treatment centers—the next challenge

Journal of Substance Abuse Treatment, Vol. 10, pp. 133-137, 1993 Printed in the USA. All rights reserved.

0740-5472193 $6.00 + .OO Copyright 0 1993 Pergamon Press Ltd.

IN THE SPOTLIGHT

Treatment Centers-The Next Challenge

The Counterpoint Unit at CPC Parkwood Hospital

SMYRNA, GEORGIA

Abstract - Treatments centers have traditionally concentrated on the treatment of alcohol and var- ious other chemical dependencies, frequently omitting treatment for nicotine dependence. Many have felt it to be too much to take away everything at once. Professionals in the treatment community are realizing more and more that nicotine dependence is another manifestation of the disease of addiction. Our philosophy challenges the old adage “don’t take everything away at once, ‘>’ by addressing the issue of nicotine dependence. We began implementation of a nicotine-free unit at CPC Parkwood Hospital in November 1989. We are currently in the process of adopting a nicotine-free policy at Ridgeview Institute in Smyrna, Georgia. This article traces the evolution of a nicotine-free unit at CPC Parkwood Hospital.

Keywords-nicotine; addiction; recovery; treatment centers: substance abuse.

CPC PARKWOOD HOSPITAL is located in Atlanta, Geor- gia. The majority of the patients come from the South- eastern United States; however, many patients are referred from the Southwest, Northeast, and North- west, as well as Canada. The socioeconomic status of the patients ranges from the very poor to the very rich. Most patients, however, are from the middle to lower middle classes, and have completed high school, and are self-supporting. The nicotine-free Adults Addic- tions Unit is, however, restricted to adults, the usual criteria being 18 years of age or older.

Whereas several years ago it was not uncommon to treat a patient with alcohol dependence without com- plicating diagnoses, we are currently seeing an increase

Requests for reprints should be addressed to Michael L. Fishman, MD, Ridgeview Institute, 4015 South Cobb Drive, Suite 120, Smyrna, GA 30080.

in patients with other psychiatric diagnoses. This may include polysubstance dependence, with depression or dissociative disorder. On the Counterpoint Unit at CPC Parkwood Hospital we treated chemical dependence, nicotine dependence, alcohol dependence, and eating disorders, including bulimia nervosa, anorexia nervosa, and eating disorders not otherwise specified. Other addictions treated include sexual and gambling

dependence. We have also hospitalized a patient in the past 2 years for compulsive spending. Specialty tracts include codependency, abuse survivors, and anxiety disorders tracts. Complicated medical problems are followed by Board-certified internists.

PROGRAM PHILOSOPHY

We believe addiction to be a primary drive that has many superficial manifestations including drug, alcohol, nicotine, disorders of food, sexual compulsive dis-

133

134 M.L. Fishman and P.H. Earley

orders, and gambling. This primary drive needs to be contained before meaningful psychotherapy can occur. Behavioral containment always predates psychother- apeutic growth according to our treatment model.

GOALS OF TREATMENT

Initially the goals of treatment are to arrest the addictive behavior so that the patient can more readily ac- cess feelings. Once the addictive behaviors are arrested, our patients are encouraged to take responsibility for their treatment using 12-step recovery as a catalyst.

THERAPEUTIC MODALITIES

Our therapeutic modalities come from an eclectic group with a strong belief in milieu management. Individual and group psychotherapy are equally dispersed in patient care. Early treatment techniques focus on the conventional behavioral interruption and cognitive ap- proaches similar to most addiction programs. As the patient progresses in treatment, the treatment shifts to emotive therapy utilizing a mix of Gestalt, psychody- namic, and object relations constructs.

HISTORICAL CONTEXT AND EVOLUTION OF TOBACCO CESSATION TREATMENT

Origins

The concept of making addiction treatment nicotine- free started as a good idea. However, this good idea was quickly absorbed into the mainstay of our treatment philosophy-a program free from all addictive behavior. We believe addiction to be a primary drive that has many superficial manifestations including nicotine dependence. Addressing nicotine dependence established model integrity-we ask patients to under- stand that the abuse of any substance is a manifestation of their addictive disease.

Administrative and Staff Support

Initially administrative and staff support at CPC Park- wood was negligible. After all, the philosophy in addiction treatment for years was to ignore or avoid nicotine dependence. Some staff felt taking away nicotine would be too much for the patient to handle at one time. Administrative concerns centered around a possible decrease in census; the fear that patients would leave the hospital when told they would not be able to smoke. Many of the recovering staff firmly believed that nicotine dependence was something to be dealt with later in a patient’s recovery. Other staff continued to use nicotine addictively and obviously were not in favor of a nicotine-free policy.

Obtaining administrative support was a long, ar- duous process that took approximately 1 year. Many administrative concerns were focused around unit census. The hospital administrator at CPC Parkwood Hospital, however, did not smoke and understood the benefits of a nonsmoking program. Many attending physicians, as well as staff members who were smoke- free, continued to put pressure on the hospital administration to look at the nicotine policy. The medical director of CPC Parkwood Hospital gently promoted and supported the change. Eventually, hospital offi- cials came to believe that a nicotine-free policy made sense in terms of patient’s health and well being. As this policy took approximately 1 year to enact, it also took the strong patronage of nonsmoking hospital staff.

Nursing and psychosocial staff opinions were mixed regarding the nicotine-free policy. Several nursing staff members were PRN and worked on other units within the hospital that were smoking units. These nurses remained ambivalent to the nicotine-free process and, in fact, continued to smoke. There were two weekend nurses who were nicotine dependent and initially were against the nicotine policy. These nurses did not participate in weekly staff meetings but did voice their concerns to the director of the unit. They continued to struggle with their own dependence and declined outside treatment options. These staff members continued to secretly smoke for 2 to 3 months after the unit became nicotine-free. Eventually they did stop smoking and became strong supporters of the policy.

One nicotine-dependent nurse who worked during the week eventually resigned her position at CPC Park- wood Hospital. It is not clear whether or not this resignation was due to the new policy or other unresolved issues. In general, the psychosocial staff remained supportive of the nicotine-free policy. One staff member, who was not nicotine dependent, remained opposed to a nicotine-free policy stating that one should not take on too much at once. This staff member voiced his opposition in unit staff meetings but later accepted the fact that a nicotine-free policy was imminent.

Tobacco Cessation Strategy

All patients, whether nicotine dependent or not, were encouraged to participate in all nicotine dependence groups and educational lectures. Tobacco detoxifica- tion fell logically into place with all other withdrawal procedures. Patients were detoxified by quickly taper- ing Nicorette@ Gum over several days or by using the Catapres TTS Patch if not contraindicated.’ Daily community meetings were a place where patients could

‘Even though we used replacement therapy as a withdrawal aid, our nicotine-free policy was named to reflect our ultimate goal.

Treatment Centers- The Next Challenge 13s

voice their frustrations, anger, or sadness around their struggles with nicotine dependence. A Smokers Anon- ymous meeting was started in early 1990 after the Counterpoint Unit had been nicotine-free for several months. This weekly Smokers Anonymous meeting lasted only 1 month-the volunteers who ran the meeting were run off by the patients’ anger. A weekly Nic- otine Dependence Group was then started in which all patients participated. Patients were encouraged to talk about their feelings and struggles around nicotine cessation. Small groups and individual therapy were also available forums for patients to express their feelings.

Implementation

Implementing a nicotine-free treatment center was a process that took approximately 2 years at the Counter- Point Center of CPC Parkwood Hospital. A timeline was developed for becoming nicotine-free. Initial ef- forts focused on the staff, including education of staff around the benefits of becoming nicotine-free, as well as the severe health consequences of nicotine dependence. The staff came to believe that dealing with nicotine dependence represented a logical progression of our program philosophy. Staff education continued for approximately 1 year, the main arena being weekly staff meetings. The hospital offered to pay for the staff’s nicotine treatment. In staff meetings, open discussion was encouraged to permit everyone to recog- nize resistance to a nicotine-free policy.

Attention was then focused on educating patients around nicotine dependence. This began in daily community meetings. After approximately 6 months of patient education, a gradual reduction in times to smoke, places to smoke, and consequences for breaking nicotine abstinence were initiated. This rapidly progressed until the unit was completely nicotine-free in Novem- ber 1989. Our final position was that there would be no use of nicotine while a patient on the Counterpoint Center, which included therapeutic leaves and off-unit la-step meetings. Consequences of using nicotine included a level drop (reduction of privileges) and 24-h unit restriction.

Evolution

With the evolution of a nicotine-free treatment center we have noticed many positive outcomes. First, patients were unable to avoid affect evasion and bury their feelings after an intense therapy session by smoking several cigarettes. Being nicotine-free also increased the model integrity of drug-free treatment and recovery. No longer were we condoning one addiction while treating other addictions. This removed the mixed mes- sages patients often hear when dealing with addiction. A nicotine-free treatment center also addressed the cross-addictive nature of all mood-altering substances.

Thus, there was not an increase in nicotine consump- tion once other drugs were discontinued. A more aes- thetic issue was that our air and our facility were cleaner. Administration was pleased with the decrease in furniture damage and maintenance costs.

RESULTS

Current Program Status

The Counterpoint Center of CPC Parkwood Hospi- tal was nicotine-free from November 1989 until No- vember 1991. There were no designated areas or times that patients were allowed to smoke, or use chewing tobacco or snuff. An effort was made to send patients to off-unit 12-step meetings that were nicotine free. If these meetings were not available in off-unit times then meetings with a nicotine-free area were chosen (see Summary and Future Directions).

Patient Outcome

The nicotine-free policy extends to all times a patient is in treatment in the Counterpoint Center. Using nicotine during a therapeutic leave, for example, is considered a relapse into nicotine dependence. Under no circumstances are the patients allowed to smoke either in the hospital or off the hospital grounds.

We have no fixed data regarding outcomes with re- spect to abstinence from tobacco. One in four patients who return for aftercare are reporting they are nicotine free.

DISCUSSION

Staff Issues

We firmly believe that staff members need to be nicotine-free for a nicotine-free policy to work. Staff members who continue to smoke tend to subversively or even directly sabotage nicotine recovery.

A majority of staff on the adult addictions unit were nicotine-free prior to the policy being executed. Most of these staff members were supportive of the policy, which was helpful in confronting other staff members about their addiction. As staff members began to dis- cuss their struggles with nicotine dependence after approximately 2 to 3 months, smoking staff began to look to nicotine-free staff for support in stopping smoking. After several unsuccessful attempts to stop smoking they were able to become nicotine-free.

There were no staff members fired; however, one weekday nurse did resign her position. It was not clear whether or not this resignation was due to the nicotine-free policy. When new staff members were hired, they were informed of our nicotine-free policy and our expectations that they would be nicotine-free. Most

136 M.L. Fishman and P.H. Earley

new staff members agreed to this policy, however, there was no way to determine whether or not they remained nicotine-free in the privacy of their own homes.

While cessation programs were offered to nicotine- dependent staff members, these staff members did not take advantage of the programs. Many of the nicotine- dependent staff members were angry about the change and were resistant to looking at their own dependency issues, however, it is unclear why they did not take advantage of the cessation resources offered. Those staff members who were later committed to becoming nicotine-free looked toward each other as well as to nicotine- free staff members for support in their struggles.

Patient Motivation

Patients are encouraged to look at their nicotine addiction as they would any other addiction for which they seek treatment. By dealing with the severe overt cravings for nicotine, patients learned to manage the overt and covert cravings of their other dependencies. Patients are also motivated by the health benefits of being nicotine-free. Some patients become motivated after watching members of the community deal with their nicotine dependence as well as their chemical dependency. These senior members of the community are able to express their experience, strength, and hope from their treatment experience.

Many patients, however, are not motivated to dis- continue their nicotine dependence. In fact, their anger keeps them defocused from treatment. Approximately 50% of these patients continued to smoke cigarettes on or off the unit. However, the other 50% were able

to ask the staff and other patients for support with their struggles.

bers, using nicotine or other drugs while in treatment. Thus, patients will often confront the offenders, usu- ally in community meetings.

Relapse is not condoned in any shape or form. How- ever, we firmly believe that a relapse can be a stepping stone to the first step of recovery. If we feel a patient is motivated to continue in treatment after a relapse, we encourage that patient to work through his relapse. We have developed treatment consequences for a relapse, including a level drop (reduced privileges) and a 24-h unit restriction. If a patient were to continue to relapse, administrative discharge from treatment might result. Therefore, the consequences for relapse for nicotine dependence are seen in the same light as

for any other substance. This has added consistency to our treatment program.

Relapses on nicotine were much more prevalent on our unit than relapse on other drugs or alcohol. Dur- ing the initial stages of our program, surreptitious smoking was much more common than after the program had been in effect for 1 year. Initially, three out of four patients relapsed on nicotine while an inpatient. This later decreased to one to two patients out of four relapsing after our nicotine-free policy was developed to the point of being an integral part of programming. At times, staff members felt like police when confronting patients about their smoking. Patients accused staff members of being police rather than therapists. These issues were discussed openly in community meetings, especially when patients expressed their anger about losing privileges, secondary to relapse on nicotine. Staff members also expressed their frustrations in weekly staff meetings. This was encouraged as an opportu-

nity to express their frustration so they would be able to get on with their work as therapists and patient advocates.

Monitoring/Consequences Community Outreach

Witnessed, modified urine drug screens are collected at the time of admission for all patients. All positive results are confirmed by CC/MS. Patients are tested randomly throughout their hospitalization and upon return from therapeutic leaves. ALCO Scans are used to detect the presence of alcohol in a patient’s saliva at any time throughout the patient’s hospitalization. Serum alcohol levels may be drawn as well. Patients are encouraged to self-report the use of any mood- altering substances, including nicotine. Finding contra- band, including cigarettes or other nicotine products, matches or lighters is considered a relapse. Smelling tobacco on a patient or in a patient’s room is considered a relapse as well.

We found that the sniff test is sufficient to detect nicotine relapse, urine cotinine is not needed. The milieu is considered one large family and many patients will not tolerate other patients, that is, family mem-

After implementation of our nicotine-free policy, a con- certed effort was begun to find nicotine free 12-step meetings. In most cases, a nicotine-free 12-step meeting was available to coordinate with the unit schedules. There were times when patients went to meetings where they only had nonsmoking sections. The nicotine- dependent patients struggled with this as they had to sit through meetings where they observed and smelled cigarette smoking. This created many heated community meetings where patients expressed anger and con- cern over having to attend the meetings. Patients were strongly encouraged to express their feelings over these issues and talk about their cravings during the meetings. It is not surprising that surreptitious smoking was at its highest at the 12-step meetings.

Early administrative concerns centered around fears of a decreasing census with a nicotine-free policy. Early in the implementation of the nicotine-free policy, CPC

Treatment Centers- The Next Challenge 137

Parkwood did, in fact, lose several patients to other

treatment centers that are not nicotine-free. However, Parkwood began to notice increasing referrals specifically for nicotine dependence. These referrals came from as far away as Canada. Pulmonologists send us their patients to treatment specifically for their nicotine dependence.

Providing a continuum of care, CPC Parkwood Hospital’s nicotine-free outpatient program received patients for nicotine dependence. It has become a real advantage as well as a challenge to help those who want help. We are also actively involved with educating the public around nicotine dependence, as well as volunteering for organizations such as the American Lung Association. Patients are further linked to other 12-step Smoker’s Anonymous groups in the city.

SUMMARY AND FUTURE DIRECTIONS

We feel our nicotine-free treatment helped place us at the leading edge of addiction treatment. Not only does nicotine freedom increase the model integrity of drug- free treatment and recovery, it also addresses affect evasion through nicotine sedation. Our patients are able to mobilize affect rapidly when they stop smoking. We feel that all chemical dependency treatment programs will eventually be forced to address nicotine dependence. No longer will patients be arbitrarily allowed to pick one addiction for treatment, while another runs rampant. Nicotine cravings management can be used to the patient’s advantage when dealing with covert and overt cravings from other drugs. Our philosophy is that all patients, as well as staff on an addiction unit, need to be nicotine-free. We are very proud of our work at CPC Parkwood Hospital. How- ever, we are saddened that 2 months after our leaving the hospital, the unit became nicotine accessible. We do not know the exact reasons for this change in policy, but can only guess that concerns around census and the hiring of a nicotine-dependent program coor- dinator contributed to this change of policy.

We are currently directing the adult addictions unit at Ridgeview Institute in Smyrna, Georgia, where we continue to treat nicotine dependence as a primary addiction. We have begun the process of speaking with staff members regarding their support of a nicotine- free unit. Currently patients are allowed to smoke in designated outside areas only. A timeline of approximately 2 years has been developed to make the adult addictions unit totally nicotine-free.

Michael L. Fishman, MD Associate Program Director of

Addiction Medicine Services Ridgeview Institute

Smyrna, Georgia

Paul H. Earley, MD Program Director of Addiction Medicine Services

Ridgeview Institute and Earley Associates, P. C.

4015 South Cobb Drive, Suite I20 Smyrna, Georgia

APPENDIX

Illustrative Clinical Vignette

A 38-year-old white female was referred from Canada to CPC Parkwood Hospital for nicotine dependence. The patient had a long history of nicotine dependence beginning at the age of 11. By the age of 13, she admitted to smoking 14 to 2 packs of cigarettes per day. The patient would steal money from her mother to buy cigarettes and lie to her mother about it. The patient smoked 2-3 packs per day throughout her adult years. Despite her developing severe asthma, she continued to smoke.

Eight years prior to her admission, when Nicorette@ Gum first appeared on the market, the patient began chewing Nicorette@ Gum. She quickly accelerated her Nicorette@ Gum usage to 32 pieces of gum per day. In order to sustain her habit, she began writing bad checks for Nicorette@. She also began doctor shop- ping, or had friends get prescriptions from their doc- tors to enable her to have a sufficient supply of the gum. She relates dreams about having large quantities of Nicorette@ Gum. She admitted to the fantasy that if she only had enough of the drug, everything would be fine. As her addiction progressed, she returned to smoking cigarettes alternated with periods of Nico- rette@ Gum abuse.

The patient finally realized that she had a problem with nicotine dependence and, after several counsel- ing sessions, was referred to CPC Parkwood Hospi- tal. Early in her hospital stay the patient was weaned off Nicorette@ Gum. She became increasingly irrita- ble and angry. An agitated depression soon surfaced. We began the patient on Tofranil, slowly increased to 200 mg p.o. qhs. With the containment of her addictive behavior, as well as pharmacological support with Tofranil, our patient was able to mobilize many feelings concerning her family or origin and her low self-esteem.

At the time of discharge, the patient was nicotine- free and strongly bonded with 12-step recovery. While still depressed, she felt hope with the work she had started in individual and group therapy. She remains committed to 1Zstep meetings and sponsorship as well as ongoing psychotherapy. She has remained nicotine- free and plans to take her recovery one day at a time.

treatment centers—the next challenge

Documents