By Marisa Markowitz, LMSW, CASAC-T
When students leave the halls of academia and decide to venture on their first social work job, there is trepidation. Will I be able to cut it? Do my skills align with the amount of knowledge I gained in school?
Students must decide what type of social worker they want to become, and where they would like to work. There are clinical, military, hospital, school social work, and other options.
Addiction is one route that a social worker can pursue, and it typically requires a Licensed Master Social Work (LMSW) certification. This simply means that an individual can marry various systems, schools of thoughts, and theories, and apply them to real-life scenarios. It also is a great selling point for large institutions that have prestigious names to carry. Large hospital systems typically employ LMSW social workers because they have demonstrated clinical acumen and the ability to navigate practice scenarios.
So why should students enter the realm of clinical social work in addiction? Well, for one, addiction is serious societal issue. There are two main types of addiction – behavioral and chemical. Common behavioral addictions include food addiction, gambling addiction, gaming addiction, and hoarding. Chemical addiction involves substances, most notably alcohol, opioids, cannabis, nicotine, amphetamines, cocaine, and methamphetamines.
One can be diagnosed with a substance use disorder if he or she meets a certain criterion determined by the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Here are some sobering statistics: In 2022 in New York (including New York City), 1,131,000 adults and 52,000 young people were diagnosed with a substance use disorder.
What are Opiates?
One form of substance is opiates. Opiates are a type of drug used to treat pain, but oftentimes these drugs are abused because of their addictive qualities.
There are natural opiates, like codeine, morphine, and heroin (heroin is made from morphine). These drugs are used after surgeries and used on an as-needed basis. There are also semi-synthetic opiates, which are part naturally producing and part manufactured drugs. One of the biggest and well-known semi-synthetic opiates is OxyContin.
A drug prescribed for serious pain in the 1990s, oxycontin is highly addictive, and has come under major media scrutiny due to its makers’ (Sackler family and Purdue Pharma) unsavory marketing strategies as ‘non-addictive’ opioids. This could not be farther from the truth, and most patients seeking help from drug use start their stories with “I got into an accident in high school and was prescribed oxycontin.” It is downhill from there.
There are also synthetic opiates, a dangerous, man-made class of drugs manufactured in laboratories. These drugs include Demerol, methadone, and fentanyl, and represent lethal classes of drugs due to their potency. According to the National Institute of Drug Abuse (NIDA), because of fentanyl’s extremely high potency (it is 50 to 100 times more potent than morphine) and its ability to readily enter brain tissue, it can be lethal to breathe air with atomized fentanyl in it or touch a contaminated surface.
In other words, if someone ingests fentanyl or uses heroin, cocaine, or cannabinoid laced with fentanyl, he or she can die. Right on the spot. The Covid-19 pandemic exacerbated the fentanyl crisis: in 2020, there was an estimated 30 percent increase of overdose deaths related to opiate use, with a growing amount due to the drug fentanyl. The number is higher today, as the pandemic has lasted two plus years and is still part of the fabric of our lives.
Those entering addiction field must ask themselves, “Am I ready to see a client overdose or even die?”
Why would a social work student decide to enter this field? It could be because they have a passion for social justice and a commitment to ending pain and suffering.
Those contemplating working in this field should also ask themselves, “Is this a field that I can realistically go into, knowing that my patients might overdose, or worse, die?” It is not an unfair question. Social workers in schools, nonprofit organizations, research, and mental health settings are likely to see their clients or patients the following day. The same cannot be said of working in a methadone clinic. Patients seeking help for opioid addiction go through phases of change, one of them being relapse. A relapse episode is the most dangerous as a patient might overdose and not be able to call 911 in time.
Methadone is a treatment for opiate use disorder and has been around since the 1950s. It reduces withdrawal symptoms and cravings for opioids. Not all medical professionals embrace this model. Abstinence models would argue that it is better to curtail drug use through complete renunciation of drug use, rather than substitute one opioid (methadone) for another (heroin, fentanyl, oxycodone, morphine, codeine). Abstinence only models frown upon the use of methadone because it does not address psychosocial factors that contribute to drug use. However, a body of research indicates that methadone is an effective model to treat opiate use and opiate dependency.
The transition from study of addiction and knowledge of opiates is not seamless. Students are taught that addiction is a chronic but treatable disease rather than a moral failing. However, in practice, patients often feel stigmatized and ashamed of their drug use. In methadone clinics, patients walk around listlessly, bang on doors to be seen, and fidget in their seats trying to get rid of the goosebumps ravaging their systems. Clinical social workers in this setting must recognize the reality of such pain and manage the needs of every staff member – not an easy task.
How addiction social workers work with nurses, doctors and psychiatrists
Clinical social workers may feel the pressure to be overly sensitive to their patients’ behavior and to help nurses and doctors. Nurses monitor diversion (are clients selling methadone instead of taking it, returning a full bottle, or forgetting to return an empty bottle). Nurses can lose their licenses if patients mismanage their medication, and social workers must help nurses, especially when they have added information that can help explain unexpected drug use or relapse.
Clinical social workers help nurses by increasing patient schedules (from once a week to three times a week, for instance), providing more intensive counseling as per nursing recommendation and exploring higher levels of care like detox programs or inpatient care if a client is struggling. There can be no egos in a methadone clinic. Everyone must work together, and there is no right way to treatment. Treatment is a collaborative effort. New clinical social workers must adapt and focus on the patient, nursing concerns, and other ad-hoc requests.
Clinical social workers also collaborate with doctors and psychiatrists who assess a patient’s overall function through dose evaluations. While a doctor’s scope is limited to chemical issues stemming from drug use, oftentimes doctors will speak with clinical social workers about changes in their patients’ lives. Did something happen at home? Did a patient lose employment and therefore resort to drug use? Is someone being abused? Social workers must be attuned to the nuances and changes in their patients’ lives to provide accurate and helpful insight into behavior changes.
A clinical social worker in addiction treatment setting is a professional juggler
This information alone is enough to make ones’ head spin. And a clinical social worker may still wonder, ‘What does it really feel like to work in such an intense environment?’ ‘Is it really for me?” Well, for one, a methadone clinic is incredibly fast paced. Everything happens in a heartbeat, and sometimes there is no downtime. Everything can feel like an emergency. It may not be possible to provide 45-minute counseling sessions to six patients in one day.
More likely a clinical social worker will see 12 to 15 patients, avert a crisis, and scramble to write up notes by end of day. The name of the game is learning the complex needs of the clinic while also considering a patient’s needs in a loving, present way. Psychodynamic therapy or looking at past traumas or family dynamics is helpful when patients are stable and can explore their urges, cravings, and needs from a more detached lens. The heart and soul of a methadone clinic is crisis management – and this can come as a shock to a bright-eyed social worker looking to be a therapist.
A clinical social worker is a professional juggler. An essential job function is to hold space for patients in crisis, to complete daily, weekly, and monthly deliverables, and to help nurses, doctors, and other key staff members stay on the same page.
This is a challenging proposition, not because clinical social work is hard, but because patients with opiate use disorder oftentimes present with other mental health issues that make treatment harder to quantify. Anxiety, depression, trauma, and personality disorders are oftentimes linked to addiction.
This level of patient complexity requires a dexterous mind. Clinical social workers are hugely integral members in the puzzle that is addiction. And stepping away is okay, too: this elevated risk, high reward environment isn’t for everyone. Practicing commitment to social justice comes in all forms. The best approach when thinking about addiction and a methadone clinic is to research, investigate, and determine a goodness of fit. If the answer is yes, working in a methadone clinic can be highly rewarding. Addiction social work is in the business of saving lives. What could be a more noble pursuit than that?
Marisa Markowitz, LMSW, CASAC-T, is a Clinical Social Worker at New York Presbyterian Hospital’s Vincent P. Dole Treatment and Research Institute for Opiate Dependency. Marisa studies the relationship between technology and its adverse effects on mental health, particularly for vulnerable populations.
Disclaimer: The National Association of Social Workers invites members to share their expertise and experiences through Member Voices. This blog was prepared by Marisa Markowitz in her personal capacity and does not necessarily reflect the view of the National Association of Social Workers.