Dr Mee-Lee and Dr Inaba review and contrast the new Diagnostic and Statistical Manual (DSM-5) from the American Psychiatric Association, and the American Society of Addiction Medicine’s (ASAM) Patient Placement Criteria, for which he is one of the main authors. The difference between the two manuals is discussed, including the changes in categories and scope in the new DSM, the ongoing issue of public perception/acceptance of the addiction as disease model, and issues around treatment and relapse.
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Transcript (edited):
HOWARD: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions.
DARRYL: Hello, I’m Dr. Darryl Inaba and today were going to take a different twist and look at a addiction and drug use from a more prospective view rather than the perspective or reactive way we’ve approached it in the past. We are honored today to be joined by Dr. David Mee-Lee. He is the chief editor of the American Society of Addiction Medicine Patient Placement Criteria (ASAM) which is considered, along with the DSM (Diagnostic and Statistical Manual of Mental Disorders) the bible of assessing and properly placing patients into the right level of treatment. It is recognized by insurance companies and treatment organizations and many US states and is something I’ve relied on for years. Dr. Mee-Lee is also Senior Vice-President of the Change Companies in Carson City, Nevada and if we have a little bit of time he will talk about what he does there as well. For over 25 years, David has developed and promoted innovative behavioral health treatment resources which emphasize clinical integrity, high quality, and cost consciousness. That is the impression I got from Washington in regards to the Affordable Care Act so David is way ahead of his time, I think, in regards to medicine. Now, David…welcome to our CNS Podcast!
DR DAVID MEE-LEE: Thanks very much, Darryl. It is a pleasure to be here. Thank you.
DARRYL: The DSM5 is due to be released in May of this year and there have been a lot of announcements and attention being paid to the changes and content and I was wondering, since we use, in many of my programs, the ASAM patient placement criteria, along with the DSM5…how the new changes in the DSM5…and may impact or affect your ASAM placement criteria.
DR DAVID MEE-LEE: Well, thats a good question, Darryl, because I think there are some misconceptions about the relationships between the diagnostic criteria and the ASAM criteria which examines what kinds of severities of presentations belong or are best treated in what levels of care. So, they are related, but the changes in the DSM5 are nothing people need to be too worried about. For example, I heard recently somebody say, oh the DSM5 is coming out…that will make the ASAM criteria sort of obsolete. So I really appreciate the question because its an opportunity to clarify the relationship between the DSM diagnostic criteria and the ASAM patient placement criteria. This requires treatment professionals to make sure that the person does indeed have an addiction illness that requires addiction treatment. And so at the beginning of each level of care, there are diagnostic admission criteria which relate to the DSM criteria or other standardized criteria which may be used in some parts of the country or parts of the world, although most people in the United States use the DSM criteria from the American Psychiatric Association, but if there was some other standardized diagnostic criteria that indicated the person had an addiction problem, that would be sufficient to make sure they got into addiction treatment. Once in treatment, the intensity of treatment depends on the patient’s particular mix of severities based on the 6 assessment dimensions of the ASAM criteria. The bottom line is you need to have a diagnosis of addiction to get into addiction treatment, but once you have the diagnosis, the kind of treatment you get and the level of care is determined by the ASAM criteria come in.
Just one more point…in the 80s, sometimes adolescents would get put into a chemical dependency or addiction program because the parents, who were themselves children of alcoholics, were perhaps very distressed by their child experimenting with substances. They would put their child into an addiction program for 3 months or however long their insurance would cover it regardless of whether or not the youngster actually had an addiction illness and needed addiction treatment. So thats why we put in the requirement that the patient must have a diagnosis to get treatment, but once the diagnosis is there, then the ASAM criteria assessment is used to determine the level of care.
DARRYL: I think my question is also based on one of the things Ive often heard about the DSM5 – that its going to look at addiction of abusive drugs from more of a spectrum disorder rather than simply determining a person is an abuser or an addict without a diagnosis. And as the spectrum widens, I hear concerns from the field that this may expand the number of people who are diagnosed as addicts or alcoholics which may make treatment across the board more expensive. Whats your perspective on that?
DR DAVID MEE-LEE: Yes, Ive certainly heard that too and it remains to be seen. I know the work group headed up by Dr. Charles OBrien in Pennsylvania, had considered that and one of the concerns of course about that is that if there are levels – mild, moderate, and severe – and for a patient to be classified as “mild” only 1 or 2 of the, I think its 11 criteria….and don’t quote me on that, I should have checked exactly how many…must be met. But, the worry is the number of patients could increase, but I personally am not so concerned about that because the people that get into addiction treatment are often going to have many more criteria than just somebody who has a mild disorder. The national survey on drug use and health which comes out every September from SAMHSA, the Substance Abuse and Mental Health Services Administration, shows that of the 19 or 20…. the latest data was 19.3 million people in the United States aged 12 years and up who have the need for alcohol or other illicit drug treatment – 95% of those people don’t think they have a problem and never reach out for help. Of the other 5% who recognize that they have a problem, only about 1.5% actually get into addiction treatment programs. And so, there’s a need to be reaching out to that population and to try to intervene sooner rather than later. I do understand how the looseness of the diagnostic criteria could be a worry but I think in the practical sense of service delivery, thats not going to cause any problems.
DARRYL: Early on there were reports that the wording was going to be changed…or the category was going to be changed from the current substance use disorders to addiction and related disorders. I think it is important to separate out the tissue dependence and effects of withdrawal that can occur to medical substances and another thing to look at is the severity of the addiction. There are reports, however, that they’re not going to make that change and of course, one of the big reasons for that change was the proposal to include gambling, sexual addiction, and maybe other types of process addictions. But, I’m not sure if they’re going to make that change or not. What have you heard?
DR DAVID MEE-LEE: Well, I think the chapter is going to be called, Substance Use Disorders and Addictive Disorders with the only addictive disorder included being gambling disorder. And I think the reason is that will be no substance abuse or substance dependence section is because substance dependence relates to the issue you were talking about physical dependence from being on opiates prescribed postoperatively for long enough periods. Anybody can acquire physical dependence but that is not the illness and disease of addiction and thats why I wanted to get rid of abuse and dependence. Now, of course ASAM has long encouraged people not to use the term substance abuse because you abuse people, not things. And so, ASAM has never liked the term substance abuse even though its used by our government and commonly used in the field. But thats not why the American Psychiatric Association cut out substance abuse and dependence. They cut it out for a couple of reasons, I think, because of the spectrum idea and also to get away from dependence which really applies more to the physical dependence that can happen to anybody rather than the disease of addiction. Now they did include gambling disorder as one of the addictive disorders because there’s enough literature on it. But they are going to, I think, include some preliminary criteria for internet addiction, but there was not enough literature to include that as a separate addictive disorder category.
DARRYL: David, you’re one of the best presenters and one of the most inspiring speakers Ive ever heard in the field of addiction and Ive often heard you comment that addiction is more recognized now as a chronic persistent medical disorder, but currently not treated as such. I wonder if you can elaborate on that.
DR DAVID MEE-LEE: Some years ago, probably in 2000, Tom McClellan had a piece in the Journal of American Medical Association showing how addiction along with diabetes, asthma, and hypertension are all very similar in terms of their recurring nature, in terms of the adherence rates of patients keeping to treatment and in terms of relapse or reoccurrences. And for the longest time people in the addiction field talked about addiction as a disease – as a lifelong disease from which you don’t get cured, but that you can recover and have some control over all of the problems in your life. So we’ve said that for a long time even in the addiction treatment field and certainly in the general health and medical field, we have not treated it that way. For example, in general medicine, if somebody came into the emergency room in a diabetic coma or experiencing a hypertensive episode where their blood pressure was very high and they were about to stroke, they would certainly stabilize the person, but then they wouldn’t just let them go out through the revolving door of the emergency room. They’d make sure that patient got some follow-up for their diabetes and their hypertension. Whereas for addiction in general health settings, somebody will come in intoxicated and even need detox and after they have been detoxed there is no attempt to diagnose and/or provide continuing care for the illness of addiction. So that happens in general health settings and the revolving door of stabilization, but no continuing care. And then on the addiction treatment side, we’ve espoused addiction as an ongoing life illness, but if somebody were to slip or have a lapse or use while in treatment, traditionally in the past, we discharge them – told them to leave. You would never discharge somebody for depression, or because they are suicidal or because their blood pressure goes up or for having an asthma attack. So we say its a disease and a relapsing one that can flare up and then we treat it as if its willful misconduct. And so, even in the addiction treatment field, we have ambivalence about whether this is really a chronic illness that can relapse because of the way we treat it – if you come to group with alcohol on your breath, you have to leave until you’re stable. If somebody showed in group with a panic attack or feeling suicidal, we would never tell them to leave and come back when theyre stable. So, on both sides of the fence…the addiction treatment side and general health care, I think there is some ambivalence about is it really a chronic illness?
DARRYL: I think Tom McClellan did the studies that show the number of relapses we see in addiction is equivalent to the number of relapses in treating diabetes and hypertension and asthma. So we need to look at that in a different way. There is a stigma surrounding addiction despite all of the studies and all the research – some believe it is a moral issue or a willpower issue – take that stigma and multiply it by a thousand…thats a stigma that even the treatment field puts on people who are chronic relapsers. What do you think has to be done to change that?
DR DAVID MEE-LEE: Well, I think were talking about it now raising consciousness and also by helping treatment programs realize that if you keep somebody in treatment who has used, were don’t just say, “oh well, its your disease…you used,
try harder next time.” If somebody has a slip, we don’t want them to leave treatment, but they have to be willing to change their treatment plan in a positive direction. So, if a patient or a client is willing to say, “okay, I used and I can see it was because I was hanging out with all those friends…I’m willing now to pull back from some of those friends.” Well then thats progress and thats moving in a positive direction and the person should stay in treatment. Were looking at progress, not perfection. If on the other hand, somebody has a slip and they say, “yes, I used, but I’m still not going to go to those AA meetings and I’m still not going to give up any of those friends and I’m still not going make any of the changes you’ve suggested” …. at that point, we might be justified in not kicking them out if we say, “well you’re not choosing to do treatment and you have a right to choose no further treatment, but if you’re going to stay in treatment and we want you to stay in treatment, you have to change your treatment plan in a positive direction and do something that is moving in a positive direction.” Otherwise, if we let the person stay and they don’t change anything, then we would be enabling, supporting the notion that if they don’t change anything they will get a good result. Well, if a person says, “I have to be here because the judge ordered me to be here”…we say, “no, you don’t have to be here…” or “the judge ordered you here for treatment, not to just sit here and do time. We don’t do time here…we only do treatment.” So, if the person wants to be in treatment, that means moving in some positive direction. Maybe not as fast or as far as we would like, but well start where ever the person is and go at a pace that makes sense, but it must be moving in a positive direction. They cant just sit here and keep everything the same because when they get a positive drug screen that means a change in the treatment plan, not just hoping something will change without them actually doing something.
DARRYL: You just brought up one of my frustrations and thats the judges and the legal system. It is very complicated the ways addiction is so mixed up with the courts and the justice system. We have clients who do well in treatment for a year, but then have a slip and come up with a positive urine analysis and we report it to, of course, the drug courts, or probation, parole, whatever they’re under and we explain that the client was doing good…we just need to change their treatment plan. Oftentimes they just get the gavel – sending them back – 6 months…back to jail. So maybe we have to work on the legal system as well.
DR DAVID MEE-LEE: Absolutely. We have to help them to mandate assessment and treatment adherence, not a particular level of abstinence because again, if somebody is agreeing to change their treatment plan in a positive direction, we can report to the courts this person is in treatment and they’re fully adherent. That doesn’t mean they’re perfect. It means though that they are in treatment so don’t sanction them for just having a symptom of their illness.
DARRYL: Would you be willing to talk about what you’re doing with the Change Companies, you know, what you’re doing there in Carson City and what kind of projects you’ve done there with them and what are you in the midst of?
DR DAVID MEE-LEE: I would love to talk about that. The Change Companies have been around for about 23 years or so and its mission is helping people make positive change and to help facilitate positive change and that message really resonates with what Ive been interested in throughout my career. It is about helping people to help themselves in many ways. Because we know from the research literature that all change is self-change and treatment is better than no treatment, but the real impact on the outcomes is in helping people to help themselves to change. And so, when the Change Companies wanted me to be more involved with helping to get that message out, I was happy to join forces with them. Our Senior Advisor is William Miller, who as you know, developed motivational interviewing. One of our former senior advisors here is Dr. James Protraska one of the developers of the stages of change. So these are the influences that have influenced my career as well as what we do at the Change Companies. There has been a good convergence of the mission – how do we help treatment providers to help people to help themselves. The Change Companies has interactive journals, like workbooks for patients and E-learning and I’ve merged parts of my training consulting work with the great team there. It is getting very sophisticated with some digital work and E-learning and certainly the interactive journals that are used throughout the federal bureau of prisons and many criminal justice settings as well as impaired driving programs and then many, many addiction and mental health programs.
DARRYL: The Change Companies talk of empowerment and also that it is self-efficacy that people can make these changes and thats just a wonderful thing to bring about. So, congratulations on your work with them. Congratulations on the ASAM PPC and its just wonderful having you on the show and just great. Thank you very much, Dr. David Mee-Lee.
DR DAVID MEE-LEE: Thank you, Darryl. Thanks for the invitation.
HOWARD: That wraps our pod for today. Thanks for visiting the CNS Podcast. Please check back soon for the next in the series and visit our website, www.cnsproductions.com