Case Study: Addiction Severity Index Assessment

SOCIAL HISTORY: Patient admits alcohol ingestion nightly and on weekends. Denies tobacco use and illicit drug us. He is married.

Ms. Bynum is a self-referral who agreed to participate in the TPAPN monitoring program. On 11/24/16, Ms. Bynum tested positive for alcohol (ETG - 2510 ng/ml, ETS - 77 ng/ml) and renewed her program with TPAPN. On 2/26/16, Ms. Bynum tested positive for alcohol (ETG - 7980 ng/ml, ETS - 1580 ng/ml). On 4/7/16, Dr. John Lehman conducted an assessment on Ms. Bynum and recommended 90-day inpatient treatment program that Ms. Bynum refused. Additionally, Dr. Lehman stated on assessment that Ms. Bynum is not fit to practice and has a high-risk for relapse.

Addiction- a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. The difference between addiction and abuse is often times unclear. It’s a difficult call to make as a family member or a close friend that is dealing with a person like this in their life, but ultimately it is a call that only the addict can make for themselves. There are tons of different sources and tests and questions out there that can be done that can

The participant is a 49 year old African American male who began using substances at the age of 13. He was diagnosed with severe alcohol, cocaine, and opioid use. The participant has been incarcerated over the past 32 years. He was recently paroled after completing eight years of a sixteen year sentence in the Illinois Department of Corrections for burglary and theft. The participant is on medications to treat HIV/AIDS and has been diagnosed with Major Depressive Disorder. He was referred to Healthcare Alternative Systems residential program through TASC as a condition of his probation.

The client met with his counselor on 05/06/2017 for his one on one session to discuss his treatment plan goals. the client has been on track with his goals and is working on his second step. the client discuss one of the things that his currently working on and that is acceptance. the client explained that he is having a hard time acceptance certain situations and things that happen in his life, and most of the time it result in him resulting to using drugs. the client as well talked about being disappointed in himself for relapsing after two years of being sober. the client reported that he didn't use the tools that were given to him from his last his was in the program, getting a sponsor and learning coping skills. the client reported that

In an effort to aid in the proper treatment recommendations for individuals presenting with substance abuse or dependence issues, the ASI was created for study purposes through the Veteran’s Administration in 1977 (McLellan et Al., 2006). It is a multidimensional assessment tool that expands its focus outside of simply substance abuse, but into other key complex domains that that either directly impact the individual’s substance abuse, or their subsequent recovery efforts (Denis, et AL., 2012). The ASI is a semi-structured assessment tool, that while it utilizes direct answers, also allows for the expansion of certain questions and the ability for assessor notes outside of provided questions, in order to allow a clearer understanding within certain domains. While I have never personally used a precise ASI assessment professionally with a client, I did notice an undeniable, almost succinct, similarity with the biopsychosocial assessment I use with clients in my position.

Xavier then reported, the applicant recovery is up and down and the reason the patient was transferred and admitted to the Norwich location was due to an altercation as the Hartford Dispensary has zero tolerance for physical violence. Since May of of this year, the applicant's UDS results are negative. Last positive result was in April for cocaine, according to the counselor. Please note, during the applicant intake, he was asked about other illicit drugs and only confirmed for use of heroin and THC, not the cocaine. The applicant's current dose at the Hartford Dispensary is 105mgs as he is being detoxed daily. His highest dose was at 145 mgs before his detoxification. The physical altercation was the applicant's first behavioral incident at the clinic. He was also on a 90 Probation for his illicit use and it would have expired in August, but due to the recent incident, he was removed from the clinic, not discharged, but transferred as mentioned before. Counselor Xavier only concern of the applicant is maintaining his

Rosa Cunningham (full name is Rosa Lee) is a 53 year old African American female client of average height, slight build, and is appropriately groomed. She has 8 children, 2 of them being female and 6 males, all adults. Rosa is a widow and reached this status after being separated from her deceased husband for many years. Rosa is currently hospitalized for pneumonia, and has been hospitalized several times in her life for diferent illnesses. Rosa’s medical history as self-reported is HIV and seizures. Rosa is a heroin addict and has been this way for several years. Rosa is involved with the local methadone clinic and receives 55mg of methadone daily. Even by receiving this daily dose of methadone, Rosa continues to use heroin. Rosa has several legal and health issues that are present also, despite which she continues to use heroin. Rosa has a lengthy criminal history to include arrests for prostitution, larceny, and selling drugs. The reason for today’s assessment is a referral made by the social worker at the hospital in which Rosa is a patient at and discharge planning is to be made for aftercare.

Mr. Goins is a 52 year old male who presented to the ED via LEO following a 4 day binge on alcohol and requesting help with his dependence. Mr. Goins reports he moved to Asheboro recently and found work, however recently lost his job. He reported a history of alcohol use and depression. Dr. Keith requested an assessment on Mr. Goins.At the time of the assessment Mr. Goins denies suicidal ideation, homicidal ideation, and symptoms of psychosis. He reports 5 days ago he became unemployed. Mr. Goins reports his fiance who is his primary support system left town to go to a doctor appointment in their home state of Georgia. He reports binge drinking for the past 4 days attempting to cope with his recent stressor. Mr. Goins reports calling his fiance last night an expressed to her he need help. He states, "I told her I felt at the time no reason to live." Further Mr. Goins stated, "I just had too much in me last night, I had about 14 of them airplane bottles." Mr. Goins denies a history of self harm. He does report a prior hospitalization for depression in Georgia. He also reports a history of attending substance abuse treatment, which was a positive experience for him.

Objectives/Progress: As the Pt. has participated in the AMS program since 8/24/16 and he has been able to maintain abstinence from all illicit drugs for 6 months straight t. Pt.'s UDS has shown no evidence of drug use or lapse/relapse. Pt. is currently in the action stage of change as indicated by reminding himself of how much progress he has made and ability to change his behavior and achieve goals during the past quarter. He has currently obtained a full-time job as a shelving installer. Patient reports as scheduled to receive maintenance medication services as instructed by AMS Doctor and attends all mandatory one therapy session once a month. He continues to share his understanding of being powerless and unmanageable over his addiction. During the next quarter sessions, Counselor will support a realistic view of change through small steps.

Problem #5 Illicit opiate use Goal(s): To become drug free Status: Active Objectives/Progress: Pt. has not done well in achieving his goal of maintaining abstinence from all illicit substance use over the last quarter as evidenced by his positive UDS. Patient’s last urine screen results indicate that opiates have been used. Pt. reported that he was able to be clean from more than 30 days but he used drugs while walking through his neighborhood. Counselor expressed concern and disappointment about his recent relapse on heroin. During last month session, Pt. recognized the danger of the situation and how he will avoid the acquaintance that offered him drug. Pt. has failed to move to Phase 1 of the AMS of DE TX program due to his four positive UDS since entering the program on 7/6/16.Counselor will meet with Pt. to examine pt.'s motivation to stay clean, how to deal with triggers in order to achieve continued abstinence, to help him recover from his recent relapse and reenter the change process.

Pt. has been in the AMS program for 2 years. Pt. has had no positive UDS results for two years. Pt. is on a dose of 150 of methadone and he is responding as expected to his prescribed medication. Pt. demonstrated responsible attitude by attending monthly AMS groups faithfully. Pt. has discontinued all illicit drugs use and now he has used financial income in a more self-sustaining manner. Pt is effectively addressing this area by making regular payments as scheduled. Demonstrates treatment maturity and appropriately participating in medical treatment services. Pt. was taught calming strategies, such as relaxation and breathing techniques as indicated by previous counselor documentation. Pt. was assigned to this writer caseload and counselor

Substance Use History: The patient denies any drug or substance use except for Alcohol and Marijuana; started using in high school and everyday use.

The client is a 14-year-old Hispanic female in a residential substance abuse treatment rehabilitation center. The client participated in Cognitive Behavioral Therapy anger management group. The client was admitted to the residential program in July of 2016 for her cannabis use. She was referred by Drug Court due to her failure to comply with the program rules. The client has a past of domestic violence and defiant behavior towards her mother and not abiding by curfew.

Johnny Obrien aged 79 years, presented to the Emergency Department after a fall at the RSL, resulting in a laceration on his left elbow which required 3 stitches. He lives by himself with no family close by, and has a history of hypertension and alcohol addiction. Clinical reasoning is a cyclic process, where cues are collected and their data processed to come to a conclusion of the patient situation so that appropriate interventions can be implemented and evaluated through reflective practices which allows for further learning (Levett-Jones 2013). Applying these clinical reasoning skills in practice is important as it has a positive impact on patient outcomes, resulting in less adverse effects due to the detection of patient deterioration throughout this process to ensure safe and effective care (Levett-Jones 2010).Subjective data is information from the patient’s point of view, including their feelings, perceptions and concerns, whereas objective data is information that is observable or measurable (Delmar Cengage Learning 2015).