ASAM Criteria Unplugged: A conversation with Dr. David Gastfriend

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Dr. David Gastfriend is an addiction psychiatrist. At Harvard, he directed Massachusetts General Hospital’s Addiction Research Program. His research has led most U.S. states to endorse the American Society of Addiction Medicine (ASAM) Criteria. His 150 publications include The ASAM Criteria and Addiction Treatment Matching. His ASAM Criteria CONTINUUM® software is being adopted nationwide. In 2016, Dr. Gastfriend co-founded DynamiCare Health, which is a nationally scalable technology for contingency management and predictive analytics.

Sitting down with The Change Companies Chief Program Officer Valerie Bagley and Train for Change Senior National Director Scott Boyles, Dr. Gastfriend shares his insights on contingency management and the continuum of care.  

Q: What is new and important to know about the ASAM Criteria Fourth Edition?

Dr. Gastfriend: "So the ASAM Criteria was, until now, a consensus-based system — expert consensus. And the computerized version, which became CONTINUUM, has undergone a substantial amount of research demonstrating the validity of the ASAM Criteria. But for the Fourth Edition, we knew from empirical experience — because we've now gathered over 800,000 computerized clinical assessments using CONTINUUM with 8,000 counselors across the country — that there are problems with it. It's complex. It's hard to understand. It doesn't address the continuity of care and the whole patient experience as well as it needs to, especially in this era of America's drug epidemic.

So for the Fourth Edition the thinking was really broadened, and it started with extensive literature review and a standardized method of extracting data from the literature and digesting that with expert review... Then it became a concern among a lot of the leadership in ASAM that we don't have properly integrated care for people with addictions. It's very fragmented, and every fragmentation gap results in people falling through the cracks because of the nature of the disease.

It's very hard if you have this disease to persistently follow through with all the different providers. 'I need one provider for my buprenorphine, a different person if I want counseling, a different person for my medical problems...' And if we think of the Fourth Edition as aspirational — where the field wants to get to so that we have truly modern treatment like the rest of healthcare — then we need to create a system that integrates.

So the Fourth Edition has sought to improve all of those challenges. And I think it does a really great job of that, but it'll take years for us to fully get there."

Q: Can you share more about the rationale behind dimension six and how it's going to help us better meet individualized needs?

Dr. Gastfriend: "One of the benefits of having used the CONTINUUM system and the short CO-triage assessment is that we were able to ask, when you got this recommendation for a level of care, where did the patient actually get set or go to? And we learned that a substantial proportion of patients did not go to the recommended level of care. And in the software, we were able to quantify how often and for what reason this placement isn't [conforming] to the recommendations.

What we found was that a substantial proportion of patients don't want to go to the level of care that's recommended, have obstacles in making use of such a program — so, for instance, if they have childcare obligations or other caregiving obligations, like with seniors, if they have employment that they'll lose, if they have maybe a panic disorder and being confined in a residential program — could cause them to reject a recommended residential level of care. So there are multiple possibilities, and we decided 'Let's calculate first the recommended level of care, but then let's use the final dimension to assess the patient's willingness and acceptability and the suitability of the program.' 

And that really becomes a treatment planning step. So we should be recording what the recommended level of care is based on the five dimensions, one through five. And then we should still do the assessment of the sixth dimension, which is now the patient-centered needs. And if the patient says, 'I won't do that, but I'll do this', then — on a harm reduction basis — we should work with the patient on that.

Now, sometimes we need motivational enhancement to help the patient understand why the recommended level is so important, but maybe we won't succeed. And maybe the circumstances of the patient's life won't really allow them to accept that. So we need to document the reasons for the alternative placement. And we want to contract with the patient that if this lower level of care that they're only willing to do doesn't work out, that they understand the recommended level of care is more intensive. And we should have a contingency agreement with them.

So it's more flexible. It takes into account patient-centered needs, but it doesn't evade the medical necessity of a level of care that would be optimal for the patient's outcome."

Q: Can you walk us through the practice of contingency management?

Dr. Gastfriend: "Contingency management is based on operant conditioning and behavioral economics and, to some extent, gamification... Contingency management has been shown to be the most effective treatment behavioral treatment for substance use disorders for around 60 years now — since the 1960s. It is effective in all kinds of patients with all the different substances and in all kinds of settings — inpatient, outpatient, MAT, abstinence model, harm reduction. It's an extremely versatile model.

Contingency management essentially rewards patients for changing their behavior. It gives patients an incentive and, in best practices, it rigorously determines that the patient has done the desired behavior so that you don't have an ability to cheat it. It then promptly rewards the patient."

"The most effective and the most preferred reward is a cash-equivalent reward, essentially money. And we now have technology that allows people to be paid all kinds of amounts of money very promptly on a debit card... optimally a smart debit card for protection against relapse and for accountability. 

So contingency management literally pays people money to change their behavior. By the way, that's the way civilization works. Anybody who got their first job and recalls how annoying and tiring and brain numbing it was understands that for money, it was worth changing my behavior."

"Dopamine is getting released every time the patient is using drugs. They stop using drugs, and they have a deficit of reward experience, of pleasure, of hedonic tone. And they're actually just dragging. Every day, they wake up, nothing to look forward to. And they're feeling like 'Today's the day I'm going to screw up.' They hear 'treatment' as 'don't, don't, don't'.

If they have contingency management rewards available — especially if they're available frequently, easily achieved, rapidly rewarded — they wake up in the morning and they want to know: what can I do today? what could work today? what can I get a reward for today? And it's more like 'yes, yes, yes.' So it changes the paradigm of early recovery."

"We do medication treatment for, you know, the physiologic receptor sites for management of withdrawal. We do talk therapies to address the cortex, where we do our thinking and reasoning. Neither of those are the actual source of the drugs of abuse effect on addiction behavior — that's in the reward center, deeper in the core of the brain. We're literally missing the source of the disease."

There are over 100 papers of controlled studies published in the peer-reviewed literature... They show that you consistently double abstinence rates. And that's 100% improvement over usual care alone... So that's starting to change and payers are now starting to cover contingency management."

Q: What role do progressive reinforcement schedules play in contingency management?

Dr. Gastfriend: "Ambivalence is very destructive to patient persistence and follow through. But with these rewards, we can convert that ambivalence into greater motivation for showing up to treatment, for paying attention to how am I doing today, for a little effort in between the week-to-week sessions to do some cognitive behavioral therapy work. And to trying to have some days of abstinence, so that maybe that random testing that I could be assigned... might be negative some days, and I could start getting those rewards. And then contingency management, the effective models, they have what's called a progressive reinforcement schedule.

So progressive reinforcement schedules are extremely powerful in capturing the brain's attention and changing ambivalence into motivation. And that's with points which have no dollar value. So when we've done this in the real world, paid for by insurance companies now, we see a doubling of abstinence rates — 100% improvement in rates of abstinence from alcohol, opioids, stimulants, tobacco, even youth nicotine vaping. 

So that's a massive improvement... It's actually changing somebody's life... Patient satisfaction ratings are through the roof. They don't experience it as coercive if it's truly geared to patient needs.

So you have to be able to do harm reduction with this. It's not just 'Everybody's got to be absent or they get nothing.' That's not a fair approach to a complex disease. But harm reduction is very feasible with these multiple behavioral options...

Just as that new sixth dimension of the ASAM Criteria calls for addressing patient motivation, the ASAM clinical practice guideline for stimulant use disorder specifically notes how difficult the ambivalence about recovery from stimulants can be. So it says the standard of care is contingency management for cocaine, for methamphetamines, any of the stimulants. That's because of how potent contingency management is for converting that ambivalence into motivation for treatment... The new ASAM clinical practice guidelines for the treatment of stimulant use disorders calls for routine use of contingency management for every patient."

Q: How do contingency management and community reinforcement approach work together?

Dr. Gastfriend: "Now, the ASAM clinical practice guidelines says that contingency management only has the best long term outcomes if you pair it with community reinforcement approach.

What is community reinforcement approach? Well it's also reinforcing, but instead of money, you're getting the patient to think, 'What are the opportunities in my real world for feeling gratification?' Might be getting my GED, getting a job, saving up for an apartment, rebuilding trust with loved ones or maybe having the first healthy relationship in my life... — but those are long term gratifications.

What we find is that we need to have a specialized person, a staff person who meets with the patient initially every week, and talks them through. 'You're doing well day-to-day now, you're out of the harm reduction phase, you've built some sobriety now... You're going to run out of your reserve account of rewards at some point in the next couple months — What are the big tickets successes you wish you could have had in life, but for your addiction?' And the patient thinks of what their community reinforcers might be. And then we help the patient break those down into little increments of progress to feel a sense of momentum.

As a result, they continue to experience the sense of rewards, but they're moving into healthy life rewards, which are the things the rest of us live for when we're healthy. And that's why at 12 months, we can achieve almost 50% retention, because they're still working on things they care about. But now, they're working on true recovery life goals."