Patient counseled regarding psychosocial and pharmacologic treatment options for alcohol dependence (SUD)
CPT4 code
Name of the Procedure:
Patient counseling regarding psychosocial and pharmacologic treatment options for alcohol dependence (Substance Use Disorder, SUD)
Summary
This procedure involves advising and educating patients on various treatment options for alcohol dependence. It covers both psychosocial therapy (like counseling and support groups) and pharmacologic treatments (medications to reduce cravings or withdrawal symptoms).
Purpose
The medical condition addressed is alcohol dependence (SUD). Goals include helping patients understand their treatment options, initiating appropriate therapies, and supporting the journey to recovery.
Indications
- Diagnosis of alcohol dependence or SUD.
- Regular excessive alcohol consumption leading to physical or psychological harm.
- Patient’s desire to seek help for alcohol dependence.
- Patients experiencing withdrawal symptoms.
- Failed self-help or non-professional attempts at reducing alcohol intake.
Preparation
- No specific fasting or physical preparation is required.
- Having a list of current medications and any previous attempts at quitting alcohol can be helpful.
- Patients may undergo a preliminary assessment to evaluate their medical history, drinking patterns, and readiness to change.
Procedure Description
Initial Assessment:
- Evaluate the patient's medical history and current status.
- Discuss the patient's drinking habits and previous attempts to quit.
Educational Session:
- Provide detailed information on psychosocial treatments such as cognitive-behavioral therapy (CBT), motivational enhancement therapy (MET), and participation in support groups like Alcoholics Anonymous (AA).
Pharmacologic Options:
- Discuss medications like disulfiram, naltrexone, and acamprosate.
- Explain how each medication works, potential side effects, and the importance of compliance.
Developing a Treatment Plan:
- Collaboratively establish a personalized treatment plan.
- Set clear goals and outline steps for implementation.
- Schedule follow-up appointments for monitoring progress and making adjustments.
Duration
The initial counseling session typically lasts about 45-60 minutes, with follow-up sessions varying in length depending on the patient’s needs.
Setting
The procedure is usually conducted in an outpatient clinic or a healthcare provider’s office.
Personnel
- Primary care physician
- Psychiatrist or addiction specialist
- Counselor or mental health professional
- Nurse
Risks and Complications
- Psychological discomfort from discussing personal issues.
- Potential adverse reactions or side effects from prescribed medications.
- Risk of relapse, requiring ongoing support and possibly adjusting the treatment plan.
Benefits
- Enhanced understanding of treatment options and their efficacy.
- Personalized care plan tailored to the patient’s needs.
- Increased likelihood of successful recovery and maintenance of sobriety.
Recovery
- Continuous support through regular follow-up appointments.
- Participation in therapy sessions and support groups as needed.
- Adherence to medication management, if prescribed.
- Recovery is an ongoing process, often varying in duration.
Alternatives
- Self-help strategies, but these often have lower success rates without professional support.
- Inpatient rehabilitation programs, which offer intensive support.
- Outpatient therapy programs that provide structured support with greater flexibility compared to inpatient care.
Patient Experience
During the counseling session, patients may experience emotional relief by sharing their experiences and concerns. They may also feel hopeful with a clear plan moving forward. Comfort measures include a supportive and non-judgmental environment, and any discomfort from discussing personal issues is managed by a compassionate approach from the healthcare team.