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Abstinence facilitation:
An outpatient treatment strategy designed to help persons who are addicted to drugs stop using them. Commonly used in association with the medical treatment of cocaine abuse.
Acute abstinence syndrome:
The aggregate of withdrawal signs and symptoms that occur shortly after a person who is physically dependent on a drug stops taking it. The adjective "acute" distinguishes this variant from the "protracted" or "chronic" drug withdrawal or abstinence syndrome.
Acute psychosis:
A disturbance in thinking that is often accompanied by delusions and visual or auditory hallucinations. An acute psychosis may be caused by alcohol or other drug (AOD) withdrawal, drug toxicity (most commonly in conjunction with abuse of cocaine, methamphetamine, or psychedelic agents), or schizophrenia.
Analgesia:
Relief from pain.
Anhedonia:
Absence of pleasure from acts that would ordinarily be enjoyable.
Anorexia:
Diminished appetite; aversion to food.
Arthralgia:
Joint pain.
Ataxia:
Unsteady walking or staggering, caused by an inability to coordinate the muscles.
Authorizing order:
An order issued by a court that permits an AOD abuse treatment program to make a disclosure about a patient that would otherwise be forbidden.
Cellulitis:
Inflammation of the cellular or connective tissues.
Chronic obstructive pulmonary disease:
A combination of chronic bronchitis and emphysema. Characterized by persistent disruption of the flow of air in and out of the lungs.
Clouded sensorium:
Confusion.
"Cold turkey":
Popular term used to describe the process of opiate withdrawal that is not treated with medication. During withdrawal, the person's skin is covered with goose bumps and resembles that of a turkey.
Decisional capacity:
The ability of a patient to make an informed choice.
Delirium:
A state of mental confusion characterized by difficulty in responding to stimuli and an absence of orientation to place and time. May be accompanied by auditory, visual, or tactile hallucinations. May be caused by drug withdrawal or severe intoxication with phencyclidine.
Delirium tremens:
A severe form of alcohol withdrawal characterized by confusion, auditory or visual hallucinations, and severe shakiness. Commonly called "DTs."
Delusions:
Fixed, irrational ideas not shared by others and not responding to a logical argument.
Diaphoresis:
Profuse sweating that is not in response to high temperature or exercise. A common symptom of opiate or sedative-hypnotic withdrawal.
Disclosure:
A "communication of patient-identifying information, the affirmative verification of another person's communication of patient-identifying information, or the communication of any information from the record of a patient who has been identified" (42 C.F.R. '2.11).
Drug receptors:
Specialized areas on the surface of brain cells to which drugs attach and through which they produce their effects.
Drug tolerance:
The body's ability to endure increasing quantities of a drug. As the brain cells adapt to the presence of a drug, more of the drug is required to produce the same effect.
Dual diagnosis:
The presence of both an AOD abuse problem and a psychiatric disorder.
Duty to warn:
The legal obligation of a health care provider to notify law-enforcement officials or the potential victim when a patient presents a serious danger of violence to an identifiable individual.
Dysphoria:
An unpleasant mood.
Electrolytes:
Compounds in the blood that conduct electricity and can be decomposed by it. They include, for example, sodium, potassium, and chloride ions. Electrolyte imbalance can be caused by protracted vomiting, diarrhea, or dehydration. It also may result from failure to administer the correct type or quantity of intravenous fluids.
Encephalopathy:
Any disease or disorder that affects the brain.
Grand mal seizures:
A type of seizure in which a person falls to the ground unconscious and suffers generalized muscle contractions. The person usually remains unconscious for a time and may have no recall of the episode on awakening. Petit mal seizures, by contrast, are characterized by a momentary loss of awareness; an observer may think the person experiencing the seizure is simply daydreaming.
Hyperpyrexia:
Extremely high fever.
Hyperreflexia:
An exaggerated response of muscle reflexes that indicates that the nervous system is in a pathologically excited state. May occur during withdrawal from sedative-hypnotic agents or alcohol.
Hypertension:
Abnormally high blood pressure. Usually defined as a resting blood pressure greater than 140 mm hg (systolic) and 90 mm hg (diastolic).
Involuntary commitment:
Process by which patients who have not committed any crime are brought into treatment against their wishes by relatives or the police or through a court proceeding. Involuntary commitment is also known as "protective custody" or "emergency commitment."
Medical comorbidity:
Presence of two serious illnesses at once; for example, drug addiction and acquired immunodeficiency syndrome.
Medical emergency:
A condition that poses an immediate threat to the health of any individual and that requires immediate medical intervention (42 C.F.R.).
Medically debilitated:
Term used to describe an individual who is both AOD-dependent and who has a chronic or severe medical disease such as emphysema.
Medication discontinuation:
The process through which therapeutic doses of a prescribed medication are tapered or withdrawn. Detoxification, by contrast, refers to discontinuation of the use of an illicit drug or a self-administered prescription medication.
Myalgia:
Muscle pain. A common complaint during opiate withdrawal.
Narcotic-dependent:
(Federal methadone guidelines): Term used to describe an individual who physiologically needs heroin or a morphine-like drug to prevent the onset of signs of withdrawal.
Narcotic treatment program:
According to Federal methadone guidelines, an organization (or a person, including a private physician) that administers or dispenses a narcotic drug to an addict for maintenance or detoxification treatment; provides, when appropriate or necessary, a comprehensive range of medical and rehabilitative services; is approved by the State authority and the Food and Drug Administration; and is registered with the Drug Enforcement Administration to use a narcotic drug for the treatment of narcotic addiction.
Network treatment:
"An approach to rehabilitation in which specific family members and friends are enlisted to provide ongoing support and to promote attitude change. Network members are part of the therapist's working 'team' and not subjects of treatment themselves" (Galanter, 1994).
Neuroadaptation:
The process by which the function of the brain cells changes in response to exposure to drugs. These adaptive changes may include increases in the number of receptor sites, alterations in the shape of the receptors, or changes in the chemical functioning of the cell.
Nonmalignant pain:
Chronic pain that is not caused by cancer. Also called "chronic benign pain."
Nystagmus:
A jerky movement of the eyes. May be seen in persons who are intoxicated as a result of ingestion of alcohol, sedative-hypnotic agents, or phencyclidine.
Orthostatic hypotension:
A rapid drop in blood pressure (usually defined as 10 mm hg or greater) that occurs when a person stands up. Such an individual may become dizzy or even faint. May be a sign of sedative-hypnotic withdrawal or opiate intoxication. Also called "postural hypotension."
Pancreatitis:
Inflammation of the pancreas. Alcohol abuse is the most common cause of chronic pancreatitis and a principal cause of acute pancreatitis.
Paresthesia:
An abnormal burning, pricking, tickling, or tingling sensation.
Patient-identifying information:
The "name, address, social security number, fingerprints, photograph, or similar information by which the identity of a patient can be determined with reasonable accuracy and speed, either directly or by reference to other publicly available information . . . " (42 C.F.R. '2.11).
Pentobarbital challenge:
A method of assessing physical dependence on alcohol or other sedative-hypnotic agents. The challenge consists of administering standard doses of pentobarbital to a patient and observing the effects. Patients who become intoxicated on 200 mg or less of pentobarbital do not have substantial tolerance to sedatives and are presumed not to be physically dependent on these substances.
Physical dependence:
A condition in which the brain cells have adapted as a result of repeated exposure to a drug and consequently require the drug in order to function. If the drug is suddenly made unavailable, the cells become hyperactive. The hyperactive cells produce the signs and symptoms of drug withdrawal.
Protracted abstinence syndrome:
The aggregate of signs and symptoms of drug withdrawal. These signs and symptoms may continue for weeks or months after cessation of drug use. (Also see "acute abstinence syndrome.")
Record:
"Any information, whether recorded or not, relating to a patient received or acquired by a Federally assisted alcohol or drug program" (42 C.F.R. '2.11).
Recrudescence:
Reappearance of symptoms after a period of remission.
Relapse prevention:
In common usage, any strategy or activity designed to assist a drug user who has become abstinent from returning to drug use. Relapse prevention also refers to specific cognitive-behavioral treatment "that combines behavioral skill-training procedures with cognitive intervention techniques to assist individuals in maintaining desired behavioral changes." It draws from both health psychology and social-cognitive therapy and uses a "psychoeducational self-management approach to substance abuse designed to teach patients new coping responses (e.g., alternatives to addictive behavior), to modify maladaptive beliefs and expectancies concerning substance abuse, and to change personal habits and lifestyles" (Marlatt and Barrett, 1994).
Signs:
Observable or measurable changes in a patient's physiology; for example, increased blood pressure or dilated pupils. Such changes may not be perceived by the patient.
Somnolence:
Sleepiness, drowsiness.
Symptom rebound:
Transient, intensified return of symptoms following termination of therapeutic doses of a benzodiazepine. The most common withdrawal consequence of prolonged benzodiazepine use.
Symptoms:
Subjective changes in mood, feelings, or bodily sensations.
Tachycardia:
Rapid heartbeat (generally more than 100 beats per minute).
Therapeutic dosage:
The amount of a drug required to produce a beneficial effect.
Triage:
Process by which patients are assessed to determine the type of services and level of care they will require.
Up-regulation:
An increase in the number of receptors on the brain cells that is caused by continuous contact with drugs.
The following organizations and agencies provide information and materials that may be useful to staff and clients of alcohol and other drug abuse detoxification programs.
The American Society of Addiction Medicine (ASAM) is an association of physicians dedicated to improving the treatment of alcoholism and other addictions, educating physicians and medical students, promoting research and prevention, and enlightening the medical community and the public about these issues. ASAM has chapters in 22 States.
ASAM publishes a quarterly medical journal, the Journal of Addictive Disease; a bimonthly newsletter, ASAM News, and practice guidelines such as the ASAM Patient Placement Criteria. It also provides continuing medical education opportunities, including the National Conference on Nicotine Dependence, and the Annual Medical-Scientific Conference. ASAM administers a national certification examination for physicians.
The Center for Substance Abuse Prevention (CSAP) is part of the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services. Until 1992, CSAP was known as the Office for Substance Abuse Prevention, or OSAP.
CSAP's National Clearinghouse for Alcohol and Drug Information (NCADI) distributes printed and audiovisual materials. NCADI coordinates the Regional Alcohol and Drug Awareness Network (RADAR), which facilitates access to State and local sources of information about alcohol, tobacco, and other drugs.
CSAP's Resource Center of Substance Abuse Prevention and Disability answers questions about alcohol, tobacco, and other drug abuse prevention and treatment issues for persons with disabilities. Services include customized database searches and fact sheets; phone: (202) 783-2900; TTY/TDD: (202) 737-0725.
CSAP's Drug-Free Workplace Helpline provides telephone consultation, resource referrals, networking services, and publications to business, industry, and unions to assist in planning and implementing drug-free workplace programs; phone: (800) 843-4971.
The CSAP Training System provides training for community prevention workers, health professionals, volunteers, and others; phone: (301) 572-0200.
The Center for Substance Abuse Treatment (CSAT) is part of the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services. Until 1992, CSAT was known as the Office for Treatment Improvement, or OTI; phone (English): (800) 662-4357; phone (Spanish): (800) 662-9832.
CSAT and the National Institute on Drug Abuse operate a Drug Abuse Information and Treatment Referral Line that provides information about drug use, treatment, support groups, and services. Information counselors can discuss problems and provide referrals to State and local drug treatment facilities and programs.
The Department of Housing and Urban Development (HUD) Office for Drug-Free Neighborhoods offers a helpline that provides information on preventing drug abuse and drug trafficking in public and assisted housing.
The Drug Enforcement Administration or DEA provides information about drug regulations.
The Food and Drug Administration (FDA) provides information on Federal regulations concerning use of methadone.
The purpose of the National Acupuncture Detoxification Association (NADA) is to provide training and consultation in the use of acupuncture as an adjunct to AOD treatment. NADA training includes didactic work as well as an apprenticeship program.
NADA sponsors annual educational conferences in the United States and Europe. Full membership in NADA is open only to persons who have completed the training program; however, associate members also are welcome.
Distributes written materials, videotapes, and audiotapes.
Guide points: Acupuncture in Recovery is a monthly independent international newsletter offering objective reporting on research, clinical practice, public policy, and clinical matters related to the use of acupuncture in treating addictive and mental disorders. Not affiliated with any advocacy group. Subscriptions cost $180 per year. Reduced rates are available for new subscribers.
Operated by the Centers for Disease Control and Prevention (CDC), the National AIDS Clearinghouse is a central source of information on acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus infection, including information on the relationship between alcohol and other drug (AOD) abuse and AIDS. Staff have access to educational materials and databases of materials, service organizations, funding sources, and conferences.
The National Institute on Drug Abuse (NIDA) is part of the National Institutes of Health of the U.S. Department of Health and Human Services. A catalog of training materials in AOD abuse, AIDS, and related areas is available from NIDA's Community and Professional Education Branch.
AA
Alcoholics Anonymous
AIDS
acquired immunodeficiency syndrome
AMSAODD
American Medical Society on Alcoholism and Other Drug Dependencies (now the American Society of Addiction Medicine [ASAM])
AOD
alcohol and other drug
APA
American Psychiatric Association
ASAM
American Society of Addiction Medicine
ASI
Addiction Severity Index
AZT
azidothymidine
CARF
Commission on Accreditation of Rehabilitation Facilities
CDC
Centers for Disease Control and Prevention
CDRH
chemical dependency recovery hospital
CFR
Code of Federal Regulations
CNS
central nervous system
CSAP
Center for Substance Abuse Prevention
CSAT
Center for Substance Abuse Treatment
DEA
Drug Enforcement Administration
DHHS
Department of Health and Human Services
DSM-III-R
Diagnostic and Statistical Manual of Mental Disorders, edition 3, revised. Superseded in 1994 by DSM-IV-R.
DTs
delirium tremens
FDA
Food and Drug Administration
FR
Federal Register
GC/MS
gas chromatography/mass spectrometry
HBV
hepatitis B virus
HCFA
Health Care Financing Administration
HCV
hepatitis C virus
HIV
human immunodeficiency virus
HUD
Department of Housing and Urban Development
ICD-9
International Classification of Diseases, ninth revision
IND
investigational new drug
IV
intravenous
JCAHO
Joint Commission on Accreditation of Healthcare Organizations
LAAM
levo-alpha-acetylmethadol
NA
Narcotics Anonymous
NAPAN
National Association for the Prevention of Addiction to Narcotics
NCA
National Council on Alcoholism (now the National Council on Alcoholism and Drug Dependency [NCADD])
NCADD
National Council on Alcoholism and Drug Dependency
NIDA
National Institute on Drug Abuse
NIMH
National Institute on Mental Health
ONDCP
Office of National Drug Control Policy
OSHA
Office of Safety and Health Administration
PPD
purified protein derivative
RIA
radioimmunoassay
SAMHSA
Substance Abuse and Mental Health Services Administration
SMA
State Methadone Authority
SSA
single State agency
STD
sexually transmitted disease
TB
tuberculosis
TLC
thin-layer chromatography
A host of legal and ethical issues affect the operation of alcohol and other drug (AOD) detoxification programs. Some have to do with consent to treat. For example, staff members often deal with patients who are inebriated or intoxicated. How can they obtain a consent to enter detoxification treatment from such individuals? Are there special consent issues when the patient is a minor?
The staff of detoxification programs are also concerned about the standards of treatment that will apply, especially as managed care becomes more commonplace. Will the staff be held liable for any decisions of a managed care entity that result in harm to a patient? If an insurance carrier decides it will not cover an additional day of detoxification treatment when the program believes an additional day is necessary, what should staff members do?
In some States, detoxification programs treat patients who have been brought in involuntarily by the police or committed to treatment by the court system. What are the legal responsibilities of staff in such cases? Prisons and jails sometimes maintain detoxification units. Do special standards apply to the professionals practicing in such facilities?
Other legal and ethical issues arise during the daily operation of detoxification programs. Some programs use medications, including scheduled drugs, to help ease the detoxification process. What laws should staff be aware of with regard to the use of these medications? How should staff handle drugs that patients bring into the program when they are admitted?
Finally, additional issues arise because of the Federal laws and regulations guaranteeing confidentiality of information about patients. How can a detoxification program and the diverse agencies responsible for the patient's welfare communicate without violating these rules? How should a program, for example, gather information from other (collateral) sources, such as relatives, employers, criminal justice agencies, schools, or medical personnel? May a program contact a parent of a minor patient without the minor's consent? May a program communicate with an employer who has referred a patient to treatment? What should a program do if a patient does not want to disclose his or her treatment to an insurance carrier? Are there special rules about sharing information with criminal justice agencies? If the patient is threatening harm to him- or herself or another, may the program call the authorities? How can programs handle intoxicated patients who decide not to enter detoxification and insist on driving home? May programs call the police if a patient becomes violent? Should they report suspected child abuse or neglect?
This chapter attempts to answer these and other questions. It is divided into five sections:
The answers to many of the questions addressed in this chapter are governed by State rather than Federal laws, and the laws vary from State to State. Consequently, while this chapter offers general advice concerning management of a patient who is too intoxicated to give informed consent, program staff who are faced with this situation should consult with a local attorney who is familiar with this area and the related issue of confidentiality. In some States, the law is still developing. As an example, a program's duty to warn of a patient's threat to harm others is constantly changing as State courts consider current cases. Programs dealing with this and other issues need up-to-the-minute legal counsel.
Adults generally have the right to consent to or to refuse treatment -- a right that is grounded in State law, judicial decision, and the United States Constitution. The right to consent to or refuse treatment -- in other words, to make an informed choice --is normally based upon a process: The treatment provider presents the patient with a diagnosis, a prognosis, a description of available alternative treatments and their risks and benefits, and a prediction of the likely outcome if there is no treatment. This process requires that the patient have the ability, sometimes called "decisional capacity," to make an informed choice.
Detoxification programs, perhaps more than any other kind of AOD abuse treatment program, deal with patients whose capacity to make rational decisions may be impaired. Persons who are intoxicated often demonstrate diminished mental capacity. Individuals who are incapacitated by AODs may be unconscious, or their judgment may be so impaired that they are incapable of making a rational decision about their basic needs, including their need for treatment. How can detoxification programs secure consent when the patient's decisional capacity is diminished?
Staff should assess each patient in order to determine whether he or she is able to give informed consent. If a patient is not able to do so because he or she is intoxicated or incapacitated by AOD use, the program should obtain consent as soon as the patient has regained his or her faculties. In the meantime, the program may obtain consent to treat from a relative or parent, if the patient is accompanied to the program. (In obtaining consent, the program must be aware of the Federal confidentiality laws, as described later in this chapter.) The validity of a third party's consent may depend on State law.
Many States have passed laws permitting minors to consent to AOD abuse treatment without parental involvement. Program staff should become familiar with the laws in their State, by consulting either with their single State agency (SSA) or an attorney familiar with the law in this area. 2
In those States that require parental consent for treatment, programs must be aware that the Federal confidentiality regulations require them to obtain a minor's consent before they contact the minor's parent (42 C.F.R. '2.14). 3 Thus, if a minor seeks treatment but refuses to authorize the program to speak to his or her parent, the program may inform the minor that it cannot provide services unless he or she consents to have the program contact the parent.
The Federal regulations do contain one exception. A program director may communicate with a minor's parents without his or her consent provided that
If these two conditions do not exist, the program must explain to the minor that, while he or she has the right to refuse to consent to any communication with a parent, the program can provide no services without such communication and parental consent, §2.14(d). Section 2.14(d) applies only to applicants for services. It does not apply to minors who are already patients; their consent to communicate with their parents is always required, as explained below.
Although programs in those States that permit minors to consent to treatment do not need to be concerned about whether they may provide services, they may still have to confront the fact that, in the absence of parental consent, it may be impossible to secure payment for these services. In States where parental consent is not required for treatment, the Federal regulations permit a program to withhold services if the minor will not authorize a disclosure that the program needs in order to obtain financial reimbursement for that minor's treatment. Such a practice, however, may abridge State or local law.
The staff members of AOD detoxification programs expect the care they provide their patients to come under the scrutiny of licensing or accrediting agencies, peer review organizations, and patient advocacy groups. With the advent of managed care, treatment providers are finding themselves under the scrutiny of a fourth group: third-party payers, who are interested not only in quality of care but also in cost containment.
Oversight by a managed care entity may be most problematic in cases where that entity disagrees with the detoxification program's judgment that a patient needs another day in the program and informs the program that it will not pay for such care. One option is for staff to explain the problem to the patient and try to obtain his or her agreement to pay for the additional day of treatment. 4 In many cases, the patient will be unable to do so. A second option is to try to arrange to have the patient admitted to a publicly funded program. A third option is to discharge the patient.
From a legal standpoint, if public care is unavailable and the patient cannot pay, programs should probably continue to treat the patient. The law in this area is unsettled. If the program discharges a patient against the judgment of its staff and the patient's outcome is adversely affected, the patient can sue the program for malpractice. This is an unfortunate situation, even if the program wins or convinces the court to place responsibility where it belongs -- on the managed care entity. Programs should also be aware that it is possible to get third-party payers to change a negative decision. Should this need arise, consultation with an attorney who can help them advocate for the patient is helpful.
In some States, detoxification programs handle patients who are brought in by the police or by relatives or who are "involuntarily committed" to treatment by the courts. (Involuntary commitment is also known as "protective custody" and "emergency commitment.") States that place the duty to accept involuntary patients on programs often grant them immunity from criminal and civil liability. Such immunity, however, does not protect a program against a malpractice claim.
Jail or prison inmates are another group of involuntary patients. Persons who are incarcerated are entitled to adequate medical care and can sue a provider for malpractice or negligence. 5Thus, involuntary patients are entitled to care that generally meets professional standards. Professionals who manage programs in prisons or jails or whose programs accept involuntary patients should stay abreast of standards in this area that have been developed by professional organizations and government agencies.
Programs often use medications, including some scheduled drugs, to help patients through the detoxification process. Program staff must be aware of Federal and State laws and regulations governing the dispensing, storage, and inventory of all medications. These laws and regulations often require that medications be dispensed by certain classes of professionals. Separate provisions often govern the storage, prescription, and dispensing of scheduled drugs. Programs may inquire about such regulations from their SSAs and State departments of health, the Federal Drug Enforcement Administration, or the Federal Food and Drug Administration.
Patients sometimes enter AOD detoxification with drugs on their person or in their luggage. Staff may wish to search all newly admitted patients and the belongings they bring with them. The safest approach is to tell the patient at admission that this is a standard part of the process and that he or she must agree to the search in order to enter detoxification. The program also may incorporate this notice in its admission papers, thereby ensuring that the patient agrees to it in writing.
If a staff member finds drugs on a patient or in a patient's luggage, what should the program do? State regulations sometimes govern how a program may dispose of drugs. They may require, for example, that the drugs be flushed down the toilet, destroyed, or turned over to the police. 6 (The Federal confidentiality laws and regulations, however, prohibit programs from turning patients who are in possession of drugs over to the police.) If a program does destroy drugs brought into treatment by patients, it is advisable for staff members responsible for such destruction to carry it out under observation and maintain a record of the act, so that a patient cannot later make a false accusation about what occurred. State regulations also govern the methods for handling prescription and over-the-counter medications that patients bring into treatment. Programs should check with their SSA for further guidance about State mandates.
Although programs cannot turn patients with illegal drugs over to the police, no such restrictions apply to visitors who enter the program facility with drugs. As long as no disclosure is made about a patient, such persons may be reported to the police. A program that plans to search visitors for drugs must obtain their consent, although it may make visiting privileges contingent on consent to search. The use of force should be avoided, as a visitor could sue the program for battery or false imprisonment.
Two Federal laws (42 U.S.C. ''290dd-2 (1992) and a set of Federal regulations (C.F.R. Part 2) guarantee the strict confidentiality of information about all persons receiving AOD abuse prevention and treatment services. 7 They are designed to protect privacy rights and thereby attract individuals into treatment. The regulations are more restrictive of communications than are those governing the doctor-patient relationship or the attorney-client privilege. Violating the regulations is punishable by a fine of up to $500 for a first offense or up to $5,000 for each subsequent offense ('2.4).
Although some persons may view the restrictions that Federal regulations place on communications as a hindrance, if not a barrier, to program goals, due foresight can eliminate most of the problems that arise from the regulations. Familiarity with the regulations will facilitate communication and minimize the incidence of confidentiality-related conflicts among program, patient, and outside agency.
Any program that specializes, in whole or in part, in providing detoxification, treatment, counseling and assessment, and referral services, or a combination thereof, for patients with alcohol or other drug problems must comply with the Federal confidentiality regulations, '2.12(e). It is the kind of services provided, not the label, that determines whether a program must comply with the Federal law. Calling itself a "prevention program" does not insulate a program that also offers treatment services from the need to comply with confidentiality regulations. Although the Federal regulations apply only to programs that receive Federal assistance, the word "assistance" is broadly interpreted and includes indirect forms of Federal aid such as tax-exempt status or State or local funding that is derived, in whole or in part, from the Federal Government.
The Federal confidentiality laws and regulations protect any information about a patient if the patient has applied for or received any alcohol- or drug-abuse-related services -- including assessment, diagnosis, detoxification, counseling, group counseling, treatment, and referral for treatment -- from a covered program. The restrictions on disclosure apply to any information that would identify the patient as an AOD abuser, either directly or by implication. The rule applies from the moment the patient makes an appointment. It applies to patients who are civilly or involuntarily committed, minor patients, patients who are mandated into treatment by the criminal justice system, and former patients. Finally, the rule applies whether or not the person making the inquiry already has the information, has other ways of getting it, enjoys official status, is authorized by State law, or comes armed with a subpoena or search warrant. 8
Information that is protected by the Federal confidentiality regulations may always be disclosed after the patient has signed a proper consent form. (As explained earlier in this chapter, if the patient is a minor, parental consent must also be obtained in some States.) The regulations also permit disclosure without the patient's consent in several situations, including communicating information to medical personnel during a medical emergency or reporting child abuse to the authorities.
The most commonly used exception to the general rule prohibiting disclosures is for a program to obtain the patient's consent. The regulations' requirements regarding consent are somewhat unusual and strict and must be carefully followed.
Disclosures are permissible if a patient has signed a valid consent form that has not expired or been revoked ('2.31). 9 According to this section, a proper consent form must be in writing and must contain each of the items that appear in Exhibit E-1.
A general medical release form, or any consent form that does not contain all of the elements listed above, is not acceptable. A sample consent form may be found in Exhibit E-2. The following required items merit further explanation:
These two items are closely related. All disclosures, especially those made pursuant to a consent form, must be limited to information that is necessary to accomplish the need for or purpose of the disclosure, '2.13(a). It would be improper to disclose everything in a patient's file if the person making the request needed only one specific piece of information.
In completing a consent form, one must determine the purpose of or need for the communication of information. Once this has been identified, it is easier to determine how much and what kind of information will be disclosed and to restrict the disclosure to what is essential to accomplish the identified need or purpose. As an illustration, if a patient needs to have the fact that he or she has entered a detoxification program verified in order to be eligible for a benefit program, the purpose of the disclosure would be "to verify treatment status," and the amount and kind of information to be disclosed would be "enrollment in treatment." The disclosure would then be limited to a statement that "Jane Doe [the patient] is receiving counseling at XYZ Program."
The patient may revoke consent at any time, and the consent form must include a statement to this effect. Revocation need not be in writing. If a program has made a disclosure prior to the revocation, the program has "acted in reliance" on the consent and is not required to try to retrieve the information it has already disclosed.
The regulations state that acting in reliance includes providing services in reliance on a consent form permitting disclosures to a third-party payer. Thus, a program may bill the third-party payer for past services to the patient even after consent has been revoked. A program may not, however, make any disclosure to the third-party payer in order to receive reimbursement for services provided after the patient has revoked consent '2.31(a)(8).
The form must also contain a date, an event, or a condition on which it will expire, if not previously revoked. A consent must last "no longer than reasonably necessary to serve the purpose for which it is given," '2.31(a)(9). If the purpose of the disclosure is expected to be accomplished in 5 or 10 days, it is better to stipulate that amount of time rather than to request a longer period or have a uniform 60- or 90-day expiration date for all forms.
The consent form may specify an event or a condition for expiration, rather than a date. For example, if a patient has been placed on probation at work on the condition that he or she attend the detoxification program, the consent form should not expire until the expected time of completion of the probationary period. Alternatively, if a patient is being referred by the program to a specialist for a single appointment, the consent form should provide that it will expire after he or she has seen "Dr. X," unless the patient is expected to need ongoing consultation with the specialist.
In order for a program to release information about a minor, even to his or her parent or guardian, the minor must have signed a consent form. The program must obtain the parent's signature only if it was required by State law to obtain parental permission before providing treatment to the minor ('2.14). ("Parent" includes parent, guardian, or other person legally responsible for the minor.) In other words, if State law does not require the program to get parental consent in order to provide services to a minor, parental consent is not required to make disclosures, '2.14(b). If, by contrast, State law requires parental consent to provide services to minors, parental consent also is required to make any disclosures. The program must always obtain the minor's consent for disclosures; it cannot rely on the parent's signature alone. The single limited exception to this rule has been discussed in Section I.A.2 above.
Once the consent form has been properly completed, one formal requirement remains. Any disclosure made with written patient consent must be accompanied by a written statement that the information disclosed is protected by Federal law and that the recipient may not make any further disclosure unless permitted by the regulations ('2.32). This statement, not the consent form itself, should be delivered and explained to the recipient at the time of disclosure or earlier.
The prohibition on redisclosure is clear and strict. Those who receive the notice are prohibited from rereleasing information except as permitted by the regulations. A patient may, of course, sign a consent form authorizing such a redisclosure. A sample Notice of Prohibition appears in Exhibit E-3.
The fact that a patient has signed a proper consent form authorizing the release of information does not force a program to make the proposed disclosure, unless the program has also received a subpoena or court order, ''2.3(b); 2.61(a)(b). The only obligation the program has is to refuse to honor a consent that is expired, deficient, or otherwise known to be revoked, false, or invalid, '2.31(c).
In most cases, the decision whether or not to make a disclosure pursuant to a consent form is within the discretion of the program, unless State law requires or prohibits disclosure once consent is given. In general, it is best to follow this rule: disclose only what is necessary, for only as long as is necessary, in light of the purpose of the communication.
Making inquiries of parents, other relatives, health care providers, employers, schools, or criminal justice agencies might seem at first glance to pose no risk to a patient's right to confidentiality, particularly if the person or entity approached for information referred the patient to treatment. Nonetheless, it does.
When a program that screens, assesses, or treats a patient asks a relative or parent, a doctor, an employer, or a school to verify information it has obtained from the patient, it is making a "patient-identifying disclosure." Patient-identifying information is information that identifies someone as an AOD abuser. In other words, when program staff seek information from other sources, they are letting these sources know that the patient has asked for detoxification services. The Federal regulations generally prohibit this kind of disclosure, unless the patient consents.
How should a program go about making such requests? The easiest way is to get the patient's consent to contact the relative, doctor, employer, school, or health care facility. When filling out the consent form, staff should give thought to the "purpose of the disclosure" and "how much and what kind of information is to be disclosed." For example, if a program is assessing a patient for treatment and seeks records from a mental health provider, the purpose of the disclosure would be "to obtain mental health treatment records to complete the assessment." The "kind of information disclosed" would be limited to a statement that "Robert Roe (the patient) is being assessed by the XYZ Program." No other information about Robert Roe would be released. If the program not only seeks records but also wishes to discuss with the mental health provider the treatment he or she provided the patient, the purpose of the disclosure would be "to discuss mental health treatment provided to Robert Roe by the mental health program." If the program merely seeks information, the kind of information disclosed would, as in the example above, be limited to a statement that "Robert Roe is being assessed by the XYZ Program;" however, if the program needs to disclose information it has gained in its assessment of Robert Roe to the mental health provider in order to further the discussion or coordinate care, the kind of information disclosed would be "assessment information about Robert Roe."
A program that routinely seeks collateral information from many sources could consider asking the patient to sign a consent form that permits it to make a disclosure for purposes of seeking information from collateral sources to any one of a number of entities or persons listed on the consent form. Such a form must still include "the name or title of the individual or the name of the organization" for each collateral source the program may contact.
Even when information is disclosed over the telephone, program staff are required to notify the recipient of the information of the prohibition on redisclosure. Mention should be made of this restriction during the conversation; for example, the staff member could say, "I'll be sending you a written statement that the information I gave you about Mr. Roe may not be redisclosed."
Communications with employers may warrant special consideration. When a patient enters treatment voluntarily, program staff should maintain an open mind about whether communications with an employer would be beneficial to the patient. A patient who tells program staff that his or her employer will not be sympathetic about the decision to enter treatment may well have an accurate picture of the employer's attitude. Should staff insist on communicating with the employer, the patient may lose his or her job. If such communication takes place without the patient's consent, the program may be faced with a lawsuit.
Programs must obtain a patient's written consent on the form required by the Federal regulations in order to communicate with any third-party payer who may be responsible for funding the patient's treatment. What should programs do in these circumstances?
The program clearly cannot make a disclosure to a third-party payer without the patient's consent. If the third-party payer is the patient's employer, the program would not only be violating the Federal regulations Some patients do not want their treatment reported to the insurer. Patients whose employers are self-insured may fear they will be fired, demoted, or disciplined, should their employer learn they have a substance abuse problem. 10Patients whose treatment is covered by health insurance may fear they will lose their benefits and be unable to obtain other coverage once their current insurer discovers they have been treated for a substance abuse problem. 11 but also would be risking a lawsuit, should the patient be fired or disciplined. If the third-party payer is an insurance company, the program is taking similar risks: If the patient's insurance is canceled or he or she cannot obtain coverage elsewhere, the program may face a lawsuit.
If a patient does not want the insurance carrier to be notified and is unable to pay for treatment, the program may refer the patient to a publicly funded program, if one is available. 12 Programs should consult State law to learn whether they may refuse to admit a patient who is unable to pay and who will not consent to the necessary disclosures to his or her insurance carrier.
Insurance carriers, particularly managed care entities, are demanding more and more information about the patients covered by their policies and the treatment provided to those patients. Programs need to be sensitive about the amount and kind of information they disclose, because the insurer may use this information to deny benefits to the patient. For example, if, in response to a request from the insurer, the program releases the patient's entire chart, the insurer may learn from the intake notes that the patient's substance abuse problem included both alcohol and illegal drugs. The insurer may then deny benefits, arguing that since its policy does not cover treatment for abuse of drugs other than alcohol, it will not reimburse for treatment when abuse of both alcohol and drugs is involved. As a second example, the insurer may learn that the patient began drinking at age 11 and deny benefits for a "preexisting condition." Treatment notes may contain personal information about the patient's family life that is extraneous for insurance company review, the sole purpose of which is to determine whether treatment should be covered and, if so, what kind.
Detoxification programs sometimes need to maintain ongoing communication with the referral source or with other professionals providing services to patients. The best way to proceed is to get the patient's consent.
In wording the consent form, one should take care to permit the kinds of communications necessary. For example, if the program will need ongoing communication with a mental health provider, the "purpose of the disclosure" would be "coordination of care for Mildred Moe;" "how much and what kind of information to be disclosed" might be "treatment status, treatment issues, progress in treatment." If the program is treating a patient who is on probation at work and whose continued employment is contingent on treatment, the "purpose of disclosure" might be "to assist the patient to comply with employer's mandates" or "supply periodic reports about treatment;" "how much and what kind of information will be disclosed" might be "progress in treatment." The kinds of information that would be disclosed in the two examples are quite different. The program might well share detailed clinical information about a patient with a mental health provider, if it would assist in coordinating care. Disclosure to an employer, by contrast, would generally be limited to a brief statement about the patient's progress in treatment. Disclosure of clinical information to an employer generally would be inappropriate.
The program should also be careful in setting the expiration date or event on which expiration of the consent form is based. A consent form with a mental health provider might expire when treatment ends, while a form permitting disclosures to an employer might expire when the patient's probationary period at work ends.
When a staff member of a detoxification program refers a patient to another treatment program and makes an appointment for the patient, he or she is making a disclosure covered by the Federal regulations -- a disclosure that the patient has sought or received detoxification services. A consent form is, therefore, required. If the detoxification program is part of a larger program to which the patient is being referred, a consent form may not be necessary under the Federal rules, since there is an exception for information disclosed to staff within the same program.
Detoxification programs, particularly those with limited medical resources, often must transfer patients to a hospital for intensive medical management and care. How should programs handle such transfers, since they involve a disclosure of patient-identifying information?
Programs may deal with this issue in two ways. First, they may ask all patients admitted to detoxification to sign a consent form permitting disclosure to the cooperating hospital, should hospitalization be required. Second, they may take advantage of a provision in the Federal regulations that permits a program to make disclosures in a "medical emergency" to medical personnel "who have a need for information about a patient for the purpose of treating a condition which poses an immediate threat to the health of any individual." The regulations define "medical emergency" as "a condition which poses an immediate threat to the health of any individual and which requires immediate medical intervention" ('2.51). If a patient's condition requires emergency treatment, the program may use this exception to communicate with medical personnel at a hospital. Whenever a disclosure is made to cope with a medical emergency, the program must document in the patient's records the name and affiliation of the recipient of the information, the name of the individual making the disclosure, the date and time of the disclosure, and the nature of the emergency.
All States require that new cases of acquired immunodeficiency syndrome be reported to public health authorities, which submit this information to the Federal Centers for Disease Control and Prevention. In some cases, they also use it for other purposes. Some States also require the reporting of new cases of human immunodeficiency virus infection. States also require reporting of certain infectious diseases, such as tuberculosis and sexually transmitted diseases. The public health authority often uses reports of infectious diseases to engage in "contact tracing," that is, finding others to whom an infected person may have spread the disease.
The types of information that must be reported and for which diseases, who must report, and the purposes to which the information is put vary from State to State. Therefore, program directors must examine their State laws to discover (1) whether they or any member of their staff is a mandated reporter, (2) when reporting is required, (3) what information must be reported and whether it includes patient-identifying information, and (4) what will be done with the information reported. 13
If State law permits the use of a code rather than a patient's name, the program may make the report without the patient's consent, since no patient-identifying information is being revealed.
If patient-identifying information must be reported, there are a number of ways programs can comply with State mandatory reporting laws without violating the Federal confidentiality regulations. They include the following:
As its name implies, '2.53 is intended to permit an outside entity, such as a peer review organization or an accounting firm, to examine or copy a program's records in order to determine whether it is operating in accordance with regulations. It was not intended to permit an outside entity to gain information to perform other tasks or accomplish other social ends. The legal validity of these two letters may, therefore, be considered debatable.
If someone telephones a patient at a detoxification program, the staff may not reveal that the patient is at the program unless the program has a written consent form signed by a patient to make a disclosure to that particular caller. Given this restriction, how should a program handle telephone calls to patients? There are at least four options:
Detoxification programs treating patients who are required to enter and participate in treatment as part of a criminal justice sanction must follow the Federal confidentiality rules. In addition, some special rules apply when a patient is in treatment as an official condition of probation, sentence, dismissal of charges, release from detention, or other disposition of any criminal proceeding, and information is being disclosed to the mandating agency.
A consent form or court order is still required before any disclosure may be made about an offender who is mandated into assessment or treatment. However, the rules concerning the length of time that a consent remains valid are different, and a "criminal justice system consent" may not be revoked before its expiration event or date.
The regulations require that the following factors be considered in determining how long a criminal justice system consent will remain in effect:
These rules allow programs to continue to use a traditional expiration condition for a consent form that once was the only one allowed, namely, "when there is a substantial change in the patient's criminal justice system status." A substantial change in status occurs whenever the patient moves from one phase of the criminal justice system to the next. For example, if a patient is on probation or parole, a change in criminal justice status would occur when the probation or parole ended, either by successful completion or revocation. Thus, the program could provide treatment or periodic reports to the probation or parole officer monitoring the patient and could even testify at a revocation hearing if it so desired, since no change in criminal justice status would occur until after that hearing. This formula appears to work well.
Concerning revocability of the consent (i.e., the conditions under which the offender can take back his or her consent), the regulations provide that the form may state that consent may not be revoked until a specified date arrives or condition occurs. The regulations permit the criminal justice system consent form to be irrevocable, so that a patient who has agreed to enter treatment in lieu of prosecution or punishment cannot later prevent the court, probation department, or other agency from monitoring his or her progress. Although a criminal justice system consent may be made irrevocable for a specified period of time, its irrevocability must end no later than the final disposition of the criminal proceeding. Thereafter, the patient may freely revoke consent.
Several other considerations relating to criminal justice system referrals are important. First, any information received by one of the eligible criminal justice agencies from a treatment program may be used by that justice agency only in connection with its official duties with respect to that particular criminal proceeding. The information may not be used in other proceedings, for other purposes, or with respect to other individuals, '2.34(d). Second, whenever possible, the judge or referring agency should require that a proper criminal justice system consent form be signed by the patient at the time he or she is referred to the treatment program. If this is not possible, the treatment program should have the patient sign a criminal justice system consent form at his or her first appointment. With a properly signed criminal justice consent form, the detoxification program can communicate with the referring criminal justice agency, even if the patient appears for assessment or treatment only once. This avoids the problems that may arise if a patient mandated into treatment does not sign a proper consent form and leaves before the assessment or treatment has been completed.
If a program fails to have the patient sign a criminal justice system form and the patient fails to complete the assessment or treatment, the program has few options when faced with a request for information from the referring criminal justice agency. The program could attempt to locate the patient and ask him or her to sign a consent form. The patient is, however, unlikely to do so. It is uncertain whether a court can issue an order to authorize the program to release information about a referred patient who has left the program in this type of case, because the regulations allow a court to order disclosure of treatment information for the purpose of investigating or prosecuting a patient for a crime only when the crime was "extremely serious." A parole or probation violation generally will not meet that criterion.
Therefore, unless the judge, criminal justice agency, or program obtains consent at the beginning of the assessment or treatment process, the program may be prevented from providing any information to the referring criminal justice agency.
If a patient referred by a criminal justice agency never applies for or receives services from the program, that fact may be communicated to the referring agency without patient consent, '2.13(c)(2). As soon as a patient has made an appointment to visit the program, a signed consent form or a court order is needed for any disclosures.
For most treatment professionals, the decision whether to report a patient's threat to commit a crime is a troubling one. Many professionals believe that they have an ethical, professional, or moral obligation to prevent a crime when they are in a position to do so, particularly if the crime is a serious one. Although these issues may not arise often, programs may face questions about their "duty to warn" someone of a patient's threatened suicide, a patient's threat to harm another, or a patient's insistence on driving while impaired.
There is a developing trend in the law to require therapists who have learned that a patient presents a "serious danger of violence to another" to take "reasonable steps" to protect an intended victim. This trend started with the case of Tarasoff v. Regents of the Univ. of Cal., 17 Cal.3d 425 (1976), in which the California Supreme Court held a psychologist liable for monetary damages because he failed to warn a potential victim his patient threatened to, and then did, kill. The court ruled that if a psychologist knows that a patient poses a serious risk of violence to a particular person, the psychologist has a duty "to warn the intended victim or others likely to apprise the victim of the danger, to notify the police, or to take whatever other steps are reasonably necessary under the circumstances."
While strictly speaking the Tarasoff ruling applies only in California, courts in a number of other States have followed it in finding therapists and others liable for damages when they failed to warn a potential victim of threats disclosed during therapy by their patients. Most of these cases are limited to situations where patients threaten a specific victim; they do not generally apply where a patient makes a threat without identifying the intended target. States that have enacted laws on the subject have similarly limited the duty to warn to situations in which the identity of the potential victim has been revealed.
Faced with a potential "duty to warn" question, program staff must answer two, or sometimes three, questions:
The first question may be answered only by an attorney familiar with the law in the State in which the program operates. If the answer is "no," it is advisable to discuss the second question with a knowledgeable lawyer as well.
There is an apparent conflict between the Federal confidentiality requirements and the duty to warn imposed by States that have adopted the principles of the Tarasoff case. Simply put, the Federal confidentiality law and regulations prohibit a program from making the type of disclosure that Tarasoff and similar cases require, 15 unless it can do so by using one of the regulation's narrow exceptions.
When a patient threatens harm to self or another, a program has four options:
If none of these options is practical, what should a program do? It is, after all, confronted with conflicting moral and legal obligations. If a program believes there is clear and imminent danger to a patient or another person, it is probably prudent to report the danger to the authorities or the threatened individual. This is especially true in States that already follow the Tarasoff rule. While each case presents different questions, it is doubtful that any prosecution (or successful civil lawsuit) under the confidentiality regulations would be brought against a program or counselor who warned about potential violence when he or she believed in good faith that there was real danger to a particular individual. On the other hand, a civil lawsuit for failure to warn might well result if a threat were actually carried out. In any event, the program should try to make the warning in a manner that does not identify the individual as an AOD abuser.
As in other areas where the law is developing, programs should find a lawyer familiar with State law who can provide advice on a case-by-case basis. "Duty to warn" issues also present an area in which staff training, as well as a staff review process, may be helpful.
Suppose that an intoxicated patient arrives at a detoxification program but decides not to enter treatment. If the patient is not in condition to drive home, what should the program do? First, it can offer the patient a ride home or taxi fare for a ride home. Second, it can maintain a room where such a person can "sleep it off." (The program would be wise to obtain the person's consent to alert his or her family.) This strategy can also be used by detoxification programs that do not admit patients who are inebriated.
What if the patient refuses both offers and leaves the premises, intending to drive home? Does the program have a duty to call the police to prevent an accident? Does it risk a lawsuit if it fails to do so? This is a question of State law.
In most States, it is unlikely that the program would be liable, particularly if it had made an effort to stop the patient from driving. As noted above, in States that follow the Tarasoff doctrine, liability has generally been limited to those situations where a patient threatens to harm a specific person. Liability has generally not been imposed in situations where a patient poses a threat to the community in general.
Liability concerns aside, the program may nonetheless believe it is obligated to call the police if its attempts to prevent the patient from driving fail. In doing so, it must take care not to violate the patient's confidentiality. For example, the program can call the police and tell them that the driver of a 1991 tan Nissan with a license number "XYZ 123," who is heading downtown from the intersection of Maple and Third streets, is not in a condition to operate a vehicle. The program should ask the police to respond immediately. The program may not tell the police that the patient has a substance abuse problem. This means it may not tell the police that the patient is impaired by alcohol or drugs and cannot reveal the program's name, since to do so would tell the police that the patient has a substance abuse problem.
In order to get the patient's license number and a description of his or her car, it may be necessary to detain the patient. If it does so, the program should avoid using force, since the patient could sue the program for battery or false imprisonment.
Programs sometimes unknowingly admit patients who are sought by the police. If the police discover that someone they are seeking is at the program and come armed with an arrest warrant, what should the program do? How should programs handle search warrants? The answers to these questions are quite different.
An arrest warrant gives police the authority to search the program facilities; however, the program is not authorized to help the police by pointing out the offender. 17The unfortunate result is that the confidentiality of all patients in the program may be compromised when the police enter and search for a fugitive. There is no solution to this problem, unless the police secure a court order under '2.66, which would authorize the program to disclose the identity of the patient. If the program cannot convince the police to obtain a court order, it can try to convince the patient to surrender voluntarily. (Voluntary surrender by a patient is a disclosure by the patient, not the program.) It is usually in the patient's best interest to surrender voluntarily, since arrest is probably inevitable and cooperation may positively influence the prosecutor and judge when the question of bail arises. The risk is that the patient will attempt to escape, which might expose the program to a charge of assisting unlawful escape. To reduce this possibility, the program should work with the police so that law enforcement personnel have secured the area around the program.
A search warrant does not authorize the program to permit the police to enter the premises. Even if signed by a judge, a search warrant is not the kind of "court order" that the Federal regulations require before the program can allow anyone to enter and see patients or patient records when patients have not consented. Law enforcement officials are unlikely to know about the restrictions of the Federal regulations, however, and they will probably believe that a search warrant permits them to enter and search the program. What should a program do?
Presented with a search warrant, program staff should show the officer a copy of the Federal regulations and explain their restrictions. Staff can suggest that the officer obtain a court order that will authorize the program to make the disclosure called for in the search warrant. No harm will ordinarily be caused by resultant delay (although the police may not agree with this view). The program should call its lawyer and let him or her talk with the police. Failing that, a program could try to call the prosecutor who has sent the police, explain the regulations, and point out that any evidence seized without the proper court order may be excluded at trial, since it will have been seized illegally.
If none of these steps works, the program must permit the police to enter. Refusal to obey a direct order of the police may be a crime, even if the police are wrong, and forcible resistance would be unwise. If the program has made a good faith effort to convince the law enforcement authorities to pursue the proper route, it is unlikely that it would be held liable for allowing entry when argument fails.
Programs should develop protocols for dealing with arrest and search warrants and have a copy of the Federal regulations available at all times to show law enforcement officials. Programs should establish a relationship with an attorney who can be called upon to help in these situations. Finally, programs should reach out to law enforcement agencies before a crisis arises and work with them to develop ways of dealing with these issues. If the regulations are explained when there is no emergency and there can be no suspicion that the program is hiding anyone or anything, and a protocol is established, unpleasant confrontations may be avoided.
What should a program do when, for example, a patient tells a counselor that she intends to get her children some new clothes by shoplifting -- a crime the counselor knows she has committed many times in the past? Does the program have a duty to tell the police? Does a program have a responsibility to call the police when a patient discloses to a counselor that he or she participated in a serious crime some time in the past? What can a program do when a patient commits a crime at the program or against an employee of the program? Each of these questions requires separate analysis.
A program generally does not have a duty to warn another person or the police about a patient's intended actions, unless the patient presents a serious danger of violence to an identifiable individual. In the example above, shoplifting rarely involves violence, and it is unlikely that the counselor will know which stores are to be victimized. Petty crimes like shoplifting are important issues, but they should be dealt with therapeutically. They are not something a program should necessarily report to the police.
Suppose that a patient admits during a counseling session that he killed someone during a robbery 3 months ago. Does the program have a responsibility to report that?
In a situation where a program thinks it might have to report a past crime, three questions must be answered:
·
Because of the complicated nature of this issue, any program considering reporting a patient's admission of criminal activity should seek the advice of a lawyer familiar with local law as well as the Federal regulations.
When a patient has committed or threatens to commit a crime on program premises or against program personnel, the regulations are more straightforward. They permit the program to report the crime to a law enforcement agency or to seek its assistance. Without any special authorization, the program can disclose the circumstances of the incident, including the suspect's name, address, last known whereabouts, and status as a patient at the program, §2.12(c)(5).
All 50 States have statutes requiring reporting when there is reasonable cause to believe or suspect child abuse or neglect. While many State statutes are similar, each has different rules about what kinds of conditions must be reported, who must report and when, and how reports must be made.
Most States now require not only physicians but also educators and social service workers to report child abuse. Most States require an immediate oral report, and many have toll-free numbers to facilitate reporting. Half of the States require both oral and written reports. All States extend immunity from prosecution to persons reporting child abuse and neglect. Most States provide for penalties for failure to report.
Because of the variations in State laws, programs should consult these documents to ensure that their reporting practices are in compliance. Since many State statutes require that staff report instances of abuse to administrators, who are then required to make an official report, programs concerned about this issue should establish reporting protocols under which staff may bring incidents of suspected child abuse to the attention of program administrators, who must then shoulder the responsibility to make the mandated reports.
The Federal confidentiality regulations permit programs to comply with State laws that require the reporting of child abuse and neglect. This exception to the general rule prohibiting disclosure of any information about a patient, however, applies only to initial reports of child abuse or neglect. Unless the patient consents or the appropriate court issues a special court order, programs may not respond to followup requests for information, or even to subpoenas, even if the records are sought for use in civil or criminal proceedings resulting from the program's initial report.
Research about and evaluation of the efficacy of different methods of detoxification are essential if advances in treatment are to be made. But can detoxification programs share patient-identifying information with researchers and program evaluators? The confidentiality regulations do permit programs to disclose patient-identifying information to researchers, auditors, and evaluators without patient consent, providing certain safeguards are met (§§2.52, 2.53).
Detoxification programs may disclose patient-identifying information to persons conducting "scientific research" if the program director determines that the researcher (1) is qualified to conduct the research, (2) has a protocol under which patient-identifying information will be kept in accordance with the regulations' security provisions (see §2.16, as described below), and (3) has provided a written statement from a group of three or more independent individuals who have reviewed the protocol and determined that it protects patients' rights. Researchers are prohibited from identifying an individual patient in any report or from otherwise disclosing any patient identities, except back to the program. 18
Federal, State, and local government agencies that fund or are authorized to regulate a program, private entities that fund or provide third-party payments to a program, and peer review entities performing a utilization or quality control review may review patient records on the program premises in order to conduct an audit or evaluation. 19 Any person or entity that reviews patient records to perform an audit or conduct an evaluation must agree in writing that it will use the information only to carry out the audit or evaluation and that it will redisclose patient information only (1) back to the program, (2) in accordance with a court order to investigate or prosecute the program (§2.66), or (3) to a Government agency overseeing a Medicare or Medicaid audit or evaluation, §2.53(a), (c), (d). Any other person or entity that is determined by the program director to be qualified to conduct an audit or evaluation and that agrees in writing to abide by the restrictions on redisclosure also may review patient records.
Research that follows patients for any period of time after they leave treatment presents a special challenge under the Federal regulations. The detoxification program, researcher, or evaluator who seeks to contact former patients to gain information about how they are faring after leaving treatment must do so without disclosing to others any information about their connection to the detoxification program. If followup contact is attempted by telephone, the caller must make sure he or she is talking to the patient before identifying himself or herself or mentioning a connection to the detoxification program. For example, asking for "Willy Woe," when his wife or child has answered the phone, and announcing that one is calling from the "ABC Detoxification Program" (or the "Drug Research Corporation") violates the regulations. The program or research agency may form another entity, without a hint of detoxification (or drugs or alcohol) in its name (e.g., Health Research, Inc.) that can contact former patients without worrying about disclosing information simply by giving its name. When a representative of such an entity calls former patients, however, care must be taken that the patient is actually on the line before revealing any connection with the detoxification program.
If followup is done by mail, the return address should not disclose any information that could lead someone seeing the envelope to conclude that the addressee had been in treatment.
Reference has been made to other exceptions the Federal confidentiality rules make to the general rule prohibiting disclosure. Presented below are five additional categories of exceptions to the general rule.
The Federal regulations permit programs to disclose information about a patient if the program reveals no patient-identifying information. Thus, a program may disclose information about a patient if that information does not identify the patient as an AOD abuser or does not verify anyone else's identification of the patient as an AOD abuser.
A program may make a disclosure that does not identify a patient in two ways. First, it may report aggregate data that give an overview of the patients served in the program or some portion of its population. For example, a program could tell the newspaper that in the last 6 months it had 43 patients, 10 female and 33 male. Second, a program may communicate information about a patient in a way that does not reveal the patient's status as a drug or alcohol abuse patient, §2.12(a)(i). For example, a program that provides services to patients with other problems or illnesses as well as alcohol or drug addiction may disclose information about a particular patient as long as the fact that the patient has a substance abuse problem is not revealed. To cite a more specific example, a counselor from a program that is part of a general hospital could call the police about a threat a patient made, as long as he or she does not disclose that the patient has an alcohol or drug abuse problem or is a patient of the detoxification program.
Programs that provide only alcohol or drug services or that provide a full range of services but are identified by the general public as drug or alcohol programs cannot disclose information that identifies a patient under this exception, since letting someone know a counselor is calling from the "XYZ Detoxification Program" will automatically identify the patient as someone who got services from the program. However, a freestanding program may sometimes make "anonymous" disclosures, that is, disclosures that do not mention the name of the program or otherwise reveal the patient's status as an alcohol or drug abuser.
A State or Federal court may issue an authorizing order that will permit a program to make a disclosure about a patient that would otherwise be forbidden. A court may issue one of these orders, however, only after it follows certain special procedures and makes particular determinations required by the regulations. A subpoena, search warrant, or arrest warrant, even when signed by a judge, is not sufficient, standing alone, to require, or even to permit, a program to disclose information 20 (§2.61).
Before a court can issue an authorizing order, the program and any patient whose records are sought must be given notice of the application for the order and some opportunity to make an oral or a written statement to the court. 21 Generally, the application and any court order must use fictitious names for any known patient. All court proceedings in connection with the application must remain confidential, unless the patient requests otherwise, §_2.64(a), (b), 2.65, 2.66.
Before issuing an authorizing order, the court must find that there is "good cause" for the disclosure. A court may find "good cause" only if it determines that the public interest and the need for disclosure outweigh any adverse effect that the disclosure will have on the patient, the doctor-patient or counselor-patient relationship, and the effectiveness of the program's treatment services. Before it may issue an order, the court also must find that other ways of obtaining the information are unavailable or would be ineffective, §2.64(d). 22 The judge may examine the records before making a decision, §2.64(c).
There are also limits on the scope of disclosure that a court may authorize, even when it finds good cause. The disclosure must be limited to information essential to fulfill the purpose of the order and restricted to those persons who need the information for that purpose. The court also should take any other steps that are necessary to protect the patient's confidentiality, including sealing court records from public scrutiny, §2.64(e).
The court may order disclosure of "confidential communications" by a patient to the program only if the disclosure is necessary to protect against a threat to life or of serious bodily injury or to investigate or prosecute an extremely serious crime (including child abuse), or is in connection with a proceeding at which the patient has already presented evidence concerning confidential communications (§2.63).
A program may make disclosures to public or private medical personnel "who have a need for information about a patient for the purpose of treating a condition which poses an immediate threat to the health of any individual." The regulations define "medical emergency" as a situation that poses an immediate threat to health and requires immediate medical intervention (§2.51).
The medical emergency exception permits disclosure only to medical personnel. It cannot be used as the basis for a disclosure to the police or other nonmedical personnel, including parents. Under this exception, however, a program could notify a private physician about a suicidal patient so that medical intervention could be arranged. The physician, in turn, could notify a patient's parents or other relatives, as long as no mention were made of the patient's AOD problem. Whenever a disclosure is made to cope with a medical emergency, the program must document in the patient's records the name and affiliation of the recipient of the information, the name of the individual making the disclosure, the date and time of the disclosure, and the nature of the emergency.
If a program routinely needs to share certain information with an outside agency that provides services to the program, it can enter into a QSOA. A QSOA (Exhibit E-4) is a written agreement between a program and a person providing services to the program, in which that person (1) acknowledges that in receiving, storing, processing or otherwise dealing with any patient records from the program, he or she is fully bound by [the Federal confidentiality] regulations; and (2) promises that, if necessary, he or she will resist in judicial proceedings any efforts to obtain access to patient records except as permitted by these regulations, §§2.11, 2.12(c)(4).
A QSOA should be used only when an agency or official outside of the program, for example, a clinical laboratory or data-processing agency, is providing a service to the program itself. An example is when laboratory analysis or data processing is performed for the program by an outside agency. A QSOA is not a substitute for individual consent in other situations. Disclosures under a QSOA must be limited to information that is needed by others so that the program can function effectively. QSOAs may not be used between programs providing alcohol and drug services
The Federal regulations permit some information to be disclosed to individuals within the same program:
The restrictions on disclosure in these regulations do not apply to communications of information between or among personnel having a need for the information in connection with their duties that arise out of the provision of diagnosis, treatment, or referral for treatment of alcohol or drug abuse if the communications are (i) within a program or (ii) between a program and an entity that has direct administrative control over that program, §2.12(c)(3).
In other words, staff (including full- or part-time employees and unpaid volunteers) who have access to patient records because they work for or administratively direct the program may consult among themselves or otherwise share information if their substance abuse work so requires.
Does this exception allow a detoxification program that is part of a larger entity, such as a hospital, to share confidential information with others that are not part of the detoxification unit? The answer to this question is quite complicated. In brief, there are circumstances under which the detoxification unit may share information with other units that are part of the greater entity to which it belongs. Before such an internal communication system is set up within a large institution, however, it is essential that an expert in the area be consulted.
The Federal confidentiality regulations require programs to notify patients of their right to confidentiality and to give them a written summary of the regulations' requirements. The notice and summary should be handed to patients when they enter the program or shortly thereafter, §2.22(a). The regulations contain a sample notice that may be used for this purpose.
Unless State law grants the right of patient access to records, programs have the right to decide when to permit patients to view or obtain copies of their records. The Federal regulations do not require programs to obtain written consent from patients before permitting them to see their own records.
The Federal regulations require programs to keep written records in a secure room, locked file cabinet, safe, or other similar container. The program should establish written procedures that regulate access to and use of patient records. The program director or a single staff person should be designated to process inquiries and requests for information (§2.16).
Administrators and staff members of AOD detoxification programs should become thoroughly familiar with the many legal issues affecting their work. Such knowledge can prevent costly mistakes. Because legal requirements often vary by State and change over time, it is also essential that programs find a reliable source to whom they may turn for up-to-date information, advice, and training.
1. This appendix was
written for the panel by Margaret K. Brooks, Esq.
2. For a discussion of AOD abuse treatment
of adolescents and informed consent, see Dubler, N.N. Legal and ethical issues
in the treatment of substance-abusing adolescents. In: Guidelines for the
Treatment of Alcohol- and Other Drug-Abusing Adolescents. Rockville,
Maryland: Center for Substance Abuse Treatment, 1993: 47-57. Treatment
Improvement Protocol (TIP) Series Number 4.
3. Citations throughout this chapter in the
form "§2..." refer to specific sections of 42 Code of Federal
Regulations (C.F.R.), Part 2, Implementing the Substance Abuse and Mental Health
Services Administration (42 U.S.C. §290dd-2) (1987).
4. For a discussion of procedures that
programs may use to collect patient fees, see Confidentiality: A Guide to
the Federal Laws and Regulations. New York: The Legal Action Center, 1991.
5. In Simmons v. City of Philadelphia, 947
F.2d 1042 (3d Cir. 1991), the mother of a man who was intoxicated when arrested
and committed suicide while incarcerated successfully sued the City for failing
to maintain a protocol to deal with emotionally disturbed intoxicated inmates,
who comprised the majority of persons committing suicide while in prison.
6. The DEA regulations permit "any
person in possession of any controlled substance and desiring or required to
dispose of such substance [to] request the Special Agent in Charge of the
Administration in the area in which the person is located for authority and
instructions to dispose of such substance," 21 C.F.R. §1307.21(a). The
regulation sets forth how such a request should be made. Subsection 1307.21(d)
specifically states that the regulation "shall not be construed as
affecting or altering in any way the disposal of controlled substances through
procedures provided in laws and regulations adopted by any State."
7. Only patients who have "applied for
or received" services from a program are protected. If a patient has not
personally sought help from the program or has not yet been evaluated or
counseled by a program, the program is free to discuss the patient's drug or
alcohol problems with others. The Federal regulations govern from the moment
the patient applies for services or the program first conducts an evaluation or
begins counseling.
8. Search and arrest warrants are discussed
below. For an explanation about how to deal with subpoenas, see Confidentiality:
A Guide to the Federal Law and Regulations. New York: The Legal Action
Center, 1995.
9. No information that is obtained from a
program (even if the patient consents) may, however, be used in a criminal
investigation or prosecution of a patient, unless a court order has been issued
under the special circumstances set forth in §2.65 (42 U.S.C. §§290dd-2; 42
C.F.R. §2.12[a],[d]).
10. Although Federal and, in some cases,
State laws may prohibit the employer from firing employees or taking other action
simply because they have entered treatment, discriminatory practices against
recovering people continue.
11. Some States prohibit insurance
companies from discriminating against individuals who have received substance
abuse treatment; however, discriminatory practices continue. Insurance
companies routinely share information about policy holders. Although the
Federal regulations prohibit insurance companies from sharing information from
a treatment program with other carriers, that prohibition is no guarantee that
such redisclosure will not take place.
12. If a patient who has signed a consent
form permitting the program to make disclosures to a third-party payer later
revokes his or her consent, the program can bill the third-party payer for
services provided before consent was revoked. A program cannot, however, make
any disclosures to the third-party payer in order to receive reimbursement for
services rendered after the patient revoked consent, §2.31(a)(8).
13. If the State's reporting law is intended
only to gather information for research purposes, detoxification programs can
include patients' names in their reports, if the public health department
complies with §2.52 of the Federal regulations. That section permits release of
patient-identifying information to researchers when (1) they are qualified to
conduct the research, (2) they have a research protocol to protect
patient-identifying information, and a group of three or more individuals
independent of the research project have reviewed the protocol and found it
adequate, and (3) they agree not to redisclose patients' names or identifying
information except back to the program and not to identify any patient in a
report. In most cases, a department of public health will easily satisfy the first
requirement. The Federal Department of Health and Human Services has suggested
in opinion letters that the second requirement may not apply when the research
is intended to track the incidence and causation of diseases. Thus, if the
State is gathering information only for research purposes, the program can
probably make reports including patients' names, if the department agrees not
to redisclose patients' names or identifying information except back to the
program and not to identify any patient in a report.
14. See Letter to Oklahoma State Department
of Health from the Legal Adviser to the U.S. Alcohol, Drug Abuse, and Mental
Health Administration, dated September 2, 1988, and Letter to the New York
State Department of Health from the Acting General Counsel to the U.S. DHHS,
dated May 17, 1989.
15. The regulations make it clear that
Federal law overrides any State law that conflicts with the regulations
(§2.20). In the only case, as of this writing, that addresses this conflict
between Federal and State law (Hasenie v. United States, 541 F. Supp.
999 [D. Md. 1982]), the court ruled that the Federal confidentiality law
prohibited any report.
16. Federal confidentiality statutes and
regulations strictly prohibit any investigation or prosecution of a patient
based on information obtained from records unless the court order exception is
used (42 U.S.C. §§290dd-2(2)(C) and 42 C.F.R. §2.12(d)(1).
17. If the patient is being sought because
he or she has committed a crime on program premises or against program
personnel, the program can point the patient out (see section IV.I.3).
18. Two statutes (42 U.S.C. §241[d] and 21
U.S.C. §872[c]), both of which cover research into drug use, permit the
Secretary of DHHS and the U.S. Attorney General, respectively, to authorize
researchers to withhold the names and identities of research subjects. The
statutes both state that the researcher "may not be compelled in any
Federal, State, or local civil, criminal, administrative, legislative, or other
proceeding" to identify the subjects of research for which such
authorization was obtained. Such authorization is commonly called a
"certificate of confidentiality." Whether or not research
investigators have obtained an authorization from the Attorney General or the
Secretary of DHHS, however, they must comply with the prohibitions on
redisclosure discussed in this section of the chapter if they have been given
access to patients' records in a federally assisted treatment program.
19. These particular entities also may copy
or remove records, but only if they agree in writing to maintain
patient-identifying information in accordance with the regulations' security
requirements (see §2.16), to destroy all patient-identifying information when
the audit or evaluation is completed, and to redisclose patient information
only (1) back to the program, (2) in accordance with a court order to
investigate or prosecute the program (§266), or (3) to a government agency
overseeing a Medicare or Medicaid audit or evaluation, §2.53(b).
20. For information on how to deal with
subpoenas, see Confidentiality: A Guide to the Federal Laws and Regulations,
New York: Legal Action Center, 1991.
21. If the information is being sought to
investigate or prosecute a patient, only the program need be notified (§2.65).
If the information is sought to investigate or prosecute the program, no prior
notice is required (§2.66).
22. If the purpose of seeking the court
order is to obtain authorization to disclose information in order to
investigate or prosecute a patient for a crime, the court also must find that
(1) the crime involved was extremely serious, such as an act causing or
threatening to cause death or serious injury; (2) the records sought are likely
to contain information of significance to the investigation or prosecution; (3)
there is no other practical way to obtain the information; and (4) the public
interest in disclosure outweighs any actual or potential harm to the patient,
the doctor-patient relationship, and the ability of the program to provide
services to other patients. When law enforcement personnel seek the order, the
court also must find that the program had an opportunity to be represented by
independent counsel. If the program is a government entity, it must be
represented by independent counsel, §2.65(d).
Donald R. Wesson, M.D.
Scientific Director
MPI Treatment Services
Summit Medical Center
Oakland, California
John Bland
Public Health Advisor
Women and Children's Programs Branch
Division of Clinical Programs
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
Janet C. Cleveland, M.S.
Health Education Specialist
Training and Technical Support Systems Branch
Division of HIV/AIDS Prevention
National Center for Prevention Services
Centers for Disease Control and Prevention
Atlanta, Georgia
Sandra M. Clunies, M.S., N.C.A.D.C.
Government Project Officer
Synthesis Branch
Office of Evaluation, Scientific Analysis, and Synthesis
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
Dorynne Czechowicz, M.D.
Associate Director
Medical and Professional Affairs
Medical Affairs Branch
Division of Clinical Research
National Institute on Drug Abuse
Rockville, Maryland
Herman I. Diesenhaus, Ph.D.
Team Leader
Scientific Analysis Team
Office of Evaluation, Scientific Analysis, and Synthesis
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
Archie S. Golden, M.D., M.P.H.
Director
Adolescent Substance Abuse Program and
Chairman
Department of Pediatrics
Johns Hopkins Bayview Medical Center
Baltimore, Maryland
Michael Jewell
Acting Director
Office of Policy and Planning
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
George Kanuck
Public Health Analyst
Program Evaluation Branch
Office of Scientific Analysis and Evaluation
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
Dorothy B. Lewis
Project Officer
Clinical Intervention Branch
Division of Practice and Systems Development
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
Robert G. Lubran, M.P.A.
Branch Chief
PPG Program Support Branch
Division of State and Community Assistance
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
Lynn McQueen, M.S., M.P.H.
Senior Health Policy Analyst
Agency for Health Care Policy and Research
Rockville, Maryland
Barbara Roberts, Ph.D.
Senior Policy Analyst
Office of National Drug Control Policy
Executive Office of the President
Washington, D.C.
Charles Roberts, Ph.D.
Statistician
Scientific Analysis Team
Division of State and Community Assistance
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
Terrence Schomburg, Ph.D.
Public Health Advisor
PPG Program Support Branch
Division of State and Community Assistance
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
Lovetta L. Smith, R.N., D.N.Sc., F.A.A.N.
Associate Chief of Nursing Services
Surgical and Special Care Service
Gainesville Veterans Administration Medical Center
Gainesville, Florida
Richard T. Suchinsky, M.D.
Associate Director
Addictive Disorders and Psychiatric Rehabilitation
Department of Veterans Affairs
Veterans Health Administration
Washington, D.C.
Norma J. Taylor, Ph.D., A.C.S.W.
Project Director
National Association of Social Workers
Washington, D.C.
Sylvia Trent-Adams, R.N., M.S.
Public Health Analyst
Maternal and Child Health Bureau
Health Resources and Services Administration
Rockville, Maryland
Marilyn Vranas, M.S., M.A., R.N., C.S., C.A.R.N.
Public Health Advisor
Healthy Start
Division of Maternal and Child Health
Health Resources and Services Administration
Rockville, Maryland
William E. Woodward, M.D.
Member, Board of Directors
American Council on Alcoholism
Baltimore, Maryland
Reginald A. Alexander, M.D.
Medical Director
Alcohol Substance Dependency Treatment Program
Substance Dependency Treatment Unit
Veterans Affairs Medical Center
Des Moines, Iowa
Douglas L. Bovee, M.D., F.A.C.P.
Chief of Staff
Oregon Counseling and Addiction Medicine
Serenity Lane
Eugene, Oregon
Margaret Kent Brooks, J.D.
Consultant
Montclair, New Jersey
Jan L. Campbell, M.D.
Chief
Substance Abuse Treatment Unit
Psychiatry Service
Veterans Affairs Medical Center
Kansas City, Missouri
C. James Coats, A.C.S.W.
Clinical Social Worker
Alcohol and Drug Services
Catholic Human Services
Traverse City, Michigan
Margaret A. Compton, R.N., Ph.D.
Research Scientist
Los Angeles Addiction Treatment Research Center
Los Angeles, California
Susan M. Doyle, R.N., C.A.R.N.
Program Director
Shoemaker Center
Westminster, Maryland
Larry Egnor, B.A., C.S.A.C.
Clinical Program Supervisor
ComCare
Phoenix, Arizona
Garland S. Ferguson
Director
Division of Detoxification
Bureau of Alcohol and Drug Abuse Prevention
Arkansas Department of Health
Benton, Arkansas
Bonnie B. Gladden, R.N.
Detoxification Coordinator
Keystone Substance Abuse Services
Rock Hill, South Carolina
Archie S. Golden, M.D., M.P.H.
Director
Adolescent Substance Abuse Program, and
Chairman
Department of Pediatrics
Johns Hopkins Bayview Medical Center
Baltimore, Maryland
Mary R. Haack, R.N., Ph.D.
Senior Research Scientist
Center for Health Policy Research
The George Washington University
Washington, D.C.
Gregory N. Hayner, Pharm.D
Chief Pharmacist
Detoxification, Rehabilitation, and Aftercare Project
Haight Ashbury Free Clinics
San Francisco, California
Marc Hertzman, M.D.
Medical Director
Department of Psychiatry
North Arundel Hospital
Glen Burnie, Maryland
Timothy James, Ed.M., L.S.A.C.
Program Director
Hope House, Incorporated
Bangor, Maine
Donald R. Jasinski, M.D.
Professor of Medicine
Johns Hopkins Bayview Medical Center
Baltimore, Maryland
Albert E. Jones, L.C.S.W.
Program Director
New Directions, Incorporated
Memphis, Tennessee
Linda Kaplan, M.A., C.A.E.
Executive Director
National Association of Alcoholism and Drug Abuse Counselors
Arlington, Virginia
Martin A. Krepcho, Ph.D.
Assistant Program Manager, HIV
Dallas County Health Department
Dallas, Texas
Roger A. Kryzanek, M.S.W., L.C.S.W.
Alcohol/Drug Program Director
Deschutes County Mental Health Services
Bend, Oregon
Jeffrey N. Kushner
Director
Oregon Office of Alcohol and Drug Abuse Programs
Salem, Oregon
Karen Larson, R.N., B.S.N.
Assistant Director
Division of Alcohol and Drug Abuse
North Dakota Department of Human Services
Bismarck, North Dakota
Lawrence S. Linder, M.D., F.A.C.E.P
Assistant Director
Emergency Department
North Arundel Hospital
Glen Burnie, Maryland
Kathy Lynn, R.N., M.S., C.S., C.N.A.A.
Director of Nursing
Mental Health Division
North Arundel Hospital
Glen Burnie, Maryland
Carole A. Madden, R.N., B.S.N., C.D.
Chemical Dependency Nurse
Intervention Services
North Arundel Hospital
Glen Burnie, Maryland
Joan McNamara
Executive Director
Gateway, Incorporated
Tucson, Arizona
Marilyn Miller, M.A.
Treatment Consultant
Center for Substance Abuse Services
Michigan Department of Public Health
Lansing, Michigan
Dorothy B. North, N.C.A.C. II, C.E.A.P.
Chief Executive Officer
Vitality Center
Elko, Nevada
Janice O'Keefe, R.N., M.P.H., C.A.R.N.
Director of Clinical Services
Boston Health Care for the Homeless
Boston, Massachusetts
Wayne Raske
Legislative Liaison/Alcoholism Specialist
Chemical Dependency Program Division
Minnesota Department of Human Services
St. Paul, Minnesota
Saranne D. Shea, M.S.W., L.I.C.S.W., B.C.D.
Associates for Counseling
Brookline, Massachusetts
Lovetta L. Smith, R.N., D.N.Sc., F.A.A.N.
Associate Chief of Nursing Services
Surgical and Special Care Service
Gainesville Veterans Administration Medical Center
Gainesville, Florida
Richard T. Suchinsky, M.D.
Associate Director
Addictive Disorders and Psychiatric Rehabilitation
Department of Veterans Affairs
Veterans Health Administration
Washington, D.C.
John T. Sullivan, M.D.
Associate Professor of Medicine
Johns Hopkins University and
Director
Center for Chemical Dependence
Johns Hopkins Bayview Medical Center
Baltimore, Maryland
Peter L. Washburn, M.D.
Associate Physician
Chemical Dependency Recovery Program
Kaiser Permanente
San Francisco, California
James Allen Wilcox, D.O., M.S.
Associate Professor
Department of Psychiatry
Texas Tech University Health Sciences Center
El Paso, Texas
Bonnie Baird Wilford, M.S.
Director
Pharmaceutical Policy Research Center
Intergovernmental Health Policy Project
The George Washington University
Washington, D.C.
Bill Wilson, B.S., M.P.A., M.B.A.
Director
Behavioral Health
MPI Treatment Services
Oakland, California
|
ASAM Patient Placement Criteria Applied to Detoxification Settings |
|
|
ASAM Patient Placement Criteria Level of Care |
Treatment Setting Recommended by Consensus Panel |
|
Level I: Outpatient treatment |
Outpatient care methadone maintenance |
|
Level II: Intensive outpatient or partial hospitalization |
Intensive outpatient program |
|
Level III: Medically monitored intensive inpatient treatment |
Medical subacute hospital |
|
Level IV: Medically managed intensive inpatient treatment |
Psychiatric hospital |
|
|
|
|
Patient: ___________________ Date: /___/___/___ Time:
___ : ______ |
|
|
NAUSEA AND VOMITING-- Ask "Do you feel sick to
your stomach? Have you vomited? " |
TACTICLE DISTURBANCES--Ask "Have you any
itching, pins and needles sensations, any burning, any numbness, or do you
feel bugs crawling on or under your skin?" |
|
TREMOR--Arms extended and fingers spread apart. |
AUDITORY DISTURBANCES--Ask "Are you more aware
of sounds around you? Are they harsh? Do they frighten you? Are you hearing
anything that is disturbing to you? Are you hearing things you know are not
there?" |
|
PAROSYSMAL SWEATS--Observation. |
VISUAL DISTURBANCES--Ask "Does the light
appear to be too bright? Is its color different? Does it hurt your eyes? Are
you seeing anything that is disturbing to you? Are you seeing things you know
are not there?" |
|
ANXIETY--Ask "Do you feel nervous?" |
HEADACHE, FULLNESS IN HEAD--Ask "Does your
head feel different? Does it feel like there is a band around your head?
" |
|
AGITATION--Observation. |
ORIENTATION AND CLOUDING OF SENSORIUM--Ask
"What day is this? Where are you? Who am I?" |
|
Total CIWA-A Score
____ |
|
|
|
|
|
EARLY |
ADVANCED |
|
Anxiety |
Insomnia |
|
|
|
Headache: Acetaminophen (Tylenol), 650 mg every 4 hours if
needed |
|
Anxiety or Insomnia: Hydroxyzine (Vistaril), 25-50 mg every 8 hours |
|
Abdominal Cramps: Dicyclomine (Bentil), 10 mg every 8 hours |
|
Constipation: Milk of Magnesia, 30 cc daily every other day |
|
Indigestion: Antacid (for example, Mylanta), 30 cc between meals and at bedtime |
|
Loose Stool: Bismuth subcarbonate (Pepto-Bismol), 30 cc after each loose stool up to 8 doses total, for no more than 2 days |
|
|
* All doses are administered orally.
|
|
||||
|
Generic Name |
Trade Name |
Therapeutic Dose Range (Mg/Day) |
|
Phenobarbital Conversion Constant |
|
Benzodiazepines |
||||
|
alprazolam |
Xanax |
0.75-6 |
1 |
30 |
|
chlordiazepoxide |
Librium |
15-100 |
25 |
1.2 |
|
clonazepam |
Klonopin |
0.5-4 |
2 |
15 |
|
clorazepate |
Tranxene |
15-60 |
7.5 |
4 |
|
diazepam |
Valium |
4-40 |
10 |
3 |
|
estazolam |
ProSom |
1-2 |
1 |
30 |
|
flumazenil |
Mazicon |
|||
|
flurazepam |
Dalmane |
15-30* |
15 |
2 |
|
halazepam |
Paxipam |
60-160 |
40 |
0.75 |
|
lorazepam |
Ativan |
1-16 |
2 |
15 |
|
midazolam |
Versed |
|||
|
oxazepam |
Serax |
10-120 |
10 |
3 |
|
prazepam |
Centrax |
20-60 |
10 |
3 |
|
quazepam |
Doral |
15* |
15 |
2 |
|
temazepam |
Restoril |
15-30* |
15 |
2 |
|
triazolam |
Halcion |
0.125-0.50* |
0.25 |
120 |
* Usual hypnotic dose
** Phenobarbital withdrawal conversion equivalence is not
the same as therapeutic dose equivalency. Withdrawal equivalence is the amount
of the drug that 30 mg of phenobarbital will substitute for and prevent serious
high-dose withdrawal signs and symptoms.
*** Not applicable
Information in this exhibit is drawn from two sources, the American Psychiatric
Association and the work of Donald R. Wesson, et al. Portions of the exhibit
are reprinted with permission from the American Psychiatric Press Textbook
of Substance Abuse Treatment, Washington, D.C. 1990.
|
|
|||||
|
Generic Name |
Name(s) |
Common Therapeutic Indication |
Dose Equal to 30 MG of Therapeutic Dose Range (mg/day) |
Phenobarbital for Withdrawal (mg)** |
Conversion Constants |
|
Barbiturates |
|||||
|
amobarbital |
Amytal |
sedative |
50-150 |
100 |
0.33 |
|
butabarbital |
Butisol |
sedative |
45-120 |
100 |
0.33 |
|
butalbital |
Fiorinal, Sedapap |
sedative/analgesic* |
100-300 |
100 |
0.33 |
|
pentobarbital |
Nembutal |
hypnotic |
50-100 |
100 |
0.33 |
|
secobarbital |
Seconal |
hypnotic |
50-100 |
100 |
0.33 |
|
Others |
|
|
|
|
|
|
buspirone |
Buspar |
sedative |
15-60 |
||
|
chloral hydrate |
Noctec, Somnos |
hypnotic |
250-1000 |
500 |
0.06 |
|
ethchlorvynol |
Placidyl |
hypnotic |
500-1000 |
500 |
0.06 |
|
glutethimide |
Doriden |
hypnotic |
250-500 |
250 |
0.12 |
|
meprobamate |
Miltown, Equanil, Equagesic |
sedative |
1200-1600 |
1200 |
0.025 |
|
methylprylon |
Noludar |
hypnotic |
200-400 |
200 |
0.15 |
* Butalbital is usually available in
combination with opiate or non-opiate analgesics.
** Phenobarbital withdrawal conversion equivalence is not
the same as therapeutic dose equivalency. Withdrawal equivalence is the amount
of the drug that 30 mg of phenobarbital will substitute for and prevent serious
high-dose withdrawal signs and symptoms.
*** Not cross-tolerant with barbiturates.
Information in this exhibit is drawn from two sources, the American Psychiatric
Association and the work of Donald R. Wesson, et al. Portions of the exhibit
are reprinted with permission from the American Psychiatric Press Textbook
of Substance Abuse Treatment, Washington, D.C., 1990.
|
|
|
|
|
||||||
|
Program Identification No. |
1 |
2 |
3 |
4 |
5 |
6 |
|
Program Type |
|
|
|
|
|
|
|
Medical Subacute |
|
X |
X |
|
|
X |
|
Social Model |
X |
|
|
X |
X |
X |
|
Modified Medical |
|
|
|
X* |
|
|
|
|
|
|
|
|
|
|
|
Region |
Northeast |
MidAtlantic |
Midwest |
West |
Northwest |
South |
|
Locale |
Small Metropolitan |
Suburban |
Large Metropolitan |
Rural |
Rural |
Large Metropolitan |
|
Medical Model |
|
|
|
|
|
|
|
Daily Residential Capacity** |
|
|
|
|
|
|
|
Annual Census*** |
|
900 (9 mo.) |
550 |
875 * |
|
250 |
|
|
|
|
|
|
|
|
|
Social Model |
|
|
|
|
|
|
|
Daily Residential Capacity** |
8 |
|
|
20 * |
4 |
25 |
|
Annual Census*** |
350 |
|
|
875 * |
190-250 |
250 |
|
|
|
|
|
|
|
|
|
Institutional Status |
Private Nonprofit |
Public Nonprofit |
Private Nonprofit |
Private Nonprofit |
Private Nonprofit |
Private Nonprofit |
|
|
||||
|
Program Identification No. |
1 |
4 |
5 |
6 |
|
Core Staffing Costs/FTEs |
|
|
|
|
|
Registered Nurse |
$42,341.00 (2) |
$11,326.00 (.33) |
0 |
$78,000.00 (3) |
|
Aide |
45,645.00 (3) |
140,00.00 (10) |
0 |
37,440.00 (3) |
|
Addictions Counselor |
15,500.00 (1) |
52,000.00 (2) |
$68,352.00 (3) |
37,000.00 (2) |
|
Social Worker |
0 |
0 |
3,000.00 (.25) |
26,000.00 (1) |
|
Financial Benefits Manager |
0 |
5,000.00 (.25) |
|
22,500.00 (1) |
|
Total Core Staffing |
$104,486.00 (6) |
$208,326.00 (12.58) |
71,352.00 |
$200,940.00 |
|
Payroll Taxes and Benefits |
17,890.00 |
47,915.00 |
14,800.00 |
40,188.00 |
|
Consultant Physician |
1,020.00 |
12,000.00 (.12) |
840.00 |
0 |
|
Direct Operating Costs |
|
|
|
|
|
Supplies (office/activities) |
(in admin.) |
6,445.00 |
2,200.00 |
5,000.00 |
|
Meds, lab fees, contr. services |
6,700.00 |
1,100.00 |
360.00 |
30,000.00 |
|
Telephone |
3,130.00 |
3,255.00 |
720.00 |
6,000.00 |
|
Vehicle |
0 |
2,000.00 |
0 |
500.00 |
|
Accounting/Legal Expense |
(in admin.) |
1,953.00 |
300.00 |
6,000.00 |
|
Staff Development |
1,725.00 |
2,000.00 |
600.00 |
3,000.00 |
|
Office and Postage |
(in admin.) |
3,075.00 |
500.00 |
3,000.00 |
|
Equipment |
1,345.00 |
2,500.00 |
450.00 |
5,000.00 |
|
Local Travel |
400.00 |
2,475.00 |
1,685.00 |
3,000.00 |
|
Miscellaneous |
575.00 |
10,485.00 |
250.00 |
800.00 |
|
Administrative Mgmt. |
5,640.00 |
30,342.00 |
2,400.00 (1) |
70,000.00 |
|
Facility |
|
|
|
|
|
Building |
27,100.00 |
72,000.00 |
6,000.00 |
0 |
|
Food |
15,590.00 |
39,600.00 |
2,800.00 |
30,000.00 |
|
Maintenance |
3,690.00 |
4,800.00 |
1,000.00 |
5,000.00 |
|
TOTAL COSTS |
$189,311.00 |
$450,271.00 |
$106,257.00 |
$408,428.00 |
|
|
||||
|
Program Identification No. |
2 |
3 |
4* |
6 |
|
Core Staffing Costs/FTEs |
|
|
(Modified |
|
|
Registered Nurse |
$288,000.00 (8) |
0 |
$33,000.00 (1) |
$78,000.00 (3) |
|
Aide |
80,000.00 (4) |
$71,400.00 (5) |
140,000.00 (10) |
37,440.00 (3) |
|
Addictions Counselor |
77,000.00 (3) |
0 |
52,000.00 (2) |
18,500.00 (1) |
|
Social Worker |
40,000.00 (1) |
40,000.00 (2) |
15,000.00 (.5) |
26,000.00 (1) |
|
Financial Benefits Mgr. |
21,000.00 (1) |
0 |
5,000.00 (.25) |
22,500.00 (1) |
|
Total Core Staffing |
$506,000.00 (17) |
$111,400.00 (7) |
$245,000.00 (13.75) |
$182,440.00 (9) |
|
Payroll Taxes and Benefits |
197,000.00 |
34,035.00 |
56,350.00 |
36,488.00 |
|
Consultant Physician |
26,000.00 (.4) |
18,548.00 |
25,000.00 (.25) |
0 |
|
Direct Operating Costs |
|
|
|
|
|
Supplies (office/activities) |
4,000.00 |
163,983.00 |
6,445.00 |
5,000.00 |
|
Meds, lab fees, contr. services |
105,000.00 |
(none given) |
5,000.00 |
30,000.00 |
|
Telephone |
5,000.00 |
3,937.22 |
3,255.00 |
6,000.00 |
|
Vehicle |
4,000.00 |
3,748.75 |
2,000.00 |
500.00 |
|
Accounting/Legal Expense |
28,000.00 |
(none given) |
1,953.00 |
6,000.00 |
|
Staff Development |
8,000.00 |
1,148.84 |
2,000.00 |
3,000.00 |
|
Office and Postage |
6,000.00 |
869.59 |
3,075.00 |
3,000.00 |
|
Equipment |
10,000.00 |
(none given) |
2,500.00 |
5,000.00 |
|
Local Travel |
2,000.00 |
(none given) |
2,475.00 |
2,500.00 |
|
Miscellaneous |
8,000.00 |
264.55 |
50,085.00*** |
6,000.00 |
|
Administrative Mgmt. |
56,000.00 |
56,578.00 |
30,342.00 |
70,000.00 |
|
Facility |
|
|
|
|
|
Building |
40,000.00 |
29,600.00 |
90,000.00 |
24,000.00 |
|
Food |
(in meds., lab, etc.) |
(in building) |
(in miscellaneous) |
(in building) |
|
Maintenance |
(in meds., lab, etc.) |
(in building) |
(in building) |
(in building) |
|
TOTAL COSTS |
$1,005,000.00 |
$425,112.95 |
$525,480.00 |
$379,928.00 |
|
|
|
|
|
|
This notice accompanies a disclosure of information concerning a client in alcohol/drug abuse treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by Federal confidentiality rules (42 C.F.R. Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. |
|
|
|
XYZ Service Center ("the Center") and the
_____________________ |
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