Vol. #14, No. 7
David Mee-Lee M.D.
SAVVY AND CONFERENCE ANNOUNCEMENT
If you’d like to come to sunny California soon for the 7th Western US Journal Training Conference October 24-26 2016, in Newport Beach, CA, The Change Companies is featuring a “Justice Services Track” for all those who work directly within the Justice System. I will be speaking and attending. And there is much more – take a look at
Hope to see you there.
Earlier this month, I got an email from Kevin Doyle, Ed.D., LPC, LSATP., who is a “longtime counselor in substance use disorder treatment, now Assistant Professor in Counselor Education at Longwood University in Farmville, Virginia. If “Longwood University” sounds familiar, but you aren’t quite sure why you remember the name, it is because it was the site of the October 4 Vice-Presidential Debate.
Kevin was asked to give one of about 10 faculty talks that afternoon as part of Longwood University’s debate-related activities. He talked about “Addiction and Public Policy” and covered many topics that I have written and spoken about before – only he covered them not in a day’s workshop, but in 14 minutes. You can see his presentation at: https://youtu.be/5UP5njyders
Since the Presidential election is heating up to a fever pitch, I thought a summary of Kevin’s points would keep us in the election mood, since he was up close and personal to at least the VP candidates. And by the way, Kevin is an “avid reader of Tips and Topics, which I enjoy very much.”
Review how attitudes and terminology about addiction, perpetuates stigma
Kevin reviewed many points about stigma and the way the public, payers and providers view addiction treatment. Here is his list with some comments I added:
1. How we perpetuate stigma – we talk of “addict” and “alcoholic” instead of saying “a person with addiction or a substance use disorder” – Use person-first language
The most recent Tips and Topics on this is September 2015:
2. When a person goes for help for treatment, we say they were “sent to rehab” instead of “they are seeking help for a condition or a particular problem.”
The public, payers and policy makers and even treatment providers think addiction treatment is doing a set length of stay in “rehab” – a residential program from which the person will graduate and complete. Some insurance benefit plans then limit the number of “rehab” admissions to two, 30-day episodes a year, instead of understanding an addiction treatment continuum of care.
3. Families and clients sometimes say “We tried treatment and it didn’t work”. But if a cancer patient tried chemotherapy and the cancer recurred, most would try it again or certainly not give up on treatment and dismiss it.
With addiction, families and even physicians feel that if treatment hasn’t cured the person, then treatment doesn’t work and it’s no use going back to treatment.
4. “Treatment is a waste of time unless the person really wants it” – few people wake up and spontaneously say this is the day for recovery. Most people getting into addiction treatment have some external pressure or loss that prompts them to seek treatment and may even say “I don’t need this. I’m no worse than anyone else. I can stop any time I want.”
Expecting people to show up fully ready for recovery from day one before treatment is available, is a good way to decrease case loads and not help people. Treatment’s job is to attract people into a change process and recovery by using motivational enhancement methods.
5. “We need to lock those people up and they can learn their lesson that way” – Society responds to addiction with a criminal justice, punishment perspective.
Happily there is a bipartisan recognition and effort to see addiction treatment as a cost-effective way to increase public safety and decrease legal recidivism and crime rather than to just incarcerate those with addiction.
6. When a person gets a urine drug screen result that is positive for a substance(s), we say they have “dirty urine” – We would never say a patient had “dirty cholesterol” and scold or sanction them for their laboratory result.
If a person’s urine is “dirty”, what does that imply? They are “dirty” too and we perpetuate stigma and discrimination.
Note how payers perpetuate stigma by policies that don’t see addiction as a disease
Payers’ policies often don’t treat addiction as a chronic disease process needing treatment.
1. “We can’t pay for residential treatment until there has been an outpatient treatment failure.” Instead of allowing a person to go immediately into a level of care that is needed, such a “fail first” policy expects a clinically inappropriate level of care to be used first.
We would never expect a person with diabetic coma to try outpatient diabetic dietary changes before admitting them for a diabetic crisis. We would never expect a patient with a heart attack to try weight loss, exercise and stopping smoking before admission to the cardiac care unit. It is true that if a person is safe to do treatment in an outpatient setting, that level of care should be tried first rather than residential care. But if they need residential treatment from day 1, then they should not need a “treatment failure” in outpatient first.
2. “Sometimes people are penalized for doing well”. If a client is progressing well, payers expect the person to be transferred to a less intensive level of care and limit further reimbursement for care. Providers feel it is then necessary to play games by reporting their client is not doing well in order to assure ongoing payment for treatment.
The solution is to explain honestly, the progress a person is making. But then the provider has to convey what clinical severity still exists that needs services that can only safely be delivered by more time in the current level of care before transferring them.
3. “Burdensome processes for accessing benefits that lead to longer waiting times and put barriers in place to get someone into treatment.” When someone is ready to access treatment, waiting lists and appointments several days and even weeks away work against treating addiction as the disease it is.
Now note how providers perpetuate stigma by policies that don’t treat addiction as a disease
1. “Length of stay is not individualized according to the needs of the client.” – 28 day programs based on insurance coverage, not based on severity of illness and progress in treatment. Adolescent treatment program design has added 2 weeks for a 42 day program because adolescents can be difficult to treat; and cookie cutter programing expects all clients to need and do the same interventions e.g., everyone has to go to Alcoholics Anonymous. For some it might not be the best fit for a mutual help group as powerful and effective as it is for others.
2. “Kick people out for violating the rules and boundaries of the program.” For example discharging people for using substances on a pass when addiction is characterized by loss of control of use – that is what addiction is that needs more treatment, not discharge.
3. “Inappropriate contact between clients can get clients thrown out because of a moralistic sense instead of this being a disease process” e.g., clients found holding hands – “Should we discharge them?” Kevin’s staff once asked.
4. “Treatment programs may be only open from 9 -5 in OP; or only open Monday-Friday.” This doesn’t fit the needs of people with addiction who are using at all hours of the day and week. This is another example of how providers do not adhere to a therapeutically-based approach.
5. “Even people in recovery can perpetuate stigma by using terms like “sober”, “clean” or “straight.” These are “good and bad” and “positive and negative” stigmatizing moralistic terms rather than empowering terms like “I am a person in long-term recovery” (“Anonymous People” film). Such terms work against a public health and treatment approach to addiction.
Consider these Addiction and Public Policy Issues
Public policy implications:
1. Be aware of these stigmatizing terms and avoid using them.
2. Treat addiction like the chronic disease that it is and compare with what we do for other chronic diseases like diabetes, asthma, heart disease and hypertension. Some say “but addiction is different because there is choice involved in using substances.” But with other chronic diseases people make diet and lifestyle choices all the time that affect the progression of their disease and their recovery. For example, 70% of cardiovascular disease can be prevented or delayed with dietary choices and lifestyle modifications (Forman D, Bulwer BE, Curr Treat Options Cardiovasc Med. 2006;8:47-57)
For more facts and figures on lifestyle change, see the October 2015 edition of Tips and Topics:
3. Individualize treatment for the variety of needs that people present with.
4. Eliminate waiting lists.
5. Respond to relapse from a treatment perspective not punitively.
6. Negative consequences can motivate change e.g., an encounter with the legal system can motivate a person to seek help, so there is no need to pamper people or not hold them accountable for their behavior. But treatment is the response for someone who has addiction that results in illegal or bad behavior, not punishment.
“From uncomfortability comes change” said one of Kevin’s mentors.
SKILLS AND STUMP THE SHRINK
More and more states are looking to The ASAM Criteria to help reorganize their addiction treatment system. I wrote about these changing forces in the August 2015 edition of Tips and Topics
Understand ASAM Criteria Level 3.1 and 3.5 and Moving from Program-Driven Services
Here are some excerpts from questions about New Hampshire’s residential levels of care and my response about the true content and spirit of The ASAM Criteria levels of care.
Hello, my name is Paul Kiernan. I am the clinical services specialist at the Division of Behavioral Health for the State of New Hampshire. You and I had exchange emails some time ago regarding helping us better define the clinical requirements for level 3.1, Clinically Managed Low Intensity Residential, a level of care provided by several agencies that are contracted with us. We are having a bit of difficulty that I was hoping you could shed some light on.
The contracted agencies we work with are required to provide services consistent with ASAM Levels of Care. The problem we are encountering is determining what services fall under the scope of the level of care (these issues are being encountered in levels 3.1 and 3.5 primarily) and what services are above and beyond this and therefore can be billed as separate services. Many of the agencies are providing Recovery Support Services with groups such as Smoking Cessation, Managing Anxiety, Importance of Self-Care, Money Management, jewelry Making, Designing a resume and Self-Empowerment to name a few. Recovery support services are listed under both levels of care but frequency is not defined. The contracts state that the contractor will provide services in accordance with ASAM Criteria, which leaves us with a bit of ambiguity. Any support or direction you could offer would be greatly appreciated.
Paul Kiernan, LADC Clinical Services Specialist
Division for Behavioral Health
Bureau of Drug and Alcohol Services
Clinical Services Unit
Email address: email@example.com
In Level 3.1, the person is getting at least 5 hours of clinical services per week. Since 3.1 is more of a 24 hour living support level, I can see that any formal individual or group clinical services could be charged separately because a person could be living in 3.1 but getting services in an outpatient (OP) agency separate from the 3.1 site.
The kind of 24 hour counseling support that is part of 3.1 would be provided under the 3.1 daily fee, because there should be trained staff there on a 24 hour basis, who can handle informal counseling support to someone who is having, for example, cravings to use at 11 PM or 2 AM and needs someone to talk to. But if there are formal clinical services like a group or individual session in 3.1, then that can be provided onsite or in collaboration with another OP service agency.
Recovery support services are not referring to Jewelry making. Helping with money management, resumes and vocational counseling if needed by the client on their treatment plan could qualify as a clinical service for Dimension 6, Recovery Environment, needs and be counted in the five hours or more of clinical services.
The daily fee for Level 3.1 would be lower than 3.5, Clinically Managed High Intensity Residential, which is for people who need 24-hour services because of imminent danger and instability. Sessions like Money Management, Jewelry making, Designing a Resume would not be in a Level 3.5 treatment plan that should be focused more on stabilization of imminent danger and preparation for continued care in less intensive levels of care. Because 3.5 is 24 hour care, the daily fee should be higher and include any formal individual and/or groups clinical sessions in the daily fee and not unbundled as in Level 3.1.
So the frequency of clinical services is not defined in the ASAM Criteria book for either level 3.1 or 3.5 as in 3.1, it depends on the severity and function of the person and the needs in their individualized plan. In 3.1 it has to be at least 5 hours/week to distinguish 3.1 from a general recovery home, halfway house or Oxford House. 3.1 clients are more severe needing the availability of 24 hour living and counseling support plus at least five hours of formal clinical services.
In 3.5, clients need 24-hour care and therefore formal and informal counseling sessions and supports all included in the daily fee. Again, frequency of sessions in 3.5 depends on the level of instability of the client and what they need to be stabilized sufficiently to continue care in a less intensive level.
Paul’s Reaction to my Response
You helped clarify a misconception I had about the 3.1 level of care and also got me thinking about what patients are appropriate for what residential levels of care and what interventions are appropriate for those patients.
We have really been trying to move to a more patient-driven system of care and have specific language in the contracts stating that patient stays are treatment plan/patient driven. Treatment plans have to be personalized and the levels of care must follow ASAM guidelines. The reality is that these are, and continue to be, program-driven with arbitrary assignments and Evidence-Based Practices (EBPs) implemented with no real evidence that they are clinically appropriate for the particular client.
In the past year I have really immersed myself in understanding ASAM clinically but also in philosophy. One of the things that I will be working on is development and implementation of a comprehensive plan to help our contracted agencies become patient-driven. Any support along the way we be greatly appreciated. I find it very difficult to articulate how grateful I am for your input.
ASAM Criteria Level 3.3 and Dealing with Behavior Problems
Another question from Paul
On another note I would like to pick your brain on Level 3.3, Population Specific High Intensity Residential Level of Care. We have none in our great State of New Hampshire and this seems to be a level of care a lot of folks who “fall through the crack” may benefit from. Patients who are not meeting criteria for psychiatric admission, but cannot function in a typical patient milieu. Patients who have behavioral problems who end up getting discharged for rule infractions (throwing things at staff, cursing at staff, stealing from other patients, stealing medication and hiding it in there room etc). For now, we have been trying to get folks set up with Co-Occurring enhanced 2.1, Intensive Outpatient or 2.5, Partial Hospitalization where there are less restrictions and it is easier for them behaviorally. Obviously problems arise when dangerousness and lethality are high. Wondering if you have any suggestions of other states that are doing this well or what a good 3.3 would look like? Also if the interim solution I mentioned is a good idea for now.
I know 3.3 is tricky and I don’t have a mecca state for you to go to. But I would make the distinction that 3.3 is for people with cognitive difficulties and Traumatic Brain Injury (TBI) that makes it hard for them to be in a typical milieu. In contrast, patients who have behavioral problems may or may not be having those because of cognitive issues like TBI. Rule infractions can be caused by multiple reasons including, but not limited to:
1. Programs that are more focused on phases in a program-driven system where patients advance by being compliant with rules. “Breaking rules” is seen a behavioral problem requiring behavioral contracts, rather than assessing why the person “broke the rule” and making this part of an individualized treatment plan. It may help to look at Tips and Topics, Volume 10, No. 11 February 2013
2. A patient may be mandated to a program and is not really doing treatment and just “doing time”. If the program is not skilled in Motivational Interviewing and stages of change work, they are going to be more focused on rule breaking and compliance instead of engaging the person in a “discovery” plan rather than a “recovery” plan for which the patient may not be ready. Such a person would be better treated in OP levels unless in imminent danger and then in 3.5 only for the time they are unsafe and unstable. Working with a person who is more interested in getting off probation than in getting into recovery and using residential levels for that work is a setup for rule breaking and the revolving door of discharging people for bad behavior.
3. If there are issues in Dimension 3, Emotional, Behavioral or Cognitive Conditions or Complications, that are causing a person to “break rules”, then the focus should be on assessing what the Dimension 3 problem is and what to do about it, not discharge. If it is an issue in Dimension 5, Relapse, Continued Use or Continued Problem Potential, and the person is willing to change their treatment plan in a positive direction, treatment continues as stealing medication and trying to get and use drugs is normal for people with addiction.
This behavior is not about rule breaking, but about the cravings of addiction. If the person is not interested in treatment, and just thinks they can have fun while “doing time” then discharge or court sanctions are appropriate, not for having used, but because they are not interested in treatment, as evidenced by not participating in a reassessment of what went wrong and changing their plan in a positive direction to get a better outcome next time they get a craving to use. In other words “rule breaking” should be assessed as a bad outcome needing a new treatment plan.
(See Appendix B on Dimension 5 in The ASAM Criteria (2013).
4. It may be that a program has too many rules trying to control behavior rather than assess six dimensional needs and do individualized treatment. Residential levels should focus on preparation of people for OP services not seen as a place for a total life makeover in residential.
Yes, there should be more OP levels that can take people with co-occurring mental disorders and addiction (COD) and for those in early stages of change who need motivational services. We should use residential only for people who need 24-hour services to be imminently safe. So developing levels 1, Outpatient, 2.1 and 2.5 that can be more enhanced and complexity capable is not an interim solution, it is an important solution in an array of approaches.
Paul’s Reaction to my Response
You helped clarify some misconceptions I had about the 3.3 level of care. During the Quality Assurance (QA) of the treatment plans, these are exactly the types of things I am encountering. On one treatment plan the goal was actually “the client will reduce feelings of shame and improve self-esteem”. I don’t think that goal is Specific, Measurable, Achievable, Realistic, or Time-Limited (SMART)
One of the many obstacles we deal with is clinicians’ knee jerk reaction to treat cases as imminent danger. So many people are dying that folks ignore or misinterpret imminent danger criteria C (“the likelihood that such adverse events will occur in the very near future, within hours and days, not weeks or months.” – The ASAM Criteria 2013, pp 65-68; 420) and are treating their own anxiety. As a result, patients end up in what appears to be an inappropriate level of care. So we have been engaging our providers in a community of practice to help them sharpen their ASAM skills and in a lot of cases teach them a basic understanding.
I have to be honest, prior to the newest edition I was one of those who just did the 1 page checklist! We have done 2 webinars consisting of an overview of the 6 ASAM Criteria dimensions, severity rating, withdrawal management, levels of care, treatment planning and a special Paul Kiernan soap box lecture on what really constitutes imminent danger.
A point I stressed during these is that just because two patients have a high severity rating in dimension 5 for example, does not mean that they are going to have the same treatment plan. One patient may be using because they do not like dealing with negative emotions and another patient may just really like getting high. Another patient may have absolutely no internal dialogue prior to using (perhaps a red flag to revisit dimension 4, Readiness to Change) where the other person has a real internal struggle.
These are some of the things that we are working on in hopes of moving providers to a patient-driven model.
Again I am so grateful for your correspondence.
Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.
For more information on the new edition: www.ASAMcriteria.org
Warning: The following is an unpaid, unsolicited, political opinion. If you are definitely voting for Donald Trump as President of the United States of America, please stop reading. I do not want to argue with or alienate you. I value you as a Tips and Topics reader and more.
But if you are undecided, you may be interested in my thoughts and concerns. These are not academic political science observations, but just my opinions that you could rightly take with a grain of salt:
1. President of the United States and leader of the free world requires intelligence, integrity, political experience and knowledge of how political systems work. While it is understandable to think career politicians are the problem, I have always favored change from within, rather than blowing things up and radical change from without. It is easy to see solutions when on the campaign trail, but much harder when faced with the real negotiations and issues when in actual office e.g., Barack Obama declared he would close down Guantanamo Bay and meant it. But easier said than done.
2. For any job, especially a highly complex position that requires interfacing with many systems, countries and personalities, I would only consider candidates who have some demonstrated experience in the duties, dilemmas, challenges and complexities of the position. Hilary Clinton apparently delivered on a consensus, collaborative and across-the-aisle style when she was a Senator; and slogan or not, I favor “Stronger Together” than “Build a Wall” type politics.
3. How a candidate has defined their life’s mission and occupied their actual work energies, tells me whether there is a consistency in what they stand for and believe in. Have they demonstrated a commitment to public service or to causes that are consistent with public service? Has their work and systems experience encompassed the kinds of challenges they will face as President? Do the values of their life’s work speak to compassion, integrity, honesty, and fair play; or to materialism, adversarial power plays, bullying and self-centeredness? Is there a value of “it takes a village” or “I alone, can make things great again”?
4. Finally, you have almost certainly heard about the infamous audio and video of Donald Trump bragging about kissing and groping women because as a star, you can do whatever you want. If you don’t know what I’m talking about, see the link:
I give many workshops and keynotes and have often been the featured speaker at a conference. What would you think of my integrity and values; my leadership and presentation content if I were to say that because I’m the keynote speaker I could kiss or grab any woman I wanted at the conference; and then say that if I didn’t do that, it was the woman’s fault that she wasn’t attractive? I am no star and I am not running for President. But I am mystified that millions are not fazed by Donald Trump’s demonstration of distorted values, lack of respect, abuse of power and failure of integrity.
I rarely speak my mind about politics, but in this case, I felt compelled to speak up. I hope you will vote – for whomever your conscience says has the skill; compassion and integrity; and knowledge, character and values to be President of the United States.
Until next time
Thanks for joining us this month . See you in late November with President Clinton or President Trump.