We’re a busy program for indigent and uninsured patients that has always had something of a problem with ASA. The program is 30 days in length and includes some subacute detox (nothing serious, but we medicate). Most of the ASAs come in the first week of the stay. Why?  And what can we do about it?”

When you see a big chunk of your ASA discharges in the first week, take a look at these possible causes.

Inadequate medication

As I’m sure you know, there’s a difference between medicating to provide safe detox, and medicating to suppress drug hunger. It’s easy to undermedicate, especially when the physician or nurse is naturally concerned about oversedation. The problem is that an addict in withdrawal is an addict on the edge of panic. His fear of withdrawal may be a bigger problem than withdrawal itself.

Suggestion: Try making some adjustments in the detox protocol.

Harried or overburdened staff

Addicts are very demanding of staff attention during the first week of treatment. If busy nurses perceive patient demands as attempts to manipulate, and ignore them, or become critical, the addict simply leaves.

Suggestion: You might do some observation of the nurses with an eye to training them in alternate ways to deal with demanding patients. One inner-city program cultivated a group of three or four recovering volunteers whose job it was to sit in the main common area and help reassure new patients. That seemed to help.

The addict isn’t being engaged quickly enough

Crisis motivates addicts to seek treatment. But the addict’s motivation to remain in treatment decreases as he feels better. Other worries come to the fore, and it’s easy for him to decide he’s ‘fine’ and no longer need help. That’s why you need motivational counseling in the initial days, in the form of a short detox discussion group or some individual attention. If the staff is too busy to provide this form of engagement, ASA goes up.

Suggestion: Maintain activities on weekends, especially after a cluster of admits, when staff is easily swamped with paperwork. If you allow visitors, be careful of contact with detox patients – they can actually assist a potential ASA in leaving the program.

The environment is just too chaotic

For all their defiance, addicts respond to order and structure. A disorganized environment creates tension that activates the client’s fight-flight response. It may literally drive him or her right out of treatment.

Suggestion: Stick to a schedule. Make sure activities occur on time. Take a ‘no big deal’ approach to minor complaints and problems. Keep intra-staff conflicts out of the sight and hearing of patients. Strive for an atmosphere of order and calm.