Beth Israel Deaconess Medical Center
Transplant Manual
Title: Substance Abuse/Dependence and Transplantation
Purpose: To provide a rational approach to evaluation and management of
substance abuse and dependency issues in the context of liver
transplantation
Policy Statement:
Individuals presenting with a history of substance abuse/dependency shall be
evaluated by an interdisciplinary team including at least the following: a transplant
physician, a transplant surgeon, a licensed social worker, and a clinical psychologist
or psychiatrist. At the time of evaluation, the patient must sign a Patient
Responsibility Agreement pledging not to use alcohol, non-prescribed medications, or
other illicit substances (including, but not limited to, heroin, opiates, amphetamines,
marijuana, and cocaine) in the future. Patients must also agree to unlimited, random
drug and/or alcohol screening both while awaiting transplantation and following
transplantation. The evaluating committee will determine the patient’s suitability for
transplantation and will make recommendations regarding rehabilitation or counseling
prior to listing or as a condition of listing.
All patients must satisfy the following requirements prior to listing:
1.
Patients must demonstrate complete abstinence from all substances of
abuse/dependence (illicit drugs and alcohol) through the pre-transplant period.
They must have an abstinence period of at least three months prior to being
listed for transplant. If a patient has not been abstinent for two years, active
participation and successful completion of a relapse prevention program is
required. The relapse prevention program must be reviewed and approved by
the transplant social worker and/or psychologist. These criteria may be
modified based on individual patient situations and will require a detailed
explanation on the patient’s medical summary. All patients must be presented
at the Liver Transplant Selection Committee meeting for approval for listing.
2.
An approved relapse prevention program must have, at minimum, the following
therapeutic and recovery goals:
a.
enhancing insight into past abuse/dependence
b.
increasing understanding of how abuse/dependency impacted current
health status
c.
developing more effective coping and stress management skills
d.
enhancing the availability and stability of a rehabilitation support system
in the patient’s natural environment
e.
identifying high-risk situations and developing an action plan to address
them
f.
development of alcohol or drug refusal skills
g.
management of negative moods and depression
h.
implementation of strategies to maximize compliance with the transplant
regimen and other modifications in lifestyle
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i.
development of effective strategies for coping with cravings and urges to
use alcohol or drugs
Patients will be encouraged to receive relapse prevention services by the
clinical psychologist in the Transplant Center. Patients not wanting relapse
prevention services in the Transplant Center must arrange for their provider to
send a written summary of their treatment plan to the transplant social worker
and/or psychologist for review. This review will determine the degree to which
the relapse prevention services meet the foregoing criteria and whether
additional services are required.
3.
Patients receiving relapse prevention services outside of the Transplant Center
are required to arrange for written monthly progress reports to be sent by their
local provider to the transplant social worker or psychologist. This will ensure
that patients are attending to policy requirements and will allow the Transplant
Center to monitor treatment progress throughout the pre-transplant period.
4.
Random toxicology and alcohol screens may be performed on all patients with
a history of substance abuse/dependency. Such patients will be called
randomly by a vendor contracted with BIDMC, at time intervals determined by
the transplant team. These calls will be made in the morning and patients must
then go their local lab by the end of the day. Results will need to be faxed to
the Transplant Center within 24 hours of the phone call to the patient. “Testing
for cause” alcohol/toxicology screens may also be requested if substance use
is suspected or reported to the transplant team.
5.
Patients receiving Methadone Maintenance Therapy (MMT) are eligible for
transplantation, provided the following conditions are met:
a.
MMT is being done under medical supervision and guidance;
b.
the patient meets the other foregoing criteria regarding participation in
or successful completion of an approved relapse prevention program;
c.
monthly written progress reports are forwarded by the provider to the
Transplant Center.
6.
Patients must report all prescribed narcotics and sedatives to their transplant
coordinator and/or transplant physician for review and approval. If misuse or
abuse of prescribed narcotics is suspected, patients will be referred to the
transplant social worker and psychologist for further evaluation.
7.
If evidence arises and is verified that the patient has failed to maintain
complete abstinence during the evaluation process, the patient’s evaluation
period will be extended and the patient will be required to undergo reevaluation by the transplant social worker and psychologist. On the basis of
this re-evaluation, the transplant social worker and psychologist will make a
recommendation to the transplant team regarding a minimum abstinence
period and/or the need for additional substance abuse/dependence treatment.
If the patient with a positive toxicology finding is listed with UNOS, under the
direction of the patient’s transplant physician the patient will immediately be
inactivated from the UNOS waiting list. Following a required re-evaluation by
the transplant social worker and psychologist, the patient will be placed on the
agenda for the Liver Transplant Selection Committee, at which time the
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evaluating team will reconsider the patient for transplant listing. In both
circumstances as described, the patient must re-qualify for listing with UNOS.
Patients and their referring physician will be notified of changes to the patient’s
status during the evaluation period or after being listed with UNOS.
8.
Patients will also be expected to maintain abstinence post-transplant. The
transplant team may encourage and support participation in ongoing addictions
and relapse prevention treatment as needed, as well as continue to administer
random and “testing for cause” alcohol/toxicology screens.
9.
All patients with a current or recent (less than 2 months) history of nicotine
dependence will be encouraged to meet with the transplant psychologist to
evaluate the need for smoking cessation and/or relapse prevention services.
All transplant patients will be strongly advised to quit smoking and will be
provided with the resources to do so.
Patient Responsibility Agreement
General Statement
There are not enough donated organs for every person who needs, or could benefit
from, a transplant. Transplant programs, such as The Transplant Center at Beth
Israel Deaconess Medical Center, try to make sure that a transplant will benefit each
recipient and that the organs donated by others at the time of their death are used
responsibly. This means that we select patients who are medically, emotionally, and
financially able to follow the many requirements of a successful transplant.
Patients with a history of substance abuse or dependency, whether or not this was
the cause of their organ failure, must show their commitment to a healthy lifestyle by
following the recommendations of the transplant team both before and after
transplantation.
Responsibility Agreement
I, _________________________________, wish to undergo evaluation for
transplant. By undergoing evaluation, I agree to the following conditions of
participation in the transplant program:
1. I understand that I have a disease that may involve alcohol or substance
abuse. I accept abstinence from alcohol and/or drugs as a long-term goal for
my medical and mental health.
2. I understand that at least 3 months of out-of-hospital abstinence is required
before transplant listing. Abstinence is defined as “no use under any
circumstances” and pertains to alcohol and other drugs of dependence or
abuse. Continued lifetime abstinence may improve the chance that I will
experience positive health outcomes. Therefore, I understand that the
transplant program expects continued lifetime abstinence. I agree to adopt this
as an expectation for myself as well.
3. I agree to participate in a behavioral health assessment by the transplant
psychologist. I understand that my primary caregiver is expected to participate
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in this evaluation as well.
4. I understand that participation in a relapse prevention program is required for
those who have been abstinent for less than 24 months. I understand that such
treatment may include, but is not limited to, support groups, individual therapy,
inpatient, outpatient, residential, and/or community-based programs such as
Alcoholics Anonymous or Narcotics Anonymous. I will work with the transplant
team to decide which type of treatment is best for me.
5. If participating in a relapse prevention program, I agree to give the transplant
program monthly written reports (usually in the form of a letter by the treating
professional) of my progress in treatment. I will allow my primary physicians to
discuss my treatment plan and progress with significant others in my life,
including concerned family members. I consent to the sharing of medical
records among all of my inpatient and outpatient providers, specifically
including psychiatric and substance use records.
6. I understand that it is my responsibility to follow up with my medications,
medical, psychiatric, psychological, and/or addictions appointments. It is also
my responsibility to adhere to any other treatment or diet recommended by my
physicians and the transplant team.
7. I understand that use of any prescription narcotics or sedatives must be preapproved by the transplant physician.
8. I agree to undergo random urine and/or blood screens for substance use as
requested by the transplant program.
9. I agree to inform the transplant team if I relapse and use substances of abuse.
10. Substance use during the evaluation process or while listed for transplantation
will be examined promptly by the transplant team. I will be required to
participate in another evaluation by the transplant social worker and
psychologist. Following this evaluation, the transplant program might require a
longer abstinence period before I can be re-considered for transplant listing.
They might also require me to participate in another substance abuse
treatment program. If I am on the transplant list, any non-approved substance
use will result in being moved immediately from active to inactive listing status.
I will have to be re-evaluated by the transplant social worker and psychologist.
Based on these evaluations, the transplant team may decide to place me back
on the transplant list, require more substance abuse treatment before re-listing,
or remove me from the transplant list permanently.
Signatures
I understand that this agreement is a part of the transplant evaluation process. My
signing it does not guarantee my acceptance by The Transplant Center at Beth Israel
Deaconess as a transplant candidate. I understand that not following this agreement
may compromise my status as a transplant candidate. I have read this policy and the
transplant social worker or psychologist has reviewed it with me. I have had the
opportunity to ask questions. These questions have been answered to my
satisfaction. I agree to follow what is in this policy. I have been given a copy of this
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policy for future reference.
Patient _________________________________________ Date____________
I have explained the policy to the patient and have answered all questions.
Transplant Social Worker ______________________
or Psychologist
Vice President Sponsor:
Approved by:
x Liver Selection Committee
Requestor Name:
Original Date Approved:
Next Review Date:
Revised:
Date____________
Dianne Anderson, Sr. VP PCS
Douglas W. Hanto, MD, PhD and Michael Curry, MD
Co-Chairs
Michael Curry, MD
2/02
1/08
3/06
Eliminated:
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