Common measures of recovery (e.g. Assessment of Recovery Capital, Substance Use Recovery Evaluator, etc.) can present complications when being asked to residential treatment program clients. Any measures specific to recovery for clients enrolled in residential-based programs (detox, acute, long-term)?
1. Patients must be educated and empowered to take charge of their recovery program from the start by establishing their own individualized plan and trajectory.
2. Motivational interviewing is critical in helping those still on the fence about recovery.
3. Medication Assisted Treatment recommendations from NIDA, SAMHSA, ASAM should become an integral part of treatment from start.
4. For those patients who are pre-contemplative about recovery, a thorough search of external motivators and leverages must be applied effectively.
First one must clarify what the residential “program” is intended to do. Detoxification not designed as a vehicle for entry into an actual treatment program is different from programs that seek to achieve remission. The goal of detoxification is to achieve physiological resolution of a medical issue. Logically, one goal might be to have the individual engage in a treatment program so as to go beyond the safe detoxificaiton.
In contrast, a “rehabilitation” treatment program goal would be achieving remission. Remission is clearly defined in the DSM-5 as absence of positive diagnostic criteria other than craving for a three or twelve month period for initial or sustained remission respectively. This would seem to be the basic outcome measure.
More complex concepts such as recovery capital and “recovery” typically involve more than remission. The problem with going beyond remission is that the various constructs may be beyond what the treatment program can deliver or be paid for. For example, it is beyond the scope of most addiction treatment programs to assist individuals in becoming employable, better spouses or parents, etc.
Hi Robert,
I'm not sure if I understand the question, but, there are some validated scales/instruments that can be used across a variety of addictions settings that might be helpful in residential settings for your purpose.
1) Addiction Severity Index (ASI) http://adai.washington.edu/instruments/pdf/addiction_severity_index_baseline_followup_4.pdf
2) ASI-Lite (http://www.who.int/substance_abuse/research_tools/addictionseverity/en/)
3) This is a nice review article of various instruments in Addictions Medicine: Article Assessing Addiction: Concepts and Instruments
4) Finally, this one might be the most relevant to your question: https://homewoodhealth.com/corporate/news/the-development-and-implementation-of-an-outcome-monitoring-system-for-addiction-treatment
Hope these are helpful,
Anees
The ASI (Addiction Severity Index) actually is an outdated outcome measure in that its primary measure for substance use disorder is days of use in the past 30. With the advent of the DSM-5 remission is clearly defined as not having any of 10 diagnostic criteria (craving is exempt from outcome monitoring) in the previous three or twelve months for initial or sustained remission respectively.
In any event, the measure, days of use, is a very imperfect measure of severity or outcome for alcohol and some other substances. An individual who has only one drink of alcohol each day (e.g., one glass of wine with dinner) would score a maximum on days of use while a binge drinker consuming huge quantities of alcohol during a binge would score as less severe.
The other measures on the ASI purport to measure constructs likely to be negatively impacted by substance use. However, some of these measures can be affected by factors other than substance use. Fore example, employment and income can be affected by the general economy, such as the recession in 2008 in the US or the local economic environment.
The primary outcome for addiction treatment programs is to achieve either remission or at least some improvement in clinical status of the individuals treated. This requires determining whether fewer, if any, diagnostic criteria continue to be positive. Determining this does not require a “tool” or necessarily a “scale” for measurement. It does require some standard, consistent, identification of positive diagnostic criteria.
Other ancillary measures of functioning, health status, relationships, etc. can be included in documenting improvements in these areas, but does require more sophistication in determining whether improvements are directly related to remission or clinical improvement of the addiction(s).
Hi Norman G Hoffmann . I believe the ASI is still in extensive use also in the US, is it not? McLellan et al. explained why they did not include quantity of use in the ASI:
Article McLellan AT, Kushner H, Metzger D. The Fifth Edition of the ...
and argue for the use of the 30 day measure. They say for example that there is a high correlation between frequency and quantity.
Your statement about alcohol is right of course, one should distinct between low quantity and high quantity (e.g., binge drinking). It is solved to some degree in the ASI interview by distinguishing between any alcohol use and alcohol use above 5 standard drinks a day. Thus, the individual who had only one drink of alcohol each day would score zero on the >5 SD 30 days measure, and the binge drinker would score 30 on both measures. Can you point us to some reference that ASI is considered "outdated"; is it a common understanding in the US or is it your personal opinion?
Best
John-Kåre
Quantity of use is one of the most unreliable measures, especially for drugs where the purity is typically unknown. Also, most adults tend to underestimate quantity of use while adolescents may over estimate.
However, neither frequency of use nor quantity is an appropriate measure of outcome given the DSM-5, which defines both severity and remission by the presence or absence of positive diagnostic criteria.
As to the wide use of the ASI, this is a case of promotion triumphing over performance. In the past, the ASI was a required measure for many grants. Since the national agencies helped fund the ASI, they had an interest in its use irrespective of the value of the instrument to either research or clinical work. Also, at the time of its development, it was all that was available. State bureaucrats got into the act by mandating the use of the ASI as an intake instrument – a function for which it was inappropriate and never intended. The ASI was designed as a pre vs. post measure focusing primarily on constructs likely to be influenced by consequences of use.
The feedback I have received from clinicians and programs treating addictions is that where the ASI is mandated, they need to spend additional time getting the information they actually need to get a diagnosis and a treatment plan. The ASI is virtually useless in meeting the ASAM Criteria for treatment planning and placement. The ASAM Criteria are the standard in the US.
A detailed critique of the ASI can be found in the research section of www.evinceassessment.com. As I noted previously, some of those constructs can be influenced by factors other than whether an individual is actively addicted or in remission.