Welcome to this lesson, where we work to put everything we know about the patient into an actual treatment recommendation. At this point, you know how to screen patients, diagnose them, and even collect a thorough substance use evaluation. But now what? Often, this is where students get stuck. In this lesson, you will review how to help make sound treatment recommendations for your patients. Admittedly, there are various factors that can make this seem complicated. But if you can learn to focus on a few basics then it actually becomes pretty simple. So let's jump into a case that illustrates how you can combine your patient's response to RIPTEAR questions with what you know about treatment settings. Annabeth is a 37 year-old female and you are seeing her in your clinic for management of hypertension. When you ask her current address, she starts to tear up and she tells you she has no place to live. With little prompting, she shares that she spends all her money on cocaine. She's restless, hungry, her body aches all over, and her desire for cocaine is really intense. For the sake of this lesson, assume you've asked her the diagnostic questions and she meets enough criteria to qualify as severe Cocaine Use Disorder. Your job now is to gather enough information to be able to decide what treatment setting would be best for her. So let's jump in and go through RIPTEAR. Let's start with risk. From what you've heard from Annabeth, do you think the risk is high? We can deduce that Annabeth is at risk for trauma given that she's homeless, she's a female, she has no money, and will likely put herself in harms way to obtain more cocaine if she doesn't enter treatment. Cocaine withdrawal isn't life threatening in and of itself. Cocaine withdrawal can lead to profound depression and suicidality. So you ask her a follow-up question about suicidality, and she tells you that yes, lately she's been having more thoughts that may be she'd be better off dead than to continue living this way. So here is our first decision point. Is the risk high? If yes, refer to urgent care setting. If no, continue through RIPTEAR. In Annabeth's case, yes, the risk is high. Given her cocaine use disorder with associated suicidality. So you encourage her to go to the nearest emergency room for evaluation and referral to the appropriate substance use treatment setting from there. But let's not stop here. What if Annabeth denied suicidality. What if she explained that she would never harm herself for religious reasons and also because of her family. Let's proceed with your RIPTEAR assessment. For all of these RIPTEAR responses, keep the question what treatment setting might be best suited for her in the back of your mind. Think of this as a spectrum. In general, if people are on the low complexity end of the spectrum, then peer or outpatient treatment alone might be sufficient. But if the answers to RIPTEAR point to more severity or complexity, then you're going to think about residential treatment or long-term recovery housing. Back to RIPTEAR. Next up is I for initiation where you want to understand the timeline or the course of her substance use. In general, earlier onset and longer course of disease should lead you to consider intensifying treatment. Remember, people who start using in adolescents tend to have more severe disease. So when asked, Annabeth tells you that she first tried cocaine at age 18, but didn't start using cocaine regularly until age 30. In fact, between 19 and 30 years old she was employed as a truck driver and her drug use was regularly monitored. She didn't use cocaine onetime during this period. So what do you think? Is this low complexity, intermediate complexity, or high complexity with regards to initiation? I would label this as an intermediate complexity. So Annabeth began using regularly as an adult not as an adolescent and she's been using for seven years. If on the other hand, Annabeth had started using at age 13 and been using continually for 24 years, this would queue you to consider that more intensive and longer treatment might be needed. You then move on to P for pattern of use which is the what, when, where, how part of the evaluation. So when you ask the what, when, where, and how questions of Annabeth, you find out that Annabeth smokes crack daily, about $200 a day. She smokes crack and has never injected drugs. She's very ashamed to tell you that she's shoplifts, but also will trade sex for crack if she has to. Now, how will this affect your treatment choice? Is the complexity low, intermediate, or high? I would place her in the high complexity end of the complexity meter. While she's not injecting drugs which is good, she's using everyday and she's putting herself in quite dangerous situations. I'm concerned she'll end up in jail, or further sexually traumatized, or even dead without treatment and recovery. Remember, high complexity is going to be pointing to more intensive settings and longer lengths of stay. Moving on to the T in our mnemonic. In the past seven years has Annabeth ever sought out treatment? You want to know what she's tried before in order to guide your recommendation. When asked, Annabeth says that she's never received any type of treatment. Since we want to apply stepped care approach, it's helpful to know which steps have been taken before. Remember, a stepped care approach is common for chronic diseases in which patients step up from less restrictive steps if unsuccessful and step down from more restrictive steps when successful. So with this answer, where does this place Annabeth? Well, if she hasn't tried outpatient treatment, then that might be a reasonable place to start. Technically, the fact that she's never tried treatment leaves us with little information on where she falls on this complexity meter. We really don't know what intensity of treatment she would respond to. So given the stepped care model, we might consider least restrictive treatment settings. However, the reason we go through RIPTEAR and not just T is that all of these things need to be considered in totality when deciding upon treatment. Now, let's continue moving through RIPTEAR and explore the effects of her use. Annabeth's cocaine addiction has had significant effects on her life, particularly financial effects which have led to homelessness. Understanding the consequences of use can help with motivation or reasons for change. It also helps thinking about what treatment options are even feasible. In Annabeth's case, she has no means of transportation and no safe place to stay if she were to engage in outpatient treatment. These social factors or what we call social determinants of health must be considered. Beyond attempts at treatment, have there been any attempts at abstinence or periods of remission? Understanding why and when someone has attempted abstinence gives you more insight into what has motivated their attempted quitting and what might have helped or hindered abstinence in the past. When asked, Annabeth tells you that she was abstinent when she was in prison for about 18 months. These legal consequences tell you much more about her situation. On the one hand, it probably makes it that much harder for her to find work. On the other hand, however, coordinating with a probation officer might be leveraged for care. Additionally, Annabeth shares that the structure of the controlled environment was helpful to her and you can factor that into treatment options. You also know that while working for a company that regularly tested her, she didn't use even once. But now this was prior to her addiction developing, but it's information to consider nonetheless. So now we're at our last letter of RIPTEAR which is R for relapse and return to use. In Annabeth's case, you want to know what happened after prison. She tells you that she relapsed to cocaine when she ran into her dealer a few months after her release. Annabeth also shares that at that time, she was feeling angry, frustrated, and hopeless after being turned down again and again for job opportunities. Identifying points of relapse can help identify triggers and patterns to avoid when working with a patient on relapse prevention. For example, finding employment and avoiding dealers will be helpful in Annabeth's treatment planning. So what do we know about Annabeth after going through RIPTEAR? To summarize, we know she's currently homeless and has been incarcerated before. Annabeth is depressed, and experiencing intense cravings and cocaine withdrawal. She's at high risk of return to use and high risk of experiencing continued trauma without treatment. She's done well in a controlled environment of prison, but relapsed within months of release in the context of social stressors including not having a home, not having money, and not having a job. She has limited access to transportation, so getting to and from daily outpatient treatment might be difficult for her. So how do we put all of this together? Given previous success in a controlled environment and the fact that she is currently homeless, that might justify an initial residential stay in order to initiate abstinence. However, were things slightly different and Annabeth had a safe place to stay and easy transportation to the treatment facility, a trial at intensive outpatient treatment first before jumping to residential might also seem reasonable. Let's keep looking at other treatment settings and see what we think. Does peer support or going to Narcotics Anonymous alone seem reasonable? I'd strongly recommend that Annabeth is going to need more than peer support alone if she's going to break the current cycle that she's in. What about simply managing her cocaine use in a regular non-intensive outpatient office? In her case she's using cocaine, unlike medications for opiate use disorder which can be immediately effective and lifesaving, and provided in an outpatient clinic, we don't have such treatments for cocaine use disorder. The primary treatments are psychotherapy and contingency management, both of which will need to be delivered in a substance use or general mental health specialty clinic. So, again, I'd strongly recommend that outpatient treatment alone will not be enough. What about recommending recovery housing? This can be a great option for Annabeth. Generally, recovery houses require a period of recovery before entering. So we will think about it once she has some abstinence under her belt. But it's a great idea to start talking about and planning for this as soon as possible. Finally, after all of this, we have to ask Annabeth what her preferences is. We might feel strongly that she goes to a residential treatment program followed by a stay at a recovery house. But what if she has reasons for not wanting this? Perhaps she feels equally strongly that she stay local and yet there is no local residential program in the surrounding area. Annabeth suggests to you that she prefers to ask her supportive sister if she can live with her while engaging in intensive outpatient treatment. As her provider, I would applaud her willingness to engage in treatment and the thought that she's given to what might work for her. I might also ask her to consider how she will know that this plan is working and under what circumstances would she think residential treatment might be needed for her in the future? In truth, in Annabeth's case, she might have less personal choice about the next treatment's depth because it might be mandated by the terms of her probation. But it is always preferable to know what the patient wants and to try within reason to accommodate this. Stay patient-centered. This doesn't mean that we always have to do what our patients ask us to do. But it does mean that we are sensitive to their preferences, that we're respectful. Let's pause for some questions. We don't actually know what happens to Annabeth? Each of these scenarios are possible. Patients can be unpredictable. So this job requires creativity and compassion in order to persist with treatment options. Hopefully, now you feel a little bit more comfortable with the rationale behind each treatment setting option. Several options might be the right option for the patient you have in front of you. The point here is to have used your clinical reasoning skills to justify your choice.
