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Challenging Veterans Court Case

David Mee-Lee, M.D.

Chief Editor, The ASAM Criteria

Senior Fellow, Justice Programs Office (JPO) American University

Washington, DC

Senior Vice President, The Change Companies

Carson City, NV

Davis, CA

www.changecompanies.net

www.ASAMCriteria.org

www.tipsntopics.com

[email protected]

BJA Drug Court Technical Assistance Project at American University

May 3, 2016


Reasons for this Challenging Case

• Many courts are now undertaking what has come to be termed

"social autopsies" to analyze the situations of persons who have

been terminated from their programs for a variety of reasons, as

well as those who died, either while in the program or later.

• Such reviews provide an important learning opportunity for

others.

• In this challenging case it is very important both from a program

integrity perspective and from an addiction awareness

perspective. “I wanted the community to be aware that addiction

is a fatal disease and it’s not an easy path to recovery. Putting

an aftercare program in place is our top priority. I felt our local

newspaper article was extremely well done.”


Key Information

BACKGROUND: Male veteran was 47 years old when he entered the

Veterans Court. He had two estranged children in a different state and no

family ties.

CRIMINAL CHARGES: His charges were felony possession of Klonopin,

Hydrocodone, and methamphetamine. He had a prior conviction for felony

distribution of dangerous drugs.

SENTENCE: Five years probation and completion of Veterans Court.

Eligible for probation discharge upon completion.

DRUG OF CHOICE: Methamphetamine and marijuana.

MENTAL HEALTH: Depressed mood.

EMPLOYMENT: Unemployed upon entering Veterans Court. Obtained

stable, successful employment with family-owned farm implement equipment

dealer. ($15 per hour). Supportive work environment. Received a managerial

promotion one month before Veterans Court graduation ($20 per hour and

company vehicle).


Key Information (cont.)HOUSING: Homeless upon entering Veterans Court. Obtained his ownapartment with VA/HUD assistance.

ANCILLARY: No drivers license or identifying immigration paperwork uponentry into Veterans Court. Drivers license, military, and immigrationpaperwork obtained.

TREATMENT: 6 week inpatient treatment the Ft. Harrison VeteransAdministration Hospital and 18 months VA outpatient treatment.

MENTOR: Assigned. Attended court every week. Regular in-personcommunication.

RELAPSES: (1) Alcohol, two months post-inpatient treatment (9 months afterentering Veterans Court). LAC identified loneliness and holidays as a trigger.(2) Alcohol, relationship with significant other ended (13 months after enteringVeterans Court). Never relapsed on drugs.

STRUGGLES: Interpersonal relationship boundaries. While in the VeteransCourt, acknowledged difficulties staying away from people who use drugs.


Key Information (cont.)

CASE MANAGEMENT: Received extensive case management assistance

in Veteran Court; more than the average participant. (Hundreds of hours).

Moral Reconation Therapy (MRT): None. (Wasn’t in place until Jan. 2016).

GRADUATION: Graduated from Veterans Court after 18 months in the

program. A media account of the Veterans Court graduation stated as

follows:

James D., a veteran of the U.S. Navy, was living on the streets prior to his

enrollment in Veterans Court.

“It took the team to help get me through,” [he] said of [Judge], [Probation

Officer] and the rest of the program staff. “I thought I was too far gone.”

D. now has a place to live and a good job. He’s sober and managing any

mental health conditions that may have led to his involvement in the

criminal justice system. [Judge] promises the veterans on their first day in

court that they will have those four things when they graduate.



POST-GRADUATION DISPOSITION: Discharged from probation and

case dismissed.

POST-GRADUATE RELAPSE AND DEATH: Anecdotal evidence he

relapsed on methamphetamine 2-3 weeks after graduating from Veterans

Court. Shortly thereafter, suffered a heart attack. Multiple surgeries and

intensive care unit stay. Four days after hospital discharge, suffered

another heart attack from methamphetamine overdose in his employer’s

vehicle. Two known drug dealers and users were present when he died

who told authorities they used methamphetamine when he died. These

individuals were not known associates.

AFTER-CARE: No formal after-care program. Indicated intention to

continue substance abuse treatment at VA and seeking assistance from

his case manager. Coincidentally, his VA treatment provider was injured

and out of the office for over a month after he graduated.



The primary issue was immigration. The participant was born in

Vietnam (one of his parents was a U.S. citizen), but he lived there

until shortly before he entered the Navy. When he came into the

court, he had no identifying documents. He could not get his

military records without identification. He could not get a drivers

license without a birth certificate or military id card. It was a never-

ending circle of bureaucracy. He had no identity whatsoever and it

took our case manager months to cut through red tape. Our

manager also assisted him with resolving unpaid traffic fines,

transportation, financial counseling, dental services, housing

applications, supplemental nutrition assistance program benefits,

and employment. He had not filed taxes or registered with social

security.



Also, I should add that he was not an assertive individual, which I

think contributed to his difficulty with boundaries. We noted that in

his progress report of March 10, 2015 (11 months before

graduation). We should have worked on assertiveness with him. It

was a defining characteristic. On April 21, 2015, we note,

“Participant shares that he feels stronger about his boundaries with

old friends. Relates no longer has anything in common with them.

He likes his job and co workers. He shared that he is in bed by 10

on work days. Something that he did not do when his addiction

was active. Likes the change.” Yet, on June 30, 2015, we received

information that he was in a dating relationship with a known

methamphetamine user. We required that relationship end, but it

illustrates the ongoing struggle with boundaries.



Again, on August 27, 2015, he reports that he needs to keep

working on boundaries. On October 6, 2015, he reported

loneliness and articulated the importance of boundaries. In his last

treatment session before graduation, he stated, “James shared that

he will graduate from the Veterans Court. He shared that he has

gained a lot from treatment and the VC. He shared that he feels

that the services provided to him helped him. He wants to

continue in group once a week and with case management. He

knows the importance of boundaries to support his recovery.”


INDIVIDUALIZED, CLINICALLY &

OUTCOMES-DRIVEN TREATMENT

ASAM Principles of Addiction Medicine

5th Edition, 2014


The ASAM CriteriaMultidimensional Assessment

1. Acute Intoxication and/or Withdrawal Potential

2. Biomedical conditions and complications

3. Emotional/Behavioral/Cognitive conditions and complications

4. Readiness to change

5. Relapse/Continued Use/Continued Problem potential

6. Recovery Environment The ASAM Criteria pp. 43-53


Criminogenic Factors/ASAM Criteria Dimensions

Criminogenic Factors

• Antisocial values,

attitudes, behavior,

personality

• Criminal/deviant peer

association

• Substance abuse

• Dysfunctional family

relations

ASAM Criteria Dimensions• Dimensions 3, 4 and 6

• Dimension 6

• Dimensions 1, 4, 5, 6

• Dimension 6


Biospychosocial Treatment Treatment Matching - Modalities

• Motivate - Dimension 4

• Manage – All Six Dimensions

• Medication – Dimensions 1, 2, 3, 5 - MAT

• Meetings – Dimensions 2, 3, 4, 5, 6

• Monitor- All Six Dimensions


The ASAM CriteriaTreatment Levels of Service

0.5 Early Intervention

1 Outpatient Treatment

2 Intensive Outpatient and Partial Hospitalization

3 Residential/Inpatient Treatment

4 Medically-Managed Intensive Inpatient Treatment

The ASAM Criteria pp. 112 -117


Level 0.5 and OTS

Level 0.5: Early Intervention Services - Individuals with problems or risk factors related to substance use, but for whom an immediate Substance -Related Disorder cannot be confirmed

Opioid Treatment Services (OTS) - Criteria for Opioid Treatment Program (OTP) (methadone); antagonist meds (naltrexone) and Office-Based Opioid Treatment (OBOT) - buprenorphine

The ASAM Criteria pp. 179 -183; 290 -298


Detoxification Withdrawal

Management Services for Dimension 1

Level 1-WM - Ambulatory Withdrawal

Management without Extended On-site

Monitoring

Level 2-WM -Ambulatory Withdrawal

Management with Extended On-Site Monitoring



Withdrawal Management Services for

Dimension 1 (continued)

Level 3.2- WM- Clinically-Managed Residential

Withdrawal Management

Level 3.7- WM - Medically-Monitored Inpatient


Level 4-WM - Medically-Managed Inpatient




Level 1 and 2 Services

Level 1 Outpatient Treatment

Level 2.1 Intensive Outpatient Treatment

Level 2.5 Partial Hospitalization



Level 3 Residential/Inpatient

Level 3.1- Clinically-Managed, Low Intensity

Residential Treatment

Level 3.3 - Clinically Managed Population-

Specific High Intensity Residential Treatment

(Adult Level only)



Level 3 Residential/Inpatient (cont.)

Level 3.5- Clinically-Managed, Medium/High

Intensity Residential Treatment

Level 3.7- Medically-Monitored Intensive

Inpatient Treatment



Level 4 Services

Level 4 Medically-Managed Intensive Inpatient



Focus Assessment and Treatment

What Does the Client Want?

Does client have immediate needs due to imminent risk in any of six dimensions?

Conduct multidimensional assessment

The ASAM Criteria p 124


Focus Assessment and Treatment (cont.)

DSM-5 diagnoses?

Multidimensional Severity/LOF Profile

Which assessment dimensions aremost important to determine Tx priorities




Specific focus/target for each priority dimension

What specific services needed for each dimension

What “dose” or intensity of these services needed




Where can these services be provided in least intensive, but “safe” level of care?

What is progress of Tx plan and placement decision; outcomes measurement?



DSM-5 diagnoses?

Multidimensional Severity/LOF Profile

Which assessment dimensions are

most important to determine Tx priorities

Specific focus/target for each priority dimension

What specific services needed for each dimension

What “dose” or intensity of these services needed

Where can these services be provided in least intensive, but “safe” level of care?

What is progress of Tx plan and placement decision; outcomes measurement? The ASAM Criteria p 124


Resources

28

www.tipsntopics.comwww.ASAMCriteria.org



David Mee-Lee, M.D.

Senior Vice President

The Change Companies

Carson City, NV


www.ASAMCriteria.org

www.tipsntopics.com

[email protected] materials have been prepared under the auspices of the Bureau of Justice Assistance (BJA) Drug Courts Technical Assistance Project at American University, Washington, D.C. This

project was supported by Grant No. 2012-DC-BX-K005 awarded to American University by the Bureau of Justice Assistance. The Bureau of Justice Assistance is a component of the Office of

Justice Programs, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, and the Office for Victims of

Crime. Points of view or opinions in this document are those of the authors and do not represent the official position or policies of the U.S. Department of Justice.

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