Referral to Treatment: Utilizing the ASAM Criteria

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1 Referral to Treatment: Utilizing the ASAM Criteria AOAAM Essentials in Addiction Medicine October 22, 2016 East Lansing, MI Stephen A. Wyatt, DO Medical Director, Addiction Medicine Behavioral Health Service Carolinas HealthCare System

2 Disclosure American Society of Addiction Medicine publishes the Patient Placement Criteria 2nd Edition Revised. This publication is used for initial evaluation, placement, continued stay, transfer and discharge planning. ASAM PPC-II-R AND THE ASAM CRITERIA (2013)

3 Historical Approach to Treatment Complications Driven Approach Diagnosis, Program-driven Treatment Individualized, Clinically driven Treatment Biopsychosocial Needs Addiction Mental Health Social Participant-Directed, Outcome-informed Treatment

4 ASAM criteria driven treatment Enhances use of limited resources Increase ability to maintain treatment Improves outcomes to help prevent relapse Fixed length to flexible length of stays Chronic disease management

5 Collaboration Understand their understanding of the problem Agreement on Goals Agreement on Treatment Methods Establishes a Therapeutic Alliance

6 Development of the Treatment Plan Patient Centered Treatment. What? Why? How? Where? When?

7 Initial Assessment Step by Step Approach Not always in the same order due patient needs Assess: Risks Needs Strengths & Resources

8 Multi-Dimensional Assessment Dimensions 1. The acute intoxication and/or withdrawal potential 2. Biomedical conditions and complications 3. Emotional, behavioral or cognitive conditions and complications 4. Readiness to change 5. Relapse, continued use or continued problem potential 6. Recovery and living environment

9 FIRST STEP IMMINENT DANGER A high probably that certain behaviors will occur The likelihood that such behaviors will present a significant risk of serious adverse consequences to the individual and/or others The likelihood adverse events will occur in the very near future

10 Stages of Change Pre-contemplation Contemplation Preparation Action Maintenance Relapse or return to old behavior/patterns (Prochaski and DiClemente, 1996).

11 Dimension 1: The acute intoxication and/or withdrawal potential. Processing current levels of acute intoxication Previous withdraw history and management Current signs of withdrawal and participants them available support networks

12 Dimension 2: Biomedical conditions/complications How does the participants health impact his or her treatment? Assessing for physical health services Any and all physical conditions and complications should be considered Severity Medication management Any treatment issues This includes current and acute ailments to chronic conditions

13 Dimension 3: Emotional/Behavioral/ Cognitive condition/ complications Assessed for any mental health services needed Make sure to address these symptoms appropriately Violence potential Ability to function Include; Thought, Mood, and/or Personality Disorders

14 Dimension 4: Readiness to Change Addresses Motivational services needed. Stages of change found in the trans-theoretical model of change This includes his or her level of understanding, commitment, and ability to follow through

15 Dementia 5: Relapse/Continued use/continued problem potential Assessed for any relapse prevention services needed Accounts for participants who: continue to use continue to experience mental health concerns

16 Dimension 5: Relapse/ Continued use/ Continued problem potential Substance use patterns Physical and mental health conditions Relapse triggers Coping skills and other demographic factors

17 Dimension 6: Recovery/Living environment Help provide recovery support services Tries to get an accurate picture of where the patient lives or plans to live Family, friends and support How he or she is doing at work or school Finances Transportation Legal mandates and requirements

18 Levels of Care 0.5 Prevention & Early Intervention 1 Outpatient Services 2 Intensive Outpatient Services 3 Residential Treatment 4 Inpatient Hospitalization

19 Treatment Models

20 Motivational Interviewing Extrinsic & intrinsic motivation Enlightened self-interest Developing discrepancy Rolling with resistance Supportive&strategicinterventions Decisional balance Change plan worksheet (Miller and Rollnick, 2002).

21 Matrix Model The model integrates treatment elements from a number of strategies, including relapse prevention, motivational interviewing, psycho-education, family therapy, and 12-Step program involvement. Combines Evidence Based Practices: Motivational Interviewing CBT & Classic Conditioning Drug & Alcohol Education Brain Chemistry Stages of Recovery The basic elements are group sessions, individual sessions, along with encouragement to participate in 12-Step activities, delivered over a 16-week intensive treatment period (Obert, Rawson, McCann, & Ling, 2006).

22 Dialectic Behavioral Therapy Learn and practice skills in the areas of: Mindfulness EmotionalRegulation Distress Tolerance InterpersonalEffectiveness Diary Cards Chain Analysis Ultimate goal to build a life worth living (Linehan, 2008).

23 12-Step Facilitation Encourages acceptance of the addiction, commitment to abstinence and willingness to participate actively in 12-step fellowships as a means of establishing recovery. Evaluate the substance use problems and advocate abstinence. Explain basic 12-step structure and concepts. Encourage client to engage in 12-Step meetings Facilitate ongoing participation Discuss and support client working each of the 12-Steps Include support system in the therapeutic process Utilizing 12-Step network when in crisis Assist the client making a moral inventory and engaging in amends Encourage involvement in 12-Step beyond formal therapy

24 Coordinating/Collaborating Care Regular conversations with treatment program Collaborative treatment planning Include ancillary providers such as PCP & dentist On the same pages with community support meetings

27 Revised title patient placement Matching patients to individually assessed needs Derive a collaborative treatment decision and service plan

28 Co-Occurring Disorders Integration treatment services Providers Needs of individuals Subdiagnostic code current conditions or Call occurring formal psychiatric diagnoses

29 Acute intoxication and withdrawal potential Detoxification Done by the liver Clinicians and practitioners manage withdrawal

30 Opioid treatment services Opioid treatment programs (OTP) Agonist medications Methadone buprenorphine Antagonist Medications Naltrexone Office based Opioid Treatment (OBOT) buprenorphine Naltrexone Psychosocial Services

31 Added Adult Special Populations Older Adults: Diagnostic criteria Prospective parents or parents receiving addiction treatment with their children A continuum of treatment needs Persons in Safety Sensitive Occupations Longer closer monitoring Persons in criminal justice settings. Adherence to treatment Unique Descriptors Settings, support systems, staff, diagnostic criteria, therapies, assessment and treatment planning, documentation, dimensional criteria.

32 Dimension Risk Rating 0 Rating Non-issue, Very low-risk No current risk Acute and chronic problems have been stabilized

33 Dimension Risk Rating #1 Rating Experiencing mild discomfort or difficulty Able to function with minimal impairment Able to stabilize any acute and chronic problems quickly

34 Dimension Risk Rating #2 rating Experience a moderate risk or difficulties Noticeable impairment in functioning Still able to cope with and understand support services

35 Dimension Risk Rating #3 Rating Serious difficulties and impairment Difficulty coping with and understanding issues Near imminent danger high!

36 Dimension Risk Rating #4 Rating - IMMINENT DANGER Severe difficulties or impairment Serious, persistent signs and symptoms Very for ability to cope with or tolerate illness

37 3 H s History Here and now How concerned? Dimension One: Example

38 Dimension Risk Rating Severity Risk Concern Level of risk will change and should be continually assesed.

39 Matching services to need Risk is multidimensional and biopsychosocial e.g. Stabilizing psychosis or managing of patients withdrawal while addressing and an unstable or dangerous living environment) Risk relates to the patient s history e.g. The patients whose withdrawal always results in seizures as a different treatment needs from the patient this withdrawl involves only mild symptoms of anxiety Risk is expressed in current status How acute, Unstable and active is the patient s current clinical presentation? Risk involves a degree of change From baseline or premorbid functioning

40 Organizing Information Assessment dimensions Risk: 0 Risk: 1 Risk: 2 Risk: 3 Risk: 4 Priority dimension Services needed Intensity of services and LOC in setting I Moderate risk rating of two or higher should be considered a priority dimension Is zero rating would indicate an low level of risk A single risk rating in the assessment dimension can then be isolated to determine the priority dimension

ASAM CRITERIA 3 rd Edition

ASAM CRITERIA 3 rd Edition Presented by Mark Disselkoen, LCSW, LADC CASAT Based on DSM 5 & The ASAM Criteria Manual The ATTC Network Ten Regional Centers Central Rockies ATTC is now the Mountain Plains