The New ASAM Criteria: Implications for Drug Courts

Transcription

1 The New ASAM Criteria: Implications for Drug Courts NADCP 21 st Annual Training Conference July 29, 2015 Washington, DC David Mee-Lee, M.D. Chief Editor, The ASAM Criteria Senior Vice President The Change Companies Carson City, NV Davis, CA

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4 INDIVIDUALIZED, CLINICALLY-DRIVEN TREATMENT ASAM Principles of Addiction Medicine 5 th Edition, 2014

5 Underlying Concepts (cont.) Multidimensional Assessment 1. Acute Intoxication and/or Withdrawal Potential 2. Biomedical conditions and complications 3. Emotional/Behavioral/Cognitive conditions and complications 4. Readiness to change 5. Relapse/Continued Use/Continued Problem potential 6. Recovery Environment The ASAM Criteria pp

6 Criminogenic Factors/ASAM Criteria Dimensions Criminogenic Factors 1. History of anti-social behavior; 2. Anti-social personality; 3. Antisocial values and attitudes; 4. Criminal/deviant peer association; 5. Substance abuse; and 6. Dysfunctional family relations ASAM Criteria Dimensions 1. Dimensions 3, 4 & 6 (3: Emotional, Behavioral, Cog. Complications & Conditions, 4:Readiness to Change, 6:Recovery Environment) 2. Dimension 3 (Emotional, Behavioral, Cog.) 3. Dimension 3, 4 and 6 4. Dimension 6 (Recovery Environment) 5. Dimension 1, 4, 5, 6 (Dim. 1Acute Intoxication & Withdrawal Potential Dim.5 Relapse, Cont. Use, Cont. Problem Potential) 6. Dimension 6 (Recovery Environment)

7 Biospychosocial Treatment Treatment Matching - Modalities Motivate - Dimension 4 Manage All Six Dimensions Medication Dimensions 1, 2, 3, 5 Meetings Dimensions 2, 3, 4, 5, 6 Monitor- All Six Dimensions

8 Underlying Concepts (cont.) Treatment Levels of Service I à 1 Outpatient Treatment II à 2 Intensive Outpatient and Partial Hospitalization III à 3 Residential/Inpatient Treatment IV à 4 Medically-Managed Intensive Inpatient Treatment The ASAM Criteria pp

9 Level 0.5 and OMT Level 0.5: Early Intervention Services - Individuals with problems or risk factors related to substance use, but for whom an immediate Substance -Related Disorder cannot be confirmed Opioid Maintenance Therapy (OMT) - Criteria for Level I Outpatient OMT, but OMT in all levels à Opioid Treatment Program (OTP) with Opioid Treatment Services (OTS) = antagonist meds (naltrexone) and Office-Based Opioid Treatment (OBOT) - buprenorphine

10 Detoxification à Withdrawal Management Services for Dimension 1 I-D à 1-WM - Ambulatory Withdrawal Management without Extended On-site Monitoring II-D à 2-WM -Ambulatory Withdrawal Management with Extended On-Site Monitoring

11 Withdrawal Management Services for Dimension 1 (continued) III.2-D à 3.2- WM- Clinically-Managed Residential Withdrawal Management III.7-D à 3.7- WM - Medically-Monitored Inpatient Withdrawal Management IV-D à 4-WM - Medically-Managed Inpatient Withdrawal Management

12 Level I and II à Level 1 and 2 Services Level I à 1 Outpatient Treatment Level II.1 à 2.1 Intensive Outpatient Treatment Level II.5 à 2.5 Partial Hospitalization

13 Level III à Level 3 Residential/Inpatient Level III.1à 3.1- Clinically-Managed, Low Intensity Residential Treatment Level III.3 à 3.3- Clinically-Managed, Medium Intensity Residential Treatment à Clinically Managed Population-Specific High Intensity Residential Treatment (Adult Level only)

14 Level III à Level 3 Residential/ Inpatient(cont.) Level III.5 à 3.5- Clinically-Managed, Medium/ High Intensity Residential Treatment Level III.7 à 3.7- Medically-Monitored Intensive Inpatient Treatment

15 Level IV à Level 4 Services Level IV à Level 4 Medically-Managed Intensive Inpatient

16 Models of Stages of Change 12-Step model - surrender versus comply; accept versus admit; identify versus compare Transtheoretical Model of Change - Pre-contemplation; Contemplation; Preparation; Action; Maintenance; Relapse and Recycling; Termination Readiness to Change - not ready, unsure, ready, trying, doing what works

17 The Stages of Change James Prochaska, Ph.D., John Norcross, Ph.D., and Carlo DiClemente, Ph.D

18 A Word About Terminology Treatment Compliance vs Adherence Webster s Dictionary defines: comply : to act in accordance with another s wishes, or with rules and regulations adhere : to cling, cleave (to be steadfast, hold fast), stick fast

19 Criminal Justice s View of Presenting Problem and Solution 3 C s Consequences Compliance Control

20 Coerced Clients and Working with Referral Sources Common purpose and mission Common language of assessment of stage of change Consensus philosophy of addressing readiness to change Consensus on how to combine resources and leverage to effect change, responsibility and accountability Communication and conflict resolution

21 Engage the Client as Participant Treatment Contract What? Why? How? Where? When?

22 Identifying the Assessment and Treatment Contract Client Clinical Assessment Treatment Plan WHAT? What does client want? WHY? Why now? What s the level of commitment? HOW? How will s/he get there? WHERE? Where will s/he do this? WHEN? When will this happen? How quickly? How badly does s/he want it? What does client need? Why? What reasons are revealed by the assessment date? How will you get him/her to accept the plan? Where is the appropriate setting for treatment? What is indicated by the placement criteria? When? How soon? What are realistic expectations? What are milestones in the process? What is the treatment contract? Is it linked to what client wants? Does client buy into the link? Referral to level of care What is the degree of urgency? What is the process? What are the expectations of the referral?

23 Focus Assessment and Treatment What Does the Client Want? Does client have immediate needs due to imminent risk in any of six dimensions? Conduct multidimensional assessment

24 Focus Assessment and Treatment (cont.) DSM-5 diagnoses? Multidimensional Severity/LOF Profile Which assessment dimensions are most important to determine Tx priorities

25 Focus Assessment and Treatment (cont.) Specific focus/target for each priority dimension What specific services needed for each dimension What dose or intensity of these services needed

26 Focus Assessment and Treatment (cont.) Where can these services be provided in least intensive, but safe level of care? What is progress of Tx plan and placement decision; outcomes measurement?

27 DSM-5 diagnoses? Multidimensional Severity/LOF Profile Which assessment dimensions are most important to determine Tx priorities Specific focus/target for each priority dimension What specific services needed for each dimension What dose or intensity of these services needed Where can these services be provided in least intensive, but safe level of care? What is progress of Tx plan and placement decision; outcomes measurement? The ASAM Criteria p 124

28 Revised Constructs for Dim. 5 A. Historical Pattern of Use or Mental Health Problems 1. Chronicity of Problem Use or MH problems 2. Treatment or Change Response B. Pharmacologic Responsivity 3. Positive Reinforcement (pleasure, euphoria) 4. Negative Reinforcement (withdrawal discomfort, fear) The ASAM Criteria pp

29 Revised Constructs for Dim. 5 (cont.) C. External Stimuli Responsivity 5. Reactivity to Acute Cues (trigger objects and situations 6. Reactivity to Chronic Stress (positive and negative stressors) D. Cognitive and behavioral measures of strengths and weaknesses 7. Locus of control and Self-efficacy The ASAM Criteria pp

30 Revised Constructs for Dim. 5 (cont.) D. Cognitive and behavioral measures of strengths and weaknesses (cont.) 8. Coping Skills (stimulus control, other cognitive strategies) 9. Impulsivity (risk-taking, thrill-seeking) 10. Passive and passive/aggressive behavior The ASAM Criteria pp

31 From Punishment to Lasting Change Implications for Sanctions and Incentives 1. Sanction for lack of good faith effort and adherence in treatment based on clinical assessment of person s needs, strengths, skills and resources. Don t sanction for signs and symptoms of their addiction and/or mental illness in formulaic manner that is one-size-fits-all 2. Treatment provider responsible for careful assessment and person-centered services and to keep court apprised of any risk to public safety. Court should be informed about client s level of good faith effort in treatment; and whether client is improving in function at pace consistent with their assessed needs, strengths, skills and resources. Provider should not just report on passive compliance with attendance and positive or negative drug screens passive compliance is not functional change

32 From Punishment to Lasting Change Implications for Sanctions and Incentives 3. If client is not changing their treatment plan in positive direction when outcomes are poor e.g., positive drug screens, attendance problems, passive participation, no change in peer group activities and support groups like AA etc., then client is doing time not doing treatment and change. Providers need to then inform judge that client is out of compliance with court order to do treatment. Client consented to do treatment and should be held accountable for their individualized treatment plan. If client is substantively modifying their treatment plan in positive direction with poor outcomes; and adhering to new direction in treatment plan, then client should continue in treatment and not be sanctioned for signs and symptoms of their illness(es) 4. Incentives for clients can be explored/matched to what is most meaningful to them e.g., incentives that allow client to choose gift certificate or coupon for restaurant may be meaningful for some. Others may find assistance in seeing their children; or help with housing; or advocacy to change group attendance times to fit better their work schedule to be more meaningful incentives. This requires an individualized approach by providers who should know their client s needs, skills, strengths and resources. It is too much to expect judge to work all this out.

33 From Punishment to Lasting Change Implications for Sanctions and Incentives 5. A close working relationship between client, judge, court team and treatment providers needed to actualize this approach. Ideas come from clinical bias/experience, but offered with awareness: That we need more discussion to make this work in real world of courts and criminal justice That to achieve public safety outcomes we all want, we have to move treatment from passive compliance and jumping through hoops mentality that allows many clients to do time in treatment instead of doing treatment and change That treatment providers need to rise to occasion and improve assessment and person-centered treatment planning that values outcomes-driven services That judges and court personnel can expect treatment providers to design and deliver individualized care; and keep them well-informed on any threats to public safety. Reports need to be on functional improvement not just compliance with attendance and drug screens.

34 Data to Identify Gaps Systems issues cannot change quickly. Each incident of inefficient or inadequate care can be a data point that promotes systems change Finding efficient ways to gather data as it happens in daily care of clients can provide hope, direction for change The ASAM Criteria page 126

35 Data to Identify Gaps (cont.) PLACEMENT SUMMARY Level of Care/Service Indicated Level of Care/Service Received The ASAM Criteria page 126

36 Data to Identify Gaps (cont.) PLACEMENT SUMMARY Reason for Difference - Circle only one number Level of care or Service not available; 2. Provider judgment; 3. Client preference; 4. Client is on waiting list for appropriate level/service; 5. Level of care or Service available, but no payment source; 6. Geographic inaccessibility etc. The ASAM Criteria page 126

37 Data to Identify Gaps (cont.) PLACEMENT SUMMARY Anticipated Outcome If Service Cannot Be Provided- Circle only one number Admitted to acute care setting; 2. Discharged to street; 3. Continued stay in acute care facility; 4. Incarcerated; 5. Client will dropout until next crisis; 6. Not listed (Specify): The ASAM Criteria page 126

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39 Drug Court Journal

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41 David Mee-Lee, M.D. Chief Editor, The ASAM Criteria Senior Vice President The Change Companies Carson City, NV Davis, CA