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What to expect from state-of-the-art addiction treatment for criminal justice populations in applying the new ASAM Criteria BJA Drug Court Technical Assistance Project at American University February 10, 2016 David Mee-Lee, M.D. Chief Editor,

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What to expect from state-of-the-art addiction treatment for criminal justice populations in applying the new ASAM Criteria

David Mee-Lee, M.D. Chief Editor, The ASAM Criteria Senior Fellow, Justice Programs Office (JPO) American University Washington, DC Senior Vice President, The Change Companies Carson City, NV Davis, CA www.changecompanies.net www.ASAMCriteria.org www.tipsntopics.com davidmeelee@gmail.com BJA Drug Court Technical Assistance Project at American University February 10, 2016

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Methamphetamine

1500

Dopamine Levels

1000 500

Frontal cortex

0 1 2 3 hr

Time after methamphetamine

500

COCAINE

400

VTA/SN

300

Nucleus accumbens

200 1 1

0 1 2 3 4 5 hr

Time After Cocaine

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Addiction is a Brain Disease

“Healthy” Brain “Cocaine Addict” Brain

Prolonged Use Changes

the Brain

in Fundamental and Lasting Ways

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“Addiction is a primary, chronic disease of

brain reward, motivation, memory and related circuitry August 15, 2011

Dysfunction in these circuits leads to

characteristic biological, psychological, social and spiritual manifestations.

ASAM’s Revamped Definition of Addiction

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Pathologically pursuing reward and/or relief

by substance use and other behaviors.”

“Addiction is about brains. Not just about

behaviors”

ASAM’s Revamped Definition of Addiction

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INDIVIDUALIZED, CLINICALLY & OUTCOMES-DRIVEN TREATMENT

ASAM Principles of Addiction Medicine 5th Edition, 2014

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The ASAM Criteria

Multidimensional Assessment

1. Acute Intoxication and/or Withdrawal Potential
2. Biomedical conditions and complications
3. Emotional/Behavioral/Cognitive conditions and complications
4. Readiness to change
5. Relapse/Continued Use/Continued Problem potential
6. Recovery Environment

The ASAM Criteria pp. 43-53

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Criminogenic Factors/ASAM Criteria Dimensions

Criminogenic Factors

Antisocial values,

attitudes, behavior, personality

Criminal/deviant peer

association

Substance abuse
Dysfunctional family

relations ASAM Criteria Dimensions

Dimensions 3, 4 and 6
Dimension 6
Dimensions 1, 4, 5, 6
Dimension 6

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Biospychosocial Treatment

Treatment Matching - Modalities

Motivate - Dimension 4
Manage – All Six Dimensions
Medication – Dimensions 1, 2, 3, 5 - MAT
Meetings – Dimensions 2, 3, 4, 5, 6
Monitor- All Six Dimensions

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The ASAM Criteria

Treatment Levels of Service

1 Outpatient Treatment 2 Intensive Outpatient and Partial Hospitalization 3 Residential/Inpatient Treatment 4 Medically-Managed Intensive Inpatient Treatment

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Level 0.5 and OTS

Level 0.5: Early Intervention Services - Individuals with problems or risk factors related to substance use, but for whom an immediate Substance -Related Disorder cannot be confirmed Opioid Treatment Services (OTS) - Criteria for Opioid Treatment Program (OTP) (methadone); antagonist meds (naltrexone) and Office-Based Opioid Treatment (OBOT) - buprenorphine

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Detoxification  Withdrawal Management Services for Dimension 1 Level 1-WM - Ambulatory Withdrawal

Management without Extended On-site Monitoring Level 2-WM -Ambulatory Withdrawal Management with Extended On-Site Monitoring

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Withdrawal Management Services for Dimension 1 (continued) Level 3.2- WM- Clinically-Managed Residential

Withdrawal Management Level 3.7- WM - Medically-Monitored Inpatient Withdrawal Management Level 4-WM - Medically-Managed Inpatient Withdrawal Management

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Level 1 and 2 Services

Level 1

Outpatient Treatment Level 2.1 Intensive Outpatient Treatment Level 2.5 Partial Hospitalization

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Level 3 Residential/Inpatient Level 3.1- Clinically-Managed, Low Intensity

Residential Treatment Level 3.3 - Clinically Managed Population- Specific High Intensity Residential Treatment (Adult Level only)

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Level 3 Residential/Inpatient (cont.)

Level 3.5- Clinically-Managed, Medium/High Intensity Residential Treatment Level 3.7- Medically-Monitored Intensive Inpatient Treatment

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Level 4 Services

Level 4 Medically-Managed Intensive Inpatient

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Focus Assessment and Treatment

What Does the Client Want? Does client have immediate needs due to imminent risk in any of six dimensions? Conduct multidimensional assessment

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Focus Assessment and Treatment (cont.)

DSM-5 diagnoses? Multidimensional Severity/LOF Profile Which assessment dimensions are most important to determine Tx priorities

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Focus Assessment and Treatment (cont.)

Specific focus/target for each priority dimension What specific services needed for each dimension What “dose” or intensity of these services needed

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Focus Assessment and Treatment (cont.)

Where can these services be provided in least intensive, but “safe” level of care? What is progress of Tx plan and placement decision; outcomes measurement?

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DSM-5 diagnoses? Multidimensional Severity/LOF Profile Which assessment dimensions are most important to determine Tx priorities Specific focus/target for each priority dimension What specific services needed for each dimension What “dose” or intensity of these services needed Where can these services be provided in least intensive, but “safe” level of care? What is progress of Tx plan and placement decision; outcomes measurement?

The ASAM Criteria p 124

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David Mee-Lee, M.D. Senior Vice President The Change Companies Carson City, NV www.changecompanies.net www.ASAMCriteria.org www.tipsntopics.com

davidmeelee@gmail.com

These materials have been prepared under the auspices of the Bureau of Justice Assistance (BJA) Drug Courts Technical Assistance Project at American University, Washington, D.C. This project was supported by Grant

No. 2012- DC-BX-K005 awarded to American University by the Bureau of

Justice Assistance. The Bureau of Justice Assistance is a component of the Office of Justice Programs, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, and the Office for Victims of Crime. Points of view or opinions in this document are those of the authors and do not represent the official position

r policies of the U.S. Department of Justice.