The ASAM Criteria - Beacon Health Options
The ASAM CriteriaIntroduction[ June 2017]
The ASAM Criteria The ASAM Criteria:Treatment Criteria forAddictive, SubstanceRelated, and Co-OccurringConditions American Society ofAddiction Medicine2
What is ASAM?ASAM is the American Society of Addiction Medicine.When managed care came on the scene in the 1980svarious MCOs developed their own placement criteria.There were up to 50 separate sets of criteria and thedifference between them varied greatly. In 1989 thecurrent incarnation of ASAM was formalized and 2yrs laterthey released their first addition of the ASAM placementcriteria.3
What is The ASAM Criteria?ASAM's criteria, formerly known as the ASAM patientplacement criteria, is the result of a collaboration thatbegan in the 1980s to define one national set of criteriafor providing outcome-oriented and results-based care inthe treatment of addiction. Today the criteria havebecome the most widely used and comprehensive set ofguidelines for placement, continued stay andtransfer/discharge of patients with addiction and cooccurring conditions. ASAM's criteria are required in over30 states. dconsensus-documents/the-asam-criteria/about4
When is The ASAM Criteria Used?ASAM criteria is used as a starting place for makingdecisions related to the course of treatment, taking intoaccount a holistic view of the patient in view of the entirecourse of formalize treatment intervention over acontinuum of care.5
ASAM Definition of AddictionASAM definition of addiction: "Addiction is a primary, chronicdisease of brain reward, motivation, memory and relatedcircuitry. Dysfunction in these circuits leads to characteristicbiological, psychological, social and spiritual manifestations.This is reflected in an individual pathological pursuing ofreward and/or relief by substance use and other behaviors.Addiction is characterized by the inability to consistentlyabstain, impairment in behavioral control, craving, diminishedrecognition of significant problems with one’s behaviors andinterpersonal relationships, and a dysfunctional emotionalresponse. Like other chronic diseases, addiction often involvescycles of relapse and remission. Without treatment orengagement in recovery activities, addiction is progressiveand can result in disability or premature death.“ -addiction6
Common Barriers for Implementation Rural Areas with lack of access to levels of care Family pressure with unrealistic expectations Criminal justice that focuses on length of stay ortreatment as punishment SUD clinicians that view levels of care as separatemodalities rather than as part of the continuum ofcare. Fragmented services7
Disclaimers ASAM criteria is not intended to be encompass allpossible SUD treatment modalities or specializedpopulations ASAM criteria is not dictated by court mandates fortreatment ASAM criteria does not substitute for the judgment anddiscretion of the individual clinician ASAM criteria is a best practice guideline8
Guiding Principles9
Individualized Treatment It has the "goal of helping move practitioners towardindividualized, clinically driven, participant-directed, andoutcome informed treatment". "What does the patient want?" "Why now?" "What life areas or dimensions are most important indetermining treatment priorities?“ "What specific services and service parameters are mostappropriate?" Moving away from fixed lengths of stay toward clinically driveninterventions with expressed intention and evaluated results "What is the outcome of the treatment plan and placementdecision?"10
Focus on the Continuum of Care The continuum of care is viewed as flexible and asa whole rather than as separate distinct modalities. "For both clinical and financial reasons, thepreferable level of care is that which is the leastintensive while still meeting treatment objectivesand providing safety and security for the patient."11
Strengths Based Approach Strengths/supports membercan draw on Problems are opportunities Person Centered treatmentfocus12
Focus on the Continuum of Care The continuum of care is viewed as flexible and asa whole rather than as separate distinct modalities. "For both clinical and financial reasons, thepreferable level of care is that which is the leastintensive while still meeting treatment objectivesand providing safety and security for the patient."13
Assessment and Reassessment Treatment outcomes arekey. We are repeatedlycycling through assessment,adjusting the plan, andadjusting the placement orintervention Any treatment intervention,including an admission to anew level of care,1. MUST be the result of anassessment2. MUST be reevaluated foreffectiveness14
Focus on the Continuum of Care The continuum of care is viewed as flexible and asa whole rather than as separate distinct modalities. "For both clinical and financial reasons, thepreferable level of care is that which is the leastintensive while still meeting treatment objectivesand providing safety and security for the patient."15
Treatment Planning The treatment plan is developed in conjunction with theclient and includes a comprehensive bio psychosocialassessment in addition to a comprehensive evaluation ofthe family. Treatment plan documentation includes both barriers torecovery and patient strengths Psychosocial stressors, finances, housing, employment, etc Skill and knowledge strengths and deficits. strategies for dealing with negative stressors Positive social supports, spiritual supports16
Treatment Plan Treatment plan lists specific services to be delivered andbehavioral responses expected “I will attend all scheduled groups and afterward I will writewhat I learned in my journal” Less focus on immediately stabilizing the currentsymptomatology and more so on developing newinsights and behaviors that move the client towardhealth. The decision to prescribe a type of service,transfer, or discharge is all geared toward moving aclient toward health rather than simply stabilizingbehavior17
Treatment Plan Goals Goals need to be short-term, measureable, andachievable. Stop using drugs -- NO! Identify and implement 5 coping strategies -- Closer When I have thoughts of using I will run one lap around thebuilding -- Yes Gives the client the ability to assess progress andeffectiveness. Did it work? Yes, great! No, try it again or trysomething new18
Treatment Reminders Intensity of the intervention is paired with the intensity of thesymptomatology. The individual is viewed as a whole person so aninterdisciplinary treatment team is needed In settings that do not offer comprehensive services, closecoordination is a must The provider must inform the patient of all the options and thepatient must choose to accept the treatment intervention,ideally the family is informed and accepts the intervention Medical necessity looks at the whole person to make anintervention recommendation rather than emphasizing anyone area.19
Focus The ASAM Criteria Deemphasizes the placement and focuses more on astarting place for discussion. Gives a common frame ofreference to conceptualize the client and the client'ssituation There was a concerted effort to improve the format ofthe manual to make it easier to understand andimplement principles, processes and procedures acrosssettings and in treating a variety of populations Access to web training is available with new manuals20
Treatment Models21
Dual Diagnosis22
Co-Occurring Disorders23
Integration24
Application25
Continuous Reevaluation All interventions areimplemented based onassessment All interventions areEvaluated for Effectiveness26
Multidimensional Assessment27
Multidimensional Assessment: Dimensions 1-6 Dim 1 – Intoxication and Withdrawal Potential Dim 2 – Biomedical Conditions Dim 3 – Emotional, Cognitive, Behavioral Conditions Dim 4 – Readiness to Change Dim 5 – Relapse Potential Dim 6 – Recovery Environment28
Assessing for Stability Dim1-3 are vital for assessing the general stability of thepatient. These must be considered first and trump allother considerations as they pertain to the safety of thepatient29
Multidimensional Assessment: Dim 1 Dimension 1: Acute Intoxication/ Withdrawal Potential Explore past and current experience of substance useand withdrawal. Vitals, CIWA, COWS, UNCOPE, CurrentSymptomatology client is experiencing is importantto validate results of assessments Assessing for safety30
Multidimensional Assessment: Dim 2 Dimension 2: Biomedical conditions and complications- Explore medical history and identify any currentmedical complications Assessing for medical stability High BP may be a result of an ongoing medicalcondition but may be exacerbated by Alcoholwithdrawal. Need to identify baseline and/or referto medically monitored detox due to complication.31
Multidimensional Assessment: Dim 2 Are there medical conditions that need to be stabilizedbefore a patient can be successful in recovery? Severe injuries Chronic pain that needs coordination Always asking how this is being addressed before,during or after but must be addressed in conjunctionwith substance abuse treatment.32
Multidimensional Assessment: Dim 3 Dimension 3: Emotional, behavioral, or cognitiveconditions and complications - Explore patientthoughts, emotions and mental health issues. Assess emotional and behavioral stability - SI/HI orPsychosis. Will the patient be a danger to themselves orothers? Does internal stimulus interfere with their ability toengage?33
Assessing for Recovery Dim 4-6 assess the patient’s ability to engage in andmaintain recovery.34
Multidimensional Assessment: Dim 4 Dimension 4: Readiness for change - Explore patient'sreadiness and interest in changing Assess stage of change Pre-contemplation - Don’t want to change Contemplation - Thinking about change Preparation - ready to make changes Action - making changes Maintenance - changes made35
Multidimensional Assessment: Dim 5 Dimension 5: Relapse, continued use, or continuedproblem potential - Explore patient's uniquerelationship with relapse or continued use or problems. Ask how much and how often they use past patterns of abstinence gage likely ability to maintain abstinence.36
Multidimensional Assessment: Dim 6 Dimension 6: Recovery/ living environment - Explorepatient's recovery or living situation and surroundingpeople, places or things. Get specific about danger of recoveryenvironment. Is there use in the home? Does the family have the ability to securemedications? Is family supportive of change?37
Building a Risk Rating Profile A recommendation for treatment begins with theseverity assigned to a case based on the Risk RatingProfile. Each dimension is assigned a severity rating from the RiskRating Matrix The combination of risk and mitigating factors form thebasis for each severity rating.38
Building the Risk Rating Profile39
Multidimensional Assessment: Risk Rating40
Application of the Risk Rating MatrixStep 1: Assess for Safety – If anyDimension is rated as High itmust be addressed in someway immediately41
Application of the Risk Rating MatrixStep 2: Determine the patientrisk rating for all 6 dimensions.42
Application of the Risk Rating Matrix Step 3: Identify the appropriate types of servicesneeded to adequately and safely address the riskrating of each dimension. Step 4: Use the risk profile from steps 2 and 3 to developa plan of care Step 5: Continue to reevaluate patient’s ongoingservice needs utilizing steps 1-4.43
Placement on the Continuumof Care44
Continuum of Care LLOC45
Continuum of Care HLOC46
Placement on the Continuum of CarePlacement along the continuum is considered in terms ofthe over all risk rating. If most dimensions are low then alower level of care is indicated. If most dimensions arehigh then a higher level of care is indicated.Note: A level of SUD treatment is an intervention designed to address aSubstance Use Disorder. If substance use has been resolved there is noindication for treatment of a Substance Use Disorder.47
Key Points:Continuum of Care48
Key Points – Continuum of Care Levels of care are viewed as benchmarks along acontinuum, point along a journey of recovery or levels ofintervention rather than self contained treatment modalities. It is possible to stabilize outside the continuum of care viacommunity support, ROSC, or mental health treatment Patient refusing a higher level of care should be offered analternative lower level of care rather than turned away.Patient symptoms may stabilize with engagement at a lowerlevel or motivation may significantly improve making thepossibility of success at a higher level of care more likely. Myth of the Magical Milieu - Residential treatment is not acure. It is a stop along the journey of recovery. It has setgoals for intensive education and case planning but theprocess of recovery ultimately takes place outside offormalized treatment altogether.49
Clinical Vignettes50
Making a DeterminationMaking a determination is a matter of weighingcomplications vs. mitigating factors to determine the leastintensive intervention where the patient can be successfuland safe. Match the risk rating for each dimension to anequally intense intervention. Note: a high dimension inany dimension requires intervention but NOT necessarilyan SUD intervention.51
AllenAllen is a 58YO male who meets DSM5 diagnostic criteriafor Alcohol use disorder, mild. Wx potential is noted ascurrently mild, the CIWA is 3 with no more than mild Wx Sxnoted by Hx.52
Allen’s ComplicationAllen presented to the ER with his wife who is an LVN andstating she is concerned about his BP. Allen noted his lastdrink was 3 days ago and current pattern of use is 6 drinks daily. Current BP noted as 140/100. Allen notesHigh BP by Hx that is not well controlled by medication.Allen noted he has been off BP medication for approx3mo.53
Allen’s Mitigating FactorsDim 3-6 are mild as Allen has no significant MH concerns(Dim3), is highly motivated to engage in community AAmeetings (Dim4), has been drinking only 3mo followinglong period of abstinence, notes that he is able to utilizeprevious relapse prevention skills and reconnect withrecovery supports within his recovery environment. Allen’swife has been on the phone with Allen’s parents who aregoing through the house to remove any alcohol beforeAllen and his wife return home(Dim 5-6)54
Is it Withdrawal or Medical?Allen has a history of Hypertension and his current vitalsare noted as high after 3 days of abstinence with no othersignificant Withdrawal Symptoms noted. We canreasonably conclude High BP is related to Dim 2, medicalconsiderations as opposed to autonomic arousal thatcould markedly increase to crisis levels if Allen wereintoxicated or experiencing other Symptoms ofwithdrawal. Dim 2 raises the overall level of concern andmust be addressed but in this case can be addressedwith medical intervention, no SUD intervention is neededto address Dim 1.55
Allen Determination We conclude that Dim1 is stable. Dim2 is being addressed with medication administeredat the ER. Recheck shows blood pressure decreasing. Recommendation for follow up with his PCP within afew days is given to refill medications and recheckblood pressure. Dim3-6 are all rated as mild.A determination for ASAM Level 1 is made to addressrelapse.56
Wait, What’s the issue?Rosa is a 16YO female who presented to the ER escortedby police responding to domestic disturbance following911 call from mother. Mother reported that Rosa wentinto a “wild rage” threatening the family. She becameverbally and physically aggressive, reportedly throwing achair which resulted in property damage. When policearrived on the scene the patient collapsed on the floor insobs and would not respond to parents or police. Mothernoted that Rosa had started hanging out with the wrongcrowd during the previous semester at school and herbehavior had progressively deteriorated. The patientadmitted to smoking THC irregularly approximately 1x permo with friends. Police decided to transport to ER to ruleout substance induced episode.57
Multidimensional AssessmentDim1: None, No indication of intoxication in the ER, toxscreen was negative for mind altering substancesincluding THC.Dim2: None, Patient has no complicating medicalconcernsDim3: Mod/High, during assessment with a nurse Rosabroke down crying indicating that she had beenmolested over a period of several years by a familymember which escalated to rape several months ago.The parents were discussing visiting this family member atthe time of the incident.58
Multidimensional AssessmentDim4: low, Patient was able to verbalize multiplereasons THC abuse was not positive, indicating thatshe did not plan to continue use.Dim5: mild, Patient pattern of use is noted as minimal.UDS was negative for THC though patient admitted tosmoking a few times approximately 1 time per monthover the past 6 months, last use is noted asapproximately 5 weeks ago.Dim6: mild, during a brief intervention the patient wasable to tell parents about the molestation andsubsequent rape. Parents appeared to exhibit thenormal range of emotions and seemed supportive ofthe patient. Child Protective Services was notified tofile a report.59
DeterminationDiscussion:What is an appropriate level of care?1. ASAM level 3.3 RTC to address substance use andtrauma in a safe and secure setting2. ASAM level 1 OP to address THC use patient hasadmitted to3. No formal SUD intervention with referral to MH OP andvictim’s assistance60
Meth MonstersRochester is a 34YO male who presented to ER escortedby police. Rochester became aggressive with policewhen confronted about urinating in public. He indicatedto ER nurse that he was killing monsters in the shadows.Labs showed positive result for Amphetamine andMethamphetamine. Rochester is noted to be a daily IVMeth user and is Hep C positive per previous contact withthe hospital. He had a large abscess on his right wrist thatwas treated in the ER, antibiotics were administered andon going wound care was recommended. Rochester’svitals were stable though he became very difficult torouse shortly after arriving in the ER.61
DeterminationDue to acute intoxication and subsequentwithdrawal we are unable to initially determinewhether psychosis is substance induced or ongoing.Rochester would not be safe to dischargeimmediately from a controlled environment. ASAMLevel 3.7 is indicated for 24-48hrs in order to establisha base line. ASAM Level 3.2 is appropriate as analternative depending on the availability of areaservices.62
ReevaluationFollowing approx. 18hrs of sleep Rochester was able to situp in bed and complete additional screenings with thefloor nurse. He was no longer experiencing psychosis andcomplained about his wrist hurting, OTC pain relieverswere administered and additional wound care wascompleted including repacking the wound. Rochesterindicated that he was homeless and needed a bus passback to the shelter before they closed the doors for thenight. When a recommendation for treatment wasoffered by the hospital discharge planner, he indicatedthat he was not interested in residential care but wouldconsider outpatient since they offered free coffee andsnacks.63
Dimensions 1-6Identify Dimensions:Dim1Dim2Dim3Dim4Dim5Dim664
What is the appropriate level of care?Rochester is clearly appropriate to continue atASAM level 3.3, however, he has refused this level ofcare. He has indicated an interest in outpatientbecause the offer coffee and snacks. Offer ASAMLevel 1, outpatient, in an attempt to engageRochester in services. Circumstances may changesuch that he may become
What is The ASAM Criteria? 4 ASAM's criteria, formerly known as the ASAM patient placement 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 treatme
History of ASAM Criteria 1991: First edition of ASAM’s Patient Placement Criteria for the Treatment of Psychoactive Substance Use Disorders 1996: ASAM PPC-2 : Included Continuing Stay and Discharge Criteria 1998/99 ASAM PPC endorsed by 30 states, Dept of Defense, & some MCOs 2001: ASAM
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ASAM Criteria must require more staff, expense, and administration to provide all the levels ASAM Criteria is a medical model and requires everyone to hire a medical director ASAM Criteria is biased to advocate for more inpatient treatment ASAM Criteria is biased to advocate for more outpatient treatmentFile Size: 556KB
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