Pt's Urine Drug Screen Summary

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.

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.

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.

The patient was placed on HOLD to see the writer to address his non-compliance with treatment. The patient was reminded about his Step 3 of the patient engagement. According to the patient as the writer reviewed the patient case history of his no show for counseling, group attendance, and continuously AWOL, the patient only response was, " I, know." The writer then inquired of the patient efforts to engage in mental health services through ICRC. The patient admits that he haven't done the intake when the deadline was extended for the third time. The writer discussed with the patient about the risk of facing an intent to discharge due to his non-compliance and addressed alternatives such as suboxone and transferring to a clinic in Massachusetts to accommodate the work location. The patient declines the writer's suggestion as he wants to remain with HCRC-Hartford due to the positive treatment and said. " You guys really care....I do not want to be discharge.....I, mean what is the process of the intent of discharge?" The writer explained to the patient about the appeal process as his record will be reviewed by the Practice Manager to determine as to whether or not to forward with the discharge or the discharge to be overturn.

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

D-The patient was advised that her bottles are in fact suspended due to the incident that occurred on 02/08/2017 of which the patient needs to accountability of taking a second dose of her methadone even though she has taken her methadone at home. The patient admits her accountability of her actions of taking the second dose. The patient then asked about how she can regained her take home bottles of which this writer explained the policy of take home bottles, referring to the reinstatement process. The patient is referred to attend the Take Home Bottle Group on 03/9/2017 to have her bottles reinstated. Then the patient shared that she wrote a grievance letter and still plans to submit it for the Program Director to review. Furthermore, this

Pt. called this writer to report that he no longer wanted to be in the program. Pt. asked if he needs to sign a Voluntary Request for Termination. Pt. reported that he is going to stop by the clinic to pay his tx services fees. Pt. stated, "I am done wit methadone. I'll go there tomorrow and pay my bill in full." Counselor told that he needs to talk to the head nurse and to sign the AMA Detoxification Agreement tomorrow, Saturday 2/25/17. After discussing this issue with him, he still insisted that he did not want to be in the program and he wants to sign the AMA Detoxification Agreement

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

Patient states that he was on unit in April of this year. Patient states that after discharge he tried to get into a program (Salvation Army in Manhatten), but there were no beds available. Patient reports that he went back to his same enviromemtn, Jersey City and started drinking and using heroin. Patient said that he had no health insurance so he was unable to fill his prescription. Patient reports that he applied for Medicaid and is currently waiting to see if he is going to be approved. Patient stated that he would like to go to Meadowview in Seacucus. Patient states that he reason why he uses is to self-medicate because he has no insurance. Patient stated that he would like to get into long-term rehab that does not require him

Mr. Barreto has a substance abuse history which includes abuse of marijuana, methamphetamine and cocaine. He began using marijuana at 15, cocaine at 16 and methamphetamine at 17. He cited his use of marijuana as an every other day occurrence, however his cocaine and methamphetamine use was more frequent. He reported that he prefers cocaine over methamphetamine and used both these substances interchangeably based on availability. His use stemmed from his involvement in construction and needing to be productive and alert at all times. Mr. Barreto denied any history of substance abuse treatment aside from RDAP. He identifies this substance as truly problematic and detrimental to his functioning. According to Mr. Barreto, he has been clean and

Counselor met with Pt. for an individual session. Counselor and Pt. discussed her progress in treatment and description of her medication compliance. Pt. reported wanting a higher dosage of methadone to side effects (cold). Pt. mentioned that she would like to switch to Vivitrol medication because she is going to move with her mother house in Lewes, DE and she cant come to the clinic everyday. Pt. requested, discussed and completed an AMS Modality Switch form. Counselor encouraged Pt. to talk about her current triggers and possible solutions she can plan ahead of time. Pt. stated, "I have no triggers." Counselor elicited the client’s perceptions on her several positive urine analysis. Pt. indicated that she use crack cocaine when she is depressed.

Participant was informed that the team is concerned with his ability to remain safe in the community. Participant has been engaging in risky behaviors that endanger him, staff as well as the continuation of his waiver services. Participant has been obtaining marijuana illegally from unknown sources despite his ability to obtain marijuana legally for medicinal purposes.

The client for this paper is a twenty-seven-year-old single mother to a six-year-old son. The client was raised in a hardworking middle class family in which her father built a successful business. Her parents divorced when she was ten years old, and she reports she never heard them argue before they announced to the family they were separating. The client describes the divorce as “ugly.” She started smoking marijuana with her friends at the age of fourteen which led to her opioid intravenous addiction by the age of eighteen. The client’s drug of choice is hydrocodone. She admits she has never tried to abstain from her drug use and has been arrested over twelve times as a result of her addiction. Her last drug charge resulted in a six-year prison sentence at the age of twenty-three. The client is currently court ordered to successfully complete an in-patient drug treatment program for up to eighteen months. If she successfully completes the program, she will be released two years early from her sentence. The client has been diagnosed with 304.00 (F11.20) Opioid Use Disorder – Severe which continues to make her eligible for treatment. Client is Hepatitis C positive.

Client is attended 10 out of 13 groups and missed 3 of them during the month of March, 2017. UA collected on 03/06 was positive for alcohol use. Client admitted 03/18/17 as his last day of alcohol use. Client appears to struggle to maintain his sobriety. Relapse prevention and ways to comply with treatment and court mendates were discussed. Client reported that he started taking Disulfiram 250 mg (Medication for alcoholism) on a daily basis to manage his cravings. Client also reported that he will try to attend self-help meeting daily. Client may benefit from a brief inpatient placement due to continued alcohol use.

Objectives/ Progress: As the Pt. has participate in the AMS Program, he has discontinue his opiates use and his UDS results indicate no evidence of ongoing abuse. Pt. demonstrated treatment maturity and appropriate control of emotions but he has never earned take home privileges because he likes to smoke marijuana and he is self-medicating with the drug as a way to battle depression and anxiety. Pt. does not want to discontinue his marijuana use. Pt. has refused to find and obtain mental health services during previous tx quarters. Patient has experienced treatment regression due to failing to attend November monthly counseling session and receiving an AMS Notice of Counseling Non-Compliance letter. Patient reported daily as instructed by AMS staff and AMS Doctor to receive prescribed daily maintenance medication. Primary Counselor will encourage Pt. to reflect on the negative aspects of his bad habit and the positives associated with giving marijuana up (or reducing). Counselor will be aware that Pt. may doubt that the long-term benefits associated with