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6 Florida Alcohol & Drug Abuse Association“TREATMENT PLANNING: From Frustration to Proficiency” November 15, 2013 Orlando, FL © 2013, Shulman & Associates Training & Consulting in Behavioral Health This product is supported by Florida Department of Children and Families Substance Abuse and Mental Health Program Office funding.

7 Disclosures for Gerald ShulmanConsultant to Prevention Research Institute Consultant to Alkermes, maker of Vivitrol Trainer & Consultant to Lifescape Solutions Trainer, American Addiction Centers Member, Clinical Advisory Board, CRC Health

8 OUR KIND OF FOLKS

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15 It is more important to understand the person who has the disease, than the disease the person has.

16 The Beginning Effective treatment planning must begin with comprehensive assessment Treatment goals address the problems identified in the assessment Treatment plan objectives provide the precise steps to meet the treatment goals The treatment plans guides the delivery of the services needed to respond to the identified problems

17 Treatment Outcome Treatment TREATMENT PLANNING Assessment

18 What Makes Treatment Planning Easier?Treatment planning is a natural outgrowth of a comprehensive assessment It is not a stand-alone activity Because of that: The first part of the workshop will be focused on assessment The middle will be a discussion of the of the treatment planning process The last part will be provide the opportunity to do a comprehensive assessment and then the treatment plan using case studies

19 Individualized vs. Program-Driven TreatmentThe approach that treatment is to be: individualized, rather than program driven and variable length of stay, rather than fixed length of stay It Remains Central To Quality Treatment And Is Reflected In The Treatment Plan

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21 How Do We Get To Individualized Treatment?By: Comprehensive patient assessment Individualized treatment planning

22 Examples of Program-Driven Treatment PlansClient will . . . Attend 3 AA meeting a week Complete steps 1, 2 and 3 Attend groups sessions 3x/week Stay sober one day at a time Meet with the counselor once/week Complete the 28 day program

23 Program-Driven Treatment PlansOnly include those services provided by the program Often do not include referrals to community services (e.g., parenting classes, literacy training, vocational assessment and rehabilitation)

24 Individualized TreatmentPATIENT ASSESSMENT Data from all BIOPSYCHOSOCIAL Dimensions PROGRESS PRIORITIES Response to Treatment BIOPSYCHOSOCIAL Severity (SI) and Level of Functioning (LOF) BIOPSYCHOSOCIAL Severity (SI) and level of Functioning (LOF) PLACEMENT MATCH SERVICE NEEDS BIOPSYCHOSOCIAL Treatment Intensity of Service (IS) - Modalities and Levels of Service

25 Comprehensive AssessmentThe existence of and type(s) and severity of substance use disorder(s) (DSM-5) The existence of and type of any co-occurring disorders (DSM-5) Assessment in each area of patient function (Dimensions in the ASAM PPC-2R Criteria) All other collateral information

26 Patients Providers Treatment Mismatch No show/Drop out

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28 Diagnostic Assessment for Substance Use DisordersSubstance Dependence GONE Substance Abuse GONE Substance Related Disorders NOS (those individuals who do not meet the criteria for abuse, but whose drinking/drug use might still create problems - “sub-threshold” abuse) GONE

29 DSM IV Criteria for Substance DependenceA. Maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: (1) tolerance (2) withdrawal (3) the substance taken in larger amounts or over a longer period of time than was intended (4) there is a persistent desire or unsuccessful attempts to cut down or control substance use (5) a great deal of time spent is in activities necessary to obtain the substance, use the substance, or recover from its effects (6) important social, occupational or recreational activities are given up or reduced because of substance use (7) substance use is continued despite knowledge of having persistent or recurring physical or psychological problems that are likely to have been caused or exacerbated by the substance

30 DSM IV Criteria for Substance AbuseA. Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring within a 12-month period: (1) Recurrent substance use resulting in failure to fulfill major role obligations at work, school, or home (2) Recurrent substance use in situations in which it is physically hazardous (3) Recurrent substance-related legal problems (4) Continuing substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance B. The symptoms have never met the criteria for substance dependence for this class of substance.

31 The DSM-5 Changes from DSM-IV Use of the term “addiction”No longer diagnoses of “abuse” or “dependence” The seven criteria from the DSM-IV for dependence and the four for abuse are collapsed into 11 criteria Substance-related legal problems (from abuse criteria) has been removed??? A new criteria of craving, strong desire or urge to use a substance has been added

32 Removal of “Legal Problems”Discrimination based on race and socioeconomic status Misuse of a DWI as equivalent to old “abuse” Geographic inequalities (crossing Colorado state line) A criterion that carried the least weight in making the diagnosis Con: For some, serves an SBIRT function, as early intervention May function as the impetus for treatment 54% of DUI offenders who received an abuse diagnosis under the DSM-IV will receive no diagnosis under the DSM-5 – what will this mean in terms of reoffending?

33 DSM-5 Criteria for Substance Use DisordersA maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by two (or more) of the following, occurring at any time in the same 12-month period: (1) tolerance (2) withdrawal (3) the substance taken in larger amounts or over a longer period of time than was intended (4) there is a persistent desire or unsuccessful attempts to cut down or control substance use (5) a great deal of time spent is in activities necessary to obtain the substance, use the substance, or recover from its effects

34 DSM-5 Criteria for Substance Use Disorders (con’t.)(6) important social, occupational or recreational activities are given up or reduced because of substance use (7) substance use is continued despite knowledge of having persistent or recurring physical or psychological problems that are likely to have been caused or exacerbated by the substance (8) recurrent substance use resulting in failure to fulfill major role obligations at work, school, or home (9) Recurrent substance use in situations in which it is physically hazardous (10) craving (11) continuing substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

35 Changes in the DSM–5 Diagnostic Criteria for Substance Use DisordersChanges from DSM-IV Meeting 0-1 of the 11 criteria results in no diagnosis Meeting 2-3 criteria qualifies as Mild (akin to old “abuse”) Meeting 4-5 criteria qualifies as Moderate (akin to old “abuse” or “dependence”) Meeting 6 or more qualifies as Severe (akin to old “dependence”) See Appendix for documentation form

36 The Issue of Criteria “Weight”All of 11 criteria weighted equally in the DSM However, some provide a greater contribution to severity than simply numbers Criteria most likely to be associated with Moderate or Severe categories Withdrawal Rule setting Time spent using Role fulfillment Compulsion Preoccupation

37 ALCOHOL DSM-5 CRITERIA All criteria are not equal in implicationsSome criteria are found almost exclusively among those in the severe alcohol use disorder designation Other criteria are more common among the mild to moderate alcohol use disorder group Tolerance and dangerous use are actually common among those with no diagnosis

38 The SUD Criteria Found Primarily in the Severe DesignationThe “Big Five” Wanting to cut down/unable to do so Craving with compulsion to use Sacrifice activities to use Failure at role fulfillment due to use Withdrawal symptoms

39 ALCOHOL CRITERIA PREVALENT IN MILD & MODERATE GROUPSUnplanned use Time spent using Medical/psych. consequences of use Use where impairment is dangerous Interpersonal conflicts Legal problems, and use to relieve emotional distress similar in distribution to those above

40 SAMPLE HYPOTHESES Hypothesis #1: Clients positive on three or more of the “big five” (withdrawal, rule setting, sacrificing activities, role fulfillment failure, and craving/compulsion to use) will find recovery more difficult (e.g., higher relapse rates) Hypothesis #2: Clients in mild or moderate designations without any positive findings on the “big five” may be able to moderate use

41 CLINICAL IMPLICATIONSMost of those in the “mild” designation can probably benefit from moderation and related harm reduction strategies (outpatient placement) Those in the “severe” designation will require more intensive and extended services where abstinence is essential to recovery (residential/inpatient or structured outpatient, IOP or PHP placement depending on the ASAM severity profile) The “moderate” group may contain cases that fit the mild or severe characteristics (placement dependent on the results of the ASAM severity profile)

42 ASAM Corollary The assessment of severity (and placement) is not determined by simply adding up the number of ASAM dimensions that are assessed as severe For example, high severity is Dimensions 1, 2 and 3 is more concerning than high severity is Dimension 4 or 6 High severity is any of the first three dimensions may require an immediate response by itself

43 Can this help explain: Why some patients seem to have more difficulty maintaining abstinence and have more extensive relapse histories? Why some “alcoholics” seem to be able to return to non-problem drinking?

44 What Does This Mean in Terms of Treatment Planning?

45 Abuse vs. Dependence We tend to think of substance dependence as addiction but not so with abuse There is a difference between the old abuse and the old dependence in terms of permanence

46 The Issue of Criteria “Weight”However, all of 11 criteria are weighted equally in the DSM – 5 (as they were in the DSM-IV) But some criteria provide greater contribution to severity others A problem with simply tallying up the number of criteria met

47 Characteristics of AddictionCompulsion Loss of control Continued use in spite of negative consequences Craving

48 Moderate Use/Harm ReductionSome people, particularly who have mild severity, are not addicted in the usual sense Some DUI offenders Treatment plan goals might be other than abstinence

49 The Conundrums Alcoholism/addiction is a chronic, relapsing brain disease Alcoholism is an insidious, progressive, incurable and fatal disease and if the person doesn’t stop drinking, they will end up either dead or institutionalized Some alcoholics are able to go back to “social” (non-problem) drinking

50 Original Medical Diagnosis of AlcoholismYou drank more than your doctor!

51 “Alcoholism/Alcoholic”Important terms for some purposes Neither diagnostic nor precise In common use incorporates: Dependence/addiction Abuse (pouring water into good scotch) Misuse (using Beefeater gin in a gin & tonic) Heavy drinker (weighing 250 pounds or more) Problem drinking (spilling more than you drink) The range of severities is from any use to a severe alcohol use disorder

52 Rethinking the Continuum of Substance UseFOUR PHASE RISK MODEL A New Way of Conceptualizing Substance Use

53 Phases of Substance UseCharacteristics Outcomes Response Phase 1 DSM-5 Severity Level 0-1 “Orphan” (no dx) Low Risk Choices No significant increase in tolerance Do not use illegal drugs Use medications only as prescribed Use results in no problems Continue to make low risk choices

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55 Phases of Substance UseCharacteristics Outcomes Response Phase 2 DSM-5 Severity Level 2-3 – Mild –old “abuse” (none of the “Big 5) Makes high risk choices Drinks high risks amounts May develop social dependence State dependent learning begins Abstract thinking skills may become impaired, e.g., illicit drug use Beginning problems Return to Phase 1 to make low risk choices

56 Phases of Substance UseCharacteristics Outcomes Response Phase 3 DSM-5 Severity Level 4-5 Moderate – old “abuse” or “depend-ence” (< 3 of the “Big 5) Development of psychological dependence Substance use more integrated into life State dependent learning High risk choices become more important than relationships Defense of choices Substance-related health or impairment problems Blackouts Drinking to cure hangovers Continued use likely to lead to Phase 4 Return to low-risk drinking choices MAY still be possible May require outside help to change choices 50% are able to return to low-risk choices unless meet 3 or > of the “Big Five”

57 Phases of Substance UseCharacteristics Outcomes Response Phase 4 DSM-5 Severity Level 6+ Severe – old “depend-ence” (3 or > of the “Big 5) Physical addiction Withdrawal Loss of control Tolerance continues to increase Like AA “invisible line” More negative, more severe outcomes than in Phase 3 Drinking to manage withdrawal Possible imprisonment or death Return to low-risk choices no longer possible Requires abstinence Usually requires outside help

58 Five Axis Diagnostic StructureGoes away for purposes of diagnosis Replaced with list of diagnoses Recommendation #1: Keep the 5 Axis system “in your head” as a way of organizing your assessment Recommendation #2: “Continue using Axes III, IV and V for purposes of informing the assessment and treatment planning”

59 Axis IV: Psychosocial Stressors and Environmental Problems & Dimensions 5 & 6Problems related to the social environment — e.g., death or loss of friend; inadequate social support; living alone; difficulty with acculturation; discrimination; adjustment to lifestyle transition (such as retirement); social support system made up of other substance using, abusing or selling people; living with an active addict; living with a dealer; rampant drug use/sale in neighborhood; rampant drug use/sale at work site/school; pressure to use substances by peers; employer not supportive of recovery efforts

60 Axis IV: Psychosocial Stressors*problems related to the social environment death or loss of friend ___ inadequate social support ___ living alone ___ difficulty with acculturation ___ discrimination ___ adjustment to lifestyle transition (such as retirement) ___ social support system made up of other substance using, abusing or selling people ___ living with an active addict ___ living with a dealer ___ rampant drug use/sale in neighborhood ___ pressure to use substances by peers ___ employer not supportive of recovery efforts ___ * See appendix

61 DSM-IV, Axis IV This allows us to begin a treatment plan immediately after the comprehensive assessment is completed This constitutes and initial relapse prevention plan

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63 ASAM Criteria Assessment

64 Dimensional Criteria AssessmentDimension 1: Acute Intoxication/Withdrawal Potential Dimension 2: Biomedical Conditions & Complications Dimension 3: Emotional/Behavioral/Cognitive Conditions & Complications Dimension 4: Readiness to Change Dimension 5: Relapse/Continued Use/Continued Problem Potential Dimension 6: Recovery Environment

65 Severity & the Treatment PlanUse the results of the ASAM assessment to construct a severity profile Use the risk ratings on the severity to determine which dimensional issues become part of the treatment plan. Risk Ratings 0 & 1: Nothing needs to be done on the treatment plan at this time Risk Ratings 2: Monitoring is called for Risk Ratings 3 & 4: Move to the treatment plan An exception is Dimension 4 where motivational enhancement is always appropriate

66 No immediate services neededRisk Rating Intensity of Service Needed Dimensions 1. 2. 3. 4. 6. (0) No Risk or Stable: Current risk absent, any acute or chronic problem mostly stabilized. No immediate services needed (1) Mild: Minimal, current difficulty or impairment. Minimal or mild signs or symptoms. Any acute or chronic problems soon able to be stabilized and functioning restored with minimal difficulty Low intensity of services needed for this Dimension. Treat strategies usually able to be delivered in outpatient settings. (2) Moderate: Moderate difficulty or impairment. Some difficulty coping or understanding, but able to function with clinical and other support services and assistance. Moderate intensity of services, skills training, or supports needed for this level of risk. Treatment strategies may require intensive levels of outpatient care (3) Significant: Serious difficulties or impairment. Substantial difficulty coping or understanding and being able to function even with clinical support Moderately high intensity of services, skills training and supports needed. May be in or near imminent danger. (4) Severe: Severe difficulty or impairment. Serious, gross or persistent signs and symptoms. Very poor ability to tolerate and cope with problems. Is in imminent danger. High intensity of services, skills training and supports needed. More immediate, urgent services may require inpatient or residential settings; or closely monitored case management services at a frequency greater then daily.

67 ASAM Criteria Dimension 1: Detoxification/Withdrawal PotentialSample Questions What risk is associated with patient’s current level of acute intoxication? Is there serious risk of severe withdrawal symptoms or seizures based on the patients previous withdrawal history, amount, frequency, and recency of discontinuation or significant reduction of alcohol or other drugs?

68 ASAM Criteria Dimension 1: Detoxification/Withdrawal PotentialSample Questions (con’t.) Are there current signs of withdrawal? Does the patient have supports to assist in ambulatory detoxification if medically safe? Has the patient been using multiple substances in the same drug class? If the withdrawal concern is about alcohol, what is the patient’s CIWA-Ar score?

69 THE BEST PREDICATOR OF CURRENT AND FUTURE WITHDRAWAL PROBLEMS ARE PAST WITHDRAWAL PROBLEMS

70 Drug and Alcohol HistoryDrug Route of First First Amount Frequency Last Tolerance Name Administration Use Problem Use Drug of Choice: ________Longest Abstinence: _______When: _____Circumstances:__________________

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72 Addiction Research Foundation Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) * NAUSEA AND VOMITING: Ask: “Do you feel sick to your stomach? Have you vomited? Observation 0 No Nausea and no vomiting 1 Mild Nausea with no vomiting 2 3 4 Intermittent nausea with dry heaves 5 6 7 Constant nausea, frequent dry heaves and vomiting * See appendix TREMOR: Arms extended and fingers spread apart. Observation 0 No tremor 1 Not visible but can be felt fingertip to fingertip 2 3 4 Moderate, with patient’s arm extended 5 6 7 Severe, even with arms not extended

73 Treatment Planning Implications for CIWA-Ar0-7: No problem or mild severity of withdrawal from alcohol 8-15: Moderate severity of withdrawal from alcohol 16 or >: Severe withdrawal from alcohol Maximum Score: 67

74 ASAM Criteria Dimension 2: Biomedical Conditions and ComplicationsSample Questions Are there current physical illnesses other than withdrawal, that need to be addressed or which complicate treatment? Are there chronic illnesses which might be exacerbated by withdrawal, e.g., diabetes, hypertension?

75 ASAM Criteria Dimension 2: Biomedical Conditions and Complications (Con’t.)Sample Questions Is there a need for medical services which might interfere with treatment (e.g., chemotherapy or kidney dialysis)? Are there chronic conditions which might interfere with treatment (e.g., chronic pain with narcotic analgesics)?

76 Two Types of Medical Conditions and ComplicationsConditions which place the patient at Risk (e.g., esophageal varices, chronic pain) Conditions which interfere with treatment (e.g., the need for kidney dialysis, chronic pain)

77 Dimension 2 & Chronic PainThe most frequent cause of chronic pain in older adults is arthritis Addiction to opioid analgesics, (e.g., hydrocodone, oxycodone/oxycontin, methadone) is now more common than addiction to heroin The source of most diverted methadone comes from pain management providers, not methadone clinics The probability for an individual with a true chronic pain problem and NO history of abuse or dependence on any substance to become addicted to an opioid is about 5% A common cause of relapse is chronic pain

78 ASAM Criteria Dimension 3: Emotional/Behavioral/Cognitive Conditions and ComplicationsSample Questions Are there current psychiatric illness or psychological, behavioral or emotional problems that need to be addressed or which complicate treatment? Are there chronic conditions that affect treatment? Do any emotional/behavioral problems appear to be an expected part of addiction illness or do they appear to be separate?

79 ASAM Criteria Dimension 3: Emotional/Behavioral/Cognitive Conditions and Complications (Con’t.)Sample Questions Even if connected to addiction, are they severe enough to warrant specific mental health treatment? Is the patient suicidal, and if so, what is the lethality? If the patient has been prescribed psychiatric medications is he/she compliant?

80 Because of the incidence of co-occurring mental health problems, a great deal of attention must be paid to Dimension 3, Emotional/Behavioral/Cognitive Conditions & Complications

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84 Comorbidity Rates in Alcohol Disorder SamplesECA: Epidemiologic Catchment Area

85 TODAY, EVERY PROGRAM TREATS PATIENTS & CLIENTS WHO ARE DUALLY DIAGNOSED BUT HOW MANY ARE TREATING BOTH THE ADDICTION AND THE PSYCHIATRIC COMORBIDITY?

86 Co-Occurring Disorders Are An Expectation, Not An Exception and Treating one disorder without the order will become an exercise in futility

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88 Co-Occurring DisordersDoes your treatment plan include specific problems. goals and objectives for any co-occurring disorder?

89 TYPES OF PSYCHIATRIC COMBORBIDITY AND IMPLICATIONS FOR TREATMENT PLANNINGAffective Disorders Major Depression

90 Most Effective Treatment for Major Depressive DisorderThe combination of: Psychotherapy, particularly cognitive behavioral therapy (CBT) PLUS Antidepressant medication

91 Time for Anti-Depressant Medications to Work6 to 8 weeks minimum To find the correct drug in the correct dose may take up to 6 months Complicated by who prescribes (PCPs) Antidepressant drugs now the most commonly prescribed class of drug in the U.S. (1 in 10 people) Work best for very severe cases of depression and have little or no benefit over placebo (inactive pills) in less serious cases

92 TYPES OF PSYCHIATRIC COMBORBIDITY AND IMPLICATIONS FOR TREATMENT PLANNINGAffective Disorders Major Depression Bipolar Disorder

93 Bipolar Disorder and Alcohol ProblemsWomen with bipolar disorder are SEVEN times more likely to have alcohol problems than women without Men with bipolar disorder are FOUR times more likely to have alcohol problems than men without

94 TYPES OF PSYCHIATRIC COMBORBIDITY AND IMPLICATIONS FOR TREATMENT PLANNINGAffective Disorders Major Depression Bipolar Disorder Schizophrenic Disorders

95 RATE OF LIFETIME SUBSTANCE USE DISORDERIn the General Population: % For Persons With Schizophrenia: %

96 TYPES OF PSYCHIATRIC COMBORBIDITY AND IMPLICATIONS FOR TREATMENT PLANNINGAffective Disorders Major Depression Bipolar Disorder Schizophrenic Disorders Antisocial Personality Disorder

97 Co-Occurring MH Problems in a Corrections PopulationEstimates range from 70 – 85% with mood disorders and antisocial personality disorders being common The corrections system houses more persons with mental illness that all the other systems combined yet provides little treatment

98 Co-Occurring MH Problems in OTP PatientsThe prevalence of psychiatric disorder is up to 10 times higher in the population on methadone maintenance than in the general population. The prevalence of psychiatric disorder in the population on methadone maintenance is two to three times higher than that found in community surveys of those with a substance-use disorder.

99 TYPES OF PSYCHIATRIC COMBORBIDITY AND IMPLICATIONS FOR TREATMENT PLANNINGAffective Disorders Major Depression Bipolar Disorder Schizophrenic Disorders Antisocial Personality Disorder Borderline Personality Disorder Attention Deficit/Hyperactivity Disorder

100 ATTENTION DEFICIT/HYPERACTIVITYDISORDER (ADHD)Incidence in the General Population is % Incidence in a Cocaine Using Population is %

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103 ADHD & Adults People do not outgrow ADHD*Undiagnosed ADHD is a frequent reason for staff-initiated non-routine discharge (treatment noncompliance, not completing assignments) If your client has ADHD and a substance use disorder, what is the plan for the ADHD? See Appendix for Adult ADHD Screen

104 Posttraumatic Stress DisorderIncidence of lifetime diagnosis of Alcohol Abuse/Dependence is: % Incidence of lifetime diagnosis of Drug Abuse/Dependence is: %

105 TYPES OF PSYCHIATRIC COMBORBIDITY AND IMPLICATIONS FOR TREATMENT PLANNINGAnxiety Disorder Eating Disorders Pathological Gambling Compulsive Sexual Disorders Mental Retardation now “Intellectual Disability”

106 The Existence of a Psychiatric Diagnosis Alone Psychiatric FunctioningDoes Not Translate to a Treatment Plan Problem Without an Assessment Of Level of Psychiatric Functioning

107 To assess progress/outcome for MH and AOD disorders, look at reduction in:intensity/severity of symptoms frequency of symptoms duration of symptoms

108 Subthreshold and Transitory Mental Health Problems

109 Mental Heath Problem and Mental Health DisordersMental health problems exist on a continuum which includes sub-diagnostic threshold symptoms and traits Even a mental health problem that does not meet diagnostic criteria may need to be on the tx. plan At some point there are enough symptoms and traits to meet diagnostic criteria In common use, “mental health problems” includes both sub-threshold and diagnosable problems Generally, the more criteria an individual meets beyond what is necessary to meet the diagnosis, the more severe the problem.

110 Mental Health Disorders vs. Mental Health ProblemsAnger management problems that do not meet criteria for Antisocial Personality, Oppositional Defiant or Intermittent Explosive Disorder

111 “IMMINENT DANGER” DefinedA strong probability that certain behaviors will occur (e.g., continued alcohol or drug use or relapse or non-compliance with psychiatric medications) The likelihood that these behaviors will present a significant risk of serious adverse consequences to the individual and/or others (as in a consistent pattern of driving while intoxicated) The likelihood that such adverse events will occur in the very near future In order to constitute “imminent danger,” ALL THREE ELEMENTS must be present

112 ASAM Criteria, Dimension 4: Readiness to ChangeSample Questions Does the patient feel coerced into treatment or actively object to receiving treatment? How ready is the patient to change (stage of “readiness to change”)? If willing to accept treatment, how strongly does the patient disagree with others’ perception that s/he has an addiction problem? Is the patient compliant to avoid a negative consequence (externally motivated) or internally distressed in a self-motivated way about his/her alcohol or other drug use problems? Is there leverage available?

113 “Resistance Ambivalencein Drag”

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116 Higher Resistance and Denial Do Not ALONE Indicate the Need for, or Clinical Appropriateness Of A Higher Intensity Level of Treatment

117 RESISTANCE & NON-C0MPLIANCEAre characteristic of all chronic illnesses/disorders, not only substance use disorders!!

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119 Administrative (e.g., Therapeutic”) DischargeThe most common reasons why alcohol and drug patients are prematurely discharged from treatment are the same reasons why they were admitted! The problem is: You can’t treat a patient who is not in treatment to be treated!

120 But Only If the Client Is In TreatmentTreatment Works! But Only If the Client Is In Treatment

121 Transtheoretical Stages of Change (Prochaska & DiClemente)Pre-contemplation Contemplation Preparation Action Maintenance Relapse and Recycling Termination

122 When you and your client are creating treatment plan, consider identifying the client’s readiness to change for each problem

123 Stage Model of the Process of ChangePermanent Exit Relapse Maintenance Enter Here Action Precontemplation Preparation Contemplation Temporary Exit Prochaska and DiClemente

124 PRE-CONTEMPLATION Not yet considering the possibility of change although others are aware of the problem Active resistance to change Seldom appear or treatment without coercion Could benefit from non-threatening information and strategies to raise awareness of a possible “problem” and the possibilities for change

125 CONTEMPLATION Ambivalent, undecided, vacillating between whether he/she really has a “problem” or needs to change Wants to change, but this desire exists simultaneously with resistance to it May seek professional advice to get an objective assessment Motivational strategies useful at this stage, but aggressive or premature confrontation provokes strong resistance and defensive behaviors Many Contemplators have indefinite plans to take action in the next six months

126 PREPARATION Takes person from decisions made in Contemplation stage to the specific steps to be taken to solve the problem in the Action stage Increasing confidence in the decision to change Performs certain tasks that make up the first steps on the road to Action Most people planning to take action within the very next month Making final adjustments before they begin to change their behavior.

127 ACTION Specific actions intended to bring about changeOvert modification of behavior and surroundings Most busy stage of change requiring the greatest commitment of time and energy Care not to equate action with actual change, or activity with action Support and encouragement still very important to prevent drop out and regression in readiness to change.

128 MAINTENANCE Sustain the changes accomplished by previous action and prevent relapse Requires different set of skills than were needed to initiate change Consolidation of gains attained Not a static stage and lasts as little as six months or up to a lifetime Learn alternative coping and problem-solving strategies Replace problem behaviors with new, healthy life-style Work through emotional triggers of relapse.

129 RELAPSE AND RECYCLING Likely, but not inevitable setbacksAvoid becoming stuck, discouraged, or demoralized Learn from relapse before committing to a new cycle of action Comprehensive, multidimensional assessment to explore all reasons for relapse.

130 TERMINATION This stage is the ultimate goal for all changersPerson exits the cycle of change, without fear of relapse Debate over whether certain problems can be terminated or merely kept in remission through maintenance strategies

131 Stages of Change and Therapists’ TasksCLIENT STAGE THERAPIST’S MOTIVATIONAL TASKS Precontemplation Raise doubt – increase the client’s perception of risk and problems with current behavior Contemplation Tip the balance – evoke reasons to change, risks of not changing: strengthen the client’s self-efficacy for change of current behavior Preparation Help the client to determine the best course of action to take in seeking change Action Help the client to takes steps toward change Maintenance Help the client identify and use strategies to prevent relapse Relapse Help the client renew the process of contemplation, preparation and action, without becoming stuck or demoralized because of relapse

132 EVERY patient who presents for assessment or treatment is motivated!

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134 Sample Questions for, Dimension Criteria 5: Relapse/Continued Use/Continued Problem PotentialHow aware is the patient of relapse triggers, ways to cope with cravings and skills to control impulses to use? What is the patient’s ability to remain abstinent or psychiatrically stable based on history? What is the patient’s level of current craving and how successfully can they resist using? See Appendix for “Urge to Drink Scale”

135 Sample Questions for ASAM Criteria, Dimension 5: Relapse/Continued Use/Continued Problem Potential (Con’t.) If on psychiatric medications, is the patient adherent? If the patient had another chronic disorder (e.g., diabetes), what is the history of adherence with treatment for that disorder? Is the patient in immediate danger of continued severe distress and drinking/drugging or other high risk behavior due to co-occurring mental health problems?

136 Sample Questions for ASAM Criteria, Dimension 5: Relapse/Continued Use/Continued Problem Potential (Con’t.) Does the patient have any recognition and skills to cope with addiction and/or mental health problems and prevent relapse or continued use/continued problems? What severity of problems and further distress will potentially continue or reappear, if the patient is not successfully engaged into treatment at this time?

137 Description of a RelapseA return to the use of psychoactive substances after a period of at least _____(?) months of abstinence/recovery, in an individual who has completed a course of inpatient or outpatient treatment or has had extensive recovery group experience, as a result of which that patient/client has made and internalized certain changes in functioning, which had allowed the patient to cope without resorting to the use of psychoactive substances in the interim period

138 Notes to Relapse It is assumed that the relapse process begins long before that actual substance use RELAPSE implies that the patient acquired and internalized certain coping skills and strategies and then something happened which brought about a return to the active addiction CONTINUED USE is just that (“You can’t fall off the wagon if you never got on it!”)

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140 Using the Continuous Assessment Model for Assessment of RelapsePATIENT ASSESSMENT PROGRESS PLAN PRIORITIES Data from all BIOPSYCHOSOCIAL Dimensions BIOPSYCHOSOCIAL Treatment Intensity of Service (IS) - Modalities and Levels of Service BIOPSYCHOSOCIAL Severity (SI) and level of Functioning (LOF)

141 For some Patients/Clientsthe issue is “Habilitation” rather than “Rehabilitation”

142 Sample Questions for ASAM Criteria, Dimension 6: Recovery EnvironmentAre there any dangerous family, significant others, living or school working situations threatening treatment engagement and success? Does the patient have supportive friendship, financial or educational/vocational resources to improve the likelihood of successful treatment?

143 Sample Questions for ASAM Criteria, Dimension 6: Recovery Environment (Con’t.)Are there barriers to access to treatment such as transportation or child care responsibilities? Are there legal, vocational, social service agency or criminal justice mandates that may enhance motivation for engagement into treatment? Is the patient able to see value in recovery?

144 Some of the Most Important Items On a Treatment Plan ARE NOT TREATMENT!

145 Demographic Predictors of Poor Treatment OutcomeUnder 25 years of age Never married or having lived as married Unemployed No high school diploma or GED

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147 for a Level III Placement!HOMELESSNESS alone is NOT sufficient reason for a Level III Placement!

148 Why Psychosocial Treatments Alone Are Limited in Effectiveness

149 In treatment planning, for alcohol dependence, consideration should always be given to anti-addiction medications along with psychosocial treatment Disulfiram (“Antabuse”) Acamprosate (“Campral”) Naltrexone (“Revia” & “Depade”) Sustained release injectable naltrexone (“Vivitrol”)

150 In treatment planning, for opioid dependence, consideration should be given to anti-addiction medications along with psychosocial treatment Methadone Suboxone (buprenorphine + naloxone) Subutex (buprenorphine) Sustained release injectable naltrexone (“Vivitrol”)

151 It is more important to understand the person who has the disease, than the disease the person has.

152 Treatment Planning

153 ”the Hallmark of Quality Treatment is the Management of Care”CARE SHOULD BE MANAGED …..in fact…… ”the Hallmark of Quality Treatment is the Management of Care”

154 How Can We Manage The Patient’s Care?Patient care is managed through the: Development of a behavioral and measurable treatment plan Treatment plan updates in which the management of care continues Progress notes which reflect the patient’s progress toward treatment goals and objectives

155 Exercise to Determine Appropriateness of Individual Treatment Plan Pre-Training Exercise “George” Assessment Information

156 Date of Assessment: February 25, 2013 Demographic Data: George is a 34 year old, white, male, who is employed as a nuclear power plant electrician. He is married (x 2) and has one child, a daughter age 6. He lives with his family. Presenting Problem and Information: George was arrested for a DUI four days ago and referred for assessment by his EAP at work. At the time of his arrest his BAC was .11gms% alcohol. There are no other alcohol connected incidents before he began his employment or since.

157 “George” (Con’t.) At the time of this assessment, George’s BAC is 0.0 gms% alcohol and his CIWA-Ar score is 0. He claims his last drink was four days ago (in preparation for the assessment). His drinking pattern is 1-3 drinks/day, in the evening, 3-4 times a week. Occasionally he drinks more than his usual 1-3 drinks. He does not believe he has any type of problem with alcohol and was just “unlucky” to be caught drinking and driving. He did not think he has that much to drink. George claims that remaining abstinent presents no problem for him. He disclaims any drinking “triggers.” ...“When I feel like drinking, I drink and when I don’t want to, I don’t drink.” He has gone for a week at a time without drinking.

158 “George” (Con’t.) George has no medical problems of significance but states that he has “allergies” and sinus problems. He has never seen a doctor about them. He describes his childhood as “O.K.” but states that he was a “nervous kid” and had few friends, usually no more than one at a time, because he felt that most of his peers did not like him. A review of his current functioning in this area indicates that he goes through periods of heightened anxiety, particularly associated with his performance, the most recent example being his performance review which was very good but not perfect. He also states that he has recently had occasional erectile difficulties with his wife.

159 “George” (Con’t.) His wife is generally supportive of him and would like him to stop drinking. She herself is a very infrequent drinker who may have one mixed drink at a social function three or four times a year. Diagnostic assessment indicates that George meets only one criterion for an alcohol use disorder

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161 “George” (Con’t.) Date of Second Assessment: March 6, 2013George was referred back to the program for assessment after he was stopped at 10:00 P.M. yesterday for his second DUI. Reassessment revealed additional information. George was sent by his mother to a pastoral counselor when he was 16 years old because of “nerves.” He saw the counselor but discontinued treatment after four sessions when the counselor suggested George arrange for an alcohol assessment. A year later he went back, again at his mother’s urging, but the issue of an alcohol assessment came up again and George once more left and never returned to the counselor. He enlisted in the Navy after graduating high school and was discharged honorably four years later.

162 “George” (Con’t.) While the pattern of drinking George provided was not different from that in the initial assessment, he now spoke about using over-the-counter (OTC) drugs including antihistamines, NyQuil, Robitussin DM and Vicks 44. He recognizes that he uses these OTC drugs and drinks at least in part to medicate his anxiety and he sees that as a problem. He says he now thinks that he may need help with his drinking. He complains about insomnia, occasional nausea and more frequent erectile difficulties than he previously claimed. He obsesses about his career opportunities and now is beside himself about the two DUIs. He reports to a supervisor who George thinks does not like him and doesn’t think he does a good job, in spite of the fact that his last two performance evaluations were good, but not perfect.

163 “George” (Con’t.) His pattern of drinking is to drink at home about half the time and with his only friend at a neighborhood bar on the other occasions. His periods of a week at a time of not drinking have been precipitated by his wife’s unhappiness with his drinking. She blames their sexual difficulties on his drinking (with which he disagrees), thinks it gets in the way of their relationship and generally likes him better when he his not drinking. His first DUI followed an argument with his wife about his drinking.

164 ASAM DIMENSION SEVERITY WORKSHEETRisk Rating (0) No Problem (1) Mild (2) Moderate (3) Significant (4) Severe Dimension 1: Acute Intoxication and /or Withdrawal Potential X Dimension 2: Biomedical Conditions & Complications Dimension 3: Emotional, Behavioral, Cognitive Conditions & Complications Dimension 4: Readiness to Change Dimension 5: Relapse, Continued Use, Continued Problem Potential Dimension 6: Recovery Environment

165 CRITIQUE of George’s Treatment Plan

166 Geo. has potential for severe withdrawal Safe withdrawal Date Ident. Tgt Date Rev Dim. # Problem Statement Goals Objectives 1. Geo. has potential for severe withdrawal Safe withdrawal from all substances 1. Help pt. feel better 2. Help pt. achieve a BAC of 0.0 2. Pt. suffers from insomnia Assist pt. to achieve adequate sleeping pattern 1. Refer pt. to sleep disorder clinic 2. Have pt. monitor his sleeping patterns

167 Date Ident. Tgt Date Dim. # Problem Statement Goals ObjectivesRev Dim. # Problem Statement Goals Objectives 3. Pt reports anxiety which may be associated with his drinking and erectile difficulties Relieve anxiety symptoms 1. Refer for med. assessment for anxiolytic 2. Pt. to keep a chart of periods of anxiety 3. Pt. to keep a erectile difficulty Self-esteem Pt. to believe in himself 1. Pt. to keep a daily journal 2. Give pt. Satir’s “Self Esteem” to read

168 Date Ident. Tgt Date Dim. # Problem Statement Goals ObjectivesRev Dim. # Problem Statement Goals Objectives 4. Pt. Is resistant to accepting that he has a problem with alcohol Acceptance 1. Confront pt. re: his 2 DUIs 2. Have pt. review relationship between his periods of drinking and erectile difficulties 5. Pt. only came in for assessment because of his DUIs Achieve & maintain permanent sobriety (“one day at a time”) 1. Broaden positive social support system 2. Go to AA at least 5X/wk. 3. Have a counseling sessions with pt.’s supervisor

169 Only friend drinks in bar with pt. Find a non-drinking friend Date Ident. Tgt Date Rev Dim. # Problem Statement Goals Objectives 6. Only friend drinks in bar with pt. Find a non-drinking friend 1. Go to AA 2. Do volunteer work in the community

170 WHAT? WHY? WHEN? HOW? WITH WHOM? of Treatment Planning

171 WHAT is Treatment Planning?Definition: A specific, prescribed written course of treatment developed by the clinician and the client to assist the client in movement from the “here and now” to the client’s desired outcomes. It is a dynamic document that can and must be updated to reflect any major change: 1. New problem identification 2. Previously identified problem definition 3. Goals 4. Objectives 5. Interventions

172 Problem Goal

173 WHAT is Treatment Planning?Goal: To assist the client in his/her journey to those outcomes

174 WHAT is Treatment Planning?Purposes: 1. Stipulate the issues that are a focus of the treatment process 2. Focus both the clinician and the client/patient on problem resolution (bring treatment plans to group?) 3. Provide the client, family and treatment team with a specific clinical direction for the client

175 WHAT is Treatment Planning?Purposes (Con’t.): 4. Provide a framework and means for measuring progress (progress notes need to reflect the treatment plan goals and objectives) 5. Provide a process which takes the identified problems and their priorities presented by the client to a plan of action to address those problems

176 WHAT is Treatment Planning?Purposes (Con’t.): 6. Provide a mechanism for revising the treatment plan (treatment plan updates) 7. Provide an added measure of protection against possible litigation

177 WHY do Treatment Planning?Facilitate the treatment process To enhance treatment retention To effectively achieve desired outcomes Provide a “road map” (treatment plan) for the client/patient which illustrates the course of “travel” (objectives, methodologies) from the current position (problem) to the desired “destination” (goals) and permits assessment of progress in “mile segments” (updates)

178 WHY do Treatment Planning? (Con’t.)To function as the “link” between assessment and treatment To monitor progress and modify treatment accordingly To enhance communication among clinical team members To access third party payment

179 WHY do Treatment Planning?To reduce liability exposure 1. Not identifying existing problems in the assessment 2. Not including problems identified in the assessment in the treatment plan 3. Decisions (e.g., administrative discharge, withholding treatment, etc.) not supported by the treatment plan.

180 WHY do Treatment Planning? (Con’t.)To enhance the overall addiction field by: 1. Providing truly individualized treatment 2. Avoiding “one size fits all” treatment To meet accrediting and licensing regulations BUT NOT MERELY to satisfy regulatory or accrediting agencies

181 WHEN to do Treatment Planning?Begins at the time of intake As soon as comprehensive, multidimensional assessment is completed (Axis IV of DSM-IV?) Revisions at planned, specified times, based on the intensity of service Revisions as a result of new problems or need for a change in interventions At the conclusion of the treatment episode (discharge plan)

182 When Writing Treatment PlansInclude all problems regardless of available agency services Include all problems whether deferred or addressed immediately Each ASAM Dimension should be reviewed A referral to outside resources is a valid approach to addressing a problem During active treatment After discharge

183 When Writing Treatment PlansNon-judgmental “Client is promiscuous” Avoid jargon statements: “Client is in denial” “Client is co-dependent” Use complete sentence structure

184 When of Revisions According to licensure requirementsAccording to the intensity of service When new problems are identified Whenever there is a significant occurrence (positive or negative) In preparation for discharge (“discharge plan”)

185 is NOT a discharge plan!)“Discharge Planning” is a form of treatment planning, NOT a discrete activity (90 meetings in 90 days is NOT a discharge plan!)

186 WITH Whom to do Treatment Planning?With the involvement and the investment of the client When appropriate, with family members/significant others With the treatment team

187 HOW to do Treatment PlanningHOW to do Treatment Planning? The Components/Requirements for an Effective Treatment Plan Be based on a comprehensive, individualized assessment Reflect the specific clinical needs, preferences and strengths of each client Specify the services to be provided by the program Specify the services to be provided by others Identify specific goals that are a response to the identified problems Contain objectives that relate to the goals Contain interventions (methodologies) to accomplish the objectives

188 The Process Starts with the Problem Statements

189 Program-Driven Problem Statements“Alcohol Use Disorder, Moderate” Not individualized Not precise Not a complete sentence Doesn’t provide enough information A diagnosis alone is not a problem statement

190 Problem Statement Based on information gathered during the assessmentA precisely constructed problem statement lead to a readily obvious goal to address the problem When not done precisely, treatment planning tends to fall apart at the beginning of the process

191 Problem Statement Examples“Frank is experiencing increased tolerance for alcohol as evidenced by the need for more alcohol to become intoxicated or achieve the desired effect and has been drinking daily for the last three months” “Mary is currently pregnant and requires assistance in obtaining prenatal care” “Al has a history of using cocaine to manage his ADHD symptoms”

192 HOW to do Treatment PlanningHOW to do Treatment Planning? The Components/Requirements for an Effective Treatment Plan Be behavioral Be achievable Be measurable Be time limited

193 HOW to do Treatment PlanningHOW to do Treatment Planning? The Components/Requirements for an Effective Treatment Plan Be understandable (NOT VAGUE) to: 1. The client 2. Other providers/clinicians 3. Payers Identify assigned staff Document anticipated and actual completion dates Identify needs beyond the scope of the program Be expressed in the words of the person being served

194 The “I Will” Treatment Plan ObjectiveWho is the “client will?” Who is “John/Mary will?”

195 TIP To determine whether your/your agency’s treatment plans are truly individualized, compare the contents of 10 closed clinical records to determine whether you can differentiate between patients by their treatment plans

196 GOAL Based on problem statementsReasonably achievable during this treatment episode A broad positive outcome to be achieved for resolution of the target problem Can be global and long term Not directly measurable Other terms: Long term goal

197 Program-Driven Goal Statements“Will refrain from all substance use now and in the future one day at a time” Not specific for the individual Not helpful in treatment planning Cannot be accomplished by program discharge

198 Goal Statement Examples“Frank will safely withdraw from alcohol. stabilize physically, and begin to establish a recovery program” “Mary will obtain the necessary prenatal care” “Al will acquire ways other than the use of cocaine to manage his ADHD symptoms

199 OBJECTIVE Do not combine different objectives in the same statement – measurement problems John (1) will attend two AA meetings this week, (2) obtain the names and phone numbers of two people he can call for support and (3) begin the process of finding a sponsor” Three different objectives

200 OBJECTIVE Other terms: Short term goalThe steps necessary to achieve the goal which must 1. be measurable and objective; 2. contain at least two for each problem; 3. be achievable; 4. have target dates assigned; 5. have interventions created; 6. have responsible staff person assigned Other terms: Short term goal

201 Program-Driven Objective Statement“Will participate in outpatient treatment” Not an objective but a method Not specific to the individual A level of care is not an objective

202 Examples of Objectives“Frank will report acute withdrawal symptoms and follow whatever withdrawal management procedures are prescribed” “Mary will visit an OB/GYN physician or clinic for prenatal care” “Al will list three times when his ADHD symptoms led to a return to his use of cocaine”

203 Treatment Plan Goals & ObjectivesThe “Johnny Test” for Goals & Objectives: If you cannot see Johnny doing it, it is a goal If you can see Johnny doing it, it is an objective

204 TIP The “Why Did I Choose? Test” for ObjectivesAlways ask yourself, “Why did I choose this Objective?” and often the answer to that question is the real objective. APPARENT Objective: Attend three AA meeting a week. ACTUAL Objective: Develop a positive, sober support system to obtain phone numbers of 3 AA members (a response to the problem of having only friends who abuse AOD) by attending three AA meeting a week (the intervention)

205 INTERVENTION Other terms:Clinician created methods to assist the client to achieve the objectives which: 1. must be accomplishable 2. must be reasonable 3. may be provide by program staff or others Other terms: Methods Strategies Steps Modalities. Actions Approaches

206 Program-Driven Intervention“Will see a counselor once a week and attend group on Monday nights for 12 weeks” This sounds specific but describes a program component rather then a specific intervention to achieve an objective

207 Example of Interventions“Medical staff will evaluate Frank’s withdrawal potential and prescribe a course of management based on that evaluation” “Mary’s case manager will set up and appointment for necessary medical services” “Staff will review Al’s list of three times when his ADHD symptoms led to a return to his use of cocaine and discuss alternatives to the use of cocaine”

208 Use The Stages Of Change Model To Engage The Patient In The Treatment Planning ProcessPre-contemplation Contemplation Preparation Action Maintenance Relapse and Recycling Termination

209 Stages of Change and Therapists’ TasksCLIENT STAGE THERAPIST’S MOTIVATIONAL TASKS Precontemplation Raise doubt – increase the client’s perception of risk and problems with current behavior Contemplation Tip the balance – evoke reasons to change, risks of not changing: strengthen the client’s self-efficacy for change of current behavior Preparation Help the client to determine the best course of action to take in seeking change Action Help the client to takes steps toward change Maintenance Help the client identify and use strategies to prevent relapse Relapse Help the client renew the process of contemplation, preparation and action, without becoming stuck or demoralized because of relapse

210 The Problem of Imprecise Problem DefinitionImprecise: Family problems Precise: The client’s family does not support his attempts to get help with his alcohol and drug problems as evidenced by their refusal to be involved with the family component and recommending to him that he leave treatment

211 THE PROCESS OF CREATING THE TREATMENT PLANIntervention creation 1. At least one intervention per objective 2. Responsible staff person 3. Time frames TIP If the client does not accomplish the objective after the initial intervention: New Interventions Should Be Added to the Plan

212 THE PROCESS OF CREATING THE TREATMENT PLANDifferences between: client objectives and clinician responsibilities (“interventions”)

213 Now What Do We Do? The patient has been diagnosed with “Alcohol Use Disorder, Severe” The patient’s treatment plan goal is to drink with control

214 Treatment Plan for Ann

215 The Three H’s of AssessmentHistory Here and Now How comfortable/uncomfortable are you?

216 “Ann” DSM IV Diagnoses:“Ann” DSM IV Diagnoses: Alcohol Use Disorder, Severe; Cannabis Disorder, Mild; Major Depressive Disorder, Moderate, In Full Remission Ann, a 32 year old white, divorced female, came in for assessment for the first time ever. She has been abstinent for 48 hours from alcohol and reports that she has remained so for up to 72 hours during the past three months. When she has done this she states she has experienced sweats, internal tremors and nausea, but has never hallucinated, experienced D.T.’s or seizures.

217 She states she is in good health except for alcoholic hepatitis for which she was just released from the hospital one week ago. Her doctor referred her for assessment. She smokes up to 2 or 3 joints a day, but stopped yesterday. In addition to the above, Ann describes two past suicide attempts using sleeping pills, but the most recent attempt was three years ago and she sees a psychiatrist once a month for review of her medication. She takes Prozac for the depression and reports taking her medication as prescribed.

218 Ann reported that she lives in a rented apartment and has very few friends since moving away after her divorce a year ago. She is currently unemployed after being laid off when the department store she worked at closed. She has worked as a waitress, check-out person and sales person before and says she has never lost a job due to addiction.

219 Ann appears slightly anxious, but is not flushedAnn appears slightly anxious, but is not flushed. She speaks calmly and is cooperative. Ann shows awareness of her consequences from chemical use, but tends to minimize it and blame others including her ex-husband who left her without warning. She doesn’t know much about alcoholism/chemical dependency, but wants to learn more. She has one son, age 11, who doesn’t see any problems with her drinking and doesn’t know about her marijuana use.

220 ASAM DIMENSION SEVERITY WORKSHEETRisk Rating (0) No Problem (1) Mild (2) Moderate (3) Significant (4) Severe Dimension 1: Acute Intoxication and /or Withdrawal Potential Dimension 2: Biomedical Conditions & Complications Dimension 3: Emotional, Behavioral, Cognitive Conditions & Complications Dimension 4: Readiness to Change Dimension 5: Relapse, Continued Use, Continued Problem Potential Dimension 6: Recovery Environment

221 Severity & the Treatment PlanUse the results of the ASAM assessment to construct a severity profile Use the risk ratings on the severity to determine which dimensional issues become part of the treatment plan. Risk Ratings 0 & 1: Nothing needs to be done on the treatment plan at this time Risk Ratings 2: Monitoring is called for Risk Ratings 3 & 4: Move to the treatment plan An exception is Dimension 4 where motivational enhancement is always appropriate

222 TREATMENT PLAN FOR ANN Problem Statement Goals ObjectivesInterventions

223 Placement for Ann

224 Ann – Four Months Later At a follow-up visit four months later, Ann reports that she has been abstinent from alcohol for almost four months. She has transitioned well to less intensive levels of outpatient care, has been discharged from a Level I program, and is attending self-help group meetings two to three times a week. She has not used marijuana for the past two weeks. Her liver function test results are within normal limits.

225 Ann – Four Months Later However, Ann discloses that her sister, from whom she had been estranged, died recently, before they could reestablish their relationship. She feels guilty that she was unable to bring about a rapprochement. She also has become involved in a relationship that she describes as being “madly in love.” The man in question moved in with her, but after coming home from an AA meeting she discovered him in bed with a friend. She has fallen into a deep depression even though she continues to use her anti-depressant medication.

226 Ann – Four Months Later Ann reports that, for the first time in three years, she occasionally thinks about suicide, although she says she does not have an active plan and is willing to make a safety contract. She reports that she is barely able to care for her son. She started a new job as a salesperson, but is still in her initial probationary period and has called in sick for the past three days.

227 ASAM DIMENSION SEVERITY WORKSHEETRisk Rating (0) No Problem (1) Mild (2) Moderate (3) Significant (4) Severe Dimension 1: Acute Intoxication and /or Withdrawal Potential Dimension 2: Biomedical Conditions & Complications Dimension 3: Emotional, Behavioral, Cognitive Conditions & Complications Dimension 4: Readiness to Change Dimension 5: Relapse, Continued Use, Continued Problem Potential Dimension 6: Recovery Environment

228 TREATMENT PLAN FOR ANN Problem Statement Goals ObjectivesInterventions

229 Placement for Ann

230 Treatment Plan for Carl

231 “Carl” Carl is a 15 year old African-American male who you suspect meets DSM criteria for Alcohol Abuse and Marijuana Abuse, with occasional cocaine (crack) use on weekends. He reports no withdrawal symptoms, but then he really doesn’t think he has a problem and you are basing your tentative diagnosis on reports from the school, probation officer, and older sister.

232 “Carl” Carl has been arrested three times in the past eighteen months for petty theft/shoplifting offenses. Each time he has been acting intoxicated but denies use. The school reports acting up behavior, declining grades and erratic attendance, but no evidence of alcohol/drug use directly. They know he is part of a crowd that uses drugs frequently.

233 Yolanda, Carl’s 24 year old sister, has custody of Carl following his mother’s death from a car accident eighteen months ago. She is single, employed by the telephone company as a secretary, and has a three year old daughter for whom she cares. She reports that Carl stays out all night on weekends and refuses to obey her or follow her rules. On two occasions she has observed Carl drunk. On both occasions he has been verbally aggressive and has broken furniture. A search of his room produced evidence of marijuana and crack which Carl claims he is holding for a friend.

234 ASAM DIMENSION SEVERITY WORKSHEETRisk Rating (0) No Problem (1) Mild (2) Moderate (3) Significant (4) Severe Dimension 1: Acute Intoxication and /or Withdrawal Potential Dimension 2: Biomedical Conditions & Complications Dimension 3: Emotional, Behavioral, Cognitive Conditions & Complications Dimension 4: Readiness to Change Dimension 5: Relapse, Continued Use, Continued Problem Potential Dimension 6: Recovery Environment

235 TREATMENT PLAN FOR CARLProblem Statement Goals Objectives Interventions

236 Tracy A 16-year-old young woman is brought into the emergency room of an acute care hospital. She had gotten into an argument with her parents and ended up throwing a chair. There was some indication that she was intoxicated at the time and her parents have been concerned about her coming home late and mixing with the wrong crowd. There has been a lot of family discord and there is mutual anger and frustration between the teen and especially her father. No previous psychiatric or addiction treatment.

237 Tracy The parents are both present at the emergency room (ER), but she was brought by the police who had been called by her mother. The ER physician and a nurse from the psychiatric unit who came from the unit to evaluate the teen, both feel she needs to be in hospital given the animosity at home, especially with her father; the violent behavior; and the question of intoxication.

238 ASAM DIMENSION SEVERITY WORKSHEETRisk Rating (0) No Problem (1) Mild (2) Moderate (3) Significant (4) Severe Dimension 1: Acute Intoxication and /or Withdrawal Potential Dimension 2: Biomedical Conditions & Complications Dimension 3: Emotional, Behavioral, Cognitive Conditions & Complications Dimension 4: Readiness to Change Dimension 5: Relapse, Continued Use, Continued Problem Potential Dimension 6: Recovery Environment

239 Using the six ASAM assessment dimensions, the ER physician and psychiatric nurse organized the biopsychosocial clinical as follows: Dimension 1, Acute Intoxication/Withdrawal Potential: though intoxicated at home not long before the chair-throwing incident, she is no longer intoxicated and has not been using alcohol or other drugs in large enough quantities for long enough to suggest any withdrawal danger. Dimension 2, Biomedical Conditions/Complications: she is not on any medications, has been healthy physically and has no current complaints. Dimension 3, Emotional, Behavioral, Cognitive Conditions and Complications: complex problems with the anger, frustration and family discord; history of chair throwing, but is not impulsive at present if separated from parents.

240 Dimension 4, Readiness to Change: willing to talk to therapist; blames her parents for being overbearing and not trusting her; agrees to come into treatment, but does not want to be at home near father, at least for tonight. Dimension 5, Relapse, Continued Use ,Continued Problem Potential: high likelihood that if released to go back home immediately, there would be a reoccurrence of the fighting and possibly violence again. Dimension 6, Recovery Environment: parents frustrated and angry too; mistrustful of patient; and want her in the hospital to cut down on the family fighting.

241 Initial Response: Based on Tracy’s recent history of violent acting out (chair throwing), the ER physician and the psychiatric nurse recommended admission to the psychiatric unit, at least for the night.   Discussion: Tracy’s acting out occurred when she was intoxicated, which she no longer is and the major conflict appears to be a family issue, especially between her and her father. There is also no current indication of any severe or imminently dangerous biomedical, emotional, behavioral or cognitive problems requiring the resources of a medically managed intensive inpatient setting.

242 Revised Response: The initial goal is to separate Tracy and her father, which might be done by having Tracy stay with a relative or family friend overnight, or by having Tracy and her mother stay at a motel for the night or having father do that. Based on the current information, Tracy’s behavior and the conflict with her parents may be more reflective of an adolescent struggling to negotiate this very difficult period of life rather than psychopathology. Outpatient family counseling should be considered. A family therapy session for early the next day keeps the focus on the need for family interventions and avoids labeling Tracy as having the pathology. A This revised plan avoids the use of unnecessary, high intensity, high cost resources.    

243 The Clinical Record as a NovelThere is a system which forces linkage between the assessment information, the treatment plan and the progress notes

244 EXAMPLE ASAM Dimension: ASAM Dimension 4, Readiness to Change Problem Statement: This client who has a severe alcohol use disorder also uses marijuana but does meet diagnostic criteria for Cannabis Disorder appears to be in the Precontemplation stage about giving up marijuana and believes he can continue to smoke marijuana and remain abstinent from alcohol.

245 Objective #1: Bill will move from Precontemplation to Contemplation in his acceptance that continued marijuana use is a major obstacle to his attaining and maintaining abstinence from alcohol by attending the Cross Dependence lecture and reporting to group three occasions when he began drinking after smoking marijuana and three occasions when he used both substances concurrently.

246 Progress Note: The patient reported three occasions when he began drinking after smoking marijuana and three occasions when he used both substances concurrently in group today. He said that after attending the Cross Dependence lecture, he is beginning to wonder whether he will have to stop smoking marijuana in order to stop drinking although he admits that he is not yet convinced of that.

247 The coding system would look like this: Dimension D-4 Problem P-1 Objective O-1 Progress Note — D-4, P-1, O-1 or simply D-4,1,1 Such a system would require that ALL progress notes have a code that relates it back to the ASAM Dimension, problem and objective. If not, it indicates that the progress note contains a new problem which should be addressed in the next Treatment Plan Update.

248 Remember Treatment Outcome Treatment Plan Assessment

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250 There Is Light At the End of the Tunnel

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