Challenging Veterans Court Case
BJA Drug Court Technical Assistance Project at American University
May 3, 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
w w w. c h a n g e c o m p a n i e s . n e t
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.”
w w w. c h a n g e c o m p a n i e s . n e t
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).
w w w. c h a n g e c o m p a n i e s . n e t
Key Information (cont.)
HOUSING: Homeless upon entering Veterans Court. Obtained his own
apartment with VA/HUD assistance.
ANCILLARY: No drivers license or identifying immigration paperwork upon
entry into Veterans Court. Drivers license, military, and immigration
paperwork obtained.
TREATMENT: 6 week inpatient treatment the Ft. Harrison Veterans
Administration Hospital and 18 months VA outpatient treatment.
MENTOR: Assigned. Attended court every week. Regular in-person
communication.
RELAPSES: (1) Alcohol, two months post-inpatient treatment (9 months after
entering Veterans Court). LAC identified loneliness and holidays as a trigger.
(2) Alcohol, relationship with significant other ended (13 months after entering
Veterans Court). Never relapsed on drugs.
STRUGGLES: Interpersonal relationship boundaries. While in the Veterans
Court, acknowledged difficulties staying away from people who use drugs.
w w w. c h a n g e c o m p a n i e s . n e t
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.
w w w. c h a n g e c o m p a n i e s . n e t
Key Information (cont.)
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.
w w w. c h a n g e c o m p a n i e s . n e t
Key Information (cont.)
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 neverending 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.
w w w. c h a n g e c o m p a n i e s . n e t
Key Information (cont.)
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.
w w w. c h a n g e c o m p a n i e s . n e t
Key Information (cont.)
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.”
w w w. c h a n g e c o m p a n i e s . n e t
INDIVIDUALIZED, CLINICALLY &
OUTCOMES-DRIVEN TREATMENT
ASAM Principles of Addiction Medicine
5th Edition, 2014
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
Level 4 Services
Level 4 Medically-Managed Intensive Inpatient
The ASAM Criteria pp. 280 -290
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
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
w w w. c h a n g e c o m p a n i e s . n e t
Resources
www.tipsntopics.com
www.ASAMCriteria.org
www.changecompanies.net
w w w . c h a n28
gecompanies.net
w w w. c h a n g e c o m p a n i e s . n e t
w w w. c h a n g e c o m p a n i e s . n e t
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
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.
w w w. c h a n g e c o m p a n i e s . n e t