The ASAM Criteria – Tips on assessment and treatment; 18 months since I lost my wife and Ricky Gervais’ “After Life”

In SAVVY and SKILLS, assessment and treatment tips for the six assessment dimensions of the ASAM (American Society of Addiction Medicine) Criteria.

In SOUL, it is 18 months since I lost my wife. Ricky Gervais’ Netflix series “After Life” got me thinking about grief and a host of other related human interests (and it entertained).

savvy and skills

It is starting to sink in that COVID-19 is not going to be under control any time soon. It is hard to get back to business as usual, but I’m pivoting this month to focus on other topics.

Many years ago I was considering full-time training and consulting. An experienced consultant shared that he got to learn what people are needing across a wide range of programs and teams. I have found that to be true as I train and consult on using the ASAM (American Society of Addiction Medicine) Criteria.

So this month, in a combined SAVVY and SKILLS, I will highlight some tips on understanding and using the six assessment dimensions of The ASAM Criteria (2013). Even if you don’t use The ASAM Criteria, the dimensions apply across health settings and hopefully you will find some useful clinical tips. If you do use The ASAM Criteria, go to page 43 and beyond for more comprehensive guidance on the six assessment dimensions.

Tip 1

Dimension 1 – Acute Intoxication and/or Withdrawal Potential and Medication-Assisted Treatment (MAT)

Leaving aside what I have written before about how I prefer the term “Medication in Addiction Treatment” for MAT, here are some issues that keep coming up about MAT:

• When establishing the most stable dose for a patient on methadone or buprenorphine for Opioid Use Disorder (OUD), the clinician is balancing intoxication and withdrawal – a Dimension 1 service.
• You don’t want the patient to have too high a dose and getting ‘high’, but you also don’t want them getting too low a dose and going into withdrawal.
• Once a person is stabilized on their medication in addiction treatment, then clinically, they should be neither intoxicated nor in withdrawal. Then the MAT is now technically a Dimension 5, relapse prevention service.
• The answer as to whether MAT is a Dimension 1 or Dimension 5 service is “yes” – Dimension 1 when establishing the most stable dose; and Dimension 5, once the patient is stabilized and continuing on the medication in addiction treatment.

Tip 2

Dimension 2 – Biomedical Conditions and Complications and Chronic Pain

It is not unusual, especially with OUD, for a person to have co-occurring addiction and chronic pain. Of course, we want to work towards abstinence from addicting, narcotic medication, but here are tips to note:

• Don’t cutoff the pain medication suddenly. It will likely push the person into illegal drug seeking to avoid withdrawal and their fear of pain.
• Discuss with the client in an empathic, compassionate, spirit of Motivational Interviewing manner their goal for chronic pain. Is it relief and “I’ll do whatever it takes” – physical therapy, acupuncture, prudent exercise, mindfulness meditation, non-narcotic medication etc.? Or is it “Just give me oxycodone because nothing else works and I don’t want to do any of those other things”?
• In other words, do you have a person in Preparation and Action for pain relief; or do you have a person in Action for narcotic medication?
• The former option calls for coordinated, collaborative care management between the patient, addiction treatment provider and the pain specialist to ensure continued medication, even narcotic medication, while attracting the patient into focusing more on non-medication solutions and skills.
• The latter goal of “just give me medication” calls for motivational enhancement therapies to explore addiction issues while also trying to work on pain relief.

Tip 3

Dimension 3 – Emotional, Behavioral or Cognitive Conditions and Complications and Diagnosed Mental Disorder and Prescribed Psychotropic Medication

Many clients present with a previously diagnosed psychiatric diagnosis and medication. It is easy to give someone a diagnostic label and a prescription. It is not wise to ignore a “diagnosed” mental disorder and stop someone’s medication. On the other hand, just because a patient was given a diagnostic label and prescription doesn’t verify that they do actually have co-occurring mental and substance use disorders (COD). Here are some points to ponder when deciding if a client has COD; or whether the emotional, behavioral or cognitive signs and symptoms are more addiction-related:

• There are assessment questions and issues to help sort out COD that I have written about before.
• These questions relate to the timeline between the psychiatric symptoms and addiction history – did the addiction predate the mental health issues; or vice versa, was their a clear psychiatric diagnosis before substance use disorder; was the person using substances not long before or at the time of the psychiatric symptoms (substance-induced disorders); have there been significant periods of abstinence and sobriety with psychiatric symptoms persisting when substance-free?
• Who gave the person a psychiatric diagnosis? Was it an addiction psychiatrist; or a primary care physician?
• How long was the assessment and did they even take a substance history? If not, did the patient tell the physician what substances they were actively using at the time of psychiatric symptoms?
• A 10 minute consultation with no assessment of substance history in a person using uppers and downers and having mood swings is not Bipolar Disorder.

Tip 4

Dimension 4 – Readiness to Change and Different Stages of Change for Different Things

Dimension 4 is not about whether a person agrees to enter treatment, often with the pressure of some mandating agency or person. It is about where is their heart and mind in their interest or not, to embrace recovery. Here are some tips:

• People are at different stages of readiness for different things. They may be at Action for getting their children back or people off their back, but at Precontemplation for addiction recovery. They may be at Preparation for stopping heroin, but in Contemplation for stopping marijuana. They may be at Action for depression, but at Contemplation for addiction.
• Job One when engaging and attracting people into recovery requires we start with what they are at Action and motivated for, not what we are at Action and want for the person. “I will focus on helping you get your children back or people off your back. Now let’s look at this assessment and see if and how you are shooting yourself in the foot in getting what you want.”
• “What are your top three favorite drugs and what do you like about them – what do they give you?” Then if the person can’t think of anything good they still get from substance use, you may have someone ready to change.
• But if they talk specifically of what works for them when using, then you know you have some engagement and motivational work to do to help them discover a connection between their use and getting what they want.

Tip 5

Dimension 5 – Relapse, Continued Use, or Continued Problem Potential and Increasing Self-Efficacy

You could have a person who is fully motivated and ready for recovery – low severity on Dimension 4 – but high severity on Dimension 5 because they have few skills, strengths and resources for dealing with triggers, urges, temptations to use with addiction and mental health flare-ups. Some tips to assess their ability to deal with flare-ups:

• Every assessment should include a question on “What is the longest time you have been able to be abstinent from all alcohol and other drugs; or have stable mental health?” Whatever time the client reports, it is an opportunity to support self efficacy.
• Many clients have been told explicitly or implicitly that they are a loser, a chronic recidivist, a no-hoper, the black sheep – they have no optimism or confidence that they can change even if they wanted to (low self efficacy). “Why even try to change if I know that I will, as usual, screw up and fail?”
• So no matter what time-frame the client answers, the response is “That’s great, how did you do that?” – “Three years sober, that’s great how did you do that?”; “Three months, that’s great, how did you do that?”; “Three weeks….”; “Three hours…..”
• Then explore what worked in their attitudes, thoughts, feelings and behavior that helped them be well for whatever time they say e.g., working and being occupied helped you with abstinence; staying away from certain people; not going to those places; going to meetings; taking medication; attending therapy; thinking about how you were hurting a loved one…whatever you did for however long you did it are skills that can be expanded upon.

Tip 6

Dimension 6 – Recovery Environment and Involving Family and Significant Others

Housing, money, vocational (unemployment), educational (illiteracy) and legal issues are common recovery support service needs in Dimension 6. But a common and too often neglected Recovery Environment need is the family and significant others. Too many programs still give the “family” (whatever people are significant to the participant) cursory or even no attention. So here are tips about the “family”:

• Family members and significant others have been affected by addiction and/or a mental illness just as much as the identified client. They have their pain, their anquish, their mixed emotions and limited knowledge and skills to know what to do, just like the client.
• They are a resource for assessment data and information on what has worked or not in the past. But they also need direct help to know how to handle their own emotions, thoughts and behaviors affected by addiction and a mental illness.
• The “family” doesn’t have to be involved in a week-long family program to be taken seriously. A joint phone call; online session; face to face meeting right at the beginning and continuing through the continuum of care addresses both assessment and treatment issues so important to achieve good outcomes.
• If a client has burned bridges with their family of origin, explore who is his or her “family” now. Assess what recovery support services are needed; and what s/he is willing to do at whatever stage of readiness they are at.

Reference:

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.

To order: The Change Companies at 888-889-8866; changecompanies.net

soul

It is 18 months since I lost my wife. I and my children are all doing well in our grief process. I actually prefer to think of it as a ‘moving forward’ process. Losing a partner and a parent has a way of focusing you on your most important priorities in work, love and play; or as I would re-order that today in love, play and work.

When I binged watched this month the first two seasons of Ricky Gervais’ Netflix series called “After Life”, it got me thinking about grief again. Gervais is not everyone’s choice of comedian. He often gives voice to attitudes, thoughts and topics that can be uncomfortable to speak out loud. He challenges unconscious biases and beliefs you might rather keep hidden.

I like his dry British humor and it always gets me thinking. When I consumed the series that he wrote and directed; and in which he played a man who lost his wife to cancer, I was intrigued. I found the series masterful in the way Ricky Gervais shaped the journey of a man struggling with losing the love of his life; and the array of surrounding characters he brought to life who were affected by his grief process and who in turn influenced his life too.

“After Life” mixes humor, drama, poignant insights, pathos and some adult-rated language. But it got me thinking about:

• How everyone has their own grief process with its varying manifestations and paths.
• The power of your dog or pet to give unconditional love and even ‘save’ you.
• The mix of emotions to be with an aging parent developing dementia.
• How everyone is looking for love, sometimes in the wrong places; and sometimes in places you couldn’t have planned.
• How there may not be a ‘one and only love’ that you have to scour the world or dating sites to find. There may be someone in your neighborhood who is an unexpected cupid match.
• How many incompetent counselors and therapists might be out there who should be shut-down?
• How the grief process can indeed be a ‘moving forward’ process. While where there may be flare-ups of sadness and longing; of regret and loss, there are also new opportunities for joy, discovery and hope.

You can tell that I am a fan of “After Life”. I hear that Ricky has finished writing the first episode of Season 3. I can’t wait for him to write the remaining five episodes and start producing them. I can’t decide if I’ll wait for Season 3 to end and then binge watch; or eke them out one episode at a time. I also hear (sadly) that there won’t be a season 4 of “After Life”.

Maybe it’s a bit like the grief, moving forward process. You can’t binge and get it all over at once. It is more of an ekeing process. But in life after grief, there is a Season 4, 5, 6 and….