Adopting ASAM What’s in the new criteria?

1. State Specialty Court Conference Adopting ASAM What’s in the new criteria? DuAne L. Young • The Change Companies®

2. What works?

3. Treatment: • Alliance/Relationship • Hope • Model/Modality Extra-therapeutic What Works The Empirical Evidence Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. New York: Lawrence Erlbaum. Miller, S.D., Mee-Lee, D., & Plum, B. (2005). Making treatment count. In J. Lebow (Ed.), Handbook of clinical family therapy. New York: Wiley.

4. Changing Compliance IntoBehavior Change

5. This person…in this settingon this dayat thisstageofinterest or readinessto change

6. Participant- centered

7. Emphasize self-efficacy

8. Self-efficacy is “The optimism & confidence to know that if you decide to make a change, it’s worth trying because you feel like you have a chance for success.” Dr. David Mee-Lee

9. Elicit personal motivation and change talk

10. Promote personal responsibility for change

11. All change is self-change

12. How many people here believe they can change another person?

13. Participant Messages • Self-changers believe change is possible. They recognize they’re deserving and capable of change, and are personally responsible for making it happen. • The choice to change is yours and yours alone.

14. Promotingself-changeis a multifaceted process

15. Implementation of ASAM supports a paradigm shift and is necessary to effectively use the criteria.

16. What are the ASAM criteria? • Guidelines for assessment, service planning, placement, continued stay and discharge • Framework for multidimensional patient assessment • Description of levels of care (service continuum)

17. What are the ASAM criteria? • Algorithm for determining appropriate Intensity of Service based on assessment of patient’s Severity of Illness • A way of unifying the addiction field around a single set of criteria

18. • Around 1989, NAATP and ASAM assembled a task force to integrate two existing admission/ continued stay criteria sets • * The Cleveland Criteria • * The NAATP Criteria • • NAATP decided to relinquish any ownership/branding of the criteria History

19. Historical and current development of the ASAM criteria • Collaborative process • Use of experienced clinical experts and researchers as editors • Coalition of stakeholders (Coalition for National Criteria, est. 1992) History

20. Brief Timeline of the ASAM Patient Placement Criteria(ASAM PPC-2R pp. 12-14)

21. Previous Editions • PPC 1991 • PPC-2 1996 • PPC-2R 2001 • Upcoming Edition October 2013: “The ASAM Criteria” Chief Editor: David Mee-Lee, MD

22. Paradigm Shift • From unidimensional to more multidimensional assessments; • From program-driven to more clinically driven treatment; • From a fixed length of stay to variable length of service; and • From a limited number of discrete levels of care to a continuum of care.

23. Client-centered Model

24. Objectivity • Choice of treatment levels • Continuum of care • Treatment failure • Length of stay • Twelve-step/Mutual-/Self-help recovery groups • Informed consent Guiding Principles

25. Program-driven Treatment

26. Generations of Clinical Care Diagnosis-driven Treatment Program Aftercare Diagnosis Relapse

27. PROGRAM-DRIVEN

28. PROGRAM-DRIVEN All patients receive the same services as “part of the program”

29. PROGRAM-DRIVEN Same treatment plan

30. PROGRAM-DRIVEN Sometimes goals are developed before thepatient is ever met

31. PROGRAM-DRIVEN Progress is measured by how the patient functions in the program

32. PROGRAM-DRIVEN Discharged based on a set length of time

33. CLINICALLY DRIVEN TREATMENT Dimensional assessment of individual needs

34. CLINICALLY DRIVEN TREATMENT Level of service based on severity of clinical problems

35. CLINICALLY DRIVEN TREATMENT Individualized treatment plan

36. CLINICALLY DRIVEN TREATMENT Variable lengths of stay, dictated by resolution of clinical problems

37. CLINICALLY DRIVEN TREATMENT Services are specific to the clinical problems that supported admission

39. The criteria have evolved over time to reflect current scientific research

40. Criteria Revision Process & Principles • Workgroup chairs and small committees developed drafts • Extensive online field review with input from the Steering Committee of the Coalition for National Clinical Criteria and others

41. Criteria Revision Process & Principles • Publication date October 2013; to be launched at ASAM’s “State of the Art Conference” in Arlington, VA • Actual criteria changed with updated science – impact on The ASAM Criteria Software

42. What’s Not New in The ASAM Criteria? • Six assessment dimensions • Overall levels of care (though not Roman numerals) for addiction management • “Decision rules” which link intensity of service back to severity of illness maintained except for updates in withdrawal management (“detox”)

43. Assessment of Biopsychosocial Severity and Level of Function • Acute Intoxication and/or Withdrawal Potential • Biomedical Conditions and Complications • Emotional, Behavioral or Cognitive Conditions and Complications • Readiness to Change • Relapse, Continued Use or Continued Problem Potential • Recovery Environment

44. Broad Treatment Levels of Service Description of the Continuum of Care 1. Outpatient Treatment 2. Intensive Outpatient and Partial Hospitalization 3. Residential/Inpatient Treatment 4. Medically Managed Intensive Inpatient Treatment • More levels of care within each of the broad levels • New edition changes to Arabic numerals, e.g., Level I becomes Level 1; Level II.1 becomes Level 2.1; etc.

45. What’s New in The ASAM Criteria? • The title: “The ASAM Criteria - Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions” • Shift from “placement” to “treatment” criteria: It’s more than just placement • Diagnostic admission criteria terminology changed to be compatible with DSM-5 • Section on working with managed care

46. What’s New in The ASAM Criteria? • Table of Contents reordered to be more user-friendly and follow the flow from historical foundations to guiding principles to assessment, service planning and placement decisions • Adolescent criteria no longer separate/standalone: consolidated adult and adolescent content to minimize redundancy while preserving adolescent-specific content • Appendices include withdrawal management instruments, Dimension 5 constructs and a glossary

47. What’s New in The ASAM Criteria? • The wording in the levels of care for withdrawal management • The former “detoxification” section is now called “withdrawal management” and the levels are now WM-1, WM-2, WM-3 and WM-4 • New approaches described to support increased use of less intensive levels of care for safe/effective management of withdrawal

48. Broader range of severity of withdrawal syndromes discussed as being able to be safely and appropriately managed on an outpatient basis • Risk Rating Assessment Format used to help understand how to link severity, function and service needs when determining treatment plans &level of care • Updated PPC-2R criteria, linked to algebraic “decision rules” of The ASAM Criteria Software Dimension 1 Withdrawal Management

49. What’s New in The ASAM Criteria? • Updated/revised terminology, to be contemporary strength-based & recovery-oriented: • “Dual diagnosis” becomes “co-occurring disorders” • “Inappropriate use of substances” becomes “high-risk use of substances” • Specialized services for opioid use disorder renamed: • “Opioid Maintenance Therapy”(OMT) becomes “Opioid Treatment Services”(OTS) • Mention made of opioid antagonist & opioid agonist medications that can be used in OTPs (regulated “Opioid Treatment Programs”) or in office-based opioid treatment (OBOT)

50. New Content & Sections • Additional text to improve application to address addiction treatment for Special Populations: • Older Adults • Persons in Safety Sensitive Occupations • Parents with Children and Pregnant Women • Persons in the Criminal Justice System (CJS)