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Defining a recovery checkup level of care

August 15, 2017
by Michael Weiner, PhD, MCAP
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Whether a chronic disease is active or in remission, its progression is monitored. People with diabetes monitor their disease daily. The same can be said for people with severe hypertension. People with progressive arthritis have frequent visits with a rheumatologist. It’s possible that the only categories of chronic diseases that are not routinely monitored beyond a period of acute care are substance use disorders.

There are some recent encouraging developments. Physicians and pilots achieve long-term recovery with a five-year period of monitoring. Even so, chronic diseases are lifelong. They don’t automatically go into remission after five years. There seems to be a need for periodic checkups over the course of a lifetime. The frequency may be quarterly, semi-annually, or annually. Check-ups for a chronic disease just make sense.

The American Society of Addiction Medicine (ASAM) describes levels of care depending upon the severity of a substance use disorder (1). The levels range from 0.5 for an extremely mild disorder to 4.00 for the most severe disorder. It is suggested that a fifth level, 0.25, be assigned to lifespan monitoring. An absolute minimal level of monitoring could come in the form of an annual recovery checkup, as suggested by William White.

What does a recovering person's life look like as time goes on? The likelihood that a person with a substance use disorder will experience anxiety, depression, illness, joy, loss, pain, panic, sleep disorders, sorrow, stress, surgeries, etc., continues to increase. How might a person in recovery continue to maintain abstinence through all of that?” The answer is that not very many people do. Would a recovery checkup reduce the incidence of recurrences and/or minimize them? I think so.

Checkup as assessment

Let’s take a look at what a recovery checkup might look like. It is helpful to keep in mind that a checkup is an assessment. It’s an assessment of the quality of a patient’s recovery and a way to make it stronger. We do many assessments during the course of treatment: psychosocial, treatment plan reviews, discharge summaries that include recommendations for what to work on at the next level. Understanding that a recovery checkup is an assessment makes it logical to place all of the information gathered into one of the six dimensions recommended by ASAM.

So, for example, consider the information that would be gathered during a recovery checkup for a person who has maintained abstinence for two decades.

Dimension 1. Acute Intoxication/Withdrawal Potential: If this were an assessment of a person seeking an initial diagnosis and treatment recommendation, the question likely would be whether the patient’s withdrawal needed to be managed. However, we have already stated that this person has maintained abstinence for 20 years. There wouldn’t be any withdrawal to manage. Perhaps here, Dimension 1 could be an appropriate place to review a person’s medications and medication history. Is the patient taking medications that could be harmful? Has the patient made decisions on his/her own regarding how to take or stop taking a medication? Making one’s own decisions about medications is not a good idea.

Dimension 2. Biomedical Conditions and Complications: Having a periodic physical examination is a concept that most people will accept. Particular systems may need special attention for a person with a substance use disorder (e.g., liver functioning).

Dimension 3. Emotional, Behavioral, or Cognitive Conditions and Complications: This dimension is clearly not going to remain consistent over the course of decades. This is true of everyone, not just for people with co-occurring mental health disorders. A recurrence is likely when a person is coping with significant loss, as well as when a person is exuding with self-confidence. Assessing Dimension 3 can easily lead to an intervention that prevents a recurrence.

Dimension 4. Readiness to Change: This never remains the same. Every person in recovery can use a periodic boost.

Dimension 5. Relapse, Continued Use, or Continued Problem Potential: I imagine that the use of the term “relapse” will soon become “recurrence.” A patient’s history is very important here. Is there a history of recurrences? Can a patient identify, avoid and/or cope with triggers?

Dimension 6. Recovery Environment: Recovery environments change. A patient who started recovery in retail sales may have found a higher-paying job on a beer delivery truck. This can be a no-brainer.

A checkup for a substance use disorder could easily become part of a regular physical examination. Most people are comfortable with, at a minimum, an annual checkup. The outcome of the recovery checkup could be anything from continuing on the current path to a recommendation to change the level of care. It is possible that an intervention involving others would be indicated. In any case, recurrences could be prevented or minimized. Recurrences do not have to be a disaster.

Need for a medical team

There are advantages of belonging to a medical group where primary care physicians and specialists all have access to a patient’s chart. If an addiction specialist was part of that group, items such as prescribed medications could be recognized instantly. There are obvious advantages to that.