Welcome to the October edition.

In SAVVY, STUMP THE SHRINK and SKILLS, a reader asks about people who have been in prison and how to evaluate addiction Full or Partial Remission when in a controlled environment. A new Fourth Edition of The ASAM Criteria is now out. I reprise a past question about assessing people in controlled environments using both the terminology of the 3^rd and new 4^th Editions of the Criteria.

In SOUL, I am excited to share a new podcast. As the proud father of three smart and emotionally intelligent kids, I hope you’ll enjoy The Chosen Blood Podcast - Three Siblings Watch Home Vids & Reflect. I think the Pod is entertaining, engaging and informative, but then again I am biased.

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY, STUMP THE SHRINK AND SKILLS

I get questions from time to time about how to diagnose and assess clients who are or have been in jail or prison. Earlier this month Ted Izydor contacted me. Ted worked for Train for Change a few years back and was doing ASAM Criteria training for them. He also trains on Motivational Interviewing and supervises newbie clinicians. In that context this question emerged about how to diagnose addiction clients in partial or sustained remission with the prison population when they are released.

Hi David,

I was hoping to get your opinion on a clinical diagnostic question for a client who had a Stimulant Use Disorder - Severe and then went to prison for 10 years and did not use stimulants. They would have the diagnosis of Stimulant Use Disorder - Severe (in full sustained remission) - in a Controlled Environment.

Here is the question:

If they get out of prison and remain “clean” from stimulants for 6 months, is the diagnosis still in Sustained Full Remission - therefore not having an active diagnosis? Or do we put it in Partial Remission post-controlled environment? I think it stays in full sustained remission, but wanted some more experts to weigh in on how to label it as the Diagnostic and Statistical Manual, DSM-5-TR (Text Revision) is not clear.

I also think of the scenario of someone in prison for 2 years who is abstinent from let’s say opioids, but is then released and before they are released they go on Medication Assisted Treatment, MAT for a previous opioid use disorder. What would that be labeled per DSM-5-TR?

Let me know what you think when you have a chance.

Best regards,

Ted Izydor, LPC, CSAC, ICS, MBA
Motivational Interviewing Trainer
tedizydor.com
fullpotentialnow.org

My Response:

Tip 1

Just because a person is in a “controlled” environment doesn’t mean they don’t have access to susbtances. It takes motivation and skill to stay abstinent.

As regards to your first scenario, I agree with Sustained Remission because 10 years abstinence even in a controlled environment and 6 months outside of that is a lot of drug-free time. As you know, prisons are not so “controlled” - drugs do get in and are used. So for someone to have enough motivation and skills to stay abstinent means that they have had to deal with cravings to use; stay away from drug using inmates; choose not to use even though it is available albeit at a higher price than the outside world. So these are skills that warrant Sustained Remission.

Note that DSM-5-TR just refers to Sustained Remission, not “Full” Sustained Remission (no symptoms of Substance Use Disorder, SUD except for craving) for 12 months or more; and Partial Remission is for no symptoms for 3 months but less than 12 months.

By the way, I put “clean” in quotes and encourage everyone to avoid saying “clean”. Use “abstinent” or “drug-free” as “clean” is stigmatizing terminology. “Clean” connotes that if you are using substances you are “dirty”....not the most engaging term and only worsens feelings of shame or guilt.

Tip 2

When a person is prescribed addiction medication and stays abstinent from all other non-prescribed and addictive substances, then they should be considered abstinent and in Partial or Sustained Remission.

In the second scenario, if the person has been 2 years abstinent and no symptoms of SUD except for cravings, then I would still say Sustained Remission even if on MAT. If while on MAT, s/he starts using cocaine or some other drug, then s/he would cease to be in Sustained Remission. If they don't use any other non-prescribed substance while on MAT, then I believe it would still be Sustained Remission because of the 2 years achieved; and taking MAT is a medication, not a flare up of addiction. I am not a DSM expert, but this is how I would think it through.

On an added note, I encourage you to start using “addiction medication” rather than “MAT” just like we say pain medication, diabetes medication, sleep medication etc.

Tip 3

How to apply ASAM Criteria multidimensional assessment for people who are incarcerated in a controlled environment.

First of all a new 4th Edition of The ASAM Criteria has just been released and you can see all about it on the American Society of Addiction Medicine (ASAM) website.

This was a STUMP THE SHRINK question from May 2008 and I will indicate the new 4th Edition Dimension terminology as those have changed slightly.

Question: Can you provide some direction about level of care determination for persons who have be incarcerated (or otherwise in a controlled environment) for an extended period of time

My Response:

1. If a person is just starting their prison sentence:

Assess, for example, Dimension 6, Recovery Environment (The ASAM Criteria 3rd edition); Dimension 5: Recovery environment interactions (4th edition)

• Explore what your client’s life and environment was like just prior to incarceration. For example:
• Were friends using substances addictively?
• Did s/he work only as a drug dealer?
• Did they live with their partners in crime; or were they unhoused living on the street? If so, their environment would not have been supportive to recovery.
• These will be the issues (relationships, living situation, vocational, skill-sets) that they will need to work on in treatment.

2. If a person is still incarcerated and not moving towards release any time soon:

You do the assessment in the present tense, as you are trying to assess what the person needs for treatment while incarcerated. Even though a person is in prison, they can still obtain drugs. So the assessment questions include for example in Dimension 5, Relapse, Continued Use, Continued Problem Potential (The ASAM Criteria 3rd edition); Dimension 4: Substance use-related risks (4th edition):

• How easy or hard is it to refuse drugs even while incarcerated?
• How do they handle cravings to use even though access to drugs may not be quite as easy as when on the outside?
• What are their attitudes towards AA/NA and relapse prevention strategies?

Similarly for Dimension 6, Recovery Environment The ASAM Criteria 3rd edition); Dimension 5: Recovery environment interactions (4th edition)

• Unhelpful, unsupportive people exist in prison - just like friends and influences on the outside. How are they dealing with those unsupportive people in prison?
• Are they able to stay away from negative influences?

3. If a person is preparing for release and re-integration into the community:

You assess the ASAM Criteria dimensions with regards to the person’s level of stability and function you anticipate they would have in the community upon their release. Assess for example, Dimension 6, Recovery Environment (The ASAM Criteria 3rd edition); Dimension 5: Recovery environment interactions (4th edition).

Gauge what it will be like out there upon release from a controlled environment, not what it is like now in the prison. The community care plan must address action steps around the immediate living situation, friends, work, finances etc. outside of the support of the controlled environment.

For example:

• Are the client’s friends to whom they will be returning still using substances?
• Does the participant have a job ready in the community?
• Or is the only job s/he has upon release involve illegal activities?
• If they plan to live with fellow offenders, then that environment would not support recovery.

Similarly for Dimension 5, Relapse, Continued Use, Continued Problem Potential (The ASAM Criteria 3rd edition); Dimension 4: Substance use-related risks (4th edition):

• Was a person able to stay abstinent while in the structure of jail or prison, but now can’t explain or demonstrate any coping mechanisms or skills to deal with cravings once they hit the street?
• With lack of abstinence skills and no established relationship with mutual help recovery groups, the risk of a flare-up would be high severity, even though they were abstinent in the structure and confines of the controlled environment.

SOUL

Warning: Proud father announcement below!

My three children, Miya, Taylor and Mackenzie just released the second podcast episode of their The Chosen Blood Pod where three siblings dig through years and years of Home Video to explore and discover what's changed and what hasn't changed over that time.

They have been pondering doing a podcast for some time and rather than think and plan incessantly before “jumping onto the court”, they decided to just “Do it!” and adjust as they go. So if you look at this second episode you will see improvements already from Episode 1.

The way it works is that the rotating host chooses a clip from years of home videos and starts the session showing that surprise clip. The topic arises from that video segment for a free flowing, unrehearsed, spontaneous sibling interaction.

Big surprise: I think it is fabulous and hope you think so too. I know their mother would be beaming with pride were she still here in the physical. Take a look.

UNTIL NEXT TIME

Thank-you for joining us this month. See you in late November.

David