Care plan
Three phases. Each does a different job. What we're pushing the care team on along the way.
The 90-day arc
Phase 1 · Detox at Haven
~30 days · West Palm Beach, FL · current (Day 14)
Chemistry. Nervous-system stabilization. Personalized taper extended once already on Ross's BP-spike flag. Mostly bed-rest is OK in this phase.
- Goal: stable baseline before residential handoff
- Open: EKG, Watchman implant date, gabapentin ask
Phase 2 · Residential PHP
~60 days · The Recovery Team · ~30 min from Haven · Dad pushing for it
Where the real therapeutic work happens. More activities, pool, phone access, in-person family visits. EMDR continues with Corrin's sister-facility counterpart.
Dad's stated motivators (5/27 call): phone access, the pool, and — most importantly — access to a neurologist for his tics. He reports Dr. Ignatov has done what he can on the tic side. Stephanie aware + supportive.
- Goal: learn to inhabit a non-numbed life
- Open: bed-hold timing, intake date, neurology access at The Recovery Team, sleep stack consolidation, MOUD decision
Phase 3 · IOP at home (Apollo Beach)
Months 3+ · stepmom-led handoff
Step-down to community living. Family-caregiver role activates. Dad's stated wish: home, with a pro care team around him.
- Lead time: begin 3–4 weeks before discharge from The Recovery Team
- Critical first appt: psychiatrist ≤7 days post-discharge
SF alternative floated on the 5/27 call — Dad considering coming to SF post-program to give Angela space + spend time with Paul + Pat. Real option; revisit when we get there. Would need an SF-based outpatient care team in parallel.
Full prep doc →What we're pushing the care team on
Considerations that fit Dad's specific profile and the 2026 standard of care. Not all need to land at Haven — many are for the Phase 3 outpatient team.
Neurologist consult for Tourette's
Dad's direct ask (5/27) · biggest current complaint
Tics are the worst-felt symptom right now. NAC 300mg + PRN clonidine aren't fully covering. Dad reports Dr. Ignatov has done what he can; he wants a neurologist for the tic side. Ask Lynn: does The Recovery Team have neurology access? If not, line one up for Phase 3.
Kindling prophylaxis
Gabapentin / pregabalin / levetiracetam
No anticonvulsant in regimen yet. Has been flagged 4+ sessions. Standing ask of Dr. Ignatov.
Continuous Glucose Monitor
Dexcom Stelo / Libre Lingo (~$80/mo, OTC)
Real-time glucose data on top of his baseline insulin 57 + olanzapine. Catches excursions before A1c reflects them. Standard now for atypical-antipsychotic monitoring.
CYP2C19 pharmacogenomics
Clopidogrel responder check
Up to 30% of patients have loss-of-function variants — clopidogrel isn't activated as expected. Routine in modern cardiology. One-time test.
CYP2D6 PGx (GeneSight / Genomind)
Duloxetine metabolism
Tells you a lot about response + discontinuation strategy. Especially valuable for a drug that's notoriously hard to come off.
Lp(a)
One-time genetic CAD marker
Missing from 2025 baseline. Genetic, only need to test once. Worth knowing for cardio handoff.
Vascepa (icosapent ethyl)
High-dose EPA, FDA-approved for CAD + high TG
OmegaCheck was 3.0% (high SCD risk per CHL); TG 237; established CAD. REDUCE-IT trial showed ~25% CV event reduction in his exact risk profile. Real Rx, not "more fish oil."
Ketamine / esketamine (Spravato)
If duloxetine doesn't land in 6–8 weeks
FDA-approved for treatment-resistant depression. Worth raising at Phase 2 review.
Long-acting naltrexone (Vivitrol)
Opioid + alcohol relapse prevention
Monthly injection. Gold-standard for opioid recovery. Should be on the table before IOP starts.
GLP-1 (semaglutide / tirzepatide)
Metabolic rescue if olanzapine worsens markers
Real literature on atypical-antipsychotic-induced weight gain mitigation. Could keep him on the antipsychotic if needed without the metabolic damage.
DEXA scan
Bone density baseline
Long Xanax history + new PPI + low DHEA + falls risk = real osteoporosis vector. Get baseline before Phase 3.
HRV / autonomic wearable
Whoop · Apple Watch · Garmin
Objective measure of kindling sensitivity over time. Tracks recovery in a way self-report can't. Cheap insurance.
NAC dose escalation
300 mg/day → 600–1200 mg BID
He's already on it (good). Research dose for tics + craving reduction is meaningfully higher. Easy ask of Dr. Ignatov.
Kindling — the load-bearing concept
Kindling is progressive neurological sensitization from repeated benzo/sedative withdrawal cycles. Each subsequent withdrawal is worse than the last — the GABA/glutamate balance keeps getting more dysregulated. Originally a 1960s epilepsy term (small repeated electrical pulses eventually trigger full seizures); applied to addiction medicine since the 1980s.
Why it matters for Dad: ~30 years of daily Xanax + at least one cold-turkey event (4/9/2026) = his CNS is now kindling-vulnerable. If he ever has another abrupt withdrawal — even from a missed pharmacy refill — the trajectory escalates: tremor → autonomic instability → seizure → status epilepticus → death. Each event lowers the threshold further.
Mitigations
- Anticonvulsant prophylaxis during any future taper (gabapentin, pregabalin, levetiracetam, oxcarbazepine, lamotrigine)
- Slow long-acting benzo taper instead of fast cessation, if ever needed again
- Never abrupt discontinuation — never let any psych med run out
- Long-term avoidance of GABA-suppressive substances (alcohol especially)
- HRV / autonomic wearable as early-warning signal
Specific asks for Dr. Ignatov / Lynn
- What's the kindling-risk assessment on file? It should be documented prominently.
- Is gabapentin (or pregabalin, levetiracetam, oxcarbazepine, lamotrigine) being considered for kindling prophylaxis? Right now: none in regimen.
- What's the discharge plan around never-cold-turkey-again? Stepmom needs explicit education.
- Is the kindling vulnerability flagged prominently for any future ER visit?
- If a future taper is ever needed, what's the protocol? Slow, long-acting benzo, anticonvulsant cover.