Tuesday, December 10, 2013

Sobriety Date

Sobriety date is neither a medical or legal term.  It was first used in Alcoholics Anonymous to refer to the date after, or indeed any day after,  a person had their last drink.
The sobriety date is a based on an 'honour' system.   In a society of decreasing respect for 'honour' it's hard to explain the importance of the 'honour system' in 'recovery'.
Each year in AA, by convention,  a person 'takes a cake' to designate another year of sobriety.  Normally, the first year cake is bought for the person who has a year of sobriety whereas in subsequent years the person buys the cake for the group.  These 'birthdays' are indication to the 'newcomer' that AA works.  Indeed millions have maintained sobriety through the program of AA.
After the success of AA, Narcotics Anonymous, Cocaine Anonymous, and Marijuana Anonymous 12 step programs developed modelled on the original AA program.
In these programs, there is the term "Clean date".  Clean in this case usually means, the day after the last use of mood altering substances.  In this case anniversaries are celebrated referring to 'clean time'.
Again this is an 'honour' system.
Individuals self report their sobriety dates and clean dates and commonly describe a 'clean and sober" date.  If a person drinks or 'uses' (i.e. drugs) then the 'clean"  or 'sober" or 'clean and sober" date will change accordingly if the person reports it.
Recovery itself refers to more than just this 'clean and sober' time.  Recovery refers to a range of behaviours in addition to abstinence from drugs and alcohol.
In contrast to these 'voluntary' 'clean and sober' dates, there are 'abstinent dates'.  The abstinent date is used by Medical Review Officers to designate a person's 'clean and sober' date for 'accountability' purposes. This is not an 'honour' system 'per se' . Medical Review Officers are physicians with specific licensing for the purpose of assessing and reporting on individuals for legal or occupational purposes.
If I am a patients physician I may report their 'clean and sober' date for 'motivational purposes'.  This is done, especially, in psychiatry where patients share 'goals' and the clinician 'records' their 'goal' or their achievement. This is intentionally for the patient doctor relationship and part of good therapy.
In contrast Medical Review Officers are not directly in service for the patient alone. They are indeed working for a third party.
I trained specifically as a Medical Review Officer and have been licensed as such in the United States.  There is no similar level or standard of licensing or training in Canada.  The Canadian system by contrast is primitive in comparison with considerable ignorance and confusion as a consequence.
As a Medical Review Officer I did urine testing formally and decided whether a 'positive' urine was indeed a 'positive' urine from an Occupation or Legal position.
Indeed my dog was murdered when I was serving as a Medical Review Officer for an American government reporting positive urines and drug abuse by individuals.  One requirement for employment in the United States Federal Government funded systems is that you do not test positive for drugs on job applications.  Clearly given the notoriety of some of Canada's recent public officials such a policy might be indicated here but that might well be shutting the gate after the goats have got free.
As a Medical Review Officer I have worked for a 'third party', in this case, serving the aims of the US federal government funding system.
I know there is considerable ignorance and confusion surrounding these terms here.  For this reason, I thought it beneficial to correct errors that have arisen, especially in those not specifically trained in the assessment and treatment of alcoholism and drug addiction.
My special interest as a physician was 'non compliance" or "non adherence to medical regimen".  In this case, people don't do what they are advised to do. The medical system in general is a 'voluntary system'.
Indeed a doctor can prescribe a medication and a patient can fill the prescription, take the medication home, and flush the medication down the toilet, and the doctor doesn't know.  Clearly, most people with drug or alcohol problems have been advised to not drink or use drugs but persisted. Most are non compliant in this regard.  But then this holds true for most of the 'chronic illnesses' of the medicine of the western world. This was perhaps one of the reasons the term 'noncompliance' was changed to 'non adherence to medical regimen', thereby removing some of the judgementalness implicit.
In general medicine, noncompliance or non adherence runs roughly 30% but in the psychiatric practice this figure rises as high as 80%. The addiction medicine figure is usually quoted as over 50%.
Hence the introduction of urine testing in relationship to occupational positions.  The highly successful medical 'accountability' program, (see research by Dr. Marc Gallanter) shows 80% long term recovery.   These programs are more about 'policing' than care for the individual doctor , since they are designed to ensure the safety of patients in general. The same was developed for pilots and other 'safety sensitive' positions.  Lawyers and judges, who were reported as having as high as 20% addiction and alcoholism problems have similar programs to physicians and similar success these days though their introduction is more recent. No such program is in place in Canada for politicians though in the US , there is a much higher success rate for a variety of 'accountability' programs.  Indeed,the Canadian system is a 'spin off' from the much more robust and evidence based systems of accountability in the US.
 Urine drug testing was developed as part of the 'accountability' programs for occupation and legal purposes. It is part of a contractual arrangement and not a part of the normal doctor patient relationship which is defined professionally by a different code of ethics, that established for physicians by the Canadian Medical Assocation and the British Columbia Medical Association locally.
Now that said, Medical Review Officers only 'test' for 'specific' compounds.  In the Transport Industry these compounds were Heroin, Amphetamine, PCP, Marijuana, and Cocaine.  So a person can 'pass' a urine test and be 'clean' for occupational purposes if they are negative for these substances.  They could well be using a 'designer' drug and 'deny' such use and the lab would not pick this up unless specifically asked for it.
Further confusion is found with an alcoholic who might well do LSD and maintain their 'sobriety date' as the last day they used alcohol.
"Clean and Sober' refers generally to all mood altering substances and 'purists' maintain this includes 'prescribed medicinal compounds'.  There are those who refuse narcotics for surgery and those in Alcoholics Anonymous who would not 'touch their tongue' to alcohol in 'communion' in the Anglican church as this would be considered a 'slip' or 'relapse'.
This makes it difficult for those patients on prescribed methadone either as pain patients or as former heroin addicts since they are no longer considered 'addicted' but rather in 'recovery' by most addiction medicine specialists.
When the Medical Review Officer position was conceptualized the unions didn't want the employers to be able to do the 'urine' testing themselves but wanted an 'objective' doctor who could stand between the 'employer' and the 'union' to make a 'decision' regarding 'impairment' and 'abuse'.  Hence the MRO decides whether a person is 'abusing' drugs on far more than the urine drug screen.  For instance, if a person has a positive urine drug screen for opiates and they were prescribed 'morphine' for surgery and can show they had surgery and the prescription from the surgeon, this would clearly not be considered an abuse of drugs. The MRO in this case would "report' the urine as 'negative' for drugs even though it was 'positive'.
If there is confusion still, it's not surprising because even judges, senior bureaucrats, media personnel and general doctors can be 'wrong' in this area and why the United States developed a specific Medical Review Officer training program and why the American Society of Addiction Medicine, Canadian Society of Addiction Medicine and the International Society of Addiction Medicine have developed certification and examination programs.  In the latter it is clearly recognized that people cannot be treated as 'convicts' but that to the largest extent the programs of recovery are most effective the more 'voluntary ' they are.
Ironically, where as there are probably no Addiction Medicine Specialists who would consider such a term as 'recreational cocaine' use acceptable, especially given it's illegality, there are still judges, politicians and media personnel who find it quite acceptable.  Individually there are clearly exceptions to the rule and yet societally there are concerns, not unreasonably about 'illegal' activity regarding drugs and alcohol.  Mothers Against Drunk Drivers were a grass roots organization that developed solely because the 'leaders' in society were, to the mind of the victims of alcoholism and drug addiction, not doing their job.
I share this, but then, I've been known to be wrong and have admitted being wrong. That makes me not only educable but teachable. I am often in the company of those who in contrast are infallible and don't admit errors since frankly, apparently, they don't make them. Personnally I have apologized when I've been wrong too but to date no one has apologized to me when they've been wrong.  The errors I have seen have also cost many lives whereas I'm thankful by the grace of God and the quality of teachers and education I have had I have minimized the potential deaths that could have occurred in the high risk areas I have chosen to serve.

No comments: