There is exciting news in the addiction treatment industry. The American Society of Addiction Medicine (ASAM) has just released its fourth edition of the ASAM Criteria:

The ASAM Criteria is the most widely used and comprehensive set of standards for placement, continued service and transfer of patients with addiction and co-occurring conditions. Formerly known as the ASAM patient placement criteria, the ASAM Criteria is the result of a collaboration that began in the 1980s to define one national set of criteria for providing outcome-oriented and results-based care in the treatment of addiction.

This new ASAM 4th Edition is an update of the 2013 ASAM 3rd Edition.  As such, the new edition reflects yet another decade of ASAM’s evolution and unmatched expertise that now spans 40 years. ASAM is without question the most respected source for clinical best practices in the administration of evidenced-based diagnostics, treatment and recovery monitoring support for substance use disorders.

Of particular interest to the Tennessee Lawyer’s Assistance Program (TLAP), and other Lawyer Assistance Programs (LAPs) across the nation, there are updates to the extensive chapter on “Supporting Patients Working in Safety Sensitive Occupations.”

Earning Public Trust

ASAM recognizes that certain industries, by definition, have a responsibility to the public. These industries include: 1) Health care (doctors, nurses, pharmacists, etc.); 2) Transportation (pilots, truckers, railroad conductors, marine captains, etc.); 3) Security and Armed Forces (military, police, firefighters, paramedics, etc.); 4) Energy (nuclear power workers, oil rig workers, etc.); and 5) Public Administration (judges, lawyers, politicians, etc.).

What do workers in all of these industries have in common? They must earn the public’s trust by demonstrating a commitment to perform their occupational duties free from impairment. Moreover, licensing authorities such as federal regulators, state medical boards and state supreme courts have a duty to reliably address fitness issues and responsibly protect the public from the harm that an impaired professional in its industry can cause.

Per ASAM, these “distinct occupational and public safety considerations add a layer of complexity to addiction treatment for workers in safety-sensitive industries.” As such, regulatory authorities can, and often do, consider medical recommendations generated by medical providers and recovery monitoring providers that are accomplished in the proper application of the ASAM Criteria.

A Continuum of Care

In addition, ASAM recognizes that a well-integrated continuum of care is the most important component of the support system in these cases. Per ASAM, profession-specific monitoring and case management programs, with peer-support groups, such as LAPs and the ABA’s Commission on Lawyer Assistance Programs (CoLAP), Physicians Health Programs (PHPs) and the airline pilots’ support program (HIMS) can be critical to recovery success and should be considered an integral part of the continuum of care.

In fact, per ASAM: “The combination of effectively managed initial treatment and long-term contingency contracting [monitoring] could be an ideal approach for addiction care in the United States.”     

The level of care for assessment, treatment and recovery monitoring for safety-sensitive workers is expected to minimize risks to the public and generate the very best recovery outcomes for the individual. The data on long-term recovery outcomes, without relapse, is astoundingly positive.

As for TLAP in particular, its participants are benefitting from support that reflects best practices in recovery monitoring. In 2022, TLAP’s program generated an 85% no relapse rate in substance use disorder cases. In 2023, TLAP’s program recovery rate rose even higher: its participants benefitted from an 88% no-relapse rate. Of the few participants who experienced a relapse while under TLAP monitoring last year, the majority followed TLAP’s recommendations to clinically address the relapse and then resumed monitoring without further complication. As such, TLAP’s programming generated a 95% overall retention success rate in recovery.

TLAP effectively supports its participants while also objectively meeting the expectations of the Tennessee Supreme Court, the profession and the public by delivering “top-tier” peer-monitoring services that work. If you want to learn more, visit www.TLAP.org for additional information.

Assessment, Residential Facilities

The ASAM Criteria’s chapter on safety-sensitive occupations is an extensive and comprehensive body of work and a full traversal is beyond the scope of what can be covered here; however, we can highlight some of the main components that generate such amazing no-relapse addiction recovery rates. For one, a careful assessment of the patient’s condition is indispensable at the outset. Sometimes, a patient may be highly motivated to underreport symptoms or otherwise intentionally evade being diagnosed with a substance use disorder so as to avoid real or perceived licensure issues. According to ASAM, treatment should not commence without a truly comprehensive and reliable assessment.

These types of assessments often include collateral information from family, workplace supervisors, co-workers and the referring monitoring entity, for instance. Drug screening lab work and psychological testing are also conducted as per the assessment team’s recommendations.

When an assessment is complete, and it comes to treatment recommendations for safety-sensitive workers, the severity of illness is considered. Special focus, however, is also placed on the expected outcome of the recommended treatment. The expectation is that the level of treatment will generate recovery without any recurrence of substance use. This level of care supports both occupational and public safety. Residential levels of care tend to be the de facto initial treatment.

In addition, the utilization of profession-specific and specialized treatment facilities is recommended. These specialized programs are not located in every city, or even in every state; thus, travel to a facility may be necessary. Locally available levels of care may lack the resources, safety-sensitive expertise and/or willingness to objectively determine fitness to practice.

Profession-specific facilities typically have familiarity with safety sensitive work environments in each profession and have staff that can manage dynamic defenses (such as intellectualization seen in highly educated patients). Empathy is needed to support processing the stress and trauma that often accompanies a certain profession, as well as an understanding of the political context of a particular occupation and how best to support the patient’s reintegration into the work environment.

Medications, Monitoring

The new ASAM Criteria also recognizes that in some cases medications may be a critical component of a treatment plan. Regarding the use of any medications when returning to work, however, ASAM adds: “Though addiction medications may be useful components of treatment plans and return-to-work agreements, clinicians need to carefully consider the use of long-term medications.” ASAM recommends that the monitoring organization (LAP, PHP, HIMS) should be consulted early in the treatment planning process to support best long-term outcomes and prevent professional damage. Also, the relative risks of both misuse and potential adverse neurocognitive effects of medications should be carefully considered.

Another valuable update from ASAM focuses on the appropriate length of post-addiction treatment recovery monitoring, which is typically five years, with an option to voluntarily extend monitoring if the participant feels it would be beneficial.

When it comes to monitoring program lengths, it is critical to recognize that addiction is a very serious, chronic illness that cannot be cured. The mission is to monitor and support recovery for a necessary period to support lifelong full remission from the disease thereafter.

The importance of five years of continuous addiction recovery began in 2003 with a Harvard medical study that focused on recovery rates from alcoholism in the general population over the course of a 60-year period of time.1 It established that alcoholism is, just like cancer, a chronic disease that cannot really be considered in complete, full remission until there has been no relapse for a period of five years: “In short, analogous to cancer patients, a follow-up of five years rather than of one or two years would appear necessary to determine stable recovery.”

Since then, and over the course of decades, numerous studies and data have confirmed the importance of five years of post-treatment monitoring.

The Social Contract

A full chronology of studies and reports on monitoring lengths can be viewed at www.tlap.org/faqs under “How are TLAP Monitoring Lengths Clinically Determined?” There you will find full information about five-year monitoring lengths, as well as additional information about clinical circumstances that may support shorter monitoring lengths.

On yet another note, the new ASAM chapter on safety-sensitive occupations recognizes what many call “The Social Contract” that applies to the privilege of professional licensure. Safety-sensitive industries are all governed by their own standards for professional conduct to which their workers must abide. Moreover, in exchange for this privilege, these industries have a societal obligation of self-regulation and to ensure that its professional standards are upheld, including fitness to practice.

Finally, against the backdrop of all the above, TLAP and its participants are grateful to ASAM and the level of care it recommends for judges and lawyers. Addiction is getting stronger, not weaker. Never before have so many dangerous drugs been so easy to get. At the same time, however, TLAP’s programming is also getting stronger, and TLAP’s participants are winning their war against the chronic disease of addiction. |||

BUDDY STOCKWELL was appointed by the Tennessee Supreme Court in July 2020 as executive director of the Tennessee Lawyers Assistance Program (TLAP). He comes from south Louisiana where he has been a volunteer and program monitor for the state’s Committee on Alcohol and Drug Abuse and the executive director of Louisiana’s comprehensive Judges and Lawyers Assistance Program (JLAP) peer professionals’ program. He is a certified clinical interventionist through “Love First” training at the Betty Ford Center and has personally been in recovery from alcoholism for over 38 years. Stockwell earned his law degree from LSU Law School in 1993. He practiced in both large and small firm settings, including a solo practice in Baton Rouge where he focused heavily on domestic litigation. Read more about him at tba.org/Stockwell.

NOTE

1. G. E. Vaillant (2003). A 60-year follow-up of alcoholic men. Addiction, 98(8), 1043–1051.