Challenging Drug Court Case
BJA Drug Court Technical Assistance Project at American University
April 19, 2016
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
davidmeelee@gmail.com
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Reasons for this Challenging Case
• My colleague and I have been listening in on Dr.
Mee-Lee’s webinars and have been learning different
ways to articulate cases to the drug court team,
finding it quite useful when presenting the needs of
individualized treatment.
• This particular client came to mind because she has
been on the program 16 months (typically can be
complete in 12 months) and has not yet been able to
move past Phase I.
• As it stands now, in our drug court program there are
3 phases and 4 levels of treatment; she is currently in
Level II. In order to graduate the participant must
have at least 120 days clean.
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Questions
1. Where should my focus be with this client if she is to
be successful in this drug court program?
2. Can someone with psychosis be successful in a
drug court program?
3. Is there such thing as too much treatment? And
where does the line get crossed?
4. What might we be overlooking?
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Demographics
• Client is 38-year-old Caucasian/White (Self-described as
"White") female who is divorced and has 4 children ages 21, 13,
9, and 5.
• Unemployed, with no intentions to work at this time and recently
approved for SSI.
• Currently resides at violence protection women’s shelter.
• In December, 2014, client referred to county drug court following
witness tampering charge given to her during her son’s
sentencing hearing. Her son remains incarcerated.
• Client raised in Georgia, now residing in New Hampshire due to
charges, claims Vermont is where she would like to be, and
describes herself as a believer in God.
• Reports feeling “proud” that “my children were raised as
Christians.” She currently does not attend church.
• Client dropped out of high school in 11th grade when she gave
birth to her son; has GED.
• Unable to drive due to her seizure disorder.
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Key Findings
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This writer/clinician has been working with client since December 2015, has had
5 one-hour individual sessions and facilitated 4 three-hour IOP sessions at
which client was present.
Over course of this time, client has had 3 positive urine screens (1 for
codeine/morphine [01/21/2016], 2 for alcohol [12/21/2015 & 01/11/2016]). All of
which she declined use, placing blame on eating an everything bagel and
drinking from a universal pitcher at the shelter she resides.
On 01/15/2016, client found out she was pregnant while at a checkup.
Client had sleep study 02/01/16-02/05/16 to observe for epilepsy; it was found
that her seizure activity was most likely psychogenic in nature & not epileptic.
Client decided to terminate her pregnancy on 02/08/16.
Client voluntarily checked herself into inpatient psychiatric hospital on 3/14/16
because of suicidal ideation and started drinking to “avoid using [heroin].”
She discharged herself in fear of losing her housing on 3/21/2016. She began
having auditory & visual hallucinations and checked herself back into the
hospital on 3/25/2016 and again discharged herself on 3/30/16.
Since this date she has drank on 2 more occasions, self admittedly to “get rid of
the hallucinations.” Client reports “the only positive thing right now is that I’m not
using[heroin].”
Aware that she can become extremely anxious, desperate, and escalated when
upset.
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Background
• In February 2015 client suffered her first reported seizure on the
Drug Court program, which led to a head injury.
• Head injury resulted in loss of her ability to taste and smell. She
appeared to struggle reading and comprehending written
material post head injury.
• Client reports she first used cocaine at age 23 and opioid use at
age 32. Also has a history of amphetamine and gabapentin
abuse within the last year.
• Client is currently on several medications: Buprenorphine,
Sertraline, Hydroxyzine, Seroquel, Topomax, Gabapentin.
• At her most recent stay in hospital she was given diagnoses of
F33.3 Major Depressive Disorder, with psychotic features,
recurrent; F11.20 Opioid Use Disorder, Severe, on Maintenance
therapy; F10.10 Alcohol Use Disorder, mild; F32.2 PTSD;
F17.200 Tobacco Use Disorder, severe; Seizure disorder,
Hepatitis C (untreated), TBI. Client displays Cluster C
personality disorder traits, more specifically dependent.
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Background (cont.)
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Client’s 2 youngest children were adopted by open adoption Summer
2015. She has had constant contact with her son who was incarcerated
to the point of speaking with him every day, and blaming herself for his
incarceration, saying on many occasions that she should be the one in
prison for five years, not him.
Her oldest son remains incarcerated and unable to make contact with
him due to her charges.
She has partial custody of her second child and able to see her on
weekends. Client self-reported having to drink in order to succumb to
her child’s father sexually in order for him to allow the visitation.
Client reports having A/V hallucinations during past pregnancies
starting in 2010.
Approximately a year ago, she was involved in a relationship with a
man who was in recovery. Client moved in with the man shortly after
relationship began, leaving her sober living environment.
Client reports the man began to sexually abuse her regularly. Client
able to leave relationship & resided with ex mother-in-law for a time.
This was catalyst for client to seek additional outpatient counseling with
a trauma specialist.
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Background (cont.)
• Client was seeing a trauma informed therapist twice a week
from July 2015 to early March. She reports having to drop her
services due to insurance changes and described this therapist
as her “best friend.” Client has referred to treatment providers
prior to drug court as “friends” and “family.”
• Client currently attends a 1 hour trauma informed peer support
group each week. Client sees counselor at Medication-Assisted
Treatment (MAT) clinic 1-2 times/week. Client sees a case
manager at least once a week through drug court.
• Client sees this writer/clinician once weekly for individual and
attends 2-three hour drug court groups weekly.
• Other drug court obligations are 5 meetings of self-help groups
weekly and 5 random UA screenings weekly.
• Client’s GAIN assessment from Dec. 2014 stated: reported a
lifetime history of being beaten, sexual abuse, emotional abuse;
and scored in the high range of the lifetime General
Victimization Scale.
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Formulation
• Client has significant mental health and personality disorder
symptoms.
• Stressors of being on a drug court program seem to have been
detrimental to client’s state. This supported by progression of
her seizure activity and TCU CESTs provided throughout her
time on drug court. (TCU CJ Client Evaluation of Self and Treatment (TCU CJ
CEST) records offender ratings of the counselor, therapeutic groups, and the program in
general)
• Client has poor boundaries that appear to not have been
supported by other professionals; or this seems to be case from
what client has reported and her perspective of professionals.
• This clinician has good/healthy boundaries and client has said
several times “I didn’t know if this was going to work out
between us”, which seems to play into the lack of trust client
appears to have in this developing therapeutic relationship.
• It seems that client is involved in too many services which
appear to be enabling client’s dependent personality traits.
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Interventions and Plans
• This clinician has tried to provide drug court and
judge information from the start of working with client
to support her in finding alternative treatment for
client given her mental health status even before the
episode of psychosis was present.
• Recently this clinician was able to formulate a plan of
reducing amount of meetings and treatment groups
client is required to do.
• This clinician also verified with case manager that
client would not lose her housing at the shelter if she
sought inpatient treatment for a longer period of time.
Client was referred to inpatient treatment on 4/12/16.
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Reasons for this Challenging Case
• My colleague and I have been listening in on Dr.
Mee-Lee’s webinars and have been learning different
ways to articulate cases to the drug court team,
finding it quite useful when presenting the needs of
individualized treatment.
• This particular client came to mind because she has
been on the program 16 months (typically can be
complete in 12 months) and has not yet been able to
move past Phase I.
• As it stands now, in our drug court program there are
3 phases and 4 levels of treatment; she is currently in
Level II. In order to graduate the participant must
have at least 120 days clean.
w w w. c h a n g e c o m p a n i e s . n e t
Questions
1. Where should my focus be with this client if she is to
be successful in this drug court program?
2. Can someone with psychosis be successful in a
drug court program?
3. Is there such thing as too much treatment? And
where does the line get crossed?
4. What might we be overlooking?
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Clarifying Questions
1. For what diagnosis or diagnoses was the client "recently
approved for SSI"? Was it for a psychosis mental health diagnosis
or seizure disorder or both or something else?
2. Were the client’s auditory and visual hallucinations time-wise,
related to drinking or drugging? Or did they occur during significant
periods of being alcohol and other drug abstinence?
3. Do you know the longest time she has ever been abstinent, or
better still in recovery and sober? Did she have any mental health
signs and symptoms during the time of abstinence or sobriety?
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Clarifying Questions
4. Does the client believe she has an addiction illness? Does she
think she has a mental illness and if so, what is the diagnosis she
believes she has? Does she think she has addiction AND mental
illness, either or both?
5. What were the circumstances of the Feb., 2015 seizure? Was
she in a clinical setting or at home? Had she been drinking and
could she have had a withdrawal seizure? Was she intoxicated or
recently using substances at the time of the seizure?
6. Is there a Mental Health Court or a Co-Occurring Disorders
Court available? Or is there only a Drug Court available?
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INDIVIDUALIZED, CLINICALLY &
OUTCOMES-DRIVEN TREATMENT
ASAM Principles of Addiction Medicine
5th Edition, 2014
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The ASAM Criteria
Multidimensional 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
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Criminogenic Factors/ASAM Criteria Dimensions
Criminogenic Factors
• Antisocial values,
attitudes, behavior,
personality
ASAM Criteria Dimensions
• Criminal/deviant peer
association
• Substance abuse
• Dimension 6
• Dysfunctional family
relations
• Dimensions 3, 4 and 6
• Dimensions 1, 4, 5, 6
• Dimension 6
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Biospychosocial Treatment
Treatment Matching - Modalities
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Motivate - Dimension 4
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Manage – All Six Dimensions
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Medication – Dimensions 1, 2, 3, 5 - MAT
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Meetings – Dimensions 2, 3, 4, 5, 6
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Monitor- All Six Dimensions
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The ASAM Criteria
Treatment 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
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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
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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
The ASAM Criteria pp. 132 -143
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Withdrawal Management Services for
Dimension 1 (continued)
Level 3.2- WM- Clinically-Managed Residential
Withdrawal Management
Level 3.7- WM - Medically-Monitored Inpatient
Withdrawal Management
Level 4-WM - Medically-Managed Inpatient
Withdrawal Management
The ASAM Criteria pp. 132 -143
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Level 1 and 2 Services
Level 1
Outpatient Treatment
Level 2.1 Intensive Outpatient Treatment
Level 2.5 Partial Hospitalization
The ASAM Criteria pp. 184 -218
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Level 3 Residential/Inpatient
Level 3.1- Clinically-Managed, Low Intensity
Residential Treatment
Level 3.3 - Clinically Managed PopulationSpecific High Intensity Residential Treatment
(Adult Level only)
The ASAM Criteria pp. 222 -243
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Level 3 Residential/Inpatient (cont.)
Level 3.5- Clinically-Managed, Medium/High
Intensity Residential Treatment
Level 3.7- Medically-Monitored Intensive
Inpatient Treatment
The ASAM Criteria pp. 244 -279
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Level 4 Services
Level 4 Medically-Managed Intensive Inpatient
The ASAM Criteria pp. 280 -290
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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
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Focus Assessment and Treatment (cont.)
DSM-5 diagnoses?
Multidimensional Severity/LOF Profile
Which assessment dimensions are
most important to determine Tx priorities
The ASAM Criteria p 124
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Focus Assessment and Treatment (cont.)
Specific focus/target for each priority dimension
What specific services needed for each dimension
What “dose” or intensity of these services needed
The ASAM Criteria p 124
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Focus Assessment and Treatment (cont.)
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
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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
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Resources
www.tipsntopics.com
www.ASAMCriteria.org
www.changecompanies.net
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gecompanies.net
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David Mee-Lee, M.D.
Senior Vice President
The Change Companies
Carson City, NV
www.changecompanies.net
www.ASAMCriteria.org
www.tipsntopics.com
davidmeelee@gmail.com
Justice Programs Office
justice@American.edu
Join us Wednesday, April 27th at 11am Eastern for the next
session entitled “How Do We Get There from Here?”
https://bja-au.webex.com/bjaau/onstage/g.php?PRID=a6642d1af8e20bd689ac7433ee634daf
These 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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