One of the most difficult times for an individual suffering with active addiction and one of the most difficult times for the nurse or clinician is the first few hours of treatment for detoxification. Subsequent addiction care can also then be challenging. If the treatment planning contract and care are not established properly, there is a high likelihood that the care being offered will be sabotaged either by the patient or the clinician. This is true for all mental health encounters. Unfortunately, not everyone is properly prepared for this treatment experience either on the patient or the clinical side. This is not being written as some chastising diatribe to insensitive providers. I struggle with the issues I am writing about on a daily basis. I have failed many times to do what I am saying. I write this to myself as much as any other reader. Having made that disclaimer…

Addiction is a disease of the brain. We know nowadays that there is a dysregulation of the dopamine pathways in the limbic (fight or flight) system of the brain which causes persons with addiction to compulsively use substances. What is understood less well is the interaction of the thousands of other variables that are occurring in the limbic system. These variables include acute intoxication, past trauma, co-occurring disorders, guilt and shame, family issues, job and life stress, and all the things that accompany a crisis.

When someone has a heart attack, there are automatic systems in medical care systems that come into play regarding monitoring, medications, protocols, and intensive care. With addiction, people may need the same intensity of care in a different way. While there are many excellent treatment centers that do a great job of the care of patients with acute intoxication and withdrawal, there is still a stigma attached to addiction in some clinical settings. To add to the problem, the patient may be in a state of intoxication or delirium which may create fear or a feeling of helplessness for both the patient and the caregiver alike. Intoxication has been used forever as a state of derision in comedy and theater, and that stereotype persists.

The first reaction and attitude of caregivers is very important in the overall care of patients who come to treatment. The intoxicated or the patient who is in early withdrawal is in great distress. Our job as providers is to create an atmosphere that is non-threatening and respectful. Intoxication and early withdrawal have patients disconnected at some level with logic and rational behavior. They represent a psychiatric emergency no less than someone with an acute psychotic episode or major depression.

Let us consider the minimal standards that would be beneficial for these patients vis-a vis the chest pain patient. Quiet room. Understanding tone. Recognition of helplessness. Medical treatment as indicated. Most of all, do not engage with the fear and shame that may be directed at you. Continue to be the helper-healer-listener. Put on your emotional overcoat and step out into the rain and snow emotionally but try very hard not to get wet.

About the Author

Joseph Troncale, M.D. FASAM
Joseph Troncale, M.D. FASAM, has been working in addiction medicine for 20 years. He is the Medical Director of the Retreat.

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