ASAM Releases New Treatment Criteria - Three Tips from David Mee-Lee

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The American Society of Addiction Medicine, ASAM, has released a new edition of ASAM treatment placement criteria - the last edition was released 12 years ago.

From the October 25th Press Release announcing the new criteria: "The new edition of The ASAM Criteria, ...is now offered in a user-friendly design – in book and web versions – that guides treatment providers from initial assessment through long-term disease management. There is also forthcoming software, funded by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), designed to be used in tandem with the book."

David Mee-Lee, Chief Editor of the ASAM Criteria, provided the following information in the October 2013 issue of "Tips and Topics":

TIP 1

Expand your knowledge about multidimensional assessment and the levels of care.

*Changes in Dimension 1, Acute Intoxication and/or Withdrawal Potential

Instead of detoxification services, the new edition now refers to withdrawal management services. This is because the liver "detoxifies" but clinicians "manage withdrawal."

This isn't just playing with words. There are good reasons to think about managing a patient's withdrawal rather than just "detoxifying" the patient.

Common Case Scenario

  • Patients are often placed in high-intensity, high-cost hospital levels of care for detoxification to make sure they don't have a withdrawal seizure.
  • However, they are discharged after 3-4 days or whenever the seizure danger has passed, only to find some people use again even within a week or two.
  • Why does this happen when we already detoxified them? The answer is that we hospitalized the person until the danger of seizures passed, but didn't manage the person's withdrawal, which can take much longer than the few days of seizure danger.
  • There are 5 levels of withdrawal management in the adult criteria.

    Too often treatment occurs just in Level 4-WM (Medically Managed Intensive Inpatient Withdrawal Management). This can cost $600, $800 or even $1,000 per day. If all 5 levels are used, as needed, a patient can receive close to 2 weeks

    of withdrawal management support, for what it costs for a few days in Level 4-WM.
  • By contrast, one day in a 24 hour supportive Level 3.2-WM (Clinically Managed Residential Withdrawal Management) can cost $100 or $200 per day. Do the math: a patient can receive 5-6 days of 24-hour withdrawal management support for every day in a high intensity hospital-based service.

*Level 1, Outpatient Services

Outpatient services are often used as the entry point at the beginning of recovery, or a brief "aftercare" level for people who have "graduated" from intensive addiction treatment. In the new edition, we emphasize that addiction is a chronic illness, and many clients need ongoing disease management in Level 1 - indefinitely.

  • How often does a patient need to be seen for ongoing recovery monitoring? Short answer: it depends on that individual's current severity of illness and level of function. If the person's addiction is unstable and they need closer monitoring, then the "dose", frequency and intensity of Level 1 care may require that- at first- the patient be seen weekly or even twice weekly. After that, as the person stabilizes, the intervals between appointments can be lengthened.
  • Level 1 now becomes a level of care to help clients maintain their recovery for successful wellness and health.
  • Again, how do I understand the levels of care in the new edition?

    Consider these parallels. How does your doctor manage hypertension, or asthma or diabetes? How does a psychiatrist manage schizophrenia, bipolar disorder or chronic panic disorder or major depression? Disease management does not mean closing the case after 10 aftercare sessions.

*Level 3, Residential Services

This level is fundamentally the same in the new edition of The ASAM Criteria, but there are 2 levels worth highlighting. One is Level 3.1, and its difference from the other residential levels; and the other is Level 3.3 with its new name.

Level 3.1. Clinically Managed Low Intensity Residential

  • It is qualitatively different from Levels 3.3, 3.5 and 3.7.
  • Level 3.1 is 24 hour supportive living mixed with some intensity of outpatient services
  • In contrast, the other level 3 programs are 24 hour treatment settings for those in imminent danger.
  • The new edition explains further "imminent danger" in Dimensions 4, 5 & 6
  • For example--

    An individual may not even think he has an addiction problem. Even though he is intoxicated, and not in withdrawal, he is intent on driving when it is obvious he is impaired. He needs 24-hour stabilization in a residential setting.
  • Another example--

    A client has overwhelming impulses to continue drinking or drugging. He has existing liver or psychotic illness. Continued heavy use with acute signs and symptoms places him in imminent danger of severe liver or psychotic problems. This calls for 24 hour treatment to prevent an acute flare-up.

Level 3.3: "Clinically Managed Population-Specific High-Intensity Residential Services"

  • This is a new name for Level 3.3 and here's why:
  • The PURPOSE of Level 3.3 programs has always been: to deliver high-intensity services and to provide them in a deliberately repetitive fashion.
  • Which populations does this level serve? The special needs of individuals such as the elderly, the cognitively-impaired or developmentally-delayed.
  • Another population is patients with chronic and Intense disease who require a program which allows sufficient time - to integrate the lessons and experiences of treatment into their daily lives.
  • Typically, level 3.3 clients need a slower pace of treatment because of mental health problems or reduced cognitive functioning (Dimension 3), or because of the chronicity of their illness (Dimensions 4 and 5).
  • Summary: this level is for specific populations; high intensity work still is needed; treatment is conducted at a slower pace.

Learn about the ASAM Criteria Dimensions

If you are not familiar with the ASAM Criteria dimensions, take a look at last month's edition.

Notice the change in the numbering system

The old edition used Roman numerals.

The new edition uses regular Arabic numerals- for Levels of Care.

So Level III is now Level 3. Level IV is now Level 4 etc.

TIP 2

Broaden your perspectives on addiction treatment

There are 2 new chapters in The ASAM Criteria, 3rd edition which move into areas which have not gained much respect in addiction treatment in the past:

                  Tobacco Use Disorder

                  Gambling Disorder

In fact, a significant number of programs still view nicotine addiction as one drug addiction which can wait until later: "You can't expect a person to quit everything at once. We don't allow smoking in the groups or in the building, but we do have a smoking gazebo on the grounds where patients can smoke in pre-designed breaks."

For both Gambling and Tobacco Use Disorders, the new edition makes the case for a continuum of levels of care for these types of addiction, just as we have had for other substance use disorders.

TIP 3

Apply the criteria to special populations

The editors have responded to feedback from counselors and clinicians who have expressed difficulty applying the criteria to special populations:

----older adults

----parents or prospective parents receiving addiction treatment concurrently with their children

----those in safety-sensitive occupations like physicians and pilots

----clients in criminal justice settings.

Mandated Clients

Many clients come from criminal justice drug courts, probation and parole or even still reside in prison treatment settings.

For example...

A judge often mandates a client to a specific level of care and length of stay, not based on an assessment of what will achieve good outcomes, but rather concerned about public safety. The ASAM Criteria recommends that a judge mandates assessment and treatment adherence which places the responsibility on clients to "do treatment and change," rather than give the impression that the client can "do time" in a program for a fixed length of stay.

What does the judge's mandate require from the clinicians and programs involved with this particular client?

--> To carefully monitor the person's risk to public safety

--> Inform the judge, probation and parole officer when a mandated client is not doing treatment and simply sitting in a program.