I.

Substance Abuse History:

Pt presents as a 27-year-old single unemployed male. Patient referred to this facility on

06/01/2023 transported directly from Robert Wood Johnson Hospital. Patient is reporting a 9-

year history of primarily methamphetamine use and subsequent one year history of opiate use,

specifically heroin, both of which pt reports consumption via insufflation and smoking

respectively. Pt reports first use of crystal form of methamphetamine at age 18 and the first use

of heroin at age 26 explained as, “I have just been on a run since then”. Pt reports beginning

both substances via nasal insufflation initially, later graduating to smoking both substances

within 6 months of first use. Patient described current use as “a vicious cycle of using meth for

3-4 days, then using a bundle a day of heroin for the come down for the next 3-4 days”.

Pt reports extensive history of overdosing on (what pt believed to be) heroin several (“at

least three times”) in the past, including but not limited to his most recent overdose on his

birthday January 13, 2023, at which time he was again narcanned and woke up in the hospital.

Patient reports two prior overdoses in 2022 requiring medical intervention via Narcan as a

rescue measure. Pt reports when attempting to reduce usage of heroin in the past he would

experience symptoms of DTs such as shakes, sweating, nausea, irritability, insomnia, and

“blackouts while drinking and being barred out (on several 2mg xanax pills via oral

consumption)”, but denies a history of seizures. Patient denies current alcohol use and denies

ever having alcohol poisoning. However, pt reports a significant period 3 years ago when he

frequently mixed alcohol and Xanax. Pt reports this combination inevitably led to being unable to

control his anger/rage, becoming involved in several physical altercations with limited to no

memory of events. Pt points to this specific combination of substances that resulted in “going to

prison for 2 years”. Patient also reports at least one past episode involving alcohol, requiring

medical intervention around the age of “16-17 …had to get the charcoal stuff in my stomach

because I took pills with a bunch of vodka”. Patient reports witnessing his cousin overdose at
age 17. Pt presented as under the influence of methamphetamine during the assessment,

reporting that it has been “about a week since he last used heroin…but my bones are starting to

hurt”. Patient is adopted with limited access to biological family history however reports both

paternal and maternal sides of biological family have a history of both substance use disorder

as well as mental illness including but not limited to his biological fathers struggles with opiate

addiction, depression, and bipolar disorder. Patient risks significant physical and mental

withdrawal symptoms, as well as relapse with significant medical implications in the event he

chooses to leave treatment early.

II. Psychological Functioning

Pt presents with an anxious mood and anxious, irritable affect. Pt reports current A/V

hallucinations that take place mostly at night, which cause him to be in a perpetual state of

paranoia. “I fear the night at this point. I fear getting high now. Forget getting high to have fun,

its not fun anymore. I am literally scared of the voices, the gang stalking, and all that. Imagine

how scary that is? That is why I am here. I need to stop. I am making myself crazy. I am at the

point where I just tell myself the shadows are not happening when I see them. I have gotten

better at it, but I am still scared of it all”. Pt describes “a lot of shadows and voices that talk

about my insecurities” taking place largely at night when it is dark. Patient reports only recently

starting to see shadows and hear voices. Writer asked Patient to expound on how recently this

started, patient response was “just these past two runs or so. That's enough for me though. I'm

done. I know it's not real and I know I sound so crazy right now”. Pt denies the current and past

history of self-harm. However, it also reports at least one past episode of intentional self

devaluation requiring medical intervention around the age of “16-17 …had to get the charcoal

stuff in my stomach because I took pills with a bunch of vodka”. Patient reports current cravings,

depression, and anxiety all as 10 out of 10. Patient reports feeling upset, anxious, and/or

depressed 28 out of the past 30 days, and using 30 out of the past 30 days. Pt reports he came
to treatment because, “I have get off the meth and heroin. I cannot keep doing this to myself

and my body. The physical part is one thing but I can no longer live with that it does to my head

and mental”.

III. Education/Vocational/Financial

Patient is a high school graduate with no continued education explaining, “I didn't go to

college…I hurt my knee and couldn't take a soccer scholarship. Now I am in your very nicely

decorated office explaining shadows that talk to me” .Pt reports he is currently unemployed and

explains the reason he voluntarily stopped attending gainful employment as a landscaper was

due to his cycle of substance abuse being a full time job. “If I am not on it, I am looking for it. If I

got it, I just did it. If I just did it, I really don't know or care what else I am doing next. Plus, I need

more by then because now I have no more. I did it all”. Patient recounts “really comfortable kind

of family life…vacations, real nice dinners on weekends, my Mom had a new car all the time.

Above average I guess you could say” type of childhood and family dynamic reporting only

recent family discord that is atypical for the household. Currently the patient reports he does not

have a bank account, cash, assets, or lines of credit. Patient has no picture identification and

signed patient attestestation to confirm identity later confirmed by insurance company where

father is subscriber.

IV. Legal

Patient reports currently being on probation after serving 2 years in prison “for fighting

during that period I was on Xanax and drinking, fighting all the time”. Patient reports over “lets

just say 20” arrests involving substances and/or being under the influence of substances, the

most recent arrest being two weeks ago for possession, with an upcoming court date of

6/20/2023. Pt reports engaging in numerous high-risk behaviors such as driving, going to work,

and obtaining several injuries/falls while under the influence. Pt confirms he has been beaten to
the point of unconsciousness and robbed several times while obtaining drugs in dangerous

areas.

V. Social History

Patient reports being adopted as an infant however also reports extensive knowledge of

biological fathers life, struggles, and death . When asked whether or not his friends and family

are supportive of his recovery, Patient described himself as isolated and withdrawn, explaining,

“I am not even around anyone. I have pushed everyone away or they have run away from me

themselves, on their own''. Pt reports history of significant trauma and loss, including but not

limited to finding his childhood best friend suspended from a hanging anchor-point (self-inflicted)

known as patients tree house at the age of 13 “and never really being myself again after that,

loss of Uncle Eddie in 2011 from a brain aneurysm”, and this past Christmas Eve 2022 the loss

of Madeline (52F) “with so much wisdom” …who reportedly played a significant role in pts life

“died from cancer out of nowhere”. Pt became tearful while reporting extensive traumatic history

of paramour relationships including one former partner becoming “pregnant by another man

while pt was serving 2 years in prison” and again the following year with a different paramour

who was later found to be using the pt for money and substances while he truly believed in their

strength and legitimacy as a couple, “I just keep getting betrayed and played by so many people

both men and women because I am just so high all the time…I really have no idea what is truly

going on even if it is right in front of me. Everyone I love, leaves me or hurts me or both”. Pt

reports he experienced abuse in his childhood but declined to expound on this while tearful

during assessment. Pt reports his substance use is in an effort to “calm and quiet all this

emotional pain I am constantly dealing with. I have so much pain but then get stuck in a cycle of

using, more pain, more using, and now I am really going completely crazy which is why I need

to stop. I know I sound crazy”. Pt and father both are favorable to dad being involved in

treatment. Patient reports discord among family and friends explaining he has “isolated himself
to the point that 80% of interactions with family and friends result in arguments/conflict in

regards to his substance abuse”.

VI. Physical History

Pt reports no history of medical conditions. Patient reports the last time he visited the

emergency room was over 30 days ago but within the past 60 days at which time pt brought

himself to emergency room “because I was just freaking out, having a panic attack and needed

to be brought down”. Patient reports having a PCP (Primary Medical Provider) but declining

their involvement in treatment, unable to remember contact details, and having no influence on

patient decision to enter treatment today. Patient denies any allergies to food, medication, and

denies dietary restrictions. Pt reports he eats very little, not even one meal a day on average

with “zero appetite…I won’t eat for 4 days and then I will binge for an hour or two straight”.

Patient presents as gaunt and reports feeling his physical health has been “very poor” but

declining to expound beyond “of course I feel physically like sh*t”. Pt reports having trouble both

falling and staying asleep. Pt reports sleeping maybe 3-4 hours a night. In addition,Pt reports

nicotine use via vaping several times per day, more so when using more. Pt denies an interest

in quitting.

VII. Treatment History

Pt reports this his 6th time in inpatient treatment, 2 of which were detox only. Pt reports

his most recent treatment center was New Bridge Medical Center in Paramus where he

received a formal diagnosis of anxiety, depression, and bipolar where he was prescribed 2-3

different medications he was in compliance with for 4 days then reports “feeling like a zombie so

I quit taking them” and denies follow up with any mental health provider or physician regarding a

desire to regain compliance. Pt reports no period of voluntary abstinence since being clean

while in prison for two years 2019 at which time he found out his partner was pregnant with
another man’s baby “and things just went straight back downhill from there”. Pt reports enjoying

the mental clarity that came with being sober during that time. Patient reports never having

attended or engaging with 12 step meetings or 12 step work.

A. Assessment

Though the patient presents under the influence and while describing his delusion of

currently being gang stalked, it is clear the patient is well spoken, smart, funny, and easily

accurately self identified as a “people person”. Patients report of “knowing I sound crazy” is

believable to the point of sympathy that he wants to break the endless cycle and rollercoaster of

using. Patient seems to be good historian and has manners as he described significant trauma

and loss beginning in early childhood. Writer suspects patients elderly adoptive parents are in

fact the parents of his deceased father. There is never mention of biological mother but Patient

appears to become agitated when the father or biological family is mentioned. Patient seems

exhausted yet restless. After denying the question of whether or not he has children during

assessment, the patient asked the writer, “why don't you think I have kids?” in a defensive

manner as if insulted.Patient has lost the majority of touch with reality and severity of his

circumstances, concerned only with himself and his addiction as it consumes all of patients life

and energy. Pt reports being able to identify past patterns of relapse as “it is constant

(emotional) pain…I don’t know how to live life sober. It is too painful”. Pt reports having no

realistic coping skills leading to constant use and relapse.

B. Treatment Plan

Pt presents appropriate for Detox. Pt does not present as an AA risk currently. Pt reports

he is open to individual and group therapy, a desire to engage in 12 step work, be educated on

his triggers that lead to relapse, as well as learning real world coping skills. Pt reports desire to

explore his options for long term aftercare and is firm in his belief that “the only way he will have
a good shot once he leaves treatment is to just go straight to staying in treatment”. Pt reports

having experience with MAT, the most recent of which was about 8 months ago with Subutex

however pt reports “I just wanted to do dope instead at that time” but currently having an open

mind and wanting more information about MAT options for the future.

Based off ASAM criteria, Patient meets criteria for 3.7 detox LOC. Patient provided a UDS at the

assessment and the results were positive for FEN, THC, AMP, MET; BAC=.000. Diagnosis

Codes: F11.20 Opioid Use Disorder, Severe; F15.20 Other Stimulant Use Disorder, Severe

C. Course of Treatment

Patient reports at time of assessment beginning to experience symptoms of withdrawal and

would benefit from seeing the MD for medically monitored detox and stabilization. Patient report

lack of knowledge or attendance of 12 step work or meetings and would benefit from working

with a recovery instructor or peer support. Patient expresses an interest in moving out of his

elderly fathers home, though it is an option as opposed to facing homelessness. Patient is open

to recommendations regarding aftercare and would benefit from working with a case manager to

find sober housing following successful completion of treatment. Without having a past formal

diagnosis, the patient believes he is experiencing depression and anxiety that is unrelated to his

drug use and to which he credits his substance abuse in an effort to mask emotional pain.

Patient is agreeable to and will undergo a full psychiatric assessment while engaged in

treatment where in psychotropic medication is an option the patient is open to recommendations

for. Patient lacks coping skills needed to identify triggers and reduce relapse potential and

would benefit from working with a SMART recovery coach.

arrangement with his elderly adoptive father, he is deeply and adamantly interested in long-term

in-patient care/treatment following successful completion of treatment. Pt reports dads home

environment is safe or stable for his recovery but acknowledges he “needs further help beyond

whatever time I am given here”.

Pt presents appropriate for Detox. Pt does not present as an AA risk currently. Pt reports

he is open to individual and group therapy, a desire to engage in 12 step work, be educated on

his triggers that lead to relapse, as well as learning real world coping skills. Pt reports a desire

to explore his options for long term aftercare and is firm in his belief that “the only way he will

have a good shot once he leaves treatment is to just go straight to staying in treatment”. Pt

reports having experience with MAT, the most recent of which was about 8 months ago with

Subutex however pt reports “I just wanted to do dope instead at that time” but currently having

an open mind and wanting more information about MAT options for the future.

Based off ASAM criteria, Patient meets criteria for 3.7 detox LOC. Patient provided a UDS at

the assessment and the results were positive for FEN, THC, AMP, MET; BAC=.000.

Diagnosis Codes: F11.20 Opioid Use Disorder, Severe; F15.20 Other Stimulant Use

Disorder, Severe