November 2021

30th Anniversary of The ASAM Criteria – A Report Card; Two videos I want you to see

Welcome to the November edition of Tips and Topics and a Happy Thanksgiving to all in the USA.

In SAVVY and SKILLS, I take a look at thirty years since the publication of the first edition of The ASAM Criteria. Here is my report card on how the addiction treatment field has implemented the true spirit and content of the Criteria.

In SOUL, I share two videos I saw this month and found so touching. I hope you can find 8 minutes to view them too, especially at this time of Thanksgiving.

savvy & skills

In an ASAM committee meeting recently, it dawned on me that this year is the 30th anniversary of the publication of the first edition of The ASAM Criteria. In 1991, it was called “Patient Placement Criteria for the Treatment of Psychoactive Substance Use  Disorder”.  Having been Editor-in-Chief since the beginning until passing on the editorship to Corey Waller, M.D., I have a unique longitudinal view of where the addiction treatment field has moved partly from the influence of the ASAM Criteria.

The American Society of Addiction Medicine (ASAM) has devoted significant financial and staff resources to explain, train and catalyse systems change and implement the full spirit and content of the Criteria.  When you go to ASAM’s website, click on the Quality and Science tab and you will see the many initiatives associated with the ASAM Criteria.

It is fitting that 30 years later, ASAM just released on November 9 a “first-of-its kind resource designed to assist interested states in establishing a common framework across all payers, providers, and patients on describing addiction care and ensuring that care remains focused on the individualized needs of those living with SUD.”  ASAM said “It’s our sincerest hope that it serves as a helpful resource for states looking for strategies and tools for strengthening the use of The ASAM Criteria to improve addiction care, specialty addiction treatment systems, and their coverage.”  

“SPEAKING THE SAME LANGUAGE

A Toolkit for Strengthening Patient-Centered Addiction Care in the United States”

This free educational toolkit includes the following topics and more:

  • a comprehensive list of strategies and potential pathways that interested states can pursue for integrating The ASAM Criteria;
  • an overview of existing implementation tools;
  • examples from current state efforts, and
  • model legislative, regulatory, and contractual language from which interested states can draw.

On pages 3-11 of The ASAM Criteria Third edition, (2013), the Guiding Principles lay out the conceptual underpinnings of the Criteria. With 30 years hindsight, here is a “report card” on where the addiction treatment field has or has not improved for some of those guiding principles.

Tip 1

Moving from one-dimensional to multidimensional assessment

This guiding principle encouraged treatment providers to base level of care and treatment on an initial multidimensional assessment to address multiple needs of the whole person.  Before the ASAM Criteria, treatment was based on one-dimension – the diagnosis alone.  

  • If you had a substance use disorder, that was enough to get admitted into a treatment program, after which the assessment was done to develop a treatment plan.  
  • In the 1970s and 1980s, it was not unusual for a person to be admitted into a residential program and the first week was designated the “assessment and treatment planning week.”
  • In contrast, the ASAM Criteria required the treatment provider to do the assessment first to determine level of care and treatment, not admit someone and then do the assessment.

Thirty years since the ASAM Criteria introduced a multidimensional assessment structured by six dimensions, all addiction treatment providers assess multiple needs of their clients. They get an A-grade for shifting from a focus on diagnosis as the only criterion for admission to treatment. However the treatment field deserves more of a C grade for any standardization of multidimensional assessment.

That’s where CONTINUUM ™, the ASAM Criteria Decision Engine, plays a key role.  ASAM CONTINUUM

provides counselors, clinicians and other treatment team members with a computer-guided, structured interview for assessing and caring for patients with addictive, substance-related and co-occurring conditions. 

  • It is an electronic assessment that aids clinicians in conducting a full biopsychosocial assessment that addresses all six dimensions of The ASAM Criteria. 
  • The decision engine uses research-quality questions (including tools such as the ASI (Addiction Severity Index), CIWA (Clinical Institute Withdrawal Assessment) and CINA (Clinical Institute Narcotic Assessment) instruments to generate a comprehensive patient report which includes a recommended level of care determination.

Tip 2

Uphold individualized treatment and person-centered services

Three guiding principles of the ASAM Criteria encouraged treatment providers to:

  • Focus treatment on the clinical needs of patients and their progress in treatment rather than on their compliance with rules and phases of the program.
  • Individualize the length of stay of a patient based on the severity and level of function of the patient’s illness, not a fixed length of stay e.g., 28 day residential; six weeks Intensive Outpatient; or 3 month extended residential.
  • Develop a broad and flexible continuum of care rather than a limited number of discrete levels of care. A patient then may begin at any initial level and move to a more or less intensive level of care, depending on his or her individual needs.

Today, few treatment providers describe their services as fixed length of stay programs and all would say they do individualized treatment.  I have never seen a brochure that says “We treat all patients with a one size fits all treatment plan based not on their assessment but based on their compliance with our pre-set program.”

  • However the functional reality is that if you ask a client “How long do you have to be here?” they likely will say things like “I have another three weeks to complete the program”; or their counselor may say they have another two weeks to graduate.
  • If you choose five Treatment Plans pulled at random, it is not unusual to see the same generic problems and treatment strategies in all five charts. It is difficult to identify any individualized approach to all five patients.
  • Rather than a seamless, flexible continuum of services, the treatment system struggles still with siloed levels of care; long waiting times for an initial assessment followed by waiting lists for residential beds and supportive living environments; and inadequate funding for all levels of care needed for comprehensive addiction services.

I give a B grade for good intentions on individualized, person-centered services and systems, but a C grade on execution and actualization.

Tip 3

Focus on Treatment Outcomes Measured in Real-Time to Guide Treatment

Increasingly, funding for practitioners and programs will be based not on the service provided, but on the outcomes achieved. Treatment services and reimbursement based on patient engagement and outcome is consistent with trends in disease and illness management, especially when conducted in real-time during the treatment experience, as with the management of hypertension or diabetes. 

  • With these chronic illnesses, changes to the treatment plan are based on treatment outcomes and tracked by real-time measurement at every visit (e.g., blood pressure or blood sugar levels are monitored to determine the success of the current treatment regimen). 
  • While there is attention on Evidence-Based Practices (EBP), more focus on patient engagement and outcomes-driven services is needed.
  • While EBPs contribute to positive outcomes in treatment, the quality of the therapeutic alliance and the degree to which hope for recovery is conveyed to the patient contribute even more to the outcome. 

On January 1, 2018, programs accredited by The Joint Commission faced a modified Standard CTS.03.01.09.  It required that outcomes of care, treatment, or services be monitored using a standardized instrument. Using Measurement-based care, organizations were to use feedback derived through these standardized instruments to inform goals and objectives, monitor individual progress, and inform decisions related to individual plans for care, treatment, or services. 

Addiction treatment gets a C or D grade if not an F (Fail) for this guiding principle. Very few programs are implementing Measurement-based care and we lag far behind other chronic disease management in focusing on treatment outcomes to drive an individual’s care.

soul

You probably have friends and loved ones who forward you a joke, video or podcast link they love and can’t help but share. This is how I feel about two videos I received this month and want to share with you.

The first is about 5 minutes long and has had nearly 20 million views since June, 2016. The creators of The DNA Journey asked “67 people from all over the world to take a DNA test. It turns out they have much more in common with other nationalities than they thought.”

In this time of Thanksgiving, I am in awe of the creativity and inspiration of people who dream up and birth projects like The DNA Journey. I am in awe even of just how people edit and splice together complex projects to summarize it all in 5 minutes. 

The second video is 3 minutes and is a compilation of babies who are wearing hearing aids and for the first time, are hearing what is being said to them.  The forwarded email said “Dare you all not to have a tear in your eye.”

I had tears in both my eyes for both these videos.  But then I cry at RomComs (Romantic Comedies) and they are just actors in a made up story!

October 2021

It’s not what you do that counts, but who you are; Self care, Personal Mission and Servant Leadership; Sunset of my career.

In SAVVY, my ‘first draft’ on meeting the challenge to write about the mix of spirit and psychology in a book – to articulate the spiritual context that gives structure to the core tools I have trained on full time for 25 years. It can be summarized by a phrase: “It’s not what you do that counts, but who you are.”  

In SKILLS, tips on ‘how to get there from here’ if you are committed to self care, clarity on your personal mission and are ready to be a servant leader.

In SOUL, trying to balance what I do in the sunset of my career to meet the goals of my personal life direction and my professional mission.

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September 2021

National Recovery Month 2021; Understanding Recovery and Recovery Capital; What to say to someone who doesn’t want AA; Katie’s story

In SAVVY, I explore what we mean by Recovery and Recovery Capital.  It isn’t all about abstinence and mental health stability, but rather whole person and whole systems perspectives.

In SKILLS, I focus on how to assess Recovery Capital and also how to approach a person who doesn’t want to go to Alcoholics Anonymous and prefers an alternative support group.

In SOUL, Katie, a person in long-term recovery, shares her recovery story.

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August 2021

Five key principles in helping people change; Skills to implement those principles; Vaccine hesitancy and using the five principles of the Better Arguments Project

In SAVVY and SKILLS, I share the wisdom of Marvin Goldfried, Ph.D. who presented in one paper five key principles on how people change. He wrote about the common principles of change that he distilled from hundreds of schools of thought and approaches to change. For each principle, I offer a few SKILLS to help implement it.

In SOUL, I don’t plan on talking with my daughter and her family about their vaccine hesitancy.  I respect their right to make their own choices.  But in case the topic of vaccines arises, I want to be grounded and centered to know what to say and do. So I used the five principles of the Better Arguments Project to help guide me.

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July 2021

Hard questions in the interface between Treatment and Justice Teams; Scripts on what to say to participants; What’s your Olympic Game?

In SAVVY, I preview a couple of hard questions that New Hampshire Chief Justice Tina Nadeau and I will discuss in the final General Session of RISE21, the National Association of Drug Court Professionals annual conference at the Gaylord National Resort and Convention Center in National Harbor, Maryland.   

In SKILLS, to help convert a clinical principle or policy and procedure into actual words to say to a client, I give some “scripts” of what to say to orient participants in Drug Court; and what to say about positive drug screens.

In SOUL, I have two connections to the Olympic Games and get into the spirit of the Games with my lifelong friends inventing new Olympic games.

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June 2021

Father’s Day, Lessons from 40 years of parenting – a grandfather’s perspective; RULER; Out of the mouths of babes.

In SAVVY, to help children, students and even adults “name their emotions to tame their emotions”, Marc Brackett coined RULER to develop critical and inter-related emotional skills.  Honor your feelings, desires and hopes for your child, but help them learn how to express feelings and needs in a way that fits their temperament and personality, not yours. But there is relief in understanding “good enough parenting”.

In SKILLS, I apply RULER to help parents have a discussion with their children about their feelings, needs and values especially in the context of the family’s values. In the immediacy of the situation, there isn’t time to have a feelings, needs and values discussion.  But in a quiet moment, parents can help their children “become the best them, not the best you.”

In SOUL, “out of the mouth of babes” is when a child says something that surprises you because it seems very wise. My 6 year old granddaughter had one of those moments of wisdom and pointed out that love for each other and arguing are not mutually exclusive.

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May 2021

Overdoses are up, but do we really need just more residential beds?; How to determine initial length of stay and authorization periods; Freddy enters my world.

In SAVVY & STUMP THE SHRINK, is residential care the first priority in responding to the increase in opioid overdoses?  Some States mandate certain periods of time that ban managed care authorizations and requirements for individualized treatment.  I suggest that what we really need in addiction treatment is not just more residential beds and time.

In SKILLS & SYSTEMS, treatment providers and Managed Care Organizations should not be “lined up on different sides of the aisle”.  To determine initial length of stay and authorization periods for an addiction client, think about what you would do for other health conditions.

In SOUL, Fred IV enters my world and joins Siri, Google and my Toyota Prius to help me navigate my cleaning, driving and knowledge worlds.

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April 2021

Rules or Treatment Plans? Relationships and Hooking Up; Getting your head and heart around understanding addiction

In SAVVY, STUMP THE SHRINK & SKILLS, in this combined section, I address co-ed relationships and hooking up while in treatment; Treatment, Rules, or Discharge, not just about these behaviors but also how to address any behavior concerns while in treatment.

In SOUL, I wonder about how hard it is for Justice teams and treatment providers to pivot away from consequences and sanctions for addiction flare-ups; rules and regulations; and compliance and mandates for prosocial behavior. Talk to people in long-term recovery.

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March 2021

Guest writers focus on Problem Gambling Awareness Month; Letting the chips fall where they may

Welcome to the March edition of Tips and Topics and guest writers focused on Gambling in honor of

Problem Gambling Awareness Month

In SAVVY, George Mladenetz informs us about Gambling Treatment Diversion Courts.

In SKILLS, Olubukunola Oyedele, PhD shares results from a small sample study he did on gambling and COVID-19 in New Jersey residents.

In SOUL, I share some natty little phrases that are rich in concept and meaning, but poor in follow through – easy to say, but hard to do.

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February 2021

Two years since I lost my wife; Hope Edelman on “The AfterGrief”; Carrying our loved ones forward; Getting back more than what you lost.

In SAVVY, the history of grief shaped our thinking that grief should be a process to be completed and from which we move on.  Hope Edelman challenges those concepts of grief and speaks of understanding grieving as a lifelong process.

In SKILLS, a couple of tips on how to move forward with grief as a lifelong process.

In SOUL, I share about work, love and play and how you really can get back MORE than what you lost.

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January 2021

Can terminology reduce stigma in opioid addiction? Different terminology for different stigma goals; Facing up to saving and losing face. FaceTime needed.

In SAVVY, a new study researched what terminology would reduce stigma in the prevention and treatment of opioid addiction.

In SKILLS, the choice of terminology may depend on the purpose of communication. Use medical terminology to decrease blame for addiction.  Use non-medical terminology to increase confidence that the person can recover and is not dangerous.

In SOUL, it is not about “losing face” or “saving face” over the Presidential election results.  It’s about “facing up” to “face our problems” and use some “FaceTime” to listen to each other.

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December 2020

Conflict, compromise, compassion; Better Arguments; Grieving a lost sister

In SAVVY, apply the three Cs to your family relationships, your clients and patients, or to your friends and neighborhood as well as bridging the political divide and the ongoing rancor.

In SKILLS, I highlight the dimensions and principles of the Better Arguments Project, a group with an initiative to heal America in the aftermath of the 2020 election.

In SOUL, two sisters’ relationship is severed prompted by the political divide and who voted for the “other side”. How about your family and friends?  Are you grieving over a fractured relationship?

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