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 30^th 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!