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1 ASAM SAIMA CHAUHAN, LCSW, CSAC, ICS, EMT-B & NICOLE BLANG, MS, CSAC, CCBT, CSIT THANK YOU FOR ATTENDING I KNOW YA LL ARE BUSIER THAN A ONE-LEGGED CAT IN A SAND BOX 2 Glasses of Wine is Good for Your Health 1

2 Lets Jump Right On In. That did not go so well for the bushy tail cat but we got this. (the cat was not hurt) What is the ASAM Criteria? It is the most widely used and comprehensive set of guidelines for placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions. 2

3 Client-Directed, Outcome- Informed Treatment I m grinnin like a possum eating a sweet tater Older Adults Persons in Safety Sensitive Occupations(police, nurses, pilots) Parents with Children and Pregnant Women Persons in the Criminal Justice System (CJS) Emotional/Behavioral/Cognitive conditions Tobacco Use Disorder Gambling Disorder Compatible with the DSM 5 3

4 Assessment of Biopsychosocial The 6 Dimensions RISK RATING Level Of Care Placement 4

5 WITHDRAWAL MANAGEMENT: Only for Dimension 1 Due to time this may not get addressed. The info on WM will be in this PP for you to refer too. When to use ASAM At intake (to see if the client is appropriate for or to see if they need a higher level of care) To determine if a client is in need of a higher/lower level of care. At discharge To see what the client needs next When your supervisor tells you to Who Can do an ASAM Criteria Assessment? All the below will need ASAM training by an approved trainer or an ASAM state approved workshop. AODA credentialed counselors/clinicians Certified addiction registered nurse Psychologist Physician SAC-IT s under supervision Fully licensed therapist? Act 262 5

6 Lets Explore Dimensions DIMENSION 1: Acute Intoxication and/or Withdrawal Potential This dimension addresses the severity of the individual s presenting SUD. The interviewer attempts to assess the severity of the individual s SUD and the degree of impairment in everyday functioning. Of particular concern is the risk of severe withdrawal syndrome. An individual who is experiencing symptoms of withdrawal (or who is at great risk of doing so) may require higher level of care (Hospitalization or Local Detox center). What to look for Dimension 1 Current withdrawal symptoms (sweats, tremors, nausea, anxiety, depression) How long have they been using regularly/daily?( I have been drinking about 5-8 beers with 1-2 shots of the hard stuff every night for the last 3 months) Has client been using multiple substance in the same drug class? (taking 2 CN depressants is double the trouble. Benzo & Alcohol can have deadly withdrawal.) History of withdrawal ( When I stopped 2 years ago I had a seizure) How long was the longest time they stayed clean (went to jail for 4 days and I started to shake and threw-up some but that s it) Does client have supports to assist in an ambulatory detox if medically safe? 6

7 THE BEST PREDICATOR OF CURRENT AND FUTURE WITHDRAWAL PROBLEMS ARE PAST WITHDRAWAL PROBLEMS Need more help on determining severity of withdrawal? CIWA-Ar Clinical Institute Withdrawal Assessment for Alcohol scale Clinical Institute Withdrawal Assessment Scale - Benzodiazepines Three Goals for Dimension 1 Avoidance of potentially hazardous consequences of discontinuation of drugs of dependence Facilitation of the client s completion of detoxification and timely entry into continued treatment Promotion of patient dignity and easing discomfort during the withdrawal process 7

8 Drug and Alcohol History Drug Route of First First Amount Frequency Last Tolerance Name Administration Use Problem Use Other Vicks 44 Dextromethorphan Drug of Addiction: Longest Abstinence: When: Circumstances: Route of Administration Route of administration can provide us with a plethora of info. Patients who inject drugs are at risk hepatitis B, C or HIV/AIDS. Because smoking a drug is the fastest way to get high(less than 10 sec), these drugs tend to be used more compulsively and achieving recovery may be more difficult. Clients who struggle with Meth addiction tend to need more of the drug because of the short duration of the high before they start tweaking therefore they are more likely to engage in illegal activities to finance their greater needs for larger amounts of Meth (drug dealing, burglary, robbery, prostitution). First Use Client-Length of time using Amount Withdrawal problems Clarification of amount: bump, 2 wholes, 7s, 40oz First Problem Adolescents Emotional/social development Progression of addiction Frequency Chronic use Has used daily and has not stopped. No recent hx of withdrawal Body had little time to heal itself 8

9 Last Use Short half life: Last use on the hr. I used yesterday around 12am(does client mean 12am this morning or 24hrs ago). Determining withdrawals Drug of (choice) addiction Getting there view and looking at insight Tolerance Liver issues Withdrawal Longest time staying clean/when/ how did you stay clean This helps build tx plan Strengths/challenges Circumstances around recovery DIMENSION 2: Biomedical Conditions & Complications This dimension investigates the individual s overall physiological condition in order to determine whether there are any medical problems or concerns that put them at risk or interfere with tx. If an individual is suffering from a medical problem that is complicated by substance use, or he or she has a health problem of such severity that medical care is immediately necessary, then the inclusion of medical management in the treatment setting becomes critically important. 9

10 Two Types of Medical Conditions and Complications Conditions which place the client at Risk (e.g. pregnancy, diabetes) Conditions which interfere with treatment (e.g., the need for kidney dialysis) Dimension 2: Biomedical Conditions & Complications Are there current physical illnesses, other than withdrawal, that need to be addressed because they create risk or complicate treatment? Are there chronic conditions that affect treatment? Chronic pain syndromes are often an issue Hypertension, cardiac disorders, vascular disorders, diabetes, and seizure disorders are all high on the list There are a range of chronic disorders that may need to be considered in placement decisions Is there medical issue(s) effecting them in the hear and now. But I am not a doctor 10

11 DIMENSION 3: Emotional, Behavioral, or Cognitive Conditions & Complications This dimension addresses the individual s mental status, in terms of the effects of any emotional or behavioral problems on the presenting SUD. The individual is evaluated in terms of his or her emotional stability, and the interviewer attempts to assess the degree to which the individual could present a danger to self or others. The goal of this dimension is to identify any mental health disorders which could complicate SUD treatment, and which may need to be treated concurrently. This dimension also identifies any unpredictable or self-defeating behaviors in response to emotional or environmental stressors Dimension 3: Emotional, Behavioral, or Cognitive Conditions & Complications Are there current psychiatric illnesses or psychological, behavioral, emotional, or cognitive problems that need to be addressed because they create risk or complicate treatment? Are there chronic conditions that could affect treatment? Do any emotional, behavioral, or cognitive problems appear to be a part of the addictive disorder, or do they appear to be independent? Even if connected with the addictive disorder, are they severe enough to warrant specific mental health treatment? Is the individual capable of managing the activities of daily living? Does the individual have the resources to cope with the emotional, behavioral, or cognitive problems? Are they CURRENTLY experiencing any EBC complications Co-Occurring Disorders ADHD is five to 10 times more common among adult alcoholics than it is in people without the condition. Among adults being treated for alcohol and substance abuse, the rate of ADHD is about 25%. ADHD Often Co-Occurs with Learning Disabilities including Dyslexia Over 8.9 million persons have co-occurring disorders that is, they have both a mental and substance use 11

12 Bipolar Disorder and Alcohol Problems Women with bipolar disorder are SEVEN times more likely to have alcohol problems than women without Men with bipolar disorder are FOUR times more likely to have alcohol problems than men without NOTES ON TRAUMA Given how commonly it exists in the SUD population, it should be screened for and treated when found Part of the Dimension 3 Assessment Includes: Assessment of suicidality Factors associated with a higher risk for suicide White, male over 65 Previous suicide attempts Family history of suicide Plan, means & opportunity Access and comfort with a lethal means of suicide (e.g., firearms) Presence of Manic-Depressive or Major Depressive Disorder Native Americans living on reservations Being in treatment 12

13 For client who have co-occurring disorders, assess dimensions 4,5 & 6 separately for both mental health and SUD D4: SUD/ RR-2 The client has impaired recognition and understanding of substance use relapse issues, but is able to self manage with prompting. D4:MH/ RR-3 The client has little recognition and understanding of mental illness relapse issues, and has poor skills to cope with and interpret mental health problems or to avoid or limit relapse. DIMENSION 4: Readiness / Motivation This dimension examines the individual s attitude towards treatment. Looks at clients willingness to explore the need for tx to deal with mental disorders. The degree to which the individual understands the nature and consequences of his or her SUD, as well as his or her motivation to engage in recovery, are vital considerations to be made when deciding upon an appropriate setting for treatment. 13

14 Dimension 4- Readiness / Motivation What is the individual s emotional and cognitive awareness of the need to change? What is his or her level of commitment to and readiness for change? Is there any leverage available? What is or has been his or her degree of cooperation with treatment? What is his or her awareness of the relationship of alcohol or other drug use to negative consequences? NOTE: External motivation is very important because it gets most individuals through the door for admission to treatment. BUT it might not keep them in tx or keep them sober long term. Why? 14

15 Dimension 4: Readiness to Change Pre-contemplation: does not know they have a problem. Very ambivalent. Avoids thinking about their behavior. Risk rating: 4a or 4b Contemplation: Reluctant to agree tx for MH/AODA but willing to be compliant to avoid consequences. Able to articulate neg. consequences but low commitment to change. Risk rating:2 or 3 Preparation: Made a commitment to make a change. Their motivation for changing is reflected by statements such as: I ve got to do something about this.. this is serious. Risk rating: 1 or 2 Action: Willing to enter tx and explore change in reducing or stopping use. Believe they have the ability to change their behavior. Risk rating: 0 or 1 Maintenance: Has personal recovery goals, proactive in tx and willing to cut negative influences. Risk rating: 0 NOTE ON RESISTANCE & LOC Higher Resistance, Denial, Ambivalence Do Not ALONE Indicate the Need for, or Clinical Appropriateness Of A Higher Intensity Level of Treatment Dimension 5: Relapse, Continued Use or Continued Problem Potential This dimension s focus is the individual s ability to maintain recovery by having an understanding of, or skills in coping with addictive or co-occurring mental health disorders to prevent relapse. It examines how the individual deals with triggers, stress and peer pressure without recurrence of addictive thinking, behaviors or continued problems such as SI or HI. 15

16 Dimension 5: Relapse, Continued Use or Continued Problem Potential Is the client in immediate danger of continued severe mental health distress and or alcohol and drug use? How aware is the client of relapse triggers, ways to cope with cravings to use, and skills to control impulses to uses or impulses to harm self or others? Does the client have any recognition of, understanding of, or skills with which to cope with his or her addictive or mental disorder in order to prevent relapse, continued use or continued problems such as suicidal behavior? Dimension 5: Would continued use/relapse be dangerous to the client or to others Children Other adults in their lives Others in the world How severe are the problems if the individual is not successfully engaged in treatment at this time? How aware is the individual of relapse triggers: Ways to cope with cravings to use, Skills to control impulses to use or, Impulses to harm self or others? Factors associated with an increased risk of relapse severity of the SUD at admission the presence of an active mood, anxiety, or personality disorder perceived high rates of stress being unemployed or having employment problems no high school diploma or GED being of a minority status having less coping resources or a low sense of self- efficacy low income or being indigent having PTSD or ADHD disorder at admission actively participating in drug-related leisure activities 16

17 NOTE: Placement after relapse In actuality, placement after relapse should be based on a current ASAM Dimensional assessment which may be the same level of care. Level of Care Placement after relapse should be based on an assessment of history and here & now and NOT on the assumption that if a client relapsed after having been treated, then the previous level of care was not intense enough! DIMENSION 6: Recovery/Living Environment This dimension evaluates the individual s social and living environment in terms of how it promotes or hurts the individual s recovery efforts. Its main concern is whether or not the individual s peers, family, and/or significant others are supportive of his or her recovery, either directly or indirectly. Severe environmental conditions can require increased tx needs. How the individual copes with this environment is crucial in developing the treatment plan. 17

18 Dimension 6: Recovery/Living Environment Assess for risks, issues, strengths, skills, and resources in: Recovery supports Living environment Family, friends, social network Work/school Finances Transportation Legal mandates/requirements =4 =2/3 When the Clients' Recovery Environment Ranges From Non-Supportive to Toxic, Possible Options Include: Helping the client develop coping skills to deal with the lack of support Helping change the lack of support (e.g., family counseling, support group, CCS) Helping the client examine the appropriateness of returning to that environment. Look into sober living options. CCS can help connect with health activates in the community 18

19 What Does the Research Say & Why ASAM can be Helpful. Clients that are mismatched to treatment have lower retention rates and poorer outcomes. Less treatment is NOT Good. More treatment is NOT good. Full functioning. Any acute or chronic problem mostly stabilized Dimension 1: No signs of withdrawal/intoxication present or signs or symptoms are resolving. Dimension 2: No issues/fully functional/able to cope with physical discomfort/stable. Medical issues will NOT interfere w/ tx. No signs/symptoms are observed Dimension 3: Good impulse control and coping skills. No dangerousness, good social functioning and self-care, problems identified are stable, no interference with recovery. Dimension 4: Willing to engage in treatment/proactive. Admits to having a problem. Talks about goals & cut negative influences. Dimension 5: Low potential for relapse. Good ability to cope. No current cravings Dimension 6: Able to cope in environment or has a supportive environment. Dry/drug free home, few liquor stores/no drug dealers in or around home, positive activates, no barriers to treatment or recovery 19

20 - Minimal, current difficulty or impairment. Minimal or mild signs and symptoms. Any acute or chronic problems soon able to be stabilized and functioning restored with minimal difficulty. Dimension 1: Minimal risk of significant withdrawal. Ability to cope and tolerate withdrawal discomfort. No danger to self/others. Dimension 2: Mild to moderate symptoms interfering with daily functioning. Adequate ability to cope with physical discomfort. Dimension 3: Suspected or diagnosis of EBC, but does not interfere with recovery. Emotional concerns due to negative consequences of AODA use/mental health symptoms. Mild symptoms that do not impair roles in a social, school or work setting. Mild/Moderate symptoms with good response to past tx Dimension 4: Willing to explore the need for tx, but ambivalent to the need to change. Willing to change AODA use and may feel they do not have a problem and can quit whenever they want. Dimension 5: Minimal relapse potential. Some risk, but fair coping and relapse prevention skills. Some cravings with ability to resist and takes meds as prescribed Dimension 6: Passive/disinterested social/family support, but still able to cope and interested in finding health support, has health activates, barriers to tx or recovery can be overcome. - Moderate difficulty or impairment. Moderate signs and symptoms. Some difficulty coping or understanding, but able to function with clinical and other support services and assistance. Dimension 1: May have severe intoxication, moderate risk of severe withdrawals. Responds well to support & Tx. Some difficulty tolerating and coping with withdrawal discomfort. No danger to self/others. Dimension 2: Some difficulty tolerating physical problems or has multiple medical issues. Acute, nonlife threatening problems present, or biomedical problems are neglected. Could interfere w/ tx due to the need of medical services. Dimension 3: Persistent EBC symptoms that significantly distract from recovery, but not imminently dangerous. Some SI with no plan or means, moderately effects social, school, work functioning. Does not prevent independent functioning. Hx of not being consistent with meds (MAT/MH) Do C-SSRS Dimension 4: Reluctant to agree to treatment. Low commitment to change. Passive engagement in treatment. Can talk about the negative consequences of AODA use but low commitment to change Dimension 5: Impaired recognition of risk for relapses /continued use. Regular use of alcohol (1-2x weekly) and moderate use of drugs(1-3x weekly). Able to self- manage with prompting and support. Some cravings with minimal ability to resist Dimension 6: Unsupportive environment, but able to cope with clinical structure most of the time. Lives alone, ready access to alc or drugs near home, very little health activates, serious barriers to tx & recovery but can be resolved. Serious difficulties or impairment substantial difficulty coping or understanding and being able to function even with clinical support. Moderately high intensity of services, skills training, or supports needed. May be in, or near imminent danger. Dimension 1: Severe intoxication with imminent risk of danger to self/others. Poor ability to tolerate or cope with withdrawal. Risk of severe w/d but manageable or w/d are worsening Dimension 2: Serious medical problems neglected during outpatient treatment that require frequent medical attention. Poor ability to cope with physical problems and/or general health is poor. Medical problems that could be exacerbated by relapse or withdrawal. Dimension 3: Severe EBC, but does not require acute level of care (Psyh unit). Impulse to harm self or others, but not dangerous in a 24-hr setting (Care Center). Not taking medication as prescribed, symptoms effect the ability to adjust to there community or past tx was not effective. Limited capacity for self-care, ADL s. Safety Plan Dimension 4: Unaware or feels treatment is unnecessary. Unwilling to follow through with recommendations for treatment. May feel forced to be here. inconsistent follow through and shows minimal awareness of AODA or mental health disorder and need for treatment Dimension 5: Little recognition of risk for relapse/continued use, not taking prescribed medications, poor skills to cope, severe cravings, frequent use of Alc/drugs, very influnced by using friends/family/culture. Dimension 6: Environment is not supportive of recovery efforts, client finds coping difficult even with clinical structure. Very prevalent around home are dealers, bars and liquor stores, drug users are in and out of the home most of the time. Risk for emotional, physical or sexual abuse. 20

21 A Risk Rating of 4 for Dimension 4, 5, &6 In DIMENSIONS 4,5 & 6 there are risk ratings of 4a (no immediate action required) and 4b (Immediate action required). 4a-unable to follow through, has little or no awareness of substance use problem, no clue about addiction, not willing to explore changes (blames others for family or legal problems and rejects help). 4b-Same as above but with addition of unable to care for self, current thoughts of self harm or HI. Continues to use drugs/alcohol which cause him/her to become violent or client is drive while intoxicated. IMMINENT DANGER=IMMEDIATE ACTION REQUIRED. - Severe difficulty or impairment, gross or persistent signs and symptoms to tolerate and cope with problems. Imminent danger is highly possible. Dimension 1: Incapacitated. Severe signs and symptoms. Presents danger, i.e. seizures. Continued substance use poses an imminent threat to life. Imminent Danger Dimension 2: Incapacitated with severe medical problems. Medical issues are life threating. Imminent Danger Dimension 3: Severe EBC symptoms. Requires acute level of care. Exhibits severe and acute lifethreatening symptoms (posing imminent danger to self/others). Gross neglect of self-care, psychosis with unpredictability. Resent hx of psychiatric instability Imminent Danger -- Take Immediate Action Dimension 4: 4a (no immediate action required)=unable to follow through, little or no awareness of SUD or Mental Health Disorder, blames others, not willing to explore change, can care for self.(4b): No awareness: Substance use or mental health symptoms places self/other in imminent danger and can t care for self. Dimension 5: 4a (no immediate action required)=no coping skills, repeated past tx with little positive effect on functioning. Able to care for self. (4b): no skills and continues daily use. Substance use and psychiatric disorder places client and others in imminent danger. Dimension 6: 4a (no immediate action required)=environment toxic/hostile to overall recovery. Unable to cope. 4b: actively hostile and posing immediate threat to safety and well being of client (domestic violence, drug dealer pressures drug use, human trafficking) What is Imminent Danger? 1. A strong probability that certain behaviors will occur (e.g., continued alcohol or drug use or non-compliance with psychiatric medications) 2. These behaviors will present a significant risk of serious adverse consequences to the individual and/or others (driving while intoxicated, primary care taker of children, medical) 3. The likelihood that such adverse events will occur in the very near future *All 3=Imminent Danger Requires Inpatient Treatment 21

22 NOTE on dimensional assessment In general, if the risk rating is: 0 or 1: Nothing needs to be done currently 2: Monitoring is called for 3 or 4: Action needs to be taken these issues should find their way onto the treatment plan One exception to the above is Dimension 4, Readiness to Change. Employing motivational enhance strategies is always appropriate A Risk Rating of 4 for Dimension 1, 2, &3 If you get a risk rating of 4 on Dimension 1,2 or 3 then this client is in imminent danger and will need to be in a Medically Managed Intensive Inpatient Treatment (AKA: hospitalization) IMMINENT DANGER=IMMEDIATE ACTION REQUIRED 22

23 Outpatient Levels of Care & Service Level 0.5 Early Intervention (not therapy/edu. groups, support groups) Level 1 Outpatient Weekly or bi-weekly Indv. sessions and/or therapeutic groups Level 2 - Intensive Outpatient/Partial Hospitalization Level 2.1(IOP) 9hr or more contact hours/ Structured Program Level 2.5 (Day Tx/partial hospitalization) - 20 or more contact hours/structured Program Residential/Inpatient Levels of Care Level 3: Residential/Inpatient Services Level 3.1- Clinically Managed Low-Intensity Residential Services (e.g. halfway house with 5hrs of clinical services) Level 3.3- Clinically Managed, Population- Focused, High- Intensity Residential Services (Cognitive impairment, TBI) Level 3.5- Clinically Managed High-Intensity Residential Services, Non Medical Component (e.g.., therapeutic community, Residential Treatment Center-managed by tx staff) --- Level 3.7- Medically Monitored Intensive Inpatient Treatment (Inpatient tx program that have nurses 24hrs and doctors for 8hrs) Level 4: Medically Managed Intensive Inpatient Treatment 23

24 Opiate Treatment Services Opiate treatment program(otp) Medication given by clinic Office Based Opiate Treatment (OBOT)- Medication by prescription, filled elsewhere Agonist or Partial Agonist medication (methadone and buprenorphine/suboxone) Antagonist medication (naltrexone/vivitrol) One More BIG Hint Withdrawal Management 24

25 WM-1: Ambulatory w/o Extended on-site Monitoring Organized outpatient service, delivered in an office setting, health care/addiction treatment facility, or in a patient s home Frequency of scheduled sessions are determined by severity of withdrawal symptoms Patient has a sufficient/stable support system (family) who can assist with monitoring symptoms OTS, collaboration w/ a prescriber/pcp, home health services, healthy support system and OP services. WM-2: Ambulatory w/ Extended on-site Monitoring A service delivered in an office setting, a general health care or mental health facility, or an addiction treatment facility by medical and nursing professionals who provide evaluation, withdrawal management and referral services. This can be in an IOP or day tx program where there is medical/nursing professional. Sessions on a daily basis with extended on site services Supportive environment and supportive family/friends especially at night. 25

26 WHY IS AMBULATORY WM NEEDED? WHO IS APPROPRIATE FOR AMBULATORY WM? Ambulatory WM may be appropriate for individuals suffering from alcohol, nicotine, opioid, sedative/hypnotic, and stimulant use disorders Level of care is based on risk severity and ratings Thorough assessment of withdrawal symptoms must be completed before recommendation and admission WM 3.2 Clinically Managed Residential Withdrawal Management Clinically managed residential withdrawal management social setting detoxification/social detox Emphasis on peer and social support rather than medical and nursing care Safely assist patient through withdrawal without the need for onsite medical staff 24hours/day access to medical evaluation and consultation if needed Self-administration of medications frequently use over the counter medications 26

27 3.7-WM: Medically Monitored Inpatient Withdrawal Management Provides 24-hour evaluation and withdrawal management in a facility with inpatient beds freestanding withdrawal management center Signs and symptoms are significant enough to require 24-hour care Full resources of an acute care general hospital are not necessary Individualized biomedical, emotional, behavioral, and addiction treatment Hourly or more frequent nurse monitoring and medication administration WM-4: Medically Managed intensive inpatient Withdrawal Management Acute care inpatient setting or psychiatric hospital inpatient unit with 24-hour care Provides services to those whose symptoms are severe enough to require primary medical and nursing care services Highly individualized biomedical, emotional, behavioral, and addiction treatment Hourly or more frequent nurse monitoring All area hospitals including the VA 27

28 See ya at Break-Out Session 2 28

29 I ll give you 1 HINT Handout #1 ANN DSM 5 Diagnosis: Alcohol Use Disorder, Severe; Marijuana Use Disorder, Mild; Major Depressive Disorder in Sustained Remission See Handout #2 29

30 Level of Care Recommendations Thoughts? What was hard What was easy What was confusing Other Additional Resources Adverse Childhood Experience Clinical Screening toolshttp:// Tobacco Screening toolshttps:// OTHERhttp://