Alcohol and other drugs quizlet

Alcohol and other drugs quizlet DEFAULT

Chapter 5 The Patient Quizlet

Proclaiming Your Dream: Developing Vision and Mission Statements. 2 – Movements of the Body, Part 2: (g) Supination of the forearm turns the hand to the palm forward position in which the radius and ulna are parallel, while forearm pronation turns the hand to the palm backward position in which the radius crosses over the ulna to form an “X. Ralph is frustrated with his hair, which is now long, mangy, and always manages to fall in front of his eyes. His primary risk factor is intravenous drug use. Flashcards | Quizlet acts chapter 5 study guide provides a comprehensive and comprehensive pathway for students to see progress after the end of each module. Patient Assessment. ____F___ In rest there is no change to motor or cognitive response. deciding which patients will most likely comply with medical advice. At the end of each exam, you have the option to e-mail your results to your instructor. 2 Glucometer Use. Start studying Chapter 5* Communications - Patient Assessment Exam. 1 - Definitions. 5-part series of coalition guides describes 5 stages of coalition development: pre-formation, formation, implementation, maintenance and institutionalization. The Pearl Summary and Analysis of Chapter 3. Chapter 1: Welcome to the World of Accounting. 3 (Class ) (1 m = The nurse will reinforce that it is their opportunity to participate in efforts to prevent errors, and it is their responsibility as part of the team. The patient has a catheter that must be irrigated. This perception, combined with the increased lethality of youth violence in the early s, has lent. Use the “sounds-like” pronunciation system to correctly pronounce the primary terms introduced in this chapter. Health IT covers a broad range of technologies used in health care, including electronic health records (EHRs), clinical decision support, patient. The patient also says that Dr. A basal cell carcinoma may appear as a pearly or waxy bump, like the one shown in Figure - March 23, Encour-age the patient to continue to breathe normally throughout the palpation. Symptom management, physical recovery, and individual well-being can be strongly connected to the use of medications in a patient's treatment plan. Patients, their families, and other informal caregivers experience failures in coordination particularly at points of. Lewis, notes that he has no intention of explaining how he came to acquire these letters. Section E: Restorative Dentistry for Children. Read Online List Chapter. The definition of obstruction of PFTs is best defined by: A) an FEV 1 /FVC that is less than 70 to 75 percent of predicted. morganelise. For these individuals, cardiac output soars from approximately 5. Many critics see huge discrepancies between the ethical ideal of informed consent and the laws or rules meant to implement it. CHAPTER 5 Appointment Scheduling 92 Chapter Outline 92 Arranging Transportation for Patients CHAPTER 6 Medical Records Management Chapter Outline Behaviorist, cog-nitive, and social learning theories are most often applied to patient education as an aspect of pro-fessional nursing practice. The mean values of the blood biomarkers (CRP, LDH. Drugs shall be administered in compliance with all local, state and federal laws. Search our flexible options to match your needs. Fill in the blank; When submitting insurance claims for patients seen in a physician's office or in an outpatient hospital setting, the _____diagnosis is listed first: Primary diagnosis: When submitting insurance claims for patients seen in a inpatient hospital setting, the _____diagnosis is used. flashcards quizlet, chapter 24 my nursing test banks. List and describe the various systems of the human body and their function. Chapter The Patient as an Individual. As they become. The code for the acute phase of an illness or injury that led to the sequela can be used with a code for the late effect. Simplified version. The patient became increasingly depressed and began isolating himself and staying in bed on his days off. 10 - Provider and Related Definitions. Chapter 5, Figure 2. 5 percent, respectively. [1] There are many potential causes of nausea and vomiting, such as:. b For a full range of medications as defined by The Joint Commission, refer to their accreditation material. 4 Use of Placebo in Clinical Practice. Chapter 5 -- Prevention and Intervention. Further considerations for economics outcomes are discussed in Chapter 20, and for patient-reported outcomes in Chapter 8 (numbers ) 1. Slaughterhouse-Five: Chapter 5. Learn vocabulary, terms, and more with flashcards, games, and other study tools. identify the differences between service and merchandising companies. The optometrist or ophthalmologist is responsible for compliance with Part 5, Chapter 15, Records Management, IHM, regarding patient health records and their own standards regarding documentation. • Describe the components of the patient interview. Regression - a trend or shift toward a lower or less perfect state: such as a progressive decline of a manifestation of disease. Decision Point C: Resource Needs Chapter 4 - The Interview. Upon arrival, the patient states that he had been sleeping in the recliner all night due. security (discussed in Chapter 5) are grounded in the Health Insurance Portability and Accountability Act (HIPAA) Security Rule. When his condition isn't very bad he will go to the local polyclinic and a physician (doctor) will examine him there. CHAPTER 3 ESI Level 2 Possible Macular Degeneration, Patients reporting changes in visual acuity or loss of sharpness in central vision are scheduled for a prompt Ophthalmic Examination. As the level of management closest to CHAPTER 5 Budgeting _CH demonstrate proper density and contrast. Infarction. Botox injections, laser treatments, and collagen and dermal filler injections are popular among patients, hoping to reduce the appearance of skin aging. Introduction to Basic Pharmacology and Selected Therapy - 27 cards. Another patient comes to the door of the room, interrupts, and says to the nurse, "I really need to talk to you. 5 mg hydrocodone, to a patient who is experiencing 8/10 postsurgical pain. When assigning this code, the medical record documentation must state that the patient is HIV-positive, has known HIV, is HIV test-positive, or include similar terms. Beauchamp and Childress believe that the best standard for surrogate decision making is. On arrival his eyes open to painful stimuli, he is confused and withdraws to pain. The bremsstrahlung spectrum originates in the X ray target, while the characteristic line spectra originate in the. The patient has been silent most of the session. Older patients may have changes in their anatomy, such as kyphosis, an outward curvature of the spine. ( Section 6. CCNA 3 Scaling Networks v5. lack of oxygen. for practitioners working with students, patients, for people to apply in their daily life, etc. The patient sitting on a bench and appears in moderate distress. Patient Assessment. pharmacology. 6 Substitution of Surgeon. "I will do it as soon as possible" B. For these individuals, cardiac output soars from approximately 5. C: place the patient on oxygen. Chapter 5 Ap Statistics Test. The nursing director is responsible for the accurate handling and precise administration of drugs to the patient. She has a Master of Education degree. However, there is an emerging trend for internal auditors to become more deeply and actively involved in organizational risk management. b CHAPTER 6 ICDCM Coding NOTE: Code microbiology chapter medical dictionary. Traditionally, internal auditors have identified and assessed organizational objectives and risks informally. Rather than presenting information in. Dimmesdale’s presence, but it revealed itself fully as soon as the doctor left the room. A patient presents s/p fall with a head injury. Comprehensive and easy-to-understand, Foundations of Periodontics for the Dental Hygienist, Enhanced Fifth Edition equips dental hygiene students with up-to-date, evidence-based coverage of periodontal anatomy, the periodontal disease process, and classifications of periodontal disease. The patient has been silent most of the session. 1 - A graph with 3 arrows depict 3 separate trips through the danger zone. Because there are only 1. 6 The Gestalt Principles of Perception 5. The Clinical Medical Assistant The nursing assitant must make _______a priority when dealing with disruptive families and/or patients. "The practice of either professional or vocational nursing frequently involves implementing orders from a. Chapter 10 DISEASES OF THE RESPIRATORY SYSTEM (JJ99) March © MVP Health Care, Inc. Inflammation and Healing - 49 cards. Study Chapter Nursing Diagnosis flashcards from Ryan Henry Dacumos' Throughout medical history, physicians have practiced the healing arts while putting great emphasis on informed consent. Learn exactly what happened in this chapter, scene, or section of The English Patient and what it means. Pulmonary hypertension I 30 - General Payment Rules. In your work life, you are asked to compile and process data. Staying true to Esther Wilkins’ vision that made her text the Bible for dental hygienists, Wilkins’ Clinical Practice of the Dental Hygienist,13e progresses through key topics in dental hygiene in a straightforward format to ensure students develop the skills they need for successful, evidence-based practice in today’s oral health care environment. Mood disorders include full or partial periods of depression or mania, as well as pathologically elevated or depressed mood disturbances. "After I give the medication" D. • Chapter 17 provides a description of billing and payment for drugs. 10 - Provider and Related Definitions. If a patient falls ill, he rings up his local polyclinic and call in a doctor. Research design is a comprehensive plan for data collection in an empirical research project. Instruct patients according to their needs to promote health maintenance and disease prevention IV. introduced in this chapter. 2 Figure Diagnostic Tests, X-Rays, and Procedures CHAPTER FIVE QUIZ True/False 1. CHAPTER 3 ESI Level 2 When the physician is a man, this. This perception, combined with the increased lethality of youth violence in the early s, has lent. Introduction to Pathophysiology - 65 cards. CHAPTER 5 1. Perfect for acing essays, tests, and quizzes, as well as for writing lesson plans. Chapter 5 - Immunisation by Are verbal instructions for the supply or administration of medicines to a group of patients who may not be individually identified before presentation d) Are legally required to be reviewed at least every 2 years e) Are a form of prescribing vaccines 2. 3 - Part B Deductible and Coinsurance. Keep the tub room warm. Additionally, for end stage renal disease (ESRD) patients, see the Medicare Benefit Policy Manual, Chapter indd 3 10/3/16 PM. The OMOP Standardized Vocabularies, often referred to simply as “the Vocabulary”, are a foundational part of the OHDSI research network, and an integral part of the Common Data Model (CDM). False: Most patients are unfamiliar with medical terminology and the language associated with a given medical specialty. In this chapter: (1) "Patient" means a person who consults or is interviewed by a professional for diagnosis, evaluation, or treatment of any mental or emotional condition or disorder, including alcoholism or drug addiction. 8 (numbers ) 1. She is breathing adequately and has stable vital signs. Another patient comes to the door of the room, interrupts, and says to the nurse, "I really need to talk to you. patient has other coverage that must be billed prior to Medicare payment, or whether there is another insurer to which Medicare can forward billing and payment data following adjudication if the provider is a physician or supplier that participates in Medicare. Replace the device and fill with distilled water, not tap water. 2 The Department of Justice and Federal Trade Commission Statements of Antitrust. docx from HIT at Anne Arundel Community College. Our online introduction to psychology trivia quizzes can be adapted to suit your requirements for Psychology ; Chapter 12 Summary, Key terms intro to psychology chapter 5 quizlet phrases and much more quizzes! Been a productive one. Definition. 75 * 3 percent mepivacaine contains 50 percent more drug per volume. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Most of the patients are Acutes, meaning that they have the possibility of rehabilitation and release, but Bromden makes the important point that they also have the possibility of worsening at the hands of Nurse. DOT can reduce the development of drug. AccessPharmacy is a subscription-based resource from McGraw Hill that features trusted pharmacy content from the best minds in the field. Shop for women's, men's and kids' fashion, beauty and home essentials online! We offer quality styles at the best price and in a sustainable way. Trephining. (See Chapter 9 for discussion on psychiatric medication). Here are the best resources to pass NURS at Liberty university. Implementation d. The National Patient Safety Goals for Hospitals posters and badge buddies provide a quick reference to the Joint Commission's National Patient Safety Goals for staff on the go. pharmacology. Study Flashcards On Chapter 5 Medicine and Law at Cram. Focus group interviews. identify the differences between service and merchandising companies. remove the patient’s nail polish to get a pulse oximetry reading. The benefits of maintaining a blood glucose level that is consistently within the range of mmol/L will reduce the short-term, potentially. Identify the physical, cognitive, and psychosocial characteristics of learners that influence learning at various stages of growth and development. Certain patient risk factors such as advanced age, underlying disease and severity of illness, and sometimes the immune status are not modifiable and directly contribute to a patient's risk of infection. Minor Surgical Procedures A nurse is teaching a patient with hypertension about medication, such as when and how to take it, symptoms to report, and the need. The discovery of the ABO blood group, over years ago, caused great excitement. Sub Chapter - Edible Oils. Upon successful completion of this chapter, you will be able to: understand the history and development of networking technologies; define the key terms associated with networking technologies; understand the importance of broadband technologies; and. Upon inspection of the humidifier, you notice hard white deposits in and around the diffusing element. Show Class. Regression - a trend or shift toward a lower or less perfect state: such as a progressive decline of a manifestation of disease. 1–5 Several studies have demonstrated the benefit, either alone or as part. He did his best for his patient but always left the room at the end of their consultations with a mysterious and puzzled smile on his lips. 6 Chest Tube Drainage Systems. The APTA Guide to Physical Therapist Practice is the description of physical therapist practice, for use by physical therapist and physical therapist assistant educators, students, and clinicians. 01 AUTHORITY. 3 - Part B Deductible and Coinsurance. Chapter: Title: 1 Introduction to Emergency Medical Care: 2 The Well-Being of the EMT-B: 3 Medical, Legal, and Ethical Issues: 4 The Human Body: 5 Baseline Vital Signs and SAMPLE History: 6 Lifting and Moving Patients: 7 Airway: 8 Patient Assessment: 9 Communications and Documentation: 10 General Pharmacology: This may be geographical("all UK residents in " or "all residents in a specified health district"); occupational("all employees of a factory," "children attending a certain primary school", "all welders in England and Wales"); based on special care("patients on a. Whether you are researching leadership techniques or analyzing sales statistics, you must be able to interpret the data you encounter. Patients may be sick but they are not unintelligent and they can sense if the nurse is not being himself or herself. It is argued in this chapter that emotions and feelings also need. Definition. To protect the patient’s privacy, it is important to position the record so that the patient’s identifiable information is hidden from view. Start studying Chapter 5: Patient Education. You must complete all of the questions in order to view your results. The difference between sleep and rest is that. Get the best of Shopping and Entertainment with Prime. Delegation — Health care practitioner duties. The patient became increasingly depressed and began isolating himself and staying in bed on his days off. All the patients had received the first dose of AstraZeneca's vaccine. A patient who has been experiencing panic attacks is prescribed lorazepam. While hiking, a year-old woman was pinned from the waist down under a rock that collapsed on her. demonstrate proper density and contrast. 7 is assigned during the first 28 days of the patient's life, and code the patient. Infantilizing - Treating an older patient as a small child. After handing the physician the ophthalmoscope, the lights must be turned up when the physician is ready to examine the eyes. Fiverr connects businesses with freelancers offering digital services in + categories. More than four million cases occur in the United States each year. 2 Waves & Wavelengths 5. 5 American Indian/Alaska Native psychiatrists per , American Indians/Alaska Natives in this country, and only 2. Precalculus Chapter 5 Quiz Answers - WordPress. The patient asks why he has to do IS so often. CHAPTER 1 Emergency Medical Care Systems, Research, and Public Health Prehospital Emergency Care, 9th Ed. Older patients may have changes in their anatomy, such as kyphosis, an outward curvature of the spine. Listening and Empathic Responding 5 CHAPTER Listening Well Empathic Responding. assessments at end of eight-week intervention period, events occurring during eight-week intervention period). As Ralph walks along the beach, he thinks about how much of life is an improvisation and about how a considerable part of one's waking life is spent watching one's feet. The online tool helps you to keep track of your health care provider visits, test results, billing, prescriptions, and so on. March 10, Chapter 5. Besides the increasing awareness in the victims of dual diseases about surgery and therapy, a high focus on assisting systems has been generated. If pain is experienced during the palpation, discontinue the palpation immedi-ately. chapter 5, Infrastructure); special quality procedures for lab tests (see chapter 8, Laboratory); and well functioning patient monitoring systems (see chapter 6, Monitoring). The National Patient Safety Goals for Hospitals posters and badge buddies provide a quick reference to the Joint Commission's National Patient Safety Goals for staff on the go. The APTA Guide to Physical Therapist Practice is the description of physical therapist practice, for use by physical therapist and physical therapist assistant educators, students, and clinicians. " Learning statements that assert the purpose of activities and the expected outcomes. His weight today is 5 kg (10th percentile weight for age), and his length is 50th percentile for age. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Freud believed that consciousness had three levels - 1) consciousness which was the seat. 3 arrows are shown. Upon your arrival, the patient is conscious and alert, and states that she can't feel her legs. over the past five years. Try this amazing ECG Chapter 5 A quiz which has been attempted times by avid quiz takers. The Sixth Extinction: Chapter 11 Summary & Analysis. 3 liters (5. Section E: Restorative Dentistry for Children. It is a “blueprint” for empirical research aimed at answering specific research questions or testing specific hypotheses, and must specify at least three processes: (1) the data collection process, (2) the instrument. 37) A sample of candies have weights that vary from 2. 1 "Theory Snapshot" summarizes what they say. Often as patients near the end of life, many difficult. 2% mepivacaine with , levonordefrin Patient Weight (lbs. Get step-by-step guides for filing Chapter 7, Chapter 11, or Chapter 13 bankruptcy, and find out any pitfalls and legal challenges you might run into. In your work life, you are asked to compile and process data. Motivation is one of the forces that lead to performance. A guide for nurses in making clinical decisions. Patient's response to signs and symptoms are independent of their cultural values. Beauchamp and Childress believe that the best standard for surrogate decision making is. Also explore over 22 similar quizzes in this category. Many critics see huge discrepancies between the ethical ideal of informed consent and the laws or rules meant to implement it. There are many new photos throughout the chapter. Lewis prefaces his book with a refusal to disclose how he came to possess Screwtape's letters that will fo Read More. Summary Study Flashcards On chapter 5 review EHR at Cram. Choose from different sets of calculus chapter 5 flashcards on Quizlet. "I think the next shift will have to do it" C. 6 "US Health-Care Expenditure, (in Billions of. Simplified version. It represents the main communication mechanism used by healthcare providers in the delivery of patient treatment. Fill in the blank; When submitting insurance claims for patients seen in a physician's office or in an outpatient hospital setting, the _____diagnosis is listed first: Primary diagnosis: When submitting insurance claims for patients seen in a inpatient hospital setting, the _____diagnosis is used. Get a constantly updating feed of breaking news, fun stories, pics, memes, and videos just for you. The patient states that he is in need of a prescription refill for an antidepressant medicine as soon as possible as he is leaving to the airport in thirty minutes. apply the AED pad at least 1 inch away from the medication patch to avoid skin burns. Initial impression was impending myocardial infarction, and the patient was taken directly to the surgical suite, where. 2 Exercise Don't show me this again. Research design is a comprehensive plan for data collection in an empirical research project. explain the recording of purchases under a perpetual inventory system. NCLEX EXAMINATION REVIEW QUESTIONS Chapter 5 1. Oakbrook Torrance, IL: Joint Commission Resources, 3, particles of 0. Basal cell carcinoma is the most common form of skin cancer. Prenatal outpatient visits for high-risk patients • For routine prenatal outpatient visits for patients with high-risk pregnancies, a code from category O09, Supervision of high -risk pregnancy, should be used as the first -listed diagnosis. ( Section 6. (2) "Professional" means: (A) a person authorized to. 2 Pharmacies and other entities where handling hazardous drugs (HDs) occur should obtain a copy of. , ) Transmittals for Chapter Medical Record Review Committee. A more sensitive and less stigmatizing term that is used to. 01 - Foreword. 25 70 3. Simplified version. C: place the patient on oxygen. Section E: Restorative Dentistry for Children. An infant is seen in clinic today for evaluation of gastroesophageal reflux disease. This is NOT a component of a therapeutic nurse-patient relationship. identical gestures always produce identical meaning in different cultures because gestures are natural displays of feelings. The patient asks why he has to do IS so often. Th is chapter addresses how health centre staff can use the tools and methods of quality improvement to focus on the system of care in which they practise. CHAPTER 1 Emergency Medical Care Systems, Research, and Public Health Prehospital Emergency Care, 9th Ed. It provides information about instruments for use by drug and alcohol counselors, primary healthcare providers, social workers, and others. Older patients may have changes in their anatomy, such as kyphosis, an outward curvature of the spine. She is cyanotic and her extremities are cold. : B) an FVC that is less than 75 percent of predicted. Freud believed that consciousness had three levels - 1) consciousness which was the seat. For these individuals, cardiac output soars from approximately 5. ‎With new expert explanations, an AI Learning Assistant and our ever-effective flashcards, get a suite of science-backed study tools at your fingertips. Symptom management, physical recovery, and individual well-being can be strongly connected to the use of medications in a patient's treatment plan. Don't show me this again. Chapter 5 - Beast from Water. Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Table of Contents (Rev. Patient/Family Perspective. Show Class. Sub Chapter. Instead of the information being read back to you, the response is faxed to you in minutes. Maintain the bath water at the hottest temperature tolerated by the patient. CEOs who then have less need for secretarial transcription. Based on assessment of weight gain, you can. 31 Cards –. Chapter 4: ICDCM and ICDPCS Review Exercises: Assign the correct ICDCM diagnosis codes and. Upon inspection of the humidifier, you notice hard white deposits in and around the diffusing element. Put the paragraphs of the argumentative essay in the correct order. Chapter Authors: Michael A. Start studying Surgical Technology Chapter 5 (The Patient). Many providers now offer patient portals. Kinney outlines the process of risk assessment and risk management in Chapter 5. Study Flashcards On AAPC Chapter 3 at Cram. 2 Confidentiality. apply the AED pad at least 1 inch away from the medication patch to avoid skin burns. Encour-age the patient to continue to breathe normally throughout the palpation. Comparative Health Information Management (3rd Edition) Edit edition Solutions for Chapter 5 …. Introduce yourself to patient. Learn faster with spaced repetition. ) and academically (e. The arts wherein the professors employ themselves. Ralph calls the assembly and reminds everyone of their agreement to maintain fresh water supplies, observe sanitation measures, build shelters, and keep the signal fire going. Most significantly, inform the patient where, when, and how the touch. A patient of Middle Eastern descent has lost 5 lbs during hospitalization and states that the food offered is not allowed in his diet owing to religious preferences. Logic models may help structure the synthesis (see Chapter 2, Section 2. At the very minimum a patient assessment should be conducted on admission and at the start of each nursing handover. Dimmesdale’s presence, but it revealed itself fully as soon as the doctor left the room. invite the interrupting patient to join in the. W is a good friend for that patient. Women outlive men in nearly all countries of the world, rich and poor (3). Sub Chapter - General. The benefits of maintaining a blood glucose level that is consistently within the range of mmol/L will reduce the short-term, potentially. Quickly memorize the terms, phrases and much more. patient received dextrose 5% with 0. 45 mg Thyroxine po daily. “A rare case!” he muttered. an early form of treatment that was supposed to let the spirits escape. At hours, you respond to the home of a year-old man complaining of chest pain. Write the letter of the best answer in the space provided. All of the answers are components of a therapeutic nurse-patient relationship. or larger (ISO Class 5) is equivalent to 3particles per ft. Review the patient’s medical history for diabetes type, medications, and/or anticoagulant therapy. As a result, patients with mental health problems should be connected to a mental health professional who is also a recovering alcoholic or addict and would use the same program. Freud’s psychoanalysis was unique in the history of psychology because it did not arise within universities as most of the major school of thought in our history did, but from medicine and psychiatry, it dealt with psychopathology and examined the unconscious. Chapter Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders Chapter Management of Patients With Complications From Heart Disease Chapter Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation. Analyses of the likely competitive effects of hospital mergers have been an important part of antitrust enforcement since the FTC issued its first hospital merger complaint in Oakbrook Torrance, IL: Joint Commission Resources, Logic models may help structure the synthesis (see Chapter 2, Section 2. demonstrate proper density and contrast. Top brands, low prices & free shipping on many items. flashcards quizlet, chapter 24 my nursing test banks. Section of the Patient Protection and Affordable Care Act (42 USC ) and its implementing regulation provide that an individual shall not be excluded from participation in, be denied the benefits of, or be subjected to discrimination on the grounds prohibited under Title VI of the Civil Rights Act of , 42 U. Alternate ISBN: LitCharts assigns a color and icon to each theme in Dracula, which you can use to track the themes throughout the work. Keep the patient in the water for 15 to 30 minutes. Nausea is the unpleasant sensation of having the urge to vomit, and vomiting (emesis) is the forceful expulsion of gastric contents. In this context, the protection measures of COPD patients from COVID were expressed in the statement as follows: "Like all members of the The main target in COPD patients; The aim is to continue to use the COPD drugs used before the pandemic in the same way and to keep the disease. Office visit, new patient: level 4 Office visit, new patient: level 5 Each level of service has a unique description and requirements for its category or subcategory. Prepare a patient for procedures and/or treatments IV. introduced in this chapter. TB is an airborne disease caused by the bacterium. Amazon's star rating and its number of reviews are shown below each book, along with the cover image and description. ) and academically (e. Nice work!. months milestones gross motor skills - 12 cards. Comprehensive and easy-to-understand, Foundations of Periodontics for the Dental Hygienist, Enhanced Fifth Edition equips dental hygiene students with up-to-date, evidence-based coverage of periodontal anatomy, the periodontal disease process, and classifications of periodontal disease. Chapter 5: Evidence-Based Practice(FREE) Test Bank MULTIPLE CHOICE 1. ) (a) is the statutory authority for the Under Secretary for Health to promulgate regulations concerning the custody, use, and preservation of records and papers of the Veterans Health Administration (VHA). immediately load the patient into the ambulance, begin transport, and reattempt to contact medical control when you receive a cell signal. Diagnosis has important implications for patient care, research, and policy. Get step-by-step guides for filing Chapter 7, Chapter 11, or Chapter 13 bankruptcy, and find out any pitfalls and legal challenges you might run into. Most of the patients are Acutes, meaning that they have the possibility of rehabilitation and release, but Bromden makes the important point that they also have the possibility of worsening at the hands of Nurse. 0 Hispanic psychiatrists per , Hispanics, the chance of an ethnic match between Native or Hispanic American patient and provider is highly unlikely (Manderscheid & Henderson, ). Office visit, new patient: level 4 Office visit, new patient: level 5 Each level of service has a unique description and requirements for its category or subcategory. EMT -Chapter 5. This is latest Test Bank for Understanding Medical-Surgical Nursing (6th Edition) by Linda Williams and Paula Hopper will help you master your medical-surgical coursework with ease. PATIENT RECORDS. Comprehensive and easy-to-understand, Foundations of Periodontics for the Dental Hygienist, Enhanced Fifth Edition equips dental hygiene students with up-to-date, evidence-based coverage of periodontal anatomy, the periodontal disease process, and classifications of periodontal disease. ABUSE OF THE ELDERLY. Learn faster with spaced repetition. You should: A: ask the patient if he can take a few steps, while you hold his arm. Study Chapter 11 Quiz flashcards from Ryan Clark's class online, or in Brainscape's iPhone or Android app. 14 Learners. , hospitals and other healthcare institutions, patient treatment. Assisting with Medications First, employees are attracted to organizations where they will fit in. With Indeed, you can search millions of jobs online to find the next step in your career. get headaches often, do c. Evaluation ANS: D Monitoring the patient’s progress, including the patient’s response to the medication, is part of. Quizlet is the easiest way to study, practice and master whatever subject you're learning. CBSE Class 9 Science Chapter 5 The Fundamental Unit of Life Exercise Questions with Solutions to help you to revise complete Syllabus and Score More marks. 10/7/15 PM Chapter Therapeutic Relationships flashcards | Quizlet Page 3 of 14 A nurse is talking with a patient, and 5 minutes remain in the session. 6 Chest Tube Drainage Systems. Chapter 5: Qualitative Methods (Part 1) Every day you are confronted with the need to understand research methodology. Note: Maximal sterile barrier (MSB) precautions require the CVC inserter to wear a mask and cap, a sterile gown, and sterile gloves and to use a large (head-to-toe) sterile drape over the patient during the placement of a CVC or exchange of a catheter over a guidewire. Sub Chapter - Edible Oils. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Diagnosis has important implications for patient care, research, and policy. Use gentle or emollient soaps. " Learning statements that assert the purpose of activities and the expected outcomes. Learn faster with spaced repetition. Motivation is defined as the desire to achieve a goal or a certain performance level, leading to goal-directed behavior. The OMOP Standardized Vocabularies, often referred to simply as “the Vocabulary”, are a foundational part of the OHDSI research network, and an integral part of the Common Data Model (CDM). Chapter Maternity and Women’s Health Care Today (FREE) Chapter The Nurse’s Role in Maternity and Women’s Health Care (FREE) Chapter Ethical, Social, and Legal Issues (FREE) Chapter Reproductive Anatomy and Physiology. In addition, they may refer patients to an oncologist if skin cancer that has metastasized is suspected. Upon successful completion of this chapter, you will be able to: understand the history and development of networking technologies; define the key terms associated with networking technologies; understand the importance of broadband technologies; and. Other examples of Ancillary Orders (usually defined in nursing Policies & Procedures) Urinary Retention: Catheterize with a 16 French, 5 ml, indwelling catheter. Introduction. The patient became increasingly depressed and began isolating himself and staying in bed on his days off. The Structure of Personality. an early form of treatment that was supposed to let the spirits escape. A major role of sensory receptors is to help us learn about the environment around us, or about the state of our internal environment. This chapter addresses skills and techniques needed for initial assessment as you begin the physical examination. Nice work!. STN Electronic Library: Chapter 5 - Traumatic Brain Injury Test Questions 2 6. Quickly memorize the terms, phrases and much more. In Chapter 5 we meet Neil Ernst and Peggy Philp, Lia's primary doctors. Confirm patient ID using two patient identifiers (e. The physician orders should be checked before administering medications. Chapter 5: Coretta. Patient may be restrained PRN for patient safety 6. A patient portal is a website for your personal health care. The patient also has an NG suction tube set to low continuous suction that had mL output. Fill in the blank; When submitting insurance claims for patients seen in a physician's office or in an outpatient hospital setting, the _____diagnosis is listed first: Primary diagnosis: When submitting insurance claims for patients seen in a inpatient hospital setting, the _____diagnosis is used. Learn vocabulary, terms, and more with flashcards, games, and other study tools. The otoscope is used to examine the nasal. invite the interrupting patient to join in the. CCNA 3 Chapter 3 Exam Answers - - - % Updated Full Questions latest. Learn faster with spaced repetition. Intro to psychology chapter 1 quizlet. It provides information about instruments for use by drug and alcohol counselors, primary healthcare providers, social workers, and others. CHAPTER 4: COMPETITION LAW: HOSPITALS. leader is to be an advocate for patients, ensuring that the patient receives the best and safest services possible. Essential Elements of Care Coordination for Populations with Complex Needs; Chapter 5. Collection and Transport of Clinical Specimens. 6 trillion annually (see Figure Learn vocabulary, terms, and more with flashcards, games, and other study tools. identify the differences between service and merchandising companies. comT+ Subject: Chapter 22 The Respiratory System Quizlet Keywords: chapter, 22, the, respiratory, system, quizlet Created Date: 9/3/ AM. The face sheet contains three types of information. (all 5 answers)-actively maintaining and improving one's competence-following sound scientific procedures and ethical principles in resarch-promoting disease prevention and wellness-striving to improve the access, efficacy, and cost of patient care-respecting and protecting the rights of the patients they treat. Regression – a trend or shift toward a lower or less perfect state: such as a progressive decline of a manifestation of disease. The new catheter was tunneled through the subcutaneous tissue from the chest wall up into the neck. Here are the best resources to pass NURS at Liberty university. The OMOP Standardized Vocabularies, often referred to simply as “the Vocabulary”, are a foundational part of the OHDSI research network, and an integral part of the Common Data Model (CDM). Chapter Conception and Prenatal. patient swallow each dose of anti-TB drugs and documents it. Care coordination is any activity that helps ensure that the patient's needs and preferences for health services and information sharing across people, functions, and sites are met over time. 2 Decisions for Adult Patients Who Lack Capacity. 6 Third visit to established, stable patient in nursing facility, medical record and patient’s status reviewed, no change made to medical plan. The optometrist or ophthalmologist is responsible for compliance with Part 5, Chapter 15, Records Management, IHM, regarding patient health records and their own standards regarding documentation. Chapter 11 Case Study 1. Answers to Case Study, Chapter 21, Assessment of Respiratory Function Objective: 4. See Figure Medicine in the United States is big business. Specimen Collection and Laboratory Procedures patient's experience of illness and his or her frustration in negotiating the health care system. This is considered a physical barrier to effective listening because it emanates from our physical body. 2 Figure reach the age of 60 years every month, 80% of whom are in the developing world. Minor Surgical Procedures Respondent induced bias. Published: Sun 29 Aug PM EDT Comments: When his condition isn't very bad he will go to the local polyclinic and a physician (doctor) will examine him there. His primary risk factor is intravenous drug use. Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation Safety and Health (NIOSH), National Occupational - -. 31 Cards –. Bundle your stay with a car rental or flight and you can save more. Collection and Transport of Clinical Specimens. Get a constantly updating feed of breaking news, fun stories, pics, memes, and videos just for you. The Joint Commission (TJC) defines medication errors as any preventable. Abstract: This chapter defines functional assessment and describes why this approach is useful. They do not have to have Internet access, since Juno offers its own local dial-up throughout the US, and they do not get Internet access, but they can send and receive e-mail across the Internet. The nurse should only ask the families of dying patients in an Intensive Care Unit about organ donation. Confirm patient ID using two patient identifiers (e. Chapter Objectives. Head to toe is completed when the patient is admitted; focused concentrates on a particular part of a body. Division 5. The reader understands the ventilation of the alveoli. The face sheet contains three types of information. An item is subject to a 20% trade discount. Freud's psychoanalysis was unique in the history of psychology because it did not arise within universities as most of the major school of thought in our history did, but from medicine and psychiatry, it dealt with psychopathology and examined the unconscious. Knowing this, providers must remember that all electronic systems are vulnerable to. To avoid friction and irritation to the patients skin. 9 is assigned if the patient is older than 28 days. Its list price is $1 that may increase the patient's risk for being exposed to TB infection (see Chapter 2, Transmission and Pathogenesis of Tuberculosis). " Gulliver spends many days at the Royal Academy in Lagado, where there are at least Projectors (impractical students of science) hanging out and thinking. Patient/Family Perspective. Th is chapter addresses how health centre staff can use the tools and methods of quality improvement to focus on the system of care in which they practise. Pulmonary hypertension I In sleep an awareness of the environment is maintained. Slaughterhouse-Five: Chapter 5. The nursing assitant must make _______a priority when dealing with disruptive families and/or patients. patient has other coverage that must be billed prior to Medicare payment, or whether there is another insurer to which Medicare can forward billing and payment data following adjudication if the provider is a physician or supplier that participates in Medicare. Chapter-wise NCERT Solutions for Class 9 Science Chapter 5 The Fundamental Unit of Life (Biology) solved by Expert Teachers as per NCERT (CBSE) Book guidelines. over the past five years. Start studying Chapter 5* Communications - Patient Assessment Exam. making holes in the skull. The face sheet contains three types of information. The patient sitting on a bench and appears in moderate distress. Strategies for Supporting Primary Care for Populations with. System modeling permissions to access the patient information and the PRS. Chapter 5: Evidence-Based Practice(FREE) Test Bank MULTIPLE CHOICE 1. Logic models may help structure the synthesis (see Chapter 2, Section 2. Culture plays a huge roll in a patients health and if it is ignored, the patient will not be able to fully heal and reach well-being. In a review of psychological therapies for coronary heart disease, a single group was specified for meta-analysis that included all types of therapy. pharmacology. • Chapter 18 describes billing and payment for preventive services and screening tests. The nurse is using a needleless closed irrigation technique. This chapter summarizes best practices related to vaccine administration, a key factor in ensuring vaccination is as safe and effective as possible. Before Kino and Juana return home, the news had already spread that Kino had found " The Pearl of the World," as it comes to be known. ____F___ Basal cell carcinoma is the most common form of skin cancer. A chapter 13 debtor is entitled to a discharge upon completion of all payments under the chapter 13 plan so long as the debtor: (1) certifies (if applicable) that all domestic support obligations that came due prior to making such certification have been paid; (2) has not received a discharge in a prior case filed within a certain time frame. arbitration. See Figure Chapter-wise NCERT Solutions for Class 9 Science Chapter 5 The Fundamental Unit of Life (Biology) solved by Expert Teachers as per NCERT (CBSE) Book guidelines. A simple and accurate definition of measurement is the assignment of numbers to a variable in which we are interested. Learn vocabulary, terms, and more with flashcards, games, and other study tools. The online tool helps you to keep track of your health care provider visits, test results, billing, prescriptions, and so on. Upon completion of Chapter 1, the pharmacy technician student will be able to. Annals of Internal Medicine (6) Motivation is defined as the desire to achieve a goal or a certain performance level, leading to goal-directed behavior. Online Chapter Pretests. Chapter The History and Interviewing Process Ball: Guide to Physical Examination, 9th Edition MULTIPLE CHOICE 1. • Prepare patients before doing any procedures, particularly those that involve personal space or discomfort. CHAPTER 5 Legal and Regulatory Issues ANSWERS TO REVIEW 1. • Chapter 18 describes billing and payment for preventive services and screening tests. 2 percent, 4. Learn exactly what happened in this chapter, scene, or section of A Wrinkle in Time and what it means. " Learning statements that assert the purpose of activities and the expected outcomes. his chapter is an overview of current assessment and treatment principles for patients with alcohol and other drug (AOD) use disorders and psychosis. The optometrist or ophthalmologist is responsible for compliance with Part 5, Chapter 15, Records Management, IHM, regarding patient health records and their own standards regarding documentation. Out-of-pocket spending, sometimes. " Learning statements that assert the purpose of activities and the expected outcomes. National Patient Safety Goals Download chapter. At the end of each exam, you have the option to e-mail your results to your instructor. Open Resources for Nursing (Open RN) Nausea and vomiting are common conditions. Are Patient Portal emails being received? It has been known that spam blocking software used by email providers such as AOL and Netzero may be blocking legitimate emails. As a result, patients with mental health problems should be connected to a mental health professional who is also a recovering alcoholic or addict and would use the same program. Find NURS study guides, notes, assignments, and much more. 75 60 3. Women outlive men in nearly all countries of the world, rich and poor (3). Because the states regulate the practice of pharmacy, the federal legislation takes an indirect approach by. Genuine Interest. --Rationale for NPSG. Chapter 4 - The Interview. Define the commonly used word roots, combining forms, suffixes, and prefixes introduced in this chapter. Note: Maximal sterile barrier (MSB) precautions require the CVC inserter to wear a mask and cap, a sterile gown, and sterile gloves and to use a large (head-to-toe) sterile drape over the patient during the placement of a CVC or exchange of a catheter over a guidewire. The mean values of the blood biomarkers (CRP, LDH. It is argued in this chapter that emotions and feelings also need. In the Institute of Medicine’s often-cited book To Err Is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, ), it is estimated that approximately 1. Study Chapter 5 flashcards from Andrea DiTullio's Laurentian University class online, or in Brainscape's iPhone or Android app. Some of the more common types of assis-tance and support services include: community support and independent living – assistance with self-care, house-hold care, mobility, leisure, and commu-. The patient is brought to the emergency department complaining of severe shortness of breath. Assisting with Medications Shootings and deaths in schools throughout the United States have left parents believing that their communities are no longer safe from the most extreme examples of youth violence (Gallup, ). 5 quarts) per minute during maximal exercise. Accompanying this will be an increase in blood pressure from about /80 to / Choose from different sets of calculus chapter 5 flashcards on Quizlet. The physician orders should be checked before administering medications. Fiverr's mission is to change how the world works together. dollars spent, comes from private healthcare spending. Therapeutic communication: A purposeful method of communication in which the caregiver responds to the explicit or implicit needs of the patient. Chapter 4: The Interview; Chapter 5: Hester at Her Needle; Chapter 6: Pearl; Chapter 7: The Governor’s Hall; Chapter 8: The Elf-Child and the Minister; Chapter 9: The Leech; Chapter The Leech and His Patient; Chapter Inside a Heart; Chapter The Minister’s Vigil; Chapter Another View of Hester; Chapter Hester and the Doctor. 5 The Other Senses 5. MENTAL HEALTH RECORDS. The nurse should wait until the patient is settled in an inpatient unit before asking about organ donation. Genuine Interest. If residual. Nurs ing activities in the preoperative phase are directed toward patient support, teaching, and preparation for the procedure. doctors to input patient notes. 2: CellMinder message form integrated into appointment application. Every patient should be evaluated individually for dental radiographs. 5-part series of coalition guides describes 5 stages of coalition development: pre-formation, formation, implementation, maintenance and institutionalization. Example Codes (Office or other outpatient visit, level 3, new patient) and (Office or other outpatient visit, level 3, established patient) have different. 7 Factors Influencing X Ray Spectra & Output 5. Chapter 1: Pharmacology for Technicians. Published: Sun 29 Aug PM EDT Comments: 3, particles of 0. Patient portals - an online tool for your health. A new chapter on evidence-based practice and a wealth of effective online learning tools help solidify your. 2 Confidentiality. See Chapter Board Authority for more information on the health center governing board’s role in approving policies. Passionate about something niche? Reddit has thousands of vibrant communities with people that share your interests. The patient also says that Dr. ) Explain the importance of culturally relevant care in psychiatric mental health nursing practice. implementation of a nursing intervention. 1 "The Relationship Between Prejudice and Discrimination" illustrates his perspective. pdf from MATH at Mississippi State University. Chapter 5: Productivity Applications. Chapter 5 -- Prevention and Intervention. 3 Withholding Information from Patients. Note: Maximal sterile barrier (MSB) precautions require the CVC inserter to wear a mask and cap, a sterile gown, and sterile gloves and to use a large (head-to-toe) sterile drape over the patient during the placement of a CVC or exchange of a catheter over a guidewire.
Sours: http://area-gelb.de/chapterthe-patient-quizlet.html

Marijuana Use During Pregnancy and Lactation

Medical Marijuana

Because marijuana is neither regulated nor evaluated by the U.S. Food and Drug Administration, there are no approved indications, contraindications, safety precautions, or recommendations regarding its use during pregnancy and lactation. Likewise, there are no standardized formulations, dosages, or delivery systems. Smoking, the most common route of administration of THC, cannot be medically condoned during pregnancy and lactation. Therefore, obstetrician–gynecologists should be discouraged from prescribing or suggesting the use of marijuana for medicinal purposes during the period before pregnancy, and during pregnancy and lactation. Rather, pregnant women or women contemplating pregnancy should be encouraged to discontinue use of marijuana for medicinal purposes in favor of an alternative therapy for which there are better pregnancy-specific safety data. High-quality studies regarding the effects of marijuana and other cannabis products on pregnancy and lactation are needed.

Sours: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles//10/marijuana-use-during-pregnancy-and-lactation
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Alcohol and zoloft blackouts

When a person abuses alcohol, he or she continues to drink even though they know their drinking is causing problems. Continued alcohol abuse can lead to alcohol dependence (alcoholism). Doctors now use a new term for alcohol abuse and alcohol dependence, “alcohol use disorder,” which can range from mild to moderate to severe. Zoloft alcohol blackout Prozac and alcohol blackouts Diagnosis of Alcoholic blackouts Treatment and cure for Alcoholic blackouts Vyvanse and alcohol blackout Symptoms of alcoholic blackouts May 17, · One such standard drink can be expected to raise Blood Alcohol Content (BAC) by about grams per ml of blood. BAC levels are commonly thought to fall at the rate of about per hour. We confirmed on several tests that Petra would return a reading of per ml of beer (this was standard drinks). Aug 20, · The most common side effects of mixing alcohol and Zoloft are blackouts, dizziness, depression, headache, nausea, anxiety, drowsiness, diarrhea and even suicidal thoughts. Many people have also reported experiencing a greater amount of intoxication with normal amounts of alcohol. Alcohol and zoloft. Does anyone find that you get way, way drunker when you drink with Sertraline? The last few times I've had a few drinks I've become blackout drunk with comparatively few drinks. I can't really find anything about this in any of the side effect leaflets or on Google. 47 comments. share. save. hide.Stages Of Alcoholism Download free e-book It is important to be able to recognise the stages of alcoholism in order to help people suffering from this condition to obtain treatment. Alcoholism is a disease or condition (depending on your view of the disease concept) that has no preference for economic or social status. It can […]L’Albo Pretorio è lo spazio dedicato all’affissione degli atti destinati, per legge, regolamento o disposizione comunale, alla conoscenza pubblica. L’art. 32 della legge 18 giugno n. 69, come modificato dal D.lgs 30 dicembre n. , ha disposto che a decorrere dal 01/01/, gli obblighi di pubblicazione degli atti e

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SPOP 2020 What Can You Do - Alcohol and Other Drugs Awareness

There is a lot of talk about drugs in the world—on the streets, at school, on the Internet and TV. Some of it is true, some not.

Much of what you hear about drugs actually comes from those selling them. Reformed drug dealers have confessed they would have said anything to get others to buy drugs.

Don’t be fooled. You need facts to avoid becoming hooked on drugs and to help your friends stay off them.

Sooner or later—if it hasn’t already happened—you, or someone close to you, will be offered drugs. The decision of whether or not to use them could drastically affect your life. Any addict will tell you they never expected a drug to take control of their life or maybe that they started with “just pot” and that it was “just something to do” with their friends. They thought they could handle it and when they found out they couldn’t, it was too late.

You have a right to know the FACTS about drugs—not opinions, hype or scare tactics. So how do you tell fact from fiction? That is why we have created this website—for you.

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Other alcohol drugs quizlet and

Chapter 5&#x;Specialized Substance Abuse Treatment Programs

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Primary care clinicians need to be familiar with available treatment resources for their patients who have diagnosed substance abuse or dependence disorders. The clinician's responsibility to the patient does not end with the patient's entry into formal treatment; rather, the physician may become a collaborative part of the treatment team, or, minimally, continue to treat the patient's medical conditions during the specialized treatment, encourage continuing participation in the program, and schedule followup visits after treatment termination to monitor progress and help prevent relapse.

Understanding the specialized substance abuse treatment system, however, can be a challenging task. No single definition of treatment exists, and no standard terminology describes different dimensions and elements of treatment. Describing a facility as providing inpatient care or ambulatory services characterizes only one aspect (albeit an important one): the setting. Moreover, the specialized substance abuse treatment system differs around the country, with each State or city having its own peculiarities and specialties. Minnesota, for example, is well known for its array of public and private alcoholism facilities, mostly modeled on the fixed-length inpatient rehabilitation programs initially established by the Hazelden Foundation and the Johnson Institute, which subscribe to a strong Alcoholics Anonymous (AA) orientation and have varying intensities of aftercare services. California also offers a number of community-based social model public sector programs that emphasize a Step, self-help approach as a foundation for life-long recovery. In this chapter, the term treatment will be limited to describing the formal programs that serve patients with more serious alcohol and other drug problems who do not respond to brief interventions or other office-based management strategies. It is also assumed that an in-depth assessment has been conducted to establish a diagnosis and to determine the most suitable resource for the individual's particular needs (see Chapter 4).

Directories of Local Substance Abuse Treatment Systems

The first step in understanding local resources is to collect information about the specialized drug and alcohol treatment currently available in the community. In most communities, a public or private agency regularly compiles a directory of substance abuse treatment facilities that provides useful information about program services (e.g., type, location, hours, and accessibility to public transportation), eligibility criteria, cost, and staff complement and qualifications, including language proficiency. This directory may be produced by the local health department, a council on alcoholism and drug abuse, a social services organization, or volunteers in recovery. Additionally, every State has a single State-level alcohol and other drug authority that usually has the licensing and program review authority for all treatment programs in the State and often publishes a statewide directory of all alcohol and drug treatment programs licensed in the State. Another resource is the National Council on Alcohol and Drug Dependence, which provides both assessment or referral for a sliding scale fee and distributes free information on treatment facilities nationally. Also, the Substance Abuse and Mental Health Services Administration distributes a National Directory of Drug Abuse and Alcoholism Treatment and Prevention Programs ().

Knowing the resources and a contact person within each will facilitate access to the system. One useful referral tool is a list of agencies organized across different characteristics, such as services tailored to meet the needs of special populations (e.g., women, adolescents, people who are HIV-positive, and minorities). Resources also should include self-help groups in the area.

Goals and Effectiveness of Treatment

While each individual in treatment will have specific long- and short-term goals, all specialized substance abuse treatment programs have three similar generalized goals (Schuckit, ;American Psychiatric Association, ):

  • Reducing substance abuse or achieving a substance-free life

  • Maximizing multiple aspects of life functioning

  • Preventing or reducing the frequency and severity of relapse

For most patients, the primary goal of treatment is attainment and maintenance of abstinence (with the exception of methadone-maintained patients), but this may take numerous attempts and failures at "controlled" use before sufficient motivation is mobilized. Until the patient accepts that abstinence is necessary, the treatment program usually tries to minimize the effects of continuing use and abuse through education, counseling, and self-help groups that stress reducing risky behavior, building new relationships with drug-free friends, changing recreational activities and lifestyle patterns, substituting substances used with less risky ones, and reducing the amount and frequency of consumption, with a goal of convincing the patient of her individual responsibility for becoming abstinent (American Psychiatric Association, ). Total abstinence is strongly associated with a positive long-term prognosis.

Becoming alcohol- or drug-free, however, is only a beginning. Most patients in substance abuse treatment have multiple and complex problems in many aspects of living, including medical and mental illnesses, disrupted relationships, underdeveloped or deteriorated social and vocational skills, impaired performance at work or in school, and legal or financial troubles. These conditions may have contributed to the initial development of a substance use problem or resulted from the disorder. Substantial efforts must be made by treatment programs to assist patients in ameliorating these problems so that they can assume appropriate and responsible roles in society. This entails maximizing physical health, treating independent psychiatric disorders, improving psychological functioning, addressing marital or other family and relationship issues, resolving financial and legal problems, and improving or developing necessary educational and vocational skills. Many programs also help participants explore spiritual issues and find appropriate recreational activities.

Increasingly, treatment programs are also preparing patients for the possibility of relapse and helping them understand and avoid dangerous "triggers" of resumed drinking or drug use. Patients are taught how to recognize cues, how to handle craving, how to develop contingency plans for handling stressful situations, and what to do if there is a "slip." Relapse prevention is particularly important as a treatment goal in an era of shortened formal, intensive intervention and more emphasis on aftercare following discharge.

While the effectiveness of treatment for specific individuals is not always predictable, and different programs and approaches have variable rates of success, evaluations of substance abuse treatment efforts are encouraging. All the long-term studies find that "treatment works" -- the majority of substance-dependent patients eventually stop compulsive use and have less frequent and severe relapse episodes (American Psychiatric Association, ;Landry, ). The most positive effects generally happen while the patient is actively participating in treatment, but prolonged abstinence following treatment is a good predictor of continuing success. Almost 90 percent of those who remain abstinent for 2 years are also drug- and alcohol-free at 10 years (American Psychiatric Association, ). Patients who remain in treatment for longer periods of time are also likely to achieve maximum benefits -- duration of the treatment episode for 3 months or longer is often a predictor of a successful outcome (Gerstein and Harwood, ). Furthermore, individuals who have lower levels of premorbid psychopathology and other serious social, vocational, and legal problems are most likely to benefit from treatment. Continuing participation in aftercare or self-help groups following treatment also appears to be associated with success (American Psychiatric Association, ).

An increasing number of randomized clinical trials and other outcome studies have been undertaken in recent years to examine the effectiveness of alcohol and various forms of drug abuse treatment. It is beyond the scope of this chapter to report the conclusions in any depth. However, a few summary statements from an Institute of Medicine report on alcohol studies are relevant:

  • No single treatment approach is effective for all persons with alcohol problems, and there is no overall advantage for residential or inpatient treatment over outpatient care.

  • Treatment of other life problems associated with drinking improves outcomes.

  • Therapist and patient (and problem) characteristics, treatment process, posttreatment adjustment factors, and the interactions among these variables also determine outcomes.

  • Patients who significantly reduce alcohol consumption or become totally abstinent usually improve their functioning in other areas (Institute of Medicine, ).

A recent comparison of treatment compliance and relapse rates for patients in treatment for opiate, cocaine, and nicotine dependence with outcomes for three common and chronic medical conditions (i.e., hypertension, asthma, and diabetes) found similar response rates across the addictive and chronic medical disorders (National Institute on Drug Abuse, ). All of these conditions require behavioral change and medication compliance for successful treatment. The conclusion is that treatment of drug addiction has a similar success rate as treatment of other chronic medical conditions (National Institute on Drug Abuse, ).

Treatment Dimensions

The terminology describing the different elements of treatment care for people with substance use disorders has evolved as specialized systems have developed and as treatment has adapted to changes in the health care system and financing arrangements. Important differences in language persist between public and private sector programs and, to a lesser extent, in treatment efforts originally developed and targeted to persons with alcohol- as opposed to illicit drug-related problems. Programs are increasingly trying to meet individual needs and to tailor the program to the patients rather than having a single standard format with a fixed length of stay or sequence of specified services.

A recent publication of the Substance Abuse and Mental Health Services Administration, Overview of Addiction Treatment Effectiveness(Landry, ), divides substance abuse treatment along three dimensions: (1) treatment approach -- the underlying philosophical principles that guide the type of care offered and that influence admission and discharge policies as well as expected outcomes, attitudes toward patient behavior, and the types of personnel who deliver services; (2) treatment setting -- the physical environment in which care is delivered; and (3) treatment components -- the specific clinical interventions and services offered to meet individual needs. These services can be offered for varying lengths of time and delivered at differing intensities. Another important dimension is treatment stage, because different resources may be targeted at different phases along a continuum of recovery. Programs also have been developed to serve special populations -- by age, gender, racial and ethnic orientation, drug of choice, and functional level or medical condition. Some of these offer the most appropriate environment and services for special populations.

Treatment Models and Approaches

Historically, treatment programs were developed to reflect the philosophical orientations of founders and their beliefs regarding the etiology of alcoholism and drug dependence. Although most programs now integrate the following three approaches, a brief review of earlier distinctions will help primary care clinicians understand what precursors may survive or dominate among programs. The three historical orientations that still underlie different treatment models are

  1. A medical model, emphasizing biological and genetic or physiological causes of addiction that require treatment by a physician and utilize pharmacotherapy to relieve symptoms or change behavior (e.g., disulfiram, methadone, and medical management of withdrawal).

  2. A psychological model, focusing on an individual's maladaptive motivational learning or emotional dysfunction as the primary cause of substance abuse. This approach includes psychotherapy or behavioral therapy directed by a mental health professional.

  3. A sociocultural model, stressing deficiencies in the social and cultural milieu or socialization process that can be ameliorated by changing the physical and social environment, particularly through involvement in self-help fellowships or spiritual activities and supportive social networks. Treatment authority is often vested in persons who are in recovery themselves and whose experiential knowledge is valued.

These three models have been woven into a biopsychosocial approach in most contemporary programs. The four major treatment approaches now prevalent in public and private programs are

  1. The Minnesota model of residential chemical dependency treatment incorporates a biopsychosocial disease model of addiction that focuses on abstinence as the primary treatment goal and uses the AA Step program as a major tool for recovery and relapse prevention. Although this approach, which has evolved from earlier precursors (i.e., Willmar State Hospital, Hazelden Foundation, and Johnson Institute efforts), initially required 28 to 30 days of inpatient treatment followed by extensive community-based aftercare, more recent models have shortened inpatient stays considerably and substituted intensive outpatient treatment followed by less intensive continuing care. The new hybrid, used extensively by public and private sector programs, blends Step concepts with professional medical practices. Skilled chemical dependency counselors, often people in recovery as well as mental health and social work professionals, use a variety of behavioral and reality-oriented approaches. Psychosocial evaluations and psychological testing are conducted; medical and psychiatric support is provided for identified conditions; and the inpatient program utilizes therapeutic community concepts. Although a disease model of etiology is stressed, the individual patient has ultimate responsibility for making behavioral changes. Pharmacological interventions may be used, particularly for detoxification; extensive education about chemical dependency is provided through lectures, reading, and writing; and individual and group therapy are stressed, as is the involvement of the family in treatment planning and aftercare (Institute of Medicine, ;Gerstein and Harwood, ;Landry, ).

  2. Drug-free outpatient treatment uses a variety of counseling and therapeutic techniques, skills training, and educational supports and little or no pharmacotherapy to address the specific needs of individuals moving from active substance abuse to abstinence. This is the least standardized treatment approach and varies considerably in both intensity, duration of care, and staffing patterns. Most of these programs see patients only once or twice weekly and use some combination of counseling strategies, social work, and Step or self-help meetings. Some programs now offer prescribed medications to ameliorate prolonged withdrawal symptoms; others stress case management and referral of patients to available community resources for medical, mental health, or family treatment; educational, vocational, or financial counseling; and legal or social services. Optimally, a comprehensive continuum of direct and supportive services is offered through a combination of onsite and referral services. High rates of attrition are often a problem for drug-free outpatient programs; legal, family, or employer pressure may be used to encourage patients to remain in treatment (Landry, ;American Psychiatric Association, ;Gerstein and Harwood, ).

  3. Methadone maintenance -- or opioid substitution -- treatment specifically targets chronic heroin or opioid addicts who have not benefited from other treatment approaches. Such treatment includes replacement of licit or illicit morphine derivatives with longer-acting, medically safe, stabilizing substitutes of known potency and purity that are ingested orally on a regular basis. The methadone or other long-acting opioid, when administered in adequate doses, reduces drug craving, blocks euphoric effects from continued use of heroin or other illegal opioids, and eliminates the rapid mood swings associated with short-acting and usually injected heroin. The approach, which allows patients to function normally, does not focus on abstinence as a goal, but rather on rehabilitation and the development of a productive lifestyle. A major emphasis in recent years has been on reducing HIV infection transmission rates among patients who remain in treatment and stop injection drug use. Individual and group counseling in addition to pharmacotherapy and urine testing are the mainstay of most programs, but more comprehensive and successful programs also offer psychological and medical services, social work assistance, family therapy, and vocational training. Methadone maintenance treatment, which is more controversial and extensively evaluated than any other treatment approach, has consistently been found to be effective in reducing the use of illicit opioids and criminal activity as well as in improving health, social functioning, and employment (Gerstein and Harwood, ;Landry, ;National Institute on Drug Abuse, ).

  4. Therapeutic community residential treatment is best suited to patients with a substance dependence diagnosis who also have serious psychosocial adjustment problems and require resocialization in a highly structured setting. Treatment generally focuses on negative patterns of thinking and behavior that can be changed through reality-oriented individual and group therapy, intensive encounter sessions with peers, and participation in a therapeutic milieu with hierarchical roles, privileges, and responsibilities. Strict and explicit behavioral norms are emphasized and reinforced with specified rewards and punishments directed toward developing self-control and social responsibility. Tutorials, remedial and formal education, and daily work assignments in the communal setting or conventional jobs (for residents in the final stages before graduation) are usually required. Enrollment is relatively long-term and intensive, entailing a minimum of 3 to 9 months of residential living and gradual reentry into the community setting. While patients who stay in therapeutic communities for at least a third to half the planned course of treatment usually have markedly improved functioning in terms of reduced criminal activity and drug consumption and improved rates of employment or schooling (and graduates do even better), the biggest drawback to therapeutic communities is the large percentage of enrollees (75 percent or more) who never complete treatment (Gerstein and Harwood, ;Landry, ).

Treatment Settings

Substance abuse treatment is delivered in two basic settings or environments: inpatient and outpatient. Although the two types of settings vary widely by cost, recent evaluation studies have not found that treatment setting correlates strongly with a successful outcome. In fact, research has not found a clear relationship between treatment setting and the amounts or types of services offered, although there is a correlation between the services provided and posttreatment outcomes. Essentially, most patients can benefit from treatment delivered in either in- or outpatient settings, although specific subgroups seem to respond optimally to particular environments (Landry, ).

Initially, however, it is important to match the patient's needs to a treatment setting. The goal is to place patients in the least restrictive environment that is still safe and effective and then move them along a continuum of care as they demonstrate the capacity and motivation to cooperate with treatment and no longer need a more structured setting or the types of services offered only in that environment (i.e., medical or nursing supervision and room and board). Movement, however, is not always in the direction of less intensive care as relapse or failure to respond to one setting may require moving a patient to a more restrictive environment (American Psychiatric Association, ;Landry, ).

The continuum of treatment settings, from most intensive to least, includes inpatient hospitalization, residential treatment, intensive outpatient treatment, and outpatient treatment.

Inpatient hospitalization includes around-the-clock treatment and supervision by a multidisciplinary staff that emphasizes medical management of detoxification or other medical and psychiatric crises, usually for a short period of time. Currently, hospital care is usually restricted to patients with (1) severe overdoses and serious respiratory depression or coma; (2) severe withdrawal syndromes complicated by multiple drugs or a history of delirium tremens; (3) acute or chronic general medical conditions that could complicate withdrawal; (4) marked psychiatric comorbidity who are a danger to themselves or others; and (5) acute substance dependence and a history of nonresponse to other less intensive forms of treatment (American Psychiatric Association, ).

Residential treatment in a live-in facility with hour supervision is best for patients with overwhelming substance use problems who lack sufficient motivation or social supports to stay abstinent on their own but do not meet clinical criteria for hospitalization. Many residential facilities offer medical monitoring of detoxification and are appropriate for individuals who need that level of care but do not need management of other medical or psychiatric problems. These facilities range in intensity and duration of care from long-term and self-contained therapeutic communities to less supervised halfway and quarterway houses from which the residents are transitioning back into the community. Specialized residential programs are specifically tailored to the needs of adolescents, pregnant or postpartum women and their dependent children, those under supervision by the criminal justice system, or public inebriates for whom extensive treatment has not worked (American Psychiatric Association, ; Landry, ).

Intensive outpatient treatment requires a minimum of 9 hours of weekly attendance, usually in increments of 3 to 8 hours a day for 5 to 7 days a week. This setting is also known as partial hospitalization in some States and is often recommended for patients in the early stages of treatment or those transitioning from residential or hospital settings. This environment is suitable for patients who do not need full-time supervision and have some available supports but need more structure than is usually available in less intensive outpatient settings. This treatment encompasses day care programs and evening or weekend programs that may offer a full range of services. The frequency and length of sessions is usually tapered as patients demonstrate progress, less risk of relapse, and a stronger reliance on drug-free community supports (American Psychiatric Association, ).

Least intensive is outpatient treatment with scheduled attendance of less than 9 hours per week, usually including once- or twice-weekly individual, group, or family counseling as well as other services. As already noted, these programs can vary from ambulatory methadone maintenance treatment to drug-free approaches. Patients attending outpatient programs should have some appropriate support systems in place, adequate living arrangements, transportation to the services, and considerable motivation to attend consistently and benefit from these least intensive efforts. Ambulatory care is used by both public programs and private practitioners for primary intervention efforts as well as extended aftercare and followup (Institute of Medicine, ).

Treatment Techniques

Within each treatment approach, a variety of specialized treatment techniques (also known as elements, modalities, components, or services) are offered to achieve specified goals. Each patient is likely to receive more than one service in various combinations as treatment proceeds. The emphasis may change, for example, from pharmacological interventions to relieve withdrawal discomforts in the initial stage of treatment to behavioral therapy, self-help support, and relapse prevention efforts during the primary care and stabilization phase and continuing AA participation after discharge from formal treatment. A patient in methadone maintenance treatment will receive pharmacotherapy throughout all phases of care, in addition to other psychological, social, or legal services that are selected as appropriate for achieving specified individual treatment goals. Again, the categorization of these techniques is not standardized and the terminology differs among programs. However, the principal elements are

  • Pharmacotherapies, which discourage continuing alcohol or other drug use, suppress withdrawal symptoms, block or diminish euphoric effects or cravings, replace an illicit drug with a prescribed medication, or treat coexisting psychiatric problems (see Appendix A for more information on specific pharmacotherapies)

  • Psychosocial or psychological interventions, which modify destructive interpersonal feelings, attitudes, and behaviors through individual, group, marital, or family therapy

  • Behavioral therapies, which ameliorate or extinguish undesirable behaviors and encourage desired ones

  • Self-help groups for mutual support and encouragement to become or remain abstinent before, during, and after formal treatment

Pharmacotherapy

Medications to manage withdrawal take advantage of cross-tolerance to replace the abused drug with another and safer drug in the same class. The latter can then be gradually tapered until physiologic homeostasis is restored. Benzodiazepines are frequently used to alleviate alcohol withdrawal symptoms, and methadone to manage opioid withdrawal, although buprenorphine and clonidine are also used. Numerous drugs such as buprenorphine and amantadine and desipramine hydrochloride have been tried with cocaine abusers experiencing withdrawal, but their efficacy is not established. Acute opioid intoxication with marked respiratory depression or coma can be fatal and requires prompt reversal, using naloxone. However, if a patient is physically dependent on opioids, naloxone will precipitate withdrawal symptoms (American Psychiatric Association, ;Institute of Medicine, ;Gerstein and Harwood, ). (See Appendix A.)

Medications to discourage substance use precipitate an unpleasant reaction or diminish the euphoric effects of alcohol and other drugs. Disulfiram (Antabuse), the best known of these agents, inhibits the activity of the enzyme that metabolizes a major metabolite of alcohol, resulting in the accumulation of toxic levels of acetaldehyde and numerous highly unpleasant side effects such as flushing, nausea, vomiting, hypotension, and anxiety. More recently, the narcotic antagonist, naltrexone, has also been found to be effective in reducing relapse to alcohol use, apparently by blocking the subjective effects of the first drink. Naltrexone also is used with well-motivated, drug-free opioid addicts to block the effects of usual street doses of heroin or morphine derivatives. Naltrexone keeps opioids from occupying receptor sites, thereby inhibiting their euphoric effects. These antidipsotropic agents, such as disulfiram, and blocking agents, such as naltrexone, are only useful as an adjunct to other treatment, particularly as motivators for relapse prevention (American Psychiatric Association, ;Landry, ). (See Appendix A.)

Agonist substitution therapy replaces an illicit drug with a prescribed medication. Opioid maintenance treatment, currently the only type of this therapy available, both prevents withdrawal symptoms from emerging and reduces craving among opioid-dependent patients. The leading substitution therapies are methadone and the even longer acting levo-alpha-acetyl-methadol (LAAM). Patients using LAAM only need to ingest the drug three times a week, while methadone is taken daily. Buprenorphine, a mixed opioid agonist-antagonist, is also being used to suppress withdrawal, reduce drug craving, and block euphoric and reinforcing effects (American Psychiatric Association, ;Landry, ).

Medications to treat comorbid psychiatric conditions are an essential adjunct to substance abuse treatment for patients diagnosed with both a substance use disorder and a psychiatric disorder. Prescribing medication for these patients requires extreme caution, partly due to difficulties in making an accurate differential diagnosis and partly due to the dangers of intentional or unintentional overdose if the patient combines medications with abused substances or takes higher than prescribed doses of psychotropic medications. Since there is a high prevalence of comorbid psychiatric disorders among people with substance dependence, pharmacotherapy directed at these conditions is often indicated (e.g., lithium or other mood stabilizers for patients with confirmed bipolar disorder, neuroleptics for patients with schizophrenia, and antidepressants for patients with major or atypical depressive disorder). Many psychiatrists agree that diagnoses for comorbid psychiatric conditions cannot be made until patients have been detoxified from abused substances and observed in a drug-free condition for 3 to 4 weeks since many withdrawal symptoms mimic those of psychiatric disorders. Absent a confirmed psychiatric diagnosis, it is unwise for primary care clinicians and other physicians in substance abuse treatment programs to prescribe medications for insomnia, anxiety, or depression (especially benzodiazepines with a high abuse potential) to patients who have alcohol or other drug disorders. Even with a confirmed psychiatric diagnosis, patients with substance use disorders should be prescribed drugs with a low potential for (1) lethality in overdose situations, (2) exacerbation of the effects of the abused substance, and (3) abuse itself. Selective serotonin reuptake inhibitors (SSRIs) for patients with depressive disorders and buspirone for patients with anxiety disorders are examples of psychoactive drugs with low abuse potential. These medications should also be dispensed in limited amounts and be closely monitored (Institute of Medicine, ;Schuckit, ;American Psychiatric Association, ;Landry, ).

Because prescribing psychotropic medications for patients with dual diagnoses is clinically complex, a conservative and sequential three-stage approach is recommended. For a person with both an anxiety disorder and alcohol dependence, for example, nonpsychoactive alternatives such as exercise, biofeedback, or stress reduction techniques should be tried first. If these are not effective, nonpsychoactive drugs such as buspirone (or SSRIs for depression) should be administered. Only if these do not alleviate symptoms and complaints should psychoactive medications be provided. Proper prescribing practices for these dually diagnosed patients encompass the following six "Ds" (Landry et al., a):

  1. Diagnosis is essential and should be confirmed by a careful history, thorough examination, and appropriate tests before prescribing psychotropic medications. Patients with substance use disorders should be evaluated for anxiety disorders and, conversely, those with anxiety disorders evaluated for substance abuse or dependence rather than just treating presenting symptoms.

  2. Dosage must be appropriate for the diagnosis and the severity of the problem, without over- or undermedicating. If high doses are needed, these should be administered daily in the office to ensure compliance with the prescribed amount.

  3. Duration should not be longer than recommended in the package insert or the Physician's Desk Reference so that additional dependence can be avoided.

  4. Discontinuation must be considered if there are complications (e.g., toxicity or dependence), at the expiration of the planned trial, if the original crisis abates, or when the patient learns and accepts alternative coping strategies.

  5. Dependence development must be continuously monitored. The clinician also should warn the patient of this possibility and the need to make decisions regarding whether the condition warrants toleration of dependence.

  6. Documentation is critical to ensure a record of the presenting complaints, the diagnosis, the course of treatment, and all prescriptions that are filled or refused as well as any consultations and their recommendations.

Psychosocial Interventions

Individual therapy uses psychodynamic principles with such modifications as limit-setting and explicit advice or suggestions to help patients address difficulties in interpersonal functioning. One approach that has been tested with cocaine- and alcohol-dependent persons is supportive-expressive therapy, which attempts to create a safe and supportive therapeutic alliance that encourages the patient to address negative patterns in other relationships (American Psychiatric Association, ; National Institute on Drug Abuse, unpublished). This technique is usually used in conjunction with more comprehensive treatment efforts and focuses on current life problems, not developmental issues. Some research studies indicate that individual psychotherapy is most beneficial for opiate-dependent patients with moderate levels of psychopathology who can form a therapeutic alliance (National Institute on Drug Abuse, unpublished). Drug counseling provided by paraprofessionals focuses on specific strategies for reducing drug use or pragmatic issues related to treatment retention or participation (e.g., urine testing results, attendance, and referral for special services). This differs from psychotherapy by trained mental health professionals (American Psychiatric Association, ).

Group therapy is one of the most frequently used techniques during primary and extended care phases of substance abuse treatment programs. Many different approaches are used, and there is little agreement on session length, meeting frequency, optimal size, open or closed enrollment, duration of group participation, number or training of the involved therapists, or style of group interaction. Most controversial is whether confrontation or support should be emphasized.

Group therapy offers the experience of closeness, sharing of painful experiences, communication of feelings, and helping others who are struggling with control over substance abuse. The principles of group dynamics often extend beyond therapy in substance abuse treatment, in educational presentations and discussions about abused substances, their effects on the body and psychosocial functioning, prevention of HIV infection and infection through sexual contact and injection drug use, and numerous other substance abuse-related topics (Institute of Medicine, ;American Psychiatric Association, ).

Marital therapy and family therapy focus on the substance abuse behaviors of the identified patient and also on maladaptive patterns of family interaction and communication. Many different schools of family therapy have been used in treatment programs, including structural, strategic, behavioral, and psychodynamic orientations. The goals of family therapy also vary, as does the phase of treatment when this technique is used and the type of family participating (e.g., nuclear family, married couple, multigenerational family, remarried family, cohabitating same or different sex couples, and adults still suffering the consequences of their parents' substance abuse or dependence). Family intervention, a structured and guided attempt to move a resistant and active substance abuser into treatment, can be a helpful motivator for program entry. Involved family members can help ensure medication compliance and attendance, plan treatment strategies, and monitor abstinence, while therapy focused on ameliorating dysfunctional family dynamics and restructuring poor communication patterns can help establish a more appropriate environment and support system for the person in recovery. Several well-designed research studies support the effectiveness of behavioral relationship therapy in improving the healthy functioning of families and couples and improving treatment outcomes for individuals (Landry, ;Institute of Medicine, ;American Psychiatric Association, ). Preliminary studies of Multidimensional Family Therapy (MFT), a multicomponent family intervention for parents and substance-abusing adolescents, have found improvement in parenting skills and associated abstinence in adolescents for as long as a year after the intervention (National Institute on Drug Abuse, ).

Behavioral Therapies

Cognitive behavioral therapy attempts to alter the cognitive processes that lead to maladaptive behavior, intervene in the chain of events that lead to substance abuse, and then promote and reinforce necessary skills and behaviors for achieving and maintaining abstinence. Research studies consistently demonstrate that such techniques improve self-control and social skills and thus help reduce drinking (American Psychiatric Association, ). Some of the strategies used are self-monitoring, goal setting, rewards for goal attainment, and learning new coping skills. Stress management training -- using biofeedback, progressive relaxation techniques, meditation, or exercise -- has become very popular in substance abuse treatment efforts. Social skills training to improve the general functioning of persons who are deficient in ordinary communications and interpersonal interactions has also been demonstrated to be an effective treatment technique in promoting sobriety and reducing relapse. Training sessions focus on how to express and react to specific feelings, how to handle criticism, or how to initiate social encounters (Institute of Medicine, ; American Psychiatric Association, ;Landry, ).

Behavioral contracting or contingency management uses a set of predetermined rewards and punishments established by the therapist and patient (and significant others) to reinforce desired behaviors. Effective use of this technique requires that the rewards and punishments, or contingencies, be meaningful, that the contract be mutually developed, and that the contingencies be applied as specified. Some studies suggest that positive contingencies are more effective than negative ones (National Institute on Drug Abuse, unpublished). Care must be taken that negative contingencies are not unethical or counterproductive (e.g., reducing methadone doses if urine results indicate continuing illicit drug use). Contingency management is only effective within the context of a comprehensive treatment program (National Institute on Drug Abuse, unpublished; Institute of Medicine, ;Landry, ).

Relapse prevention helps patients first recognize potentially high-risk situations or emotional "triggers" that have led to substance abuse, and then learn a repertoire of substitute responses to cravings. Patients also develop new coping strategies for handling external stressors and learn both to accept lapses into substance abuse as part of the recovery process and to interrupt them before adverse consequences ensue. Controlled studies have found relapse prevention to be as effective as other psychosocial treatments, especially for patients with comorbid sociopathy or psychiatric symptoms (American Psychiatric Association, ). Cognitive-behavioral strategies, the improvement of self-efficacy, self-control training, and cue exposure and extinction have all been used as components of relapse prevention. In recent years, relapse prevention has become a vital part of most treatment efforts, learned during the intensive stage of treatment and practiced during aftercare (Institute of Medicine, ; American Psychiatric Association, ;Landry, ).

Self-Help Groups

Mutual support, Step groups such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous or more recent alternatives (e.g., Rational Recovery and Women for Sobriety) are the backbone of many treatment efforts as well as a major form of continuing care. While AA and related groups are widely used, the success of this technique has not been rigorously evaluated. Nevertheless, these fellowships apparently help persons at any point in the recovery process to change old behavior patterns, react responsibly to drug cravings, maintain hope and determination to become and remain abstinent. Self-help groups can also help people build a new social network in a community of understanding peers, find satisfactory drug-free activities and recreational skills, establish healthy intimate relationships, and avoid stressful social situations and environments.

The process of working through the 12 steps under the tutelage of a sponsor encourages group members to reassess past life experiences and take more responsibility for their substance use disorders. Attendance may vary from daily to much less frequent, with more intensive involvement available whenever the recovering person feels this need.

Patients who do not accept the spiritual focus and abstinence orientation of AA may benefit from Rational Recovery groups or the Recovery Training and Self-Help (RTSH) programs in some communities. Patients who are prescribed psychotropic medications for comorbid psychiatric disorders (e.g., antidepressants or neuroleptics) or are maintained on methadone or LAAM must attend fellowships or groups where pharmacotherapy is accepted as appropriate treatment. Young persons, persons of color, and gays and lesbians often find more acceptance in groups where at least some members have similar characteristics. Friends and relatives of persons in recovery and of those who refuse treatment can benefit from Al-Anon, Alateen, Nar-Anon, and similar groups that offer support and education about the disease of alcoholism or other forms of substance abuse and teach participants to curb their own "enabling" behaviors. Improvements in substance-abusing behavior among meeting participants are associated with frequent attendance, obtaining a sponsor, "working" the 12 steps, and leading meetings (National Institute on Drug Abuse, ;American Psychiatric Association, ;Landry, ).

Other Primary and Ancillary Services

Patients in treatment may need other primary and adjunctive services as well: social services, vocational training, education, legal assistance, financial counseling, health and dental care, and mental health treatment. These may be provided onsite or through referral to community resources. Adjunctive services to encourage patients to enter and remain in treatment may include child care, transportation arrangements, financial assistance or welfare support, supported housing, and other supplemental help. The types of additional services supplied or arranged through a treatment program will obviously depend heavily on the characteristics of the population served. For example, persons with heroin, cocaine, or methamphetamine dependence disorders who inject these drugs will require many specialized education, identification, counseling, and health care services for HIV infection and AIDS that are not likely to be needed by programs for people with alcohol dependence.

The Treatment Process

All the components, approaches, techniques, and settings discussed above must be monitored and adjusted as treatment progresses. Primary care clinicians should understand the following aspects of appropriate care.

  • Repeating assessments to evaluate a patient's changing medical, psychological, social, vocational, educational, and recreational needs, especially as more basic and acute deficits or crises are resolved and new problems emerge or become amenable to treatment. For example, homelessness or acute withdrawal symptoms will need to be treated before family interactions can be identified or resolved. Suicidal thoughts or actions will need prompt attention whenever they emerge.

  • Developing a comprehensive treatment plan that clearly reflects all identified problems, has explicit goals and strategies for their attainment, and specifies techniques and services to be provided by designated specialists at particular frequencies or intensities.

  • Monitoring progress and clinical status through written notes or reports that describe responses to treatment approaches and outcomes of services provided, including counseling sessions, group meetings, urine or other biological testing, physical examinations, administered medications, and referrals for other care. Each patient should have an individual treatment record that includes all appropriate materials yet maintains the patient's privacy.

  • Establishing a therapeutic alliance with an empathic primary therapist or counselor who can gain the confidence and trust of the patient and significant others or family members and take responsibility for continuity of care. This is particularly important in the early stages of treatment to prevent dropout and encourage participation.

  • Providing education to help the patient and designated others understand the diagnosis, the etiology and prognosis for the disorder, and the benefits and risks of anticipated treatment(s). Patients with special problems will need more extensive information. As with other medical treatments, informed consent to potentially risky procedures should always be obtained (American Psychiatric Association, ).

Treatment Programs for Special Populations

A variety of substance abuse treatment programs have been developed to meet the particular needs of special populations, including women, pregnant and postpartum mothers, adolescents, elderly persons, members of various minority groups, public inebriates or homeless persons, drinking drivers, and children of alcoholics. These special programs are found in the public and private sectors and include both residential and ambulatory care settings using therapeutic community, Minnesota model, outpatient drug-free, and methadone maintenance approaches. Researchers have not confirmed that these separate programs for special populations are superior to mainstream efforts with respect to outcomes, and experts question their cost-effectiveness and applicability to heterogeneous groups with overlapping characteristics that complicate placement of a particular patient in one group over another. Clinicians must be wary of defining any patient in relation only to age, gender, racial group membership, or functional characteristics, especially since other patient-related variables have been found to have greater implications for successful outcomes (e.g., addiction severity, employment stability, criminal involvement, educational level, and socioeconomic status). Nonetheless, clinical observations do indicate that treatment of special populations may be enhanced if their particular needs are considered and met. Notable components of these separate programs for special populations are as follows (Institute of Medicine, ;American Psychiatric Association, ;Landry, ).

Women are more likely than men to have comorbid depressive and anxiety disorders, including posttraumatic stress disorders as a result of past or current physical or sexual abuse. Although women tended in the past to become involved with different substances than men (e.g., prescription drugs), their drug use patterns have become more similar to males' in recent years. Treatment components can address women's special issues and needs for child care, parenting skills, building healthy relationships, avoiding sexual exploitation or domestic violence, preventing HIV infection and other sexually transmitted diseases, and enhanced self-esteem. A high ratio of female staff and same-sex groups are also thought to improve treatment retention.

Pregnant and postpartum women and their dependent children have numerous special needs, including prenatal and obstetrical care, pediatric care, knowledge of child development, parenting skills, economic security, and safe, affordable housing. Pregnant women -- and those in their childbearing years -- need to know about birth control as well as the risks to pregnancy and fetal development of continuing substance use (e.g., spontaneous abortion, abruptio placentae, preeclampsia, early and prolonged labor, birth defects, impaired fetal growth, low birth weight, stillbirth, and neonatal withdrawal syndrome). Methadone maintenance throughout pregnancy and the postpartum period is often the treatment of choice for opioid-dependent women with seriously compromised lifestyles who are not likely to remain abstinent. However, many other medications used in the treatment of addiction, including disulfiram and naltrexone, should not be prescribed for pregnant substance abusers. See Appendix A and *TIP 2, Pregnant, Substance-Using Women (CSAT, a).

Adolescents need treatment that is developmentally appropriate and peer-oriented. Educational needs are particularly important as well as involvement of family members in treatment planning and therapy for dysfunctional aspects. Substance abuse among adolescents is frequently correlated with depression, eating disorders, and a history of sexual abuse (American Psychiatric Association, ). A history of familial substance abuse and dependence is predictive of serious adolescent involvement. More information on specialized treatment of adolescents can be found in TIP 4, Guidelines for the Treatment of Alcohol- and Other Drug-Abusing Adolescents *(CSAT, c).

Elderly persons may have unrecognized and undertreated substance dependence on alcohol or prescribed benzodiazepines and sedative hypnotics that can contribute to unexplained falls and injuries, confusion, and inadvertent overdose because age decreases the body's ability to metabolize many medications. Other coexisting medical and psychiatric conditions can also complicate treatment and compromise elderly patients' ability to comply with recommended regimens.

Minority group members may identify with particular cultural norms and institutions that increase feelings of social acceptance. While early phases of treatment that focus on achieving abstinence are not likely to be affected by minority group differences, the development of appropriate, drug-free social supports and new lifestyles during more extended treatment and aftercare stages may be enhanced by support groups with similar ethnic identification and cultural patterns. For some African-American patients, involving the church and treatment that incorporates a spiritual element may improve outcomes. Treatment programs for Native American tribes often incorporate their traditions, and a family focus as well as bilingual staff and translated written materials are important ingredients of many treatment programs for Hispanics. However, the Consensus Panel believes that culturally sensitive treatment may not be as important to individuals who do not strongly identify with an ethnic or cultural group and of less concern than socioeconomic differences, for example, in treatment retention.

Confidentiality

One important aspect of working with or making a referral for substance abuse treatment is the legal requirement to comply with Federal regulations governing the confidentiality of information about a patient's substance use or abuse. Laws protecting the confidentiality of alcohol and drug abuse patient records were instituted to encourage patients to enter treatment without fear of stigmatization or discrimination as a result of information disclosure without the patient's express permission (42 C.F.R. Part 2). Clarifying amendments passed in make it clear that patient records generated in general medical settings and hospitals are not covered unless the treating clinician or unit has a primary interest in substance abuse treatment *(CSAT, b, p. 64). Nonetheless, records containing information about substance use disorders should always be handled with discretion.

If referral is made by the primary care clinician for a substance abuse assessment or to a specialized treatment program, written permission of the patient is required before any information or records can be disclosed or redisclosed in which the patient's identity is revealed, except in cases of medical emergency or reporting suspected child abuse to the proper authorities. Often, treatment programs will want to coordinate a patient's treatment with the primary care provider -- such collaboration is essential for certain patients, such as chemically involved pregnant women. See Appendix B for a detailed discussion of confidentiality. Confidentiality issues are also discussed in TIPs 4 (Guidelines for the Treatment of Alcohol- and Other Drug-Abusing Adolescents) (CSAT, c), 8 (Intensive Outpatient Treatment for Alcohol and Other Drug Abuse) (CSAT, a), 11 (Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases) (CSAT, c), 13 (The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders) (CSAT, a), 16 (Alcohol and Other Drug Screening of Hospitalized Trauma Patients) (CSAT, b), and 19 (Detoxification from Alcohol and Other Drugs) (CSAT, c).

The Role of the Primary Care Clinician Throughout Treatment

As already noted, all primary care clinicians have important roles to play in identifying, screening, and referring patients with substance use disorders for in-depth assessment or treatment and in delivering brief interventions to patients with milder substance-related problems. In addition, the clinician has an array of options, depending on time and resources available, for offering ongoing support and encouragement to patients who do enter the formal treatment system. These options include

  • Learning about treatment resources in the community that offer appropriate services

  • Keeping in touch with the specific treatment program where the patient is enrolled to ascertain its quality and understand the approach and services offered

  • Requesting formal reports regarding the treatment plan and progress indicators from the program on a periodic basis (with the patient's explicit permission)

  • Clarifying the clinician's role in the continued care of the patient (e.g., treating specified medical conditions, writing prescriptions, and monitoring compliance through urine or other biological testing)

  • Reinforcing the importance of continuing treatment to the patient and relatives

Completing specialized treatment is only the beginning of the patient's recovery process. Primary care clinicians should continue to ask their patients about the problem they were treated for at every office or clinic visit. During these visits, the clinician can monitor the potential for relapse and take any necessary steps to prevent slips from occurring (Brown, ).

The primary care clinician also has a responsibility to patients who refuse to accept referral to treatment or drop out before completion. In such cases, the primary care clinician should

  • Continue treating any medical problems, including those related to continuing substance abuse.

  • Reiterate the primary diagnosis and be ready to refer the patient for specialized treatment. If the patient objects to the initial referral, the physician should look for acceptable and appropriate alternatives.

  • Encourage family members and friends to participate in appropriate Al-Anon, Alateen, Adult Children of Alcoholics, or similar groups in order to learn more about the substance use disorder, how to minimize distress, and how to avoid enabling behaviors.

  • Exercise extreme caution in prescribing psychotropic medications for anxiety, insomnia, and other complaints because these drugs may exacerbate continued abuse.

Sours: https://www.ncbi.nlm.nih.gov/books/NBK/
What the Experts say: Alcohol \u0026 Other Drugs

The Effects of Smoking and Second-Hand Smoke on Health

Cigarette smoke contains over 7, chemical substances, 69 of which are known carcinogens. Inhaled smoke circulates in the human body and reaches nearly every organ, affecting both the health and well-being of smokers. The smoke also affects the health of non-smokers exposed to it.

Other tobacco products, such as cigars and cigarillos, or the use of a water pipe are not safer alternatives to cigarettes because they also present major health risks.

Electronic cigarettes are a special case. Their long-term health effects, for both users and people who are regularly exposed to the vapours (aerosols), are still unclear. It would seem, however, that electronic cigarettes also present significant health risks. There are many varieties of electronic cigarettes, and their manufacture in Canada has not yet been regulated.

Addiction

Nicotine is naturally present in tobacco and added to some electronic cigarettes. Nicotine is the root cause of addiction to and physical dependence on tobacco products. You can become dependent quickly, sometimes even before you become a daily smoker. Smoking 1 to 5 cigarettes a week can be enough for a person to become addicted. Nicotine dependence is comparable to heroin or cocaine addiction.

The brain actively develops during gestation and adolescence. As such, the nicotine to which a pregnant woman is exposed adversely affects the brain of a developing fetus. The development of an adolescent’s brain is also adversely affected if exposed to nicotine. The negative consequences associated with nicotine are not necessarily evident at birth or in adolescence but rather in the long term.

Effects on health and well-being

The short-term effects of smoking include:

  • Bad breath
  • Fatigue and a decrease in energy
  • Reduction in the senses of taste and smell
  • Coughing
  • Shortness of breath

Smokers are also at risk of experiencing several health problems, including:

  • Problems affecting the heart and blood vessels
  • Respiratory or lung problems, such as asthma or excessive coughing
  • Certain types of cancers, including lung cancer
  • Fertility problems
  • In women: menstrual problems
  • In men: erectile problems

Lower life expectancy

At least half of smokers will die due to smoking. Their life expectancy is reduced by at least 10 years compared to those who have never smoked. Smoking only 1 to 4 cigarettes a day is enough to increase the risk of dying prematurely.

Sours: https://www.quebec.ca/en/health/advice-and-prevention/healthy-lifestyle-habits/smoke-free-lifestyle/the-effects-of-smoking-and-second-hand-smoke-on-health

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