Detox Only, and a Job Interview in Ten Days
Denise R., 34, has injected illicit fentanyl for three years and has had two overdoses, one reversed with naloxone by a friend five weeks ago. She has no stable housing and stays with a partner who also uses. Her 9-year-old daughter is placed with Denise's mother. She carries a diagnosis of generalized anxiety disorder, was psychiatrically hospitalized two years ago, and denies current suicidal ideation. She wants 'detox only, then I'm done' because she has a job interview in ten days and cannot go inpatient. Her insurer will authorize up to 14 days of residential. She has no primary care, no car, and her phone was shut off last week.
1. Recommend a level of care using ASAM criteria and justify it dimension by dimension, given that the client is asking for something else.
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Walk the six dimensions explicitly, because the recommendation has to be defensible to the insurer and to her.
- Dimension 1, withdrawal and intoxication potential: high - daily fentanyl, physical dependence; withdrawal management alone is not treatment for opioid use disorder and carries high post-detox relapse risk.
- Dimension 2, biomedical: uncomplicated, no acute medical instability.
- Dimension 3, psychiatric/cognitive: mild to moderate - GAD, remote hospitalization, no current SI.
- Dimension 4, readiness to change: low; she wants detox only. Readiness informs engagement strategy, not the level of care.
- Dimension 5, relapse/continued use potential: high - injection, two overdoses in the recent past, no phone, no support network.
- Dimension 6, recovery environment: high risk - partner uses, unstable housing.
Recommendation: residential (3.1, or 3.5 if medically supervised withdrawal is needed), with buprenorphine initiation, not detox alone. Dimensions 5 and 6 alone justify residential placement. Document the rationale and the risk discussed if she declines - ASAM places the client at the least restrictive level that can still meet her needs, and her current environment cannot.
2. She rejects residential. How do you handle the disagreement in a way that keeps her engaged and still protects her?
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- Do not argue the level of care. Arguing converts a clinical recommendation into a power struggle and she will leave.
- Surface the real constraint. 'You have an interview in ten days' is concrete. Ask what residential would cost her - the job, childcare, the partner, income. Sometimes the barrier is solvable; often it is the thing she is actually protecting.
- Use motivational interviewing. Elicit her own reasons for wanting to stop; reflect the discrepancy between 'I'm done' and two overdoses in a year.
- Offer a real alternative, not a threat. If she declines residential, propose buprenorphine started now, intensive outpatient at the highest frequency she will accept, a housing referral, and naloxone with overdose education. Add a specific reassessment date and the criteria that would trigger a move to residential.
- Make it a shared decision, documented as such. Record the recommendation, her refusal, the risks you explained, the plan she agreed to, and the criteria for re-evaluation. That protects her and it protects you.
- Never make continued treatment conditional on the higher level - a client at a lower level of care is still in care.
3. Rewrite her goals into a treatment plan that will satisfy a utilization reviewer.
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A plan that gets authorized has four features: it is derived from the assessment, it is measurable, it is time-bound, and it names who does what.
Example structure:
- Problem (from Dimension 1/5): Opioid use disorder, severe, with injection use and two lifetime overdoses.
- Goal: No illicit opioid use, verified by urine drug screening twice weekly.
- Objectives (30/60/90 days): Induction onto buprenorphine by day 3; 100% negative screens by day 30; naloxone in possession and one person trained in its use by day 7.
- Problem (from Dimension 6): Unstable housing; partner actively using.
- Goal: Enrolled in recovery housing or documented alternative by day 30; attend one session addressing relationship safety by day 14.
- Problem (from Dimension 3): GAD symptoms that increase relapse risk.
- Goal: Re-established psychiatric care within 14 days; report two coping skills applied during cravings by day 21.
- Interventions: individual counseling 1x/week, IOP group 3x/week (9 hours), medication management weekly, peer recovery coaching, documented care coordination.
- Review date and discharge criteria stated explicitly.
Vague entries like 'client will stay sober and attend groups' are the usual reason a plan is denied.