The Devil is in the Details

by Norman Hoffmann

An often-used phrase is “The devil is in the details.” This applies to determining syndromes, specifying diagnoses, and developing treatment plans. Unfortunately, many clinical records found in addiction treatment programs report only the generic diagnosis and treatment placement. Failure to document the details of the diagnosis may obscure both the nature of the conditions and hinder justification of a treatment placement or treatment plan in general.

Delving into the specific positive criteria can yield a clearer understanding of a given patient’s condition, but also the likely treatment goals and strategies for the treatment plan. To illustrate this, let’s consider two hypothetical cases consisting of first-time DUI/DWI offenders – both of whom meet a diagnosis of moderate alcohol use disorder. Case 1 has the following positive findings: uses when use is hazardous (DUI); spending a great deal of time drinking with co-workers in the bar after work; has developed a level of tolerance from this use; has unplanned use in that he sometimes has another drink when a friend shows up when he was about to leave; and has considerable conflicts with his spouse related to the time spent in the bar.

Case 2 also has a DUI, so he meets Criterion 8 for use that is dangerous; he too has unplanned use, but his use often involves promising himself not to drink but does so anyway; has tried to cut down but failed due to intense cravings and compulsion to use; and has missed work due to drinking.

Both individuals have five positive DSM-5 criteria, but the patterns indicate a very different condition. Case 1 has no indications of an inability to control use. It is entirely possible that he could switch to nonalcoholic drinks while socializing; could spend less time at the bar and more time with his spouse. In short, Case 1 may not require abstinence to avoid another DUI or to resolve the other issues that indicate a moderate alcohol use disorder. Case 2 is a different story altogether. He has a history of unsuccessfully trying to cut back or stop drinking and has indications of craving and even role obligation failures. Unless he pursues abstinence, he is not likely to avoid future problems.

Here we see two individuals with the same overall diagnosis of moderate alcohol use disorder, but two very different patterns of findings with two likely different treatment requirements. The first individual might resolve his condition with or without being abstinent while the other is likely to require abstinence to avoid continuing issues.

If a program or provider intends to provide individualized treatment, the details found in the dimensions of the ASAM Criteria can indicate radically different treatment plans even within the same level of care. Again, let’s consider two hypothetical cases in the same level of care. Case 3 is in denial of her condition; has no understanding of addictions; is resistant to attend peer-support groups; and has no commitment to change. On the other hand, her family was successful in getting her into treatment, and close friend are very supportive. Both family and friend are willing to do what they can to help her achieve remission. Case 4 is highly motivated to change; has demonstrated an understanding of her conditions and is willing to do whatever is recommended to achieve recovery. However, all of her close friends and family members are heavily into using drugs and a friend is a dealer

The first case will require considerable motivational enhancement, but has a supportive recovery environment. In contrast, the second may not need any additional motivation, but may require strategies and assistance in avoiding negative influences.

In short, we see that simply determining a diagnosis or making a treatment placement decision is far from sufficient for true individualized treatment. The devil is indeed in the details.

Photo by Andrew Pons on Unsplash