Respite News | Spring 2010

2. Don't miss the presence of an alcohol or drug use disorder
Every patient requires individual assessment and screening for alcohol and substance use disorders. Various screening tools are available but simply asking in a non-judgmental manner about drinking and drug use and any associated problems may be very effective in a medical respite setting.

3. If opioid analgesics are used, they should be used in appropriate doses taking into account possible high tolerance in patients with co-occurring opioid dependence
Adequate doses of long-acting medications are preferred to short-acting or p.r.n. (as needed) doses. It is not unusual for a patient to be treated with high dose opioids while hospitalized only to be discharged with a p.r.n. medication at a much lower dose. Patients are at high risk of resuming illicit drug use and leaving medical respite if pain is not treated.

4. Adjunctive treatments--especially touch-based treatments--can be very effective in a medical respite setting
An individualized treatment plan should be developed with each patient with a goal of improving functioning.

5. Create appropriate program structure and policies to assist patients who have difficulty controlling their drug use
"Loss of control" is one of the hallmarks of addiction. A person with an addiction disorder may take more than prescribed or divert their prescribed medication to obtain their drug of choice. We can help create appropriate structure by talking to the referring physician about less abusable, less divertible medications. The case patient initially received a one-day supply of medications each morning when there was a nurse available, but he invariably did not have medication for an evening dose. He did well changing his medication regimen to a transdermal fentanyl patch.

Programs that are unable to hold or administer medications can ask referring providers to post-date prescriptions to be left on file at the pharmacy for serial pain medication refills (for example, refills every three days). Respite programs that do not administer medications should provide individual locked cabinets or lockers for patients to safely keep their medications.

6. Provide harm reduction-informed addiction treatment
Medical respite providers should be trained in motivational interviewing and basic harm reduction principles. One of the first principles of harm reduction is overdose prevention. Harm reduction strategies could include training staff to be able to effectively teach safer injecting or alternative ways of using drugs for a patient admitted with abscess or other infections. Every medical respite program should also be equipped to handle an overdose with staff trained to use naloxone and administer rescue breathing.

Medical respite programs are also an ideal setting to work with patients on motivating readiness to change. Many patients while in respite will be more receptive to suggestions about making changes in their drug use. Staff should be competent in understanding and recommending various avenues to change including 12-step participation, harm reduction therapy, and medications for addiction. When possible, programs should employ or partner with substance abuse counselors and others with special training in addictions.