housekeeping using the asam criteria to guide assessment ... training you… · 3/19/19 1 using the...

3/19/19

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Using the ASAM Criteria to Guide Assessment and Treatment of Youth

Housekeeping

•  Approvedfor1hourSUDCon:nuingEduca:onUnits

•  Arecordingofthiswebinarandslideswillbepostedon:hCps://idph.iowa.gov/substance-abuse/families-in-focus

•  Surveyfollowingthewebinarand30-dayfollow-up

Outline

•  Thebasics:IntrototheASAMCriteria•  ASAMCriteriaassessmentdimensionsasaroadmapfortreatment

•  Placementinlevelofcare

•  Casediscussion

Relationship between Past Month Substance Use and Age

Source: Dennis (2002) and 1998 NHSDA.

0

10

20

30

40

50

60

70

80

90

10012 13 14 15 16 17 18 19 20 21

22-2

3

24-2

5

26-2

9

30-3

4

35-3

9

50-6

4

65 +

Age

Alcohol UseTobacco UseBinge Alcohol useAny Illicit Drug UseMarijuana Use

ASAMCRITERIAPATIENTPLACEMENTCRITERIA(PPC)

Usingmul:dimensionalassessmenttoguidetreatment

ASAMPa:entPlacementCriteria(PPC)AssessmentDimensions

1:Intoxica:on/WithdrawalPoten:al2:BiomedicalCondi:ons3:Emo:onal/Behavioral/Cogni:veCondi:ons4:ReadinesstoChange5:Relapse/Con:nuedUse/Con:nuedProblemPoten:al

6:RecoveryEnvironment

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DIMENSION4READINESSTOCHANGE

Treatment Engagement: What Do Adolescent Addiction Patients Want?

•  Whatyou’reselling:– Longtermsolu:ons– Func:on– Abs:nence

•  Whatthey’reshoppingfor:– Crisisrelief– BeCerdrugs,moretrouble-freepartying– Comfort– Getsomemeddlingadultoffmyback

ENGAGEMENT•  Whyisthispa:entpresen:ngfortreatmentnow?– Ourversion– Theirversion

TreatmentEngagement

•  Treatmentreadiness•  Mee:ngthepa:entswheretheyare

•  Discoveryvsrecovery•  Prehabvsrehab

TreatmentEngagementStagesofChange

•  Progressivetreatmentengagement

•  Roleinduc:on•  Mo:va:onalenhancement

Mo:va:onalapproaches

•  Doyouknowotherpeoplewhohavebeenintrouble…•  DoyouknowwhyIoryourlovedonesmightthinkit’saproblem…

•  Whatarethepro’sandcon’sforyou…•  Whatwouldbeevidenceinyourviewthatit’saproblem…

•  Ifyoucouldstopany:me,wouldyoubewillingtoseewhatit’slike…

•  Let’sscheduleyoutocomebackandseehowit’sgoing…

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Extraac:veingredients–engagement,rela:onship,monitoring

•  Careprovidershaveenormousimpactonpa:entsandfamilies

•  Importanttosetclearstandard:ourstanceshouldbethatanyintoxicantuseisunhealthy

•  Longitudinalfollow-upcanholdupamirrorofdynamicchange,bothposandneg

Counseling as sales

DIMENSION1INTOXICATION/WITHDRAWALPOTENTIAL

ASAMCriteriaDimension1Considera:ons(Withdrawal/Intoxica:on)

ExamplesbyDrugClass•  Marijuanawithdrawal:insomniaandirritability

•  Marijuanaintoxica:on:persistentmemoryandthinkingproblems

•  Opioidwithdrawal:physicalsicknessandseverecraving•  Anyintoxica:on:agita:on,psychosis•  Inhalantintoxica:on:subacutedeliriumanddisorganiza:on

•  S:mulantwithdrawal:depressionandseverecraving

•  Hallucinogeninducedpersis:ngperceptualdistor:onsyndromes

Detoxifica:on•  Opioidwithdrawal

– Needformedica:ons

– Usuallyinpa:ent•  Alcoholwithdrawal–dangerousbutinfrequentinyouth

•  Allsubstances–aCen:ontosleep•  Allsubstances–discon:nua:onofanengrainedhabitneedsspecialfocus

Detoxifica:on•  Canbearevolvingdoor,butitshouldleadsomewhere

•  Detoxifica:onnecessarybutinsufficient–mo:va:onalmomentforlinkagetocon:nuingcare

•  Opportunityforrelapsepreven:onmedica:onswhenappropriate

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DIMENSION2BIOMEDICALCONDITIONSANDCOMPLICATIONS

ASAMPPCDimension2Considera:ons

•  Severebiomedicalcondi:ons– Trauma:cinjuries

– Seizures– HIV,HBV,HCV– Sequelaeofinjec:onuse– Overdose

ASAMPPCDimension2Considera:ons

•  Otherbiomedicalcondi:ons–  Asthma(reac:veairwaysdisease)–  STDs(urethri:s,cervici:s,chlamydia,gonorrhea,syphilis)–  Exacerba:onofchronicillness–  Pregnancy(Don’tforgetcontracep:on)–  Poornutri:on(bothmalnutri:onandobesity)–  Anemia–  Dentalproblems–  Gastri:s–  Generalhealthmaintenance–  Chronicpain

MedicalCo-morbidity

•  Wherearethedoctorsandothergeneralhealthcareproviders?

•  Howdowecollaboratewiththem?

DIMENSION3EMOTIONAL/BEHAVIORAL/COGNITIVECONDITIONSANDCOMPLICATIONS

Age

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

5 10 15 20 25 30 35 40 45 50 55 60 65

% in

Eac

h A

ge G

roup

to D

evel

op

Firs

t-tim

e D

epen

denc

e

THC ALCOHOL

TOBACCO

70 75

Addiction and mental illness: developmental disorders

½ psychiatric disorders onset before age 15

¾ psychiatric disorders onset before age 24

Age for tobacco, alcohol and cannabis dependence

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DualDiagnosisCastthenetwide

•  Highprevalenceofco-morbidity•  Inclusionofsymptomsandsub-syndromalproblemswithoutrequiringformaldiagnosis

•  Pre-morbid,drug-induced,anddrugexacerbatedcondi:ons

•  Suspectco-occurringpsychiatricdisorders•  Treatco-occurringpsychiatricdisorders

AdolescentDualDiagnosisGreatestHits

•  MajorDepression•  DepressionNOS•  Dysthymia•  BipolarDisorder•  MoodDisorderNOS•  Disrup:veMoodDysregula:onDisorder

•  Opposi:onalDefiantDisorder

•  ConductDisorder•  IntermiCentExplosiveDisorder

•  ImpulseControlDisorderNOS

Dual Diagnosis Which Comes First?

The Psychiatric View of Our Patients

SubdomainsforAssessmentofSeverityandRiskinDimension3

•  Dangerousness/Lethality•  InterferencewithRecoveryEfforts•  SocialFunc:oning•  AbilityforSelfCare•  CourseofIllness

PastYearMajorDepressionAssociatedwithIni:a:onofSubstances

0%

5%

10%

15%

20%

25%

30%

Initiated Alcohol

Initiated Illicit Drugs

29.2

16.1 14.5

6.9

Past Year MDE

No Past Year MDE

Amongyouth12-17:

•  Pastyearini:a:onofalcohol-15.4%

•  Pastyearini:a:onofillicitdrugs-7.6%

•  Pastyearmajordepression-8.8%

SAMHSA. National Survey on Drug Use and Health. NSDUH Report 5-07 (2005 data).

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Depressive Symptoms Correlate with Substance Use Outcomes

0%10%20%30%40%50%60%70%80%90%

100%

Baseline 3 Mos. 6 Mos. 9 Mos. 12 Mos

Baseline BDI <11

Baseline BDI > 11

% S

ubst

ance

usi

ng d

ays

Psychiatricconsequencesofcannabis

MJuseassociatedwithdepressivesymptoms

Horwoodetal.DrugandAlcoholDependence126(2012)369–378

Pooleddata,4longitudinalstudies,n=6900

CannabisandpsychosisProspec:veexposurecohortstudy

•  10yrprospec:vecohortof1923Germanyouth(14-24atbaseline)

•  Examina:onofchangeover3:mepoints

KuepperetalBri:shMedJ.2011

OR=2.2

OR=1.9

Cannabisandcogni:veimpairment

•  IQmeasuredage13,38;N=1037•  MJusemeasuredage18,21,26,32,38•  IQdeclineassociatedwithregularuseanddependence,doseresponserelatedtopersistence

•  Nodifferencewithcontrolsforeduca:on,recentuse,othersubstances,schizophrenia

•  Adolescentonsetworse,-8pointsfor3+waves

None Someuse 1wave 2waves 3+waves

Regularuse +1 -1 -3 -2 -5

Dependence +1 -1 -2 -3 -6

Meieretal.PNAS.2011

Reductions in substance use associated with reductions in depression

BothPlacebo(p<.0001)andFluoxeRne(p<.0003)Respondershavesignificantpre-postreducRonwhereasNon-Respondersineachgroupdonot

RespondersdiffersignificantlyfromNon-Responders(p<.02)

Days

/ 3

0 d

rug

use

Riggsetal.

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DIMENSION5RELAPSE/CONTINUEDUSE/CONTINUEDPROBLEMPOTENTIAL

Dimension5AssessmentDomains

•  HistoryandpaCernofuse•  Responsetodrugeffects•  Responsetotriggers(internalandexternal)•  Cogni:veandbehavioralmeasuresofstrengthsandweaknesses

Dimension5HistoryandpaCernofuse

•  Specificsubstancesused•  Dura:onofuse•  Amountofuse

•  Frequencyofuse•  PaCernofchange

– Abs:nenceandrelpase– Responsetointerven:on

Dimension5Responsetosubstanceeffects

•  Posi:vereinforcement(rewardcraving)•  Nega:vereinforcement(reliefcraving)

Dimension5Responsetointernalandexternals:muli

•  Responsetocuesortriggers•  Responsetoacuteand/orchronicstressors

Dimension5Featuresoftemperament,vulnerability

andresilience•  Locusofcontrolandselfefficacy•  Copingskills•  Impulsivity

•  Goalorienta:onandstance–  Asser:ve–  Compliant

–  Passive–  PassiveAggressive–  Opposi:onal

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ATM Baltimore Site Substance Using Days Heroin Users vs Others

0%10%20%30%40%50%60%70%80%90%

100%

Baseline 3 Mos. 6 Mos. 9 Mos. 12 Mos.

Heroin UsersOther

Featuresofyouthopioidtreatment

•  Developmentalbarrierstotreatmentengagement–  Invincibility–  Immaturity– Mo:va:onandtreatmentappeal–  Salienceofburdensoftreatment

•  Variableeffec:venessoffamilyleverage(ornot)•  Pushbackagainstsenseofparentaldependenceandrestric:on

•  Prominenceofco-morbidity

Medica:onsforyouthopioidtreatment

•  Buprenorphineclearlyeffec:veforyouth,extendedreleasenaltrexoneverypromising

•  Butengagementandadherenceproblema:c

•  Recommenda:on:integra:onofrelapsepreven:onmedica:onintocomprehensivecare

•  Developmentallyinformedspecialtyprogrammingessen:al

Respondingtolapseandrelapse

•  Mul:pletreatmentepisodesisthenormforSUDandco-occurringdisorders

•  Notapersonalortreatmentfailure

•  Encouragehonestrepor:ng•  Whatarewegoingtododifferent?

DIMENSION6RECOVERYENVIRONMENT

Family•  Familyinfluencesarecri:cal

–  Bothposi:veandnega:ve–  Familydruguse–  Familyastudestowardsdruguse–  Familyvalues

•  Adolescentsrelysubstan:allyonthesupportofadults–  Generalparen:ngandsupport– Monitoringandsupervision–  Treatmentsupport

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ModelingofBehavior•  Kidsmimicwhattheysee•  Kidslearnfromexperience,morethanfromexplana:on

•  NomaCerwhatyousay,theywilldowhatyoudo

Unrealis:cparen:nginterven:ons

Dimension6Considera:onsSubstanceusewithinsocialnetwork

•  Householdsubstanceuse•  Roman:cpartnersubstanceuse

•  Peersubstanceuse•  Substanceinfestedcommuni:es

Dimension6Considera:onsInfluencesonrecovery

•  Chao:chomelife•  Domes:cviolence

•  Homelessness

•  An:-socialinfluences•  Economicsufficiency

•  Abuseandneglect

Dimension6Considera:onsSupportfortreatment

•  Ac:vesupportfortreatment–  Supervision– Monitoring

–  Enthusiasmandcheerleading–  Assistance(egtransporta:on,payment,par:cipa:onetc)

•  Neutralacceptancebutwithoutabilitytosupport•  Opposi:onorundermining

Dimension6Considera:onsBurdensoftreatment

•  Work•  Childcare•  Transporta:on•  Financial•  Time

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OvercomingBarriers--Astudes,Access,Culture

•  “No big deal” •  “It’s natural” •  “We used it when we were kids”

•  “They should learn to drink at home” •  “Every kid drinks a little beer”

OvercomingBarriersMixedMessages

•  Whichisright?– Zerotolerance-nothingbutabs:nence– Delayingini:a:on– Norma:veexperimenta:on– Freedisclosureofuse

•  Yes

Not In My House

•  Address the supply: • Monitorandsecuremedica:ons

• Disposeofmedica:onsnolongerinuse

• Coordinatewithpeers,friends,parents,grandparents

•  Parental Use? (trickyterritory) • Remindthemthatkidsaremimics• “Notthatthisappliestoyou,butsomefamiliesmayusesubstancessocially…”

LEVELOFCAREPLACEMENT

ASAMPPCLevels of Care

Level0.5: EarlyInterven:onLevel1: Outpa:ent

Level2: IntensiveOutpa:entand Par:alHospital

Level3: Residen:al/Inpa:ent

Level4: Hospital

ASAMCriteriaCrosswalk

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Ra:onaleforlevelofcare•  Appropriateintensity•  Appropriatemodali:esandservicecomponents

•  Inpa:entvsoutpa:ent•  Flexiblemovementupanddownlevels

•  Anytreatmentisagoodstart…

Considera:onsforlevelofcareDim1

•  Medicaldetoxneedsresiden:al•  Dangerouspersistentintoxica:onneedsresiden:al

•  Withdrawalwithnon-medicaldetoxneedshigherLOC


•  Physicalsymptomsneedaccesstomedicalcare

•  Severemedicalillnessneedsresiden:alifmanageablethere

•  Pregnancymayneedresiden:al


•  Dangerousnessneedsresiden:al•  Psychiatricproblemsneedaccesstomentalhealth/psychiatricevalua:onandtreatment

•  Mentalhealthseverityneeds“dualdiagnosisenhanced”servicesandhigherLOC

•  Persistentmentalhealthproblemsneedslongerdura:on


•  Lowmo:va:onsome:mesneedshigherintensity

•  Butpersuasionsome:mesworksbeCerwithgradualexposureoverlongeratlowerintensity

•  Highmo:va:onsome:mesneedslowerintensity

•  Butsome:mescantakeadvantageofhigherintensityfortherightopportunity


•  Dangeroususe,moreconsequencesneedshigherLOC

•  DifficulttointerruptuseneedshigherLOC

•  OpioidsneedhigherLOC

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•  Lackoffamilysupportneedshigherintensity,higherLOC

•  Familydisorganiza:onneedshigherfamilyinterven:onintensity

Adolescent Treatment Models (ATM) Change in Substance Frequency Index

by Level of Care

\a Source: Adolescent Treatment Model (ATM) data; Level of cares coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.

Change in Substance Frequency Index T-Score (TSFI)by Level of Care\a

40

50

60

Intake 3 6 9 12

Months from Intake

STR\t,s,ts

LTR\t,ts

OP\t,s,ts

CASEILLUSTRATION

AdolescentCaseHistory(I)•  16girlreferredfromdeten:onforevalua:on

•  Substances:MJonset12,progressingtodailyby15.Alcoholonset13,withweekendbingestosevereintoxica:on.Sporadicexperimenta:onwithnasalcocaine,hallucinogens,andprescrip:onopioids.Abs:nencebyconfinementwhileindeten:onforthepast3weeks.Hadafewsessionsofsubstanceabusecounselingseveralmonthsago,butmostlynoshowbecausefamilycouldn’t“makeher”aCend.

•  Family:LiveswithGM.Fincarcerated,liClecontact.Mhxaddic:onand“breakdown”.

Adolescentcasehistory(I)•  Personal:Allega:onofmolesta:onbyneighborage9.

Sexuallyac:vesince13,8life:mepartners,currentunprotectedsexwitholderboys,owenwhileintoxicated.Poorschoolperformance,repeated3rdgrade,toldshewasa“slowlearner,”nospecialedservices,mul:plesuspensionsfordisrup:vebehavior,assignedto10thgradebuttruantmostofyear.Mostfriendsareinvolvedwithdrugsanddelinquentbehaviors.

•  Medical:Asthma,hxofchlamydia,S/Pspontaneousabor:on,chronicstomachaches.

•  Legal:ArrestedCDSpossessionschoolgrounds14,chargesdropped.Receivedproba:on14forassault.Housearrest15forCDSintenttodistribute.Deten:on3weeksagoforVOPthewandUUV.

Adolescentcasehistory(I)

•  Psychiatric:InaCen:onandhyperac:vitysincechildhood,notx.Chronicemo:onallabilityanddysphoricmood,tantrums,explosivetemper,muchworsesinceonsetofsubstanceusepastfewyears.Progressivelyopposi:onalandungovernableathome.Staysawayfromhomehabituallyun:llateandranawayovernightonce.Chronicnighsmeinsomniaandsleepinglate,withsleep-wakecycledisrup:on.SaysMJhelpsher“chill”andavoidfightswithpeers.SeveralaCemptsatfamilyandschoolcounseling,butneversustained.Noformalpsychevalua:on.Insomniaandirritabilityworsesincediscon:nua:onofMJ3weeksago.

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DimensionalAssessment,TreatmentService,AndPlacementConsidera:ons

Dimension1 •  Assessment.Abs:nentfor3weeks,somemild“subacute”persistentabs:nenceeffectsofinsomniaandirritability.

•  TreatmentServiceNeeds.Needseduca:onresleephygieneandinsomniaaspoten:alrelapsetrigger.Considermildtemporarysleepaid(egdiphenhydramineorlow-dosetrazodone).

•  Placement.DimensionalserviceneedsmetbyLeveIIplacement(andcouldbeaddressedinanylevelofcare).


Dimension2

•  Assessment.Noacuteproblems.•  TreatmentServiceNeeds.Needsgeneralhealthmaintenance.NeedsSTDscreening,contracep:onservicesandsexualriskbehaviorcounseling.Considerexacerba:onofreac:veairwaysdiseasefromheavyMJuse.

•  Placement.DimensionalserviceneedsmetbyLeveIIplacement.


Dimension3

•  Assessment.Significantaffec:vedisturbancewithoutevalua:onortreatment.Noimminentdangerousness.Socialfunc:oningsignificantlyimpairedintheschool,legalandfamilydomains.Emo:onal/behavioralsymptomshavecausedsevereinterferencewithaddic:onrecoveryeffortsthroughlackofcoopera:onwithtreatment,deviantpeergroupaffilia:on,andself-professedpsychologicalbenefitsofsubstanceuse.Impairedabilityforselfcarecharacterizedbyongoingsexualriskbehaviors.

•  TreatmentServiceNeeds.Needspsychiatricevalua:on,includingconsidera:onoftreatmentforaffec:vedisorder.Needsprogramma:ctreatmentsesngforimplementa:onandclosemonitoringofpsychiatrictreatment(pharmacologicaland/orpsychotherapeu:c).Needsatleastmoderatelyhighintensitydailystructureandassessmentofbehavioralresponse.


Dimension3•  Placement.Dimensionalserviceneedsprobablymetby

LeveIII.5placementwithpsychiatrictreatmenteitherbuiltintothesubstanceabuseprogramorprovidedthroughcoordinatedpsychiatricservices.(Considera:onmightreasonablybegiventoaLevelIII.5placement,especiallyifaddi:onaldetailsofassessmentorlackofprogressatLevelII.5suggesttheneedforhigherintensityincluding24hrstructureandboundariesunavailableinthehomeenvironmenttopreventfurtherdeteriora:onofsocialfunc:oning.)


Dimension4

•  Assessment.Currentlyinpre-contempla:vestageofchange.Seesherselfashavingaproba:onofficerproblembutnotasubstanceproblem.

•  TreatmentServiceNeeds.Needssignificanttreatmentfrequency,intensityandaprogramma:cmilieutosupportmo:va:onandprogressionthroughthestagesofchange.Needsmo:va:onalenhancementtherapy(MET)techniquesincludingfunc:onalanalysisofprosandconsofsubstanceuse,aswellasjuvenilejus:celeverage(suchasproba:onarymandate)toimprovetreatmentengagement.

•  Placement.DimensionalserviceneedsmetbyLeveIII.5placement.


Dimension5•  Assessment.Despitebriefabs:nencebyconfinement,no

appreciableacquisi:onofrecoveryskillsandremainsatveryhighriskofimmediatecon:nueduse/relapseandfunc:onaldeteriora:on.HasnotbeenamenabletopreviousLevelItreatmentbecausewouldnotaCend.

•  TreatmentServiceNeeds.Needsnear-dailymonitoringandstructuretoovercomepaCernofhabitualuse,impulsivebehaviorsandsuscep:bilitytorelapsetriggers.Needsrelapsepreven:oninterven:onsincludingrelapsetriggeriden:fica:onandrefusalskillsrehearsal,guidanceinsupportofalterna:veprosocialleisureac:vi:esandpeergroup.


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Dimension6•  Assessment.GMissuppor:vebutlacksthepersonalresourcestoeffec:velysustaintreatment.Peergroupispredominantlysubstanceusing.

•  TreatmentServiceNeeds.Needsfamilyinterven:onincludingtrainingforGMonmonitoring,homebehaviornego:a:onandmanagement,u:liza:onofservicesandsystem(juvenilejus:ce)leverage.



IntegratedMul:-DimensionalPlacement •  BasedonthecriteriaforeachoftheindividualassessmentDimensionsabove,thePPCdecisionrulesleadtoanoverallrecommenda:onforaLevelII.5placement.

Varia:onA•  Runsawayawer2nddayinII.5

Varia:onB•  Whileindeten:onshewasinvolvedinrepeateddangerousaggression

Varia:onC•  Theevalua:onwaspostponedun:l2weeksawerreleasefromdeten:on,duringwhich:meherexperimenta:onwithoxycon:nhasprogressed

Varia:onD•  Sheremainsabs:nentduringthefirstweekofLevelII.5,aCendsseveral12stepmee:ngsandissurprisedthatit’s“notasstupidasIthought…”,

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Varia:onE•  Shehasapsychiatricevalua:on,beginstoseeatherapist,andisconsideringanan:depressanttrialthoughhasconcernsthat“I’mnotcrazy…”

Varia:onF•  Missesseveraldaysduring1stweekofII.5andreportsuseofMJandalcoholoverweekend

Varia:onG•  Shedoesn’tshowupatII.5,GMsays“can’tmakehercome..”

VariantH•  Primarysubstanceisheroin

Varia:onI•  ShehashadnumerouspreviousfailedaCemptsattreatment

Varia:onJ•  Shehashadpreviouspsycho:csymptomsduringperiodsofheavycannabisuse.Slightlysuspiciousnow“youallaretryingtogetmeintoodeep…”

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TakeHomeMessages

•  ThesixASAMCriteriaassessmentdimensionsarehelpfultoguidetreatmentandplacement

•  Treatmentplanningisbasedonindividualizedneedsofthepa:ent

•  Bethoughxulaboutwhogoeswhereandwhoneedswhat

•  Treatmentengagementisagreatplacetostart•  Adaptflexiblytotheadolescentandfamilyinfrontofyou

•  Alwayshaveaplan!

Hypothetical Miracle Cures

TreatmentWorksResources

LighthouseInsRtute,ChestnutHealthSystemshCp://www.chestnut.org/LI

NaRonalInsRtuteonDrugAbuse(NIDA)hCp://www.drugabuse.gov

hCp://www.drugabuse.gov/pa:ents-families

NIDAforteenshCp://teens.drugabuse.gov

ThePartnershipatdrugfree.orghCp://www.drugfree.org

SAMHSAco-occurringinfohCp://www.samhsa.gov/co-occurring/

Resources

SAMHSA’sRegistryofEvidence-BasedProgramsandPracRceshCp://www.nrepp.samhsa.gov/ViewAll.aspx

SAMHSA’sWebGuide

hCp://www.samhsa.gov/ebpwebguide/

housekeeping using the asam criteria to guide assessment ... training you… · 3/19/19 1 using the...

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