Question: Should children of a person in active addiction visit/see them regardless of their current condition or situation?

Mr. Segal: My short answer would be no. As a parent, your primary responsibility is to your children and not to your spouse, or girlfriend/boyfriend. Children often are perceptive and understand that something is "wrong" with Mommy or Daddy. The instability inherent with a person in active addiction outweighs the possible benefits to the children by having visits in most cases. In this questioner's situation, she reported that her children are well adjusted and the father has little interest in actually seeing them, which is even more indicative that visits are not essential to the children's well being.

Sometimes the significant other of an addict hope that an addicts involvement with there children will motivate them to quit using drugs or in the very least allow them (significant other) to maintain contact with the addict. It is very hard emotionally to love and care about someone who is self destructive. For some people, it is even more hard to begin letting go of the unhealthy relationship. If this is the case, I would recommend initiating individual therapy to explore and resolve possible internal conflicts that the significant other may be experiencing. I would also recommend AL-ANON, a self help group for family and Friends of addicts. They meet to help each other learn how to cope with an addicts behavior, set healthy boundaries for themselves and be mutually supported when doing so.

When an addict is in the recovery process and has built a foundation for themselves, at some point visits with children can be a healthy experience by all parties.

Question: Please reference a good screening instrument for adolescents.

Mr. Segal: I would like to begin answering this question by letting you know my bias. I believe a well trained clinician doing a complete bio/psych/addiction/social assessment that includes a detailed mental status evaluation would produce the most accurate assessment. The oral interview skills by a clinician using open ended questions is a true art, which is part of the problem. Not all clinicians have equal interviewing skills, so results may vary. A standardized test/assessment will produce easily replicated results no matter the interviewer.

My organization uses the POSIT (pre-assessment) and the Addiction Severity Index. The Gain Q can also be helpful.

Question: Can cooperation exist between the mental health fields and the addiction Fields, and if so, what would they look like?

Mr. Segal: My short answer is yes, cooperation can exist. Traditionally, mental health and addiction have been separated by having different government agencies that regulate treatment and funding , as well as health insurance companies that require a primary diagnosis that will send the patient into one system or the other. We now know that mental illnesses and addiction effect one another and to treat one in preference to the other often leaves the patient a risk for relapse or psychiatric deterioration.

Some states have eliminated separate Mental Health and Addiction regulatory/funding agencies and combined them into a Behavioral Health agency. This reduces systems that are incompatible in dealing with one another. My state of Maryland still uses two separate systems; one grant based (addiction) and one insurance fee-for service (mental health). Not only can it be challenging for the consumer to get both his/her addiction and mental health needs met simultaneously, it can be hard on the providers. A consequence of having two separate systems is in creating clinicians that perhaps do not have the expertise to deal with both sets of problems, as there primary experience and training is geared towards one set of problems.

Ideally, a consumer would be referred to have an assessment and in that process a determination and implementation of the appropriate type of care could be implemented. The referral could be made from any source; school, family physician, social service, police/courts, self, etc... If a client has both a severe mental illness and addiction they might be referred to a residential treatment that provides integrated co-occurring treatment. Both illnesses are treated simultaneously. The client has one therapist that is qualified to treat both issues simultaneously. The facility I am the clinical director of is such a facility. We have our own psychiatrist, Nurse and all groups address both mental health and addiction problems. The therapist have 1/2 the case load that the state of Maryland will allow (8 instead of 15). As such, this treatment is in the short run more expensive then traditional treatments. In the long run it saves money by having less arrests, jailing, emergency room visits etc...

If a client has a less severe mental illness or addiction, they may benefit from parallel treatment. Instead of one provider comprehensively treating both issues, they may have separate providers. An example: If a client is employed, has cocaine addiction, has a healthy support system and suffers from depression, they may be referred to an Intensive Outpatient Addiction program, as well as a psychiatrist/therapist for depression management.

Question: How can religious institutions play a part in the recovery process?

Mr. Segal: Spirituality can be very important to people attempting to become sober. The 12-step community encourages addicts to learn to turn over anxieties and problems that they have no control over to there "Higher Power" which may or may not be G-d. Often when addicts worry about problems, they will go use drugs to relieve the anxiety or depression, even though they are often aware that the relief is temporary and may carry significant consequences.

Religious Institutions can provide a since of community and belonging, both of which can be vital in the recovery process. Often an addict feels alone and cut off from everyone. Perhaps their families and friends have literally cut off contact because of past behaviors. A welcoming community that is often found within our religious institutions are sometimes one of the few supports a person in early recovery may have.

Also, places of worship have been very generous in allowing their buildings to be used by the 12-step communities.

Question: How long is it necessary is it for a young adult to stay in-patient after heroin, meth-amphetamine or cocaine addictions?

Mr. Segal: Short answer: it depends. Sometimes no inpatient treatment at all may be indicated. The first step is to have an accurate assessment done by a qualified individual. Often this will include a medical exam to insure that no life threatening issues are present (heart defect as an example) and a toxicology screen can also be important to rule-out that a drug such as a benzodiazapine is being used, which may be life threatening if stopped abruptly and therefore require detoxification.

Some insurance policies and some government agencies provide funding for detoxification only if there is medical necessity which may be defined as a withdrawal of a substance that can be life threatening. The two most common drugs that may produce life threatening withdrawal are alcohol and benzodiazipines, both of which may produce severe seizures if the person meets the criteria for physical dependence. Please note that the mere use of alcohol or benzodiazapines do not necessitate physical withdrawal. The three drugs mentioned in this question; heroin, meth-amphetamine, and cocaine are not typically life-threatening when the drug is ceased. They are more likely to cause death during the use of the substance. Withdrawal from these three drugs can be uncomfortable and will often result in the addict going out to use their drug of choice again to eliminate their discomfort. In-patient detox can make the withdrawal more tolerable.

After the initial detox period has concluded (about 3 days for heroin) a determination of the level of care and length of stay for that treatment is made. The determination is very individualistic and should be based upon severity of drug dependence or abuse, past recovery experience (example: 2 years sobriety after 1 outpatient treatment episode), employment status, living situations, presence of mental illness, criminality, among other factors.

Often the decision is made based upon what is available and not always the clinical indication. The reality is that government funding sources have limited resources and would like to treat as many people as possible, so they fund programs for specific length of stays (short). There is evidence that out patient programs of at least 16 weeks work very well for those that meet that criteria, that 28 day programs work well for that target population and longer stay of at least 210 days work well for those that meet the clinical criteria. However access to treatment is not always based upon need. If a client can only get into a 28 day program, even though they may need a longer stay, then they enter the 28 day program.

I could post many studies that would indicate x number of days is needed for various severities of addictions, but then again, other studies would indicate otherwise.