Transcript Treatment Selection: How to choose the facility and level

TREATMENT SELECTION: HOW TO CHOOSE
THE FACILITY AND LEVEL OF CARE
CAPTASA 2015
LEXINGTON, KY
THE PRACTICE GAP
• Many people are not placed in optimal treatment environments
• Often, decisions driven more by administrative or patient preference,
rather than clinical needs
• Assessment and treatment occurring within the same organizationpotential for conflicts of interest
• Newly diagnosed cases may need very different treatment than those
with relapse- even if the “facts” are similar
“WARM BEER AND COLD WOMEN,
I JUST DON'T FIT IN
EVERY JOINT I STUMBLED INTO TONIGHTTHAT'S JUST HOW IT'S BEEN”
WARM BEER AND COLD WOMENTOM WAITS
BEFORE WE GO ON… SOMETHING NICE
ASAM SIX (6)DIMENSIONS: THE CLIENT’S RISK STATUS IN EACH OF THE SIX
DIMENSIONS COLLECTIVELY INFORM THE PATIENT PLACEMENT DECISION.
1. Acute Intoxication and/or Withdrawal Potential.
2. Biomedical Conditions and Complications.
3. Emotional, Behavioral, or Cognitive Problems and Complications.
4. Readiness to Change.
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment.
*** Safety Sensitive Professions have own criteria***
IT’S A CLINICAL DECISION NOT A CHECKLIST
• Criteria are NOT substitutes for GOOD Clinical
Judgment.
• Selection Tools and Criteria support, guide and
enhance GOOD Clinical Judgment!
ASAM LEVELS OF SERVICE:
• Level 0.5 Early Intervention
• Level I Outpatient Treatment
• Level II Intensive Outpatient / Partial Hospitalization
• Level III Residential/Inpatient Treatment
• Level IV Medically Managed Intensive
• Hospital/Inpatient Treatment
ACUTE INTOXICATION AND/OR WITHDRAWAL
POTENTIAL
• History of recent use
• Alcohol always first billing
• Benzos or Z-drugs
• Combinations are worse
• Route of use
• Past Detox and/or withdrawal experiences
• Concomitant medical conditions
• Age
BIOMEDICAL CONDITIONS AND COMPLICATIONS
• Overlaps with above
• Includes unrelated but complicating factors like
surgeries, recent injuries
• Sensory deficits and other challenges
• Special conditions- Pregnant, dialysis…
• Chronic Pain (careful! Self reports are very poorly
correlated with outcomes)
• Mobility issues
EMOTIONAL, BEHAVIORAL, OR COGNITIVE PROBLEMS
• Any other Psychiatric Dx
• Mood or thought D/O
• Suicidality
• Aggressive behaviors
• Uncooperative attitudes and behaviors
• Criminal behaviors
• Delirium
• Cognitive decline
MY LIST OF “OTHER DX’S”
• CAIDs
• DITTs
• DAIGHOMBs
READINESS TO CHANGE
• What is the motivator?
• Stages of Change
• Acceptance-Denial spectrum
• Are they willing to be there and not disrupt others?
• Where is the leverage?
PROCHASKA AND DICLEMENTE
RELAPSE, CONTINUED USE, OR CONTINUED PROBLEM
• Danger and damage of continued use or relapse
• Consequences and their Legal situation
• Level of insight
• Relapse triggers
• Their history of treatment and relapses
• Use while in treatment
RECOVERY ENVIRONMENT
• Huge criteria
• Makes for more quick relapses than anything else
• Where they live, who with and work environment…
• Access to drug of choice
• Dangers, especially domestic violence
• After acute withdrawal is addressed, this is most pressing
safety issue
SPECIAL SITUATIONS
• Pregnant or with children
• Gender
• Adolescents
• Corrections
• Safety Sensitive Professionals
ADDICTION'S SHRINKING GENDER GAP
• All over the world, women have always had lower
rates of addiction than men. But when women gain
more rights as nations grow richer, they begin to
catch up; in one drug type, they're already ahead.
• There is one notable exception in the gender gap,
one substance that women use and abuse in greater
numbers than men: tranquilizers.
• Kelly Bourdet 03/07/13 The Fix
MY EXPERIENCE AND OBSERVATIONS
• ASAM Criteria are most useful if you don’t do this work full time
• ASAM Criteria are primarily about who will get paid and how long treatment is
approved
• Insurance Companies use it to avoid or deny treatment
• Correlates OK for section of patients in middle of the Bell curve, but very poor at
margins
• Takes a lowest possible initial level approach and moves up if lower level fails
• That can use up resources and commitment on front end- my biggest concern
with it
• I found it useful as an organizational tool, but rarely made decisions based on it
WHAT ELSE I HAVE NOTICED
• Treatment for Addictive disorders is less standardized than any other area of
medicine
• Same clinical situations can be placed and treated almost anywhere in the
spectrum
• Treatment of Addictions is like real estate- Location, Location, Location
• The Treatment community (some) took advantage of the surge in funding
back when- now we are facing the consequences
• The single most important driver of selection is what do you have at hand
• Second is how much leverage do you have with the person who needs
treatment
BRAVE NEW WORLD?
ABSTINENCE VS HARM REDUCTION
• Well I don’t have much problem with this myself
• Society just wants “them fixed” and quickly
• And money drives both sides- Providers and Payers
• The patients usually opts for what is quick and easy
• Harm reduction is the most common approach now (Standard
of Care by most estimates)
• What passes for treatment is often a business model rather
than a clinical model
• I think CAPTASA serves as a place to hear the alternative
SO WHAT ARE WE TO DO?
• Know your Local resources
• Know you own strengths and limits
• Decide what you believe about Addiction and treatment
• Keep up with what you see work and what doesn’t
• Remember this is a Chronic, Progressive and Fatal Illness- so relapse
happens and we don’t always get a good outcome
• Take good care of yourself- I think Alanon helps Helpers help
• If you are in Recovery yourself you need more meetings and Recovery
work, not less!
THANK YOU