TIPS & TOPICS from David Mee-Lee, M.D.
Volume 9, No.3
June 2011

In this issue

— SAVVY   Top 10 reasons to use the ASAM Criteria
— SKILLS  How close your services are to the spirit/use of the ASAM Criteria
— SOUL   R&D – not doing the same old thing
— Until Next Time

Welcome and thank-you for joining us for the June edition.


SAVVY

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If you want a comprehensive understanding of addiction medicine, “Principles of Addiction Medicine”is the book to get – the current and fourth edition was published in 2009.  There has just been released a companion to this book- “Principles of Addiction Medicine – The Essentials”.

The Essentials is a condensed version of the main textbook. It was designed to make this information more accessible to a wider variety of addiction medicine practitioners, including physicians, trainees, counselors, nurses and many other health professionals.
Today we work in an environment of shrinking budgets, healthcare reform and the need for interdisciplinary teams in new “medical or health homes”.  In the 2009 Principles book is a chapter co-written by Jerry Shulman and myself – entitled “The ASAM Placement Criteria and Matching Patients to Treatment”.  As I re-read our condensed chapter in this new publication, I was reminded of the significance of the spirit and content of the ASAM Criteria.

Top 10 list of “Why you should understand and use the ASAM Criteria”

No. 1  – Broad, flexible continuum of care with detailed criteria

We all have a responsibility to be good stewards of resources: to increase access to care, to stretch resources as far as possible; to provide as much care as possible to achieve positive outcomes.
·    The ASAM Criteria provides the broadest continuum of care.  This spans early intervention; five levels of detoxification services; opioid treatment; outpatient, intensive outpatient, partial hospital; four levels of residential care; plus acute hospital level of care.
·    No other criteria provide detailed descriptions and clinical guidelines on which client can best be treated in what level of care.
·    The ASAM Criteria encourages flexible use of this broad seamless continuum of care – to match resources to the specific needs and desires of patients, clients and consumers.

No. 2  – Use clinical criteria, not “dollar-driven” or “filling-beds” criteria

Criteria developed by managed care organizations, payer and funders are biased towards minimizing use of healthcare resources by denying care.  Criteria developed by providers and programs are biased towards admitting people into services and often the most intensive services.  The ASAM Criteria were developed by an interdisciplinary team of clinicians, administrators and experts in the field with broad review and input from both payer and provider stakeholders. (See Appendix F in ASAM PPC-2R, 2001, pages 371-379 for the Contributors to the Development of the ASAM PPC-2R)

No. 3  – The most researched of any criteria

The ASAM Criteria are the most studied placement criteria with a decade of research under the leadership of David Gastfriend, M.D.  The Federal Government has funded research to the tune of six million dollars through the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Drug Abuse (NIDA), and the Center for Substance Abuse Treatment (CSAT).

No. 4 – Recovery-oriented and individualized

The goal of treatment using the ASAM Criteria extends “beyond the simple resolution of symptoms or behaviors to the achievement of overall healthier functioning – the difference between abstinence alone and recovery.” (“Principles of Addiction Medicine – The Essentials” Page 128).

·    The ASAM Criteria promote recovery goals and community-based services. If acute or residential care is needed, re-integration into the community is encouraged as soon as possible.
·    There are no fixed program lengths of stay in the ASAM Criteria.  This encourages individualized services based on outcomes, not pre-determined program lengths of stay from which to complete or graduate.

No. 5 – Model criteria for how the treatment system should be

The ASAM Criteria are intended as a “clinical guideline for making the most appropriate placement recommendation for an individual patient, not as a reimbursement guideline.  If the criteria only covered the levels of care commonly reimbursable by private insurance carriers, they would not address many of the resources of the public sector and, thus, would tacitly endorse limitations on a complete continuum of care.” (“Principles of Addiction Medicine – The Essentials” Page 130).

No. 6 – Criteria for Co-Occurring Conditions

People with co-occurring mental and substance use conditions are an expected subset of those who present for services. Mental health and addiction services can no longer ignore integrated services for co-occurring disorders (COD).  The ASAM Criteria summarize what kinds of patients with COD are best treated in what kinds of dual diagnosis services. Specific criteria are provided to guide clinicians in making those decisions for Dual Diagnosis Capable (DDC) and Dual Diagnosis Enhanced (DDE) services.

No. 7 – Widespread Use

The ASAM Criteria has been published since 1991 and has stood the test of time.  They are required and used to some degree by over 30 states in the USA; the Department of Defense in programs around the world; Veterans Health services; some major managed care organizations and payers, including Medicaid; and by numerous public and private programs.

·    Broadly-mandated and broadly-used instruments like the Addiction Severity Index (ASI) were not designed as an assessment and placement tool or criteria; they do not cover all the areas of the ASAM Criteria’s six assessment dimensions.

No. 8 – Common Language of Assessment

In the current 2001 edition of the ASAM Criteria (ASAM PPC-2R), we re-designed the six assessment dimensions to apply to addiction, mental health and even general health clients.  This provides a common language of assessment and clinical focus.

For more detail on understanding the six assessment dimensions in behavioral health, see SAVVY in the January 2011 edition.

For more detail on understanding the six assessment dimensions in general healthcare settings, see SAVVY in the March 2007 edition.

No. 9 – Improvements and New Directions Coming!

While the ASAM Criteria have stood the test of time since 1991, they could be better understood and implemented. The field needs more support to do so. So here are just a few developments under way:

·    The Steering Committee of the ASAM Coalition for National Clinical Criteria is embarking on at least a Text Revision of the ASAM Criteria and possibly more, to approximate publication of DSM-5 in 2013. We want your feedback on what is working or not in the ASAM Criteria.
·    Research software is being readied for eventual use by providers and payers. The goal is to provide standardized use of the ASAM Criteria, decrease utilization management time for all concerned, and bring the ASAM Criteria into the age of the electronic health record.
·    The partnership between ASAM and The Change Companies will soon announce a wide variety of affordable and accessible training, consultation, clinical support tools and products to enhance treatment to the people we serve.  Look soon for www.asamcriteria.com which will contain all things ASAM Criteria available to you.  But don’t go there yet, it’s not “live”.

No. 10 – Holistic and person-centered

The ASAM Criteria promotes holistic, person-centered, individualized services to engage and attract people into recovery. The spirit of the ASAM Criteria is to meet people where they are; to explore their biopsychosocial challenges and obstacles, but also identify their multidimensional strengths, skills and resources.  The ASAM Criteria isn’t about paperwork, it’s about peoplework!

References:

“Addiction Treatment Matching – Research Foundations of the American Society of Addiction Medicine (ASAM) Criteria” Ed. David R. Gastfriend  released 2004 by The Haworth Medical Press.  David Gastfriend edited this special edition that represents a significant body of work presented in eight papers.  The papers address questions about nosology, methodology, and population differences and raise important issues to continually refine further work on the ASAM PPC.

Mee-Lee D, Shulman GD, Fishman M, Gastfriend DR, and Griffith JH, eds. (2001). ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition-Revised (ASAM PPC-2R).  Chevy Chase, MD: American Society of Addiction Medicine, Inc.
American Society of Addiction Medicine – 4601 Nth. Park Ave., Arcade Suite 101, Chevy Chase, MD  20815.  (301) 656-3920; Fax: (301) 656-3815; www.asam.org; To order ASAM PPC-2R: (800) 844-8948.

Mee-Lee D, Shulman GD (2011): “The ASAM Placement Criteria and Matching Patients to Treatment”, Chapter 27 in Section 4, Overview of Addiction Treatment in “Principles of Addiction Medicine – The Essentials”  Christopher A. Cavacuiti.  Lippincott Williams & Wilkins, Philadelphia, PA.,USA. pp 127-141.

Principles of Addiction Medicine  (2009) Eds Richard K. Ries, Shannon Miller, David A Fiellin, Richard Saitz.  Fourth Edition.  Lippincott Williams & Wilkins, Philadelphia, PA.,USA.

SKILLS
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Long ago when I was a rookie consultant, an experienced colleague offered me some good advice.
Here’s what he said was good about being a consultant:

·You are asked to help solve problems and dilemmas.
·You get to know what people in the marketplace want.
·You learn what kinds of services and products are needed.
·You hear about clients’ challenges and frustrations.
·You learn what works (or not) in the real world.

With that in mind, it’s great for me to trumpet the Top 10 reasons to use the ASAM Criteria, but maybe you don’t use them at all; or are frustrated about real world implementation.

In SKILLS this month, I invite you to assess how close your services are to the spirit and implementation of the ASAM Criteria.

Even if you aren’t familiar with the ASAM Criteria, this can still be useful for you to consider.

TIP 1
Are your services “program-driven” or “person-driven”?

Every profession has its occupational hazards.  In the world of behavioral health, we recognize unmet needs and then go about setting up programs to meet them.  We then look for clients who meet the criteria for admission.  (This is especially true when there is some new funding grant, which dictates what the program should look like, who is eligible and how long it should last.)
So see if you identify with any of these:

·    The client asks: “How long do I have to be here for?” and you have an answer in numbers – numbers of days, weeks or months.

·    A client wants to leave your residential or intensive outpatient program because he/she feels they can do just as well at a less intensive level of care.  They are not in imminent danger of harm to self or others.  Do you administratively discharge them for non-compliance?  Or have them leave Against Medical Advice (AMA) or Against Staff Advice (ASA)?  Can you accept their choice to test out alternative ideas on what will work in their life? Are you able to still work with them on a new treatment plan, one which involves continuing treatment, but at a different level of care so your client can work on a motivational “discovery” plan.

For more detail on Programs versus People and the Top Ten Ways You Know You’re a Program-Driven Service When……..  read SAVVY and SKILLS in the November 2008 edition.

TIP 2
Do your services address the needs of people with co-occurring conditions?

Whether you work in an addiction treatment setting or mental health, it is unusual to have clients interested in both their substance use and mental health issues with equal readiness to change in both areas.  Consider:

·    The client has co-occurring mental health and substance use difficulties and needs supportive housing in the community.  Since total abstinence is the only acceptable admission agreement and state of being to allow continued stay, what do you do with the person who is in the ambivalence stage of change (Contemplation)?  Is it acceptable for them to have a chemical health plan that is abstinence-oriented rather than abstinence-mandated?  Is it OK for them to work through a process of change towards abstinence or non-problem use?  Or must they fit into the program or lose housing?

·    A client is on anti-anxiety medication or psycho-stimulants for Attention Deficit Hyperactivity Disorder (ADHD). He/she wants to enter addiction treatment. 
Must he first agree to immediate detoxification off the potentially addictive psychotropic medications? 
Alternatively, can he be admitted, continue on the medication while further assessment gets under way, and while there’s time to conduct collaboration with the client, family and prescribing physicians?  
(The aim of further evaluation is to answer several questions:  Does a co-occurring anxiety or ADHD disorder truly exist?  Was psychotropic medication prescribed hastily without a careful substance use history? Perhaps an addiction psychiatrist, who had tried treating with non-addictive medication and psychosocial treatment with minor success, prescribed it. Finally the psychiatrist decided to resort to psychotropic medication to achieve some stability.)

For more detail on “How Dual Diagnosis Capable are you or your program?” see SAVVY and SKILLS in the May 2009 edition.

TIP 3
Do your services engage and assess strengths and skills, not just pathology and problems?

Most assessment and intake forms have a place or section for “Presenting complaint”. It’s here that they document why a client is presenting for services.  As well these days, forms also ask for an assessor to document a client’s strengths and resources.

·    If you were to pull 10 client records and look at what is written in the “Presenting complaint” section, what would they reveal? 
Would they say things like: “Legal issues”, “Referred by drug court”, “Depression”, “Employment and housing problems” or “Psychotic and hearing voices”? 

Or would they say: “I want to get off probation and I don’t really think I have a drug problem”
Or “I want everyone to leave me alone and stop locking me up and making me take medication.”

·    What about the “strengths” section? 
Is the space filled with words like: “Good sense of humor”, “Cooperating with treatment”, “Motivated” or “Likes baseball” …
versus skills and strengths statements that mean something like:
“Was able to achieve 12 months of sobriety by active AA involvement, reaching out to a sponsor and supportive friends and practicing meditation”; “Has one family member who is very supportive and is willing to participate in family sessions to help fashion a Wellness Recovery Action Plan (WRAP).”

For more detail on engaging a client in treatment see SKILLS in the May 2010 edition.

For more detail on using ASAM multidimensional assessment to identify a person’ needs and strengths, liabilities and resources see SAVVY and SKILLS in the December 2005 edition.

So, how did you do?

SOUL
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I was listening to Morning Edition on National Public Radio last month and a part of a series they call Smart Jobs.  In the series, they interview “people around the country to find what areas of our economy are doing well.” Two things caught my attention:

·    “If you want a job – a good job, a job that will be around for a while and pays well – find a company that creates some new product or service that nobody else has.”
·    “If the company you work for provides a product or service that’s pretty much the same as what was offered last year and a few years before that, it might be time to start looking for something new.”
(www.npr.org/blogs/money/2011/05/27/136690812/looking-for-high-tech-job-try-cotton)

When they started talking about the importance of research and development (R&D), it got me thinking.  In the addiction and mental health industries, what R&D do we do? Or are our products and services “pretty much the same as what was offered” before year after year?  I know the pharmaceutical companies believe in R&D.  It seems like a new medication for depression, schizophrenia or bipolar disorder comes out every other week – well maybe every other month!

When it comes to psychosocial treatment, I wonder if we have done as much R&D. Some might say: “Indeed we have!”  A case can be made that lots of innovation and changes have occurred.  The way our field delivers services to our mental health and addiction clients is vastly improved.  Those days I feel hopeful.

Then there are days I look at what we still do with people who relapse in addiction treatment, especially those mandated to care. I wonder if we have learnt anything about treating relapse rather than punishing relapse. Then I think about admission criteria to addiction programs that assume or require everyone to be at Action for abstinence whether they are or not.  I question whatever happened to “attraction not promotion” and “progress, not perfection”. Now I’m getting more depressed.

At a psychiatric inpatient unit, I listened to a treatment team discuss whether they should cancel a female client’s therapeutic pass with a male friend.  The client was soon to be re-integrated into the community.  She mentioned to the staff that her friend may have romantic notions more than what she feels for him.  Instead of helping her set her own limits with her friend, they went into protection and disempowering mode.  “Why don’t we just cancel the pass?” they said.  It didn’t even occur to them that they could role-play with her and support her in speaking her truth to the friend.  And then we talk about empowerment and recovery?  Now I’m losing hope that we can change how we do business.

So what do we do about all this talk about strengths-based, person-centered, recovery-oriented services? I choose to believe that we can move to new products and services that aren’t “pretty much the same as what was offered” before year after year.  There are too many reasons to rethink how we design and deliver services to stay stuck in the same old attitudes and practices.  I have seen what great things happen when patients, clients and consumers are actually given the opportunity to tap into their strengths and skills.

Now I’m feeling hopeful.

PS.  I am completing this Tips and Topics on the plane to Sydney, Australia. You can see a lot of movies in a 14-hour plane ride. I was touched, moved and inspired watching “The Company Men”.  Ben Affleck, Kevin Costner and Tommy Lee Jones brought alive those dry, impersonal unemployment statistics.  I was touched by the pain and disruption that comes with losing a job.  I was moved by how the corporate downsizing forced these three men to redefine their lives as men, husbands and fathers.  I was inspired by the importance of family; the responsibility to create opportunities for people to work and create; and the gratefulness to appreciate everyday what we have.

Until Next Time

Thanks for reading. Join us again in late July.

David