Drug Free Status Active Case Study

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

will schedule an appointment to discuss and create a budget plan. Patient is currently free from all illicit drugs, which has helped her Adderall medication to be more beneficial. Primary Counselor will encourage Pt. to follow through with all mental health appointments. Counselor will prompt Pt. to develop a positive self-image. Pt. has denied having any auditory or visual hallucinations during the last quarter as evidenced by group and individual session notes. Pt. has had some setback in achieving her goals of decreasing her family conflicts and resolving intimate relationship issues. Counselor will encourage Pt. to attend the AMS parenting group and share her expectations regarding having a more functional family unit. During the next quarter therapy sessions, Counselor will utilize role-playing, role reversal, modeling, and behavioral rehearsal to assist Pt. in order to develop positive ways to resolve conflict with ex-husband. Pt.’s current treatment plan goals focus on opiate use disorder, financial, mental health services and parent-child relational problems. During the upcoming quarter, current goals will continue to be

Client was considered to be in semi-compliance with treatment during this reporting period. Client attended two secheduled groups with two absences. UA were negative for all tested substances. Client reported participating in self-help meeting regularly; verification was provided. Treatment attendance needs to be improved in 30 days.

Met with client for ISP review and to discuss treatment progress. Client appeared to be stable and engaged in the conversation. Client reported that she completed the FAFSA and is planning to go to Everette Community College in the summer. Client reported no use of substances. Client reported coping with temptation by walking away from the situations. Client was reminded that her relapse potential was moderate to high at this time and that she thus would be cautioned to avoid any unintended consequences; with help and support from treatment and her family, client would make his treatment a success. Reviewed ISP in Dim.5 dated 11/29/17, reported completion on approach C, but was unable to identify which peer pressure could be positive (approach

Problem # 5 Illicit opiate use Goal(s): to be free from illicit drugs. Status: Active Objectives/Progress: Pt. has struggled with continued use of illicit drugs (marijuana, opiates and amphetamines) and his last quarter UDS reflect a pattern of heavy substance use. Pt. was encouraged to work with the medical staff to achieve a stable dosing level. Pt. is regularly taking his medication as prescribed by AMS Doctor and he stated his current prescribed methadone 90 mg is working "well". During the last quarter, Pt. made progress on developing a therapeutic relationship with his new AMS counselor for the upcoming quarter. Also, Counselor focused therapy session on establishing rapport and building trust with him. Pt. is currently in the contemplation stage of change because he more open to receiving information about his negative habits and willing to use educational interventions which he agreed with this assessment. Pt. was reinforced for any statement that reflected acceptance of his chemical dependence and acknowledgment of the negative consequences that opiates has had on his life. During the upcoming quarter, Counselor will assist Pt. to discuss and weigh the pros and cons of continuing his addictive

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.

Other services include a referral program for detox, followup counseling after base treatment has been concluded and a referral program for transitional or sober living housing. All of these services are provided by highly-trained counselors and clinicians who are highly motivated to help patients find a better way of

PATIENT ASSESSMENT The case study patient is a 41 year old female, originally from Nebraska, where her family still resides. She currently works part-time and just recently started going back to college part-time for drug counseling. The patient’s interest in drug counseling is from past recreational drug and tobacco use for over 25

D-The patient reports he is not stable at his current dose to the point he want to taper off. He expressed the need to want to get off on methadone. This writer listened to the patient vent about issues in his personal life and problematic issues with his transportation to ensure he dose daily. This writer then proceeded to discuss with the patient as to why he had entered treatment, his aspiration for his recovery process, and addressing alternatives to his barriers. The patient then reports he hasn't used any illicit drugs for three days, at which this writer commended the patient. When asked about what strategies to used to refrain from illicit drugs, he reports keeping himself busy and continue to care for his parents. The patient was

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.

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

Plan - The counselor Interventions until next review: Client is to continue current level of treatment to fulfill the court requirement. Counselor will work closely with the probation officer to help the client to complete his treatment successfully. Counselor will continue to motivate and educate to address alcohol use disorder and support remission and long-term

Client has no know history of previous treatments. Client desires treatment due to unhappiness with current life style. Client states that his longest abstinence from alcohol is 4 days, nicotine an hour, and marijuana and cocaine 1-2 years over the last 5 years. Client recognizes several triggers for drinking episodes (social anxiety, loneliness, fear, feelings of inadequacy, and guilt). Client is not experiencing any cravings for chemicals at this time (currently using nicotine). Client states he has current problems with family resentments and anger, self-esteem, and anxiety that are unresolved. At this time, potential for relapse is moderate to severe. Client a limited support network and no relapse prevention plan.

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.

In Counseling for Alcohol and Drug Abuse, the need to use different techniques is an integral part of the process. Working with an individual that is either entering into recovery or actively in recovery, the clinician must take their time with introducing the 12 Steps. The individual may not be open to the 12 Step philosophies at the onset. Addiction is very complex and actively affects the person on a daily basis; therefore, it is so important to start from the beginning of counseling to create a structured program.