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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