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Public safety and public health did not always know how to sit at the same table. For many years, addiction was treated mainly as a criminal justice problem, while clinicians saw the same people cycling through crisis, withdrawal, relapse, illness, arrest, and court. The systems touched the same lives, but they often worked from different maps.


The late Honorable Judge Seth Norman helped change that map.


In Davidson County, Tennessee, Judge Norman became a foundational figure in drug court work at a time when the model still faced doubt, resistance, and hard questions. Alongside early pioneers such as Kenneth Osborn, he helped make space for a new operating idea: courts could protect the public while also opening a structured path toward treatment, recovery, and restored responsibility.


Having worked with the man, you see this as a post that honors Judge Norman’s legacy and offers clinicians, public safety leaders, court professionals, treatment providers, and recovery advocates a clearer view of why his work still matters.


Wide-angle view of an empty courtroom bench with soft morning light.
Judge Norman in court

A judge who helped widen the purpose of the courtroom


A courtroom is usually built around decision, order, evidence, and consequence. It is not usually imagined as a place where public health practice can take root. Judge Seth Norman’s work in the Davidson County Drug Court helped show that the courtroom could become part of a larger care response without losing its public safety role.


That idea may sound familiar now. Drug courts, recovery courts, treatment courts, reentry programs, and specialty dockets are now part of many justice systems across the United States. They are debated, studied, revised, and adapted. Clinicians now often sit on multidisciplinary teams with probation officers, prosecutors, defense attorneys, peer support workers, case managers, and judges.


But in the early days, this was not obvious.


The older model was simpler on paper. Arrest led to prosecution. Conviction led to punishment or supervision. Treatment, if it happened, often sat outside the core justice process. People with substance use disorders moved between jail, emergency departments, detox programs, family crisis, homelessness, and short windows of forced abstinence. The public wanted safety. Families wanted help. Clinicians wanted continuity. Courts wanted compliance. Few systems knew how to build all of that into one working structure.


Judge Norman’s contribution was not merely procedural. It was cultural. He helped demonstrate that a court could ask more demanding questions than “What rule was broken?” A court could also ask:


  • What pattern keeps bringing this person back?

  • What level of supervision protects the community?

  • What clinical needs must be addressed for change to last?

  • What incentives and consequences help a person stay engaged?

  • What does accountability look like when addiction is part of the case?

  • How can public systems stop repeating the same failure?


Those questions did not weaken the court’s role. They made it more honest.


A drug court does not erase accountability. At its best, it makes accountability clearer, closer, and more frequent. Participants must return, report, test, engage, and face sanctions or rewards based on behavior. Treatment providers must communicate. Public safety staff must track risk. Judges must hold the center while respecting clinical realities.


That balance is difficult. Judge Norman’s legacy lives inside that difficulty.


The early resistance was real


Every major change in public systems meets resistance. Drug court work was no exception.


To some people in public safety, treatment-based court responses looked too soft. They feared that the court might excuse criminal behavior or place community safety second. To some clinicians, court involvement raised ethics questions. They worried about coercion, confidentiality, punishment for symptoms of illness, and the risk that legal pressure could distort the treatment relationship.


Both concerns deserved serious attention.


Judge Norman and those working with him had to operate in that tension. Kenneth Osborn’s role as an early pioneer belongs in that same story. The early builders of this work did not inherit a finished manual. They had to help form the working habits, shared language, and practical agreements that allowed public health and public safety to function together.


That required more than goodwill. It required structure.


Drug court models depend on a set of difficult agreements. The court must know enough about treatment progress to respond to behavior. Treatment providers must protect clinical integrity while participating in a legal process. Supervision officers must recognize both risk and recovery progress. Attorneys must preserve rights while allowing problem-solving practices to work. Judges must lead without practicing medicine from the bench.


Those boundaries are not always neat. In the early days, each one had to be tested, clarified, and defended.


The resistance also came from a deeper place. Many systems were built around separation. Courts handled law. Clinicians handled illness. Jails held people. Community programs treated people if they could reach them. Drug court challenged that separation. It forced professionals to admit that no single system could solve addiction, crime, poverty, trauma, and behavioral health needs alone.


That admission changed the work.


Eye-level view of a worn courthouse hallway with sunlight across the floor.
Change often begins in ordinary public spaces.

Kenneth Osborn’s place in the early bridge-building work


Kenneth Osborn’s work with Judge Norman speaks to a specific kind of leadership. It is the leadership of building in the middle, between systems that do not naturally trust one another.


Early public safety and public health collaboration demanded people willing to translate. A clinician might speak in terms of assessment, diagnosis, stage of change, relapse risk, trauma response, and level of care. A court professional might speak in terms of compliance, public risk, due process, violation, sanction, and case status. Both groups could be describing the same person, yet come away with very different conclusions.


Bridge-builders helped those groups hear one another.


Osborn’s contribution, as described in this acknowledgment, belongs to the practical side of reform. He worked in the early days of resistance, when the idea of bridging public safety and public health still needed proof. The task was not just to believe in the model. It was to help make the model operational.


That means asking grounded questions:


  • How should a participant enter the program?

  • What information should be shared with the team?

  • What information should remain protected?

  • How should relapse be understood?

  • When should relapse lead to treatment adjustment?

  • When should behavior lead to a court response?

  • How should progress be measured?

  • What does completion mean beyond simply finishing a checklist?


These are not abstract questions. They decide whether a treatment court becomes a pathway to recovery or another confusing stop in the justice process.


Judge Norman’s leadership gave the work judicial gravity. Osborn and other early collaborators helped give it operational shape. Together, their efforts point toward the model many professionals still seek today: one that is firm enough to protect the public and humane enough to recognize the clinical nature of substance use disorders.


What Judge Norman’s legacy teaches clinicians


Clinicians who work near the justice system often face a special strain. They must serve the person in care while navigating court orders, supervision requirements, reporting duties, and safety concerns. They may see the human being behind the charge more clearly than the system does. They may also see risk factors that a hopeful courtroom narrative can miss.


Judge Norman’s legacy offers several lessons for clinical professionals.


Treatment must be connected to real-world accountability


Recovery does not happen in a vacuum. Many people referred through courts face unstable housing, strained family ties, untreated mental health conditions, unemployment, transportation barriers, and long histories of distrust toward institutions.


A therapeutic plan that ignores those realities may look good in a file but fail in daily life.


Drug court practice, at its best, connects treatment goals to lived accountability. Participants are expected to show up, tell the truth, engage in care, and respond to setbacks. That structure can help some people remain connected long enough for treatment to take hold.


For clinicians, the lesson is not that court pressure is a treatment method by itself. It is not. The lesson is that structure, when used carefully, can support care. Clear expectations can reduce chaos. A reliable response system can help participants understand that choices matter and that setbacks do not have to end the process.


Relapse must be understood without being ignored


One of the hardest questions in treatment court work is how to respond to relapse.


A purely punitive model may treat relapse as defiance. A purely permissive model may fail to address rising risk. A clinically informed court has to hold both truths. Substance use disorder often involves recurrence of symptoms, and behavior still has consequences.


Judge Norman’s work helped advance a space where the court could respond with more nuance. That does not mean every relapse receives the same response. It means the team asks better questions.


Was the participant honest? Did they return to treatment? Did the use signal a need for higher care? Was there a pattern of avoidance? Did public safety risk increase? What support was missing? What condition needs adjustment?


Clinicians bring essential knowledge to those questions. Public safety partners bring essential context. The court holds the structure. The participant remains responsible for the next step.


Respect must be visible


People do not recover because a system labels them. They are more likely to engage when the system treats them as capable of change.


Respect in a treatment court setting does not mean praise without standards. It means the person is seen as more than a case number, charge, diagnosis, or relapse history. It means professionals speak plainly, set limits, and avoid humiliation. It means success is recognized, not just failure.


Judge Norman’s legacy is often described through the bridge between public safety and public health. That bridge rests on respect. Without it, collaboration becomes control. With it, accountability can become a path toward restoration.


What his legacy teaches public safety professionals


Public safety professionals carry a heavy public trust. Communities expect them to respond when harm occurs. Victims, families, neighborhoods, and local systems all feel the cost of untreated addiction and repeat justice involvement.


Judge Norman’s work did not ask public safety leaders to abandon that responsibility. It asked them to pursue it with a wider set of tools.


Risk can be managed with more than custody


Jail and incarceration have a role in public safety, but they cannot provide the full answer to addiction-driven justice involvement. Many people return to the same conditions that contributed to arrest. Without treatment, supervision, housing support, and recovery planning, the cycle often resumes.


Drug court practice created another option for certain cases. It gave the court a way to monitor behavior closely while requiring treatment participation. It allowed public safety partners to stay involved rather than simply waiting for the next arrest.


This is one of the most important parts of Judge Norman’s legacy. He helped show that public safety can include treatment engagement, frequent review, graduated responses, and coordinated care.


That broader idea has influenced many later models, including mental health courts, veterans treatment courts, reentry courts, and deflection efforts in some communities.


Accountability works best when it is predictable


People caught in addiction often live inside chaos. A system that responds randomly adds to that chaos. A system that sets clear rules and follows through creates a different environment.


Treatment courts use predictability as a public safety tool. The participant knows what is expected. The team knows what will be reviewed. Progress brings recognition. Violations bring response. Treatment needs bring adjustment.


For public safety professionals, this can create a clearer way to distinguish between noncompliance, clinical instability, rising risk, and genuine progress. It also gives the court a record of behavior over time rather than a single snapshot.


Predictability does not make the work easy. It makes the work more fair.


Close-up view of a wooden chair circle in a community room.
Recovery work often depends on steady, face-to-face support.

The Davidson County Drug Court as part of a larger movement


The Davidson County Drug Court stands in a larger national movement that changed how many communities think about substance use, crime, and recovery. Across the country, courts began experimenting with specialized dockets that brought justice supervision and treatment coordination into one process.


The movement grew because the old divide was failing too many people. Police officers encountered repeated addiction-related calls. Judges saw familiar faces return. Jails managed withdrawal and untreated mental illness. Hospitals stabilized people in crisis, then watched them return. Treatment providers struggled to keep clients engaged after court pressure ended or life instability returned.


Drug courts did not solve all of this. No single model can. They also brought valid concerns that the field continues to study and debate, including equity, access, participant rights, clinical quality, and appropriate responses to relapse.


A true acknowledgment of Judge Norman’s legacy should make room for that complexity. He helped build a model that later professionals must keep improving. Honoring him does not mean freezing the model in time. It means carrying forward the courage to revise systems when the old answers no longer meet the need.


The best legacy is not imitation. It is faithful continuation.


That continuation now shows up in many forms:


  • Courts that use validated screening and assessment tools

  • Programs that coordinate with community treatment providers

  • Teams that include peer recovery support

  • Responses that distinguish clinical need from willful noncompliance

  • Greater attention to trauma and mental health

  • Reentry planning that begins before release

  • Partnerships between law enforcement and behavioral health providers

  • Public health strategies that aim to reduce overdose risk

  • Debate over how to preserve rights and improve access


These later developments rest on the same foundation Judge Norman helped lay. Public safety and public health must share responsibility for complex human problems.


Why his work still matters now


The need for this bridge has not faded. Communities across the United States continue to face substance use disorders, overdose deaths, behavioral health crises, homelessness, justice involvement, and family disruption. Clinicians still struggle to keep people engaged in care. Courts still see repeat cases connected to addiction and untreated mental illness. Public safety agencies still respond to emergencies that are partly health crises.


Judge Norman’s legacy matters because it points to a more mature public response.


A mature response does not reduce addiction to crime. It also does not deny the reality of harm. It recognizes that untreated illness, illegal behavior, public safety risk, and personal responsibility can exist in the same case.


That recognition asks more of everyone.


It asks judges to learn from clinicians without surrendering judicial duty. It asks clinicians to understand court structure without becoming agents of punishment. It asks public safety professionals to value treatment engagement as part of risk reduction. It asks communities to support recovery long enough for it to become real.


It also asks professionals to resist easy language. Words like “soft” or “tough” often fail to describe what treatment court work actually requires. The work is demanding. It requires people to show up again and again. It requires careful documentation, team communication, honest assessment, court authority, clinical skill, and patience when progress is uneven.


Judge Norman helped make that demanding middle ground possible.


An epitaph for a public servant who saw the bridge before it was common


An epitaph should be brief, but a life of public service rarely fits into a few words. For Judge Seth Norman, the clearest tribute may be this:


He helped the court see that justice could protect the community while calling people toward recovery.

That is not a small statement. It names a shift in how systems understand responsibility.


Judge Norman’s work in the Davidson County Drug Court helped open a door for others. Kenneth Osborn’s early work alongside him deserves acknowledgment within that same chapter. Together with other early builders, they helped lay foundations for operational models that continue to shape the future of public safety and public health.


Those models are still unfinished. They should be. Any system that deals with human suffering, community harm, addiction, and recovery must keep learning. The point is not to preserve a perfect model from the past. The point is to carry forward the values that made the work possible.


Those values include:


  • Accountability with dignity

  • Treatment joined to structure

  • Public safety informed by public health

  • Clinical care grounded in real life

  • Respect for the person and the community

  • Courage to build under resistance


Judge Norman’s legacy is not only found in court records or program history. It lives whenever a judge asks what will actually reduce harm. It lives whenever a clinician stays engaged with someone under court supervision. It lives whenever a probation officer recognizes genuine recovery progress. It lives whenever a public safety agency treats addiction as a crisis that requires both boundaries and care.


It lives in the bridge.


Low-angle view of courthouse steps in late afternoon light.
The work of justice continues through the people who carry it forward.

Carrying the legacy forward


To honor Judge Seth Norman is to do more than remember him kindly. It is to examine the work he helped begin and ask how it should guide the next generation.


Clinicians can honor him by bringing clinical clarity into justice settings without losing compassion. Public safety professionals can honor him by treating recovery engagement as part of community protection. Court leaders can honor him by insisting on fairness, structure, and respect. Program designers can honor him by building models that are practical, measurable, humane, and honest about risk.


Kenneth Osborn’s early role in this work also reminds us that reform depends on people willing to build before the path is accepted. The early days required persistence. They required patience with skepticism. They required the steady labor of turning a humane idea into daily practice.


That is still the work.


The late Honorable Judge Seth Norman helped widen the meaning of justice in Davidson County and beyond. He stood at an early crossing point between public safety and public health. He helped show that courts could do more than process repeated failure. They could become part of a structured chance for change.


May his memory continue to guide those who stand in that difficult, necessary space between accountability and healing.


Kenneth Osborne takes the stage at Rise 26 to deliver the Keynote Address. Full transcription is below.

ken_osborne_keynote_rise26_gs1_pm (1080p)


Great afternoon There's just a lot of you out there. How many of you this is your first conference? So I gotta tell you in all honesty, you know, having been in that, I never thought such a moment as this for me would happen. I was used to being one of the presenters, you know, that one of the people you go without, you know, after the big con- after the guest speaker speaks and does their thing, and you go off to one of the side rooms and you hear one of the presentations.


I'm used to being in that role, so when I tell you that it is a blessing and an honor to be here with you, I really mean that from the depths of my heart. So before I go any further, can we please give one more round of applause to Deana?


I want you to sit with what you've witnessed for just a moment because in the rush of the conference, the breakout sessions, the data presentations, the policy debates, it can be easy to forget that every conversation we have here, at its core, is about a human being, a person with a name, a family, a story that almost ended very differently.


W- what you have heard, though, is not a miracle. It's not an exception to the rule. Dina's story and countless other stories like hers are exactly why we do this work. When I tell you about being the stuff of miracles, you know, I'm a just a guy from the... grew up on the West Side of Chicago in the projects in a single female-headed household with four other brothers who was a nerdy kid and did good in school but took a sharp left turn off the road of rightness, right?


And then someone with, with the promise of hope and po- positive possibility poured into me, and I got back on the right path. And so I stand before you forty-one years later, one day at a time, through the grace of a power greater than myself- ... and the hope and power-


Of the people who do this work never imagining such a moment. So if you're new to the field, the possibilities are endless, and dream, please dream and think big. So before I say another word, I want to acknowledge all of you, no matter what your role or your discipline, no matter what stage of the justice system or the type of treatment you specialize in, whether you're someone like myself who's been around for a minute or someone brand new, you are connected to something bigger than your own program.


You create a profound human impact, and that is worth celebrating


So let me take you on a little journey this afternoon. Let's talk about the beginning. How did we get here? Let me take you back to a time when the idea of connecting public safety and public health sounded to many people in the, uh, in the legal establishment like professional heresy. The year, nineteen eighty-nine.


The crack cocaine epidemic was devastating communities and j-- uh, across the country, and jails were overflowing. The same people were cycling in and out of the system, arrested, processed, sentenced, released, and arrested again. Nothing was changing, and the human cost was staggering. In Dade County, Florida, a judge and a prosecutor looked at each other, and they asked a simple question: "What if we tried something completely different?


What if, instead of just processing cases, we try to address the substance use and mental health needs driving criminal behavior? What if the courtroom could be a place of intervention rather than conviction?"


They didn't have a playbook. They didn't have a body of research. They had a vision grounded in humanity and the professional expertise of court and behavioral health personnel, and they had the courage to act on it.


That first drug court, the Miami-Dade Drug Court, established in nineteen eighty-nine, was the crack in the dam. And once it opened, the water started at-- the water started flowing. Soon, jurisdictions across the country were taking note. They too were frustrated and wanted to do something dis-- different. These early programs watched each other, listened, and learned.


They shared ideas and tried new things. They came together to create a national organization to support the growing field. So in 1983, practitioners from all across the country came together to establish what was then called the National Association of Drug Court Professionals, now known to us as All Rise, to build the field, champion the science, and ensure this moment-- movement had a lasting institutional home.


My humble beginnings in this began right here in Davidson County with the Davidson County Drug Court under the guidance at that time of the late Honorable Judge Seth Norman and the m-magnificent team of folk. I was one of those early pioneers and worked with some of the people who went on to become and found, helped to found the National Court-- National Association of Drug Court Professionals.


What those pri-- pioneers created against institutional skepticism, against polit-political headwinds, against the deeply ingrained assumption that people struggling with addiction are simply moral failures, was nothing less than a transformation of how the American justice system understands and responds to human behavior.


They didn't know that they were starting a movement. They just knew they had to try something different. And because they did, because of their courage, because of their creativity and their persistence, we are all here today.


So where are we now? Thirty-five years later, look what has grown from that one courtroom in Miami.


Today, there are more than four thousand treatment courts operating in all fifty states, the District of Columbia, and the United States territories. Together, they serve more than one hundred and fifty thousand persons every single year. And here's what I want you to understand. This is not a monolith, it's an ecosystem.


The original drug court model proved that dre-- addressing substance use through accountability, treatment, and collaboration could transform lives and improve public safety. Over the past thirty-five years, that evidence-based approach has expanded to meet the unique needs of other populations. Today, we have programs that guide parents to achieve recovery while promoting child safety, reunification, and permanency.


Intervention early to redirect youth toward healthy development and long-term success. Restore health and wellness to tribal communities. To make our roads safer by targeting behaviors and substance use that contribute to dangerous behavior by repeat impaired offenders, drivers. Recognize the unique impact of military service and trauma, and to address the underlining-- the underlying behavioral conditions that too often contribute to justice involvement.


But the treatment court model has had an impact beyond the courtroom itself. The principles that made it work, accountability, accountability compare-- a-accountability paired with treatment, multidisciplinary collaboration, supervision, behavioral responses, recovery capital, these didn't stay contained in a single docket.


They moved upstream and downstream. They are found in how law enforcement responds to a crisis on a street corner. They are found in probation and parole, reentry programs, behavioral health systems that used to operate in isolation from the justice system altogether. The model didn't just create more kinds of courts, it changed what we believe is possible at every point where the justice system and a person's life intersect.


Although each model and each program serve a distinct population, they all share the same fundamental principle. The most effective justice system responds with evidence-based strategies that address the underlying factors driving justice involvement. Every one reflects the same foundational insight: that the most infective just-- the most effective justice is justice that treats the whole person, not just the offense.


And because of this, there are people alive today, people raising their children, going to work, paying taxes, being happy, coaching little leagues, because you saw them as a person worth saving.


That is the ecosystem you have built. That is the movement you are a part of. Now I want to speak directly to the four pillars that define our work and that define you as practitioners.


The first one is resilience. Everyone in this room knows addiction is not easy to overcome, that substance use disorder does not pe- make people unworthy of help. It makes them human. We know from decades of neuroscience that addiction changes the brain. We know that returning to use is not moral failure, it is a clinical event.


And we know that the question is not whether someone will struggle, but what surrounds them when they do. Our work answers this question. Every check-in, every court appearance, every drug test, every time a judge says, "I see you, and I'm not giving up," those are not bureaucratic rituals. They are the scaffolding, indeed, the brick and mortar for a life being re-rebuilt.


These are acts of structured resilience. But resilience is not just a participant's responsibility, it belongs to the field. Think about the resilience that has led us to this moment. Think about the debates we've had to win over, over and over with legislators, with skeptics, with other professionals who weren't sure this was the right use of their offices, and yet here we are, stronger, more evidence-based, and more widely replicated than ever.


The resilience of this field mirrors the resilience of the people we serve, and I want you to own that because the fact that treatment courts and other evidence-based interventions are still here thriving is not an accident. It is the product of your relentlessness and your resilience. When we refuse to give up on participants, we are also refusing to give up on the idea that justice can be redemptive.


That is not weakness. That is the most sophisticated position in criminal justice policy today. Pillar number two, transformation


The most visible transformation is the one we celebrate at graduation ceremonies. A person who came to us in crisis, they may have lost their children, their home, and their health, and they stand before the court holding their certificates, surrounded by their children and family members that they have been separated from for years.


That transformation is real, and it is earned, and it is profound.


But now, I wanna spend a moment on the other transformation, the one that happened to us in this system. For most of this history, the American courtroom operated one way, two sides, one outcome, with the judge presiding over the process.


That is... That system exists for a good reason, and it still exists, and it does the essential work of holding people accountable. But that doesn't mean that there aren't areas of our justice system that can't be improved, and that's where we come in. When we ask a multidisciplinary team to come and sit at the same table to work toward the same outcome, we are not rejecting accountability.


We are offering a more effective version of it for the populations that we serve. It's what happens when the science of behavior change gets taken seriously by the rules of evidence. That is a significant shift for an institution that is centuries old, and you have accomplished it.


When treatment providers sit at the same table as probation officers, judges, and attorneys, when police respond to a mental health crisis alongside a clinician instead of alone, when probation officers see themselves as partners in someone's recovery and not just monitors of their compliance, when a defense attorney becomes an advocate for a client's future and not just their case, that is transformation of collaboration, of culture, of outcomes.


Every one of these moments, whether inside a courtroom or far outside of one, is proof of the same idea. A justice system that holds people accountable can also reduce crime, strengthen families, and rebuild communities all at the same time.


I want to be direct with you about something. You know the phrase second chances can sometimes sound soft, maybe even sentimental, like something you might see on a bumper sticker. Anyone who's worked in a treatment court knows what a second chance can do, though. We know that it can break generational cycles of addiction.


We know that it can alter the trajectory of a young person's life. We know that it can give a veteran the chance to live at peace. But I want to speak to each of you specifically about what a second chance means from where you sit. To the judges in this room, your voice is the most powerful therapeutic instrument in the courtroom, not your gavel, not your voice.


When you look a participant in the eye and say, "I see you. I see how hard you're working, and it matters," that lands differently than any prescription, any program, or any intervention


Never underestimate the therapeutic power of judicial acknowledgement. To the prosecutors and district attorneys, every time you choose treatment over incarceration, you are not being easy on crime. You are being precise about it. You are matching the sanction to the science. You are implementing evidence-based approaches that promote accountability and, for certain populations, often achieve better outcomes than incarceration alone.


That takes more sophistication and often more courage than simply seeking the maximum sentence. To community corrections, behavioral health, healthcare, child protection, social services staff, and other community partners, you are the bridge between two cultures that often speak very different languages, treatment and justice.


You carry clinical knowledge into a legal setting, and you carry legal reality into your clinical work. That is uniquely difficult and uniquely essential. This field does not function without you.


To law enforcement, you are frequently the first person a justice-involved individual encounters in a moment of crisis. The referral you make, the phone call you place may be the single intervention that ends a year-long cycle of calls to the same address. Your discretion is not a loophole. It is a lifeline.


Second chances are not charity. They are an investment, and you are the investors. The fourth pillar,


leadership The one that makes all the other ones possible. The leadership you model every day is unlike any other leadership anywhere else in the justice, treatment, and social services system. You may le-- you lead not through authority alone, but through relationship.


That doesn't happen by accident. It happens because leaders in the field prioritize the outcome over the role. I call that courageous collaboration, and it is not given to you when you accept a position. It is a choice you make again and again every time you walk into a courtroom. You are data-driven and heart-led.


You know your completion rates. You know your recidivism numbers. You can defend this model in a legislative budget hearing with the rigor of a researcher. You know the names of your participants' children. You remember the day someone achieved thirty days of abstinence for the first time. That combination, head and heart, evidence and humanity, is the gold standard of leadership in this field.


But I also want to, to name something that doesn't get talked about enough, the institutional courage it requires to do this work. Every person in this room has had to defend this model to someone who didn't believe. You are the advocates. You carry the evidence, and you speak for the people who cannot yet fully speak for themselves.


That is leadership And so as I end and you begin this conference, I want to invite you to carry these thoughts with you, not just as inspiration for the week ahead, but as guideposts for the conversations you have, the connections you make, and the work you will continue long after you leave Rise '26.


First, expand the table. We are nowhere near finished. We got work to do. There are still justice-involved populations who do not have any port of entry to evidence-based and promising programs. Expanding access is not mission-driven, it is mos- it is mission fulfillment.


Second, tell the story. Your data is powerful. Your graduation ceremonies are powerful. Invite your legislators to them. Bring community members in. Post your outcomes. Write the op-eds. The best antidote for misunderstanding is a direct encounter with the truth, and you have the compelling truth on your side.


And finally, I want to speak of something larger. There is a phrase that defines this organization, it names this conference, and it begins every court session that any judge has ever presided over, "All rise." Traditionally, those words were a command, a call to, to deference, a signal that someone in authority has entered the room.


But I want you to hear those words differently today because that is why... that is what we say to every person who walks through our doors. All rise. You can rise. You are worth the effort of rising. We will hold this space for you while you find your footing. We will celebrate you when you get there, and we will not give up on you when it is hard.


That is the declaration of this movement


It is not that we get to rise in status, in professional recognition, or in pro- in- institutional prestige, but that the people we serve get to rise, families who are still whole because of what happens in our courtrooms. Dina rose, I rose because you decided this work was worth doing. That is why each and every one of you is in this room, and that is the promise of All Rise.


As long as we keep that promise to the people that we serve, to the communities we represent, to the science we are accountable to, and to each other, this movement will not just survive, it will rise.


Thank you. Now go have a great week.


Host: "Thank you, Ken Osborne"



The addiction treatment field has evolved considerably over the past twenty years as our country has worked to respond to an epidemic of overdose deaths. In my training with SUD treatment professionals, I like to describe the ASAM 4th edition Criteria as a disruptive force that promotes change and transformation and will invariably help us to save lives.


Take a moment and ask yourself what events in the last 10-20 years have transformed the way we live and move about in the world.


  • What made Fast Food even faster?  The drive through.Simple but disruptive, fast became even faster.


  • What revolutionized the way we move and communicate across the planet?  The Internet, email, cellphones, texting, FaceTime, ZOOM, Microsoft Teams and social media.  


  • What about traveling? Now we have Trip Tiks, MapQuest, WAZE, Google Maps or your car’s built in navigation system, the CLEAR program of facial and fingerprint recognition at airports.  


These events have arguably created disruption to our otherwise normal routines.


Don’t let the term “disruption” throw you off. The 4th Edition of The ASAM Criteria still follows the same guiding principles as previous editions:


Patient admission into treatment is based on needs rather than arbitrary prerequisites  

Patients receive multidimensional assessments that address the broad range of factors that contribute to substance use and co-occurring disorders. 


Treatment plans are individualized based on these multidimensional assessments.

Reassessments drive patients’ movement along the clinical continuum of care based on their progress and outcomes rather than arbitrary predetermined lengths of stay. 


Care is interdisciplinary, evidence-based, and patient-centered, with informed consent and shared decision-making at the center of treatment decisions.


The ASAM Criteria also recognizes that many patients with SUD have co-occurring conditions. They are the expectation, not an exception. And this is a foundational concept.  

One of main goals of the ASAM 4th edition criteria is to reflect the current state of science and practice. The dimensions were updated to simplify the language and to align with the updated dimensional admission criteria framework.  Now each Dimension is broken down into actionable subdimensions.  


Subdimensions can be found in Dimensions 1-5 and are used to develop the level of care recommendation as well as assist in the development of the treatment plan.  A new dimension was added Person-centered consideration that considers barriers to care, patient preferences, and need for motivational enhancement services.  


There is the explicit consideration of addiction medication needs now in Dimension 1.  The Readiness to Change dimension has been removed and is considered throughout each Dimension. The previous Dimensions 4, 5 and 6 shifted to the new Dimension 4 – substance use related risks and Dimension 5 – recovery environment interactions


Let’s take a closer look at the changes within the six dimensions and their accompanying subdimensions.


Dimension 1: Intoxication, Withdrawal, and Addiction Medications


Subdimensions:

- Intoxication and withdrawal associated risks

- Addiction medication needs


Practical Application:

When assessing a client, consider both their immediate intoxication state and potential withdrawal risks. For example, a client with severe alcohol dependence may require gabapentin, diazepam or clonidine as a part of their detoxification protocolto manage potentially life-threatening withdrawal symptoms.


Additionally, evaluating the need for addiction medications may be critical. A client with opioid use disorder might benefit fromusing buprenorphine or methadone for a determinant time period. By addressing these subdimensions, you can ensure a safer and more comfortable start to the recovery process.


Dimension 2: Biomedical Conditions


Subdimensions:

  • Physical health concerns

  • Pregnancy-related concerns

  • Sleep problems


Practical Application:

Medical staff should develop treatment plans for Dimension 2 concerns that are addressed directly by a medically managed program. Clinical staff may support management of Dimension 2 issues by providing referrals for care when needed, supporting the patient to effectively engage in treatment and adhere to the treatment plan, and by providing psychoeducation and other psychosocial services to address health behaviors, including treatment adherence.  


All patients should have a physical exam within a reasonable timeframe of admission to treatment. The recommended timing of the physical exam for each level of care is outlined in the service characteristic standards.


For pregnant clients, develop a treatment plan that prioritizes both maternal and fetal health. This might involve coordinating care with obstetricians and using pregnancy-safe treatment modalities.

Address sleep issues, which are common in early recovery. Implement sleep hygiene education and consider non-addictive sleep aids when appropriate.


Dimension 3: Psychiatric and Cognitive Conditions


Subdimensions:

  • Active psychiatric concerns

  • Persistent disability

  • Cognitive functioning

  • Trauma exposure and related needs

  • Psychiatric and cognitive history


Practical Application:

The goals of the Dimension 3 assessment are to identify the patient’s treatment needs including:

  • Medically managed care

  • Psychiatrically managed care

  • Skilled mental health treatment

  • Enhanced staff support


And to determine the interactions between the patient’s substance use and mental health concerns.  Medically managed care is care that is directly managed by a physician or advanced practice provider.


Medical management is provided by Levels 1.7, 2.7, 3.7, and 4.  Psychiatric management is care that is directly managed by a psychiatrist or psychiatric specialty advanced practice provider. Psychiatric management is provided by Levels 1.7 Co-Occurring Enhanced (COE), 2.7 COE, 3.7 COE, and Level 4 Psych.  The level of care assessment is focused on assessing active psychiatric symptoms and persistent impairment to determine what level of support, supervision and monitoring the patient needs.


Consider cognitive functioning when designing treatment interventions. A client with cognitive impairments may require simplified educational materials or more frequent, shorter therapy sessions.


For clients with trauma history, incorporate trauma-informed care principles into your treatment approach. This might include offering EMDR or other trauma-specific therapies alongside addiction treatment.


Dimension 4: Substance Use Related Risks


Subdimensions:

  • Likelihood of substance use

  • Likelihood of substance use related behaviors


Practical Application:

Risky substance use refers to any use with significant risk for adverse medical, psychological, emotional, social, financial and/or legal outcomes. The goals of the Dimension 4 assessment include determining the patient’s current risks related to substance use and SUD-related behaviors, identifying the need for supervision and the need to build insight and skills needed to support recovery.


The subdimensions include the likelihood of engaging in risky substance use and likelihood of engaging in risky SUD-related behaviors, such as driving while intoxicated and problem gambling.


The level of care assessment for Dimension 4 considers both the likelihood of continued substance use and the level of harm associated with that risk. Does the patient’s substance use or behaviors pose a significant risk for:

• Serious harm

• Destabilizing loss

• Negative but not destabilizing consequences


The clinician should focus on harms that are likely to occur or become imminent in hours or days, not weeks or months. 

 

Dimension 5: Recovery Environment


Subdimensions: 

  • Ability to function in current environment

  • Safety in current environment

  • Support in current environment

  • Cultural perceptions of substance use


Practical Application:

Evaluate the client's living situation and its impact on recovery. For a client living in an environment where substance use is prevalent, consider recommending sober living arrangements or developing strategies to create a substance-free space within their current home.

Assess the client's support system and cultural context. For example, if a client comes from a culture where substance use is stigmatized, incorporate culturally sensitive education for both the client and their family members.


Dimension 6: Person-Centered Considerations

Subdimensions:

  • Patient preferences

  • Barriers to care

  • Need for motivational enhancement


Practical Application:


Dimension 6 supports a shared decision-making process. Motivational interviewing can be used during the Dimension 6 assessment to better understand a patient’s reservations about treatment and encourage participation in the recommended level of care. It should also be used to consider strategies to overcome obstacles to care.


Involve the client in treatment planning by discussing their preferences and goals. For instance, if a client expresses interest in holistic approaches, consider incorporating mindfulness or yoga into their treatment plan.


Identify and address barriers to care, such as transportation issues or childcare needs. This might involve connecting the client with community resources or offering telehealth options when appropriate.


Assess the client's motivation for change and incorporate motivational interviewing techniques when needed. For a client in the precontemplation stage, focus on building rapport and providing education rather than pushing for immediate abstinence.


Conclusion


By thoroughly assessing and addressing each dimension and its subdimensions, addiction counselors can create more comprehensive, individualized treatment plans. This approach ensures that we consider the full spectrum of our clients' needs, from medical and psychiatric concerns to environmental and personal factors.


Remember, the ASAM criteria are not meant to be a rigid checklist but rather a framework to guide our clinical decision-making. By combining these criteria with our clinical expertise and the client's own input, we can provide truly client-centered care that addresses the complex nature of addiction and supports long-term recovery.

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