Identifying, Intervening and Preventing Against Medical Advice (AMA) Discharges in the Treatment Setting

The need for drug and alcohol treatment is growing rapidly in the United States. The Substance Abuse and Mental Health Services Administration (SAMHSA) reported in the 2013 National Survey on Drug Use and Health that an estimated 22.7 million people ages 12 and older needed treatment for an illicit drug or alcohol use problem. This equals 8.6% of the population that is age 12 or older. Among the 22.7 million people who needed treatment, an estimated 2.5 million received treatment at a specialty facility for their drug or alcohol problem. This means that 20.2 million individuals who needed treatment did not get treatment that year (3). For those who do get treatment, the next challenge is getting them to stay for the duration of treatment. Most people come into treatment expecting not to need the full stay. When they choose to leave before their recommend discharge date, they are often referred to as leaving AMA, or against medical advice. This means they choose to leave treatment early, despite the recommendations of the clinical and medical team, and this decision can be costly not only to their recovery efforts, but also to the healthcare organization providing care.

Top Reasons for Leaving AMA

Clients leaving treatment AMA has been deemed a phenomenon by many, but the reality is that a multitude of reasons can be blamed for this type of discharge occurring. Some people believe it is due to what the clients report, such as they are leaving for personal reasons, sickness or death in their family, reparation of a relationship, financial problems, or legal issues(1). Continuing to hold the belief that it is a phenomenon or that people leave for reasons such as the ones previously listed is detrimental not only to the organization, but also to the client’s safety and well-being.

A leading cause for AMAs occurring within the residential setting is trait impulsivity and neurocognitive expressions of impulsivity. Trait impulsivity has characteristics, such as a lack of premeditation, sensation seeking, lack of resiliency and perseverance, and difficulties in coping with strong impulses (2). Neurocognitive expressions of impulsivity separates it into two categories, impulsive action and impulsive choice. Impulsive action is defined more by poor inhibitory control, while impulsive choice refers to a distorted view or inability to see delayed consequences(2). These are a concern because clients leaving treatment AMA are doing so impulsively.

Most clients with substance use disorders will have issues surrounding impulsive acts and impulsive choices. Learning to identify, interrupt, and intervene on clients who display these characteristics will not only reduce AMA discharges, but it also may help prevent a rise in readmission rates and relapse occurrences.

Additional Exacerbating Factors and Warning Signs

Although impulsivity is the most prevalent cause for clients leaving residential treatment AMA, there are also many other factors and warning signs that can worsen the already deteriorated state of a possible AMA discharge. These issues must always be recognized and interceded upon in order to give the best possible outcome.

Some of the additional exacerbating factors and warning signs that can aggravate an AMA discharge are:

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