Review of Attendance at Mutual-Support Group Meetings

Ask the patient if he/she has been going to mutual-support group meetings. If the patient has gone to meetings, reinforce the importance of this action. If he/she has not gone, provide encouragement to do so.

6.7. Recommendations/Troubleshooting (5 to 10 minutes)

Because the patient is not taking medications, the recommendations and troubleshooting focus will be on drinking status.

6.7a. The Patient Is Not Drinking.

Many patients will attend their MA appointments faithfully and discontinue drinking. Some will do so early in treatment; others will do so 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 initially achieving and maintaining abstinence. Inquire about how, specifically, he/she was able to do so well.
  
  
• Review with the patient that when things are going well, it is important to remember that compliance with treatment also means continuing to attend his/her MA appointments and continuing to make the scheduled visits until the end of treatment. Address the common but incorrect belief that the patient can abandon the plan constructed at the initial visit as soon as he/she feels successful in treatment. Focus on the fact that completing treatment as prescribed may better ensure recovery after treatment is over. Explain to the patient that even when things have been going well for some period of time, the visits to you serve as “booster shots” or extra insurance to help his/her successful compliance and response to treatment continue beyond the end of treatment.
  
  
• Reinforce the benefits of abstinence (e.g., improved health, fewer drinking-related problems).
  
  
• Encourage and reinforce attendance at mutual-support group meetings between appointments.
  
  
• Use the last minutes to provide support. End the visit by saying something such as, “It sounds like things are going well. Keep up the good work!”
  
  
• If the patient has not been coming to MA sessions, probe further as to why he/she missed appointments and suggest that continuing to come to the MA sessions regularly may help sustain recovery.

   

6.7b. The Patient Is Drinking.

Encouraging patients to go to mutual-support groups such as AA or SMART Recovery is the first-line response in this situation. 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 the types of responses that a primary care clinician (not an alcoholism treatment specialist) would likely employ in such a situation. Review with the patient the data on his/her Clinician Report (Form A–1) from the initial MM session to remind him/her why he/she originally sought treatment.

REFERENCE Form A–1: Clinician Report

• Review the benefits of abstinence in general terms (e.g., improved health, fewer drinking-related problems). Encourage the patient to give abstinence a chance. Tell him/her you know that beginning 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 to be reluctant to try.

• If the patient appeals to you for advice on how to stop drinking, determine if he/she has been drinking at home or at a bar or another regular place. If at home, encourage him/her to remove alcohol from the house. If at a bar or with specific people, suggest that the patient not associate with drinking buddies or stop going to the bar.

• 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.

• Encourage the patient to attend MA visits and to give treatment a chance. Briefly evaluate the patient’s reasons for failing to attend MA appointments, and help the patient construct a plan for circumventing the obstacles to attending these visits.

6.8. Coexisting Medical/Psychiatric Problems

In all cases, evaluate coexisting medical/psychiatric problems, and if clinically appropriate, refer the patient to the appropriate practitioner (e.g., an internist or psychiatrist) for further evaluation and perhaps treatment of the coexisting problem. If the severity of the patient’s medical condition warrants it, schedule more frequent visits than ordinarily recommended by the MA protocol.