American Society of American Society of Addiction Medicine (ASAM)Addiction Medicine (ASAM)

How and when to use the CriteriaHow and when to use the Criteria

Definition of TermsDefinition of Terms

Clinically managed:Clinically managed: Directed by non physician addiction specialist rather Directed by non physician addiction specialist rather than medical personnel. Appropriate for individuals whose primary than medical personnel. Appropriate for individuals whose primary problems involve emotional, behavioral, cognitive, readiness to change, problems involve emotional, behavioral, cognitive, readiness to change, relapse or recovery environment concerns. relapse or recovery environment concerns. Intoxication/withdrawal/biomedical concerns are all minimal if they exist at Intoxication/withdrawal/biomedical concerns are all minimal if they exist at all.all.

Medically Monitored:Medically Monitored: Services provided by an interdisciplinary staff of Services provided by an interdisciplinary staff of nurses, counselors, social workers, addiction specialist and other health and nurses, counselors, social workers, addiction specialist and other health and technical personnel under the direction of a licensed physician. Medical technical personnel under the direction of a licensed physician. Medical monitoring is provided through appropriate mix of direct patient contact, monitoring is provided through appropriate mix of direct patient contact, review of records, tram meetings, 24 hour coverage by a physician and a review of records, tram meetings, 24 hour coverage by a physician and a quality assurance program.quality assurance program.

Medically Managed:Medically Managed: Services that involve daily medical care, where Services that involve daily medical care, where diagnostic and treatment services are directly provided an/or managed by diagnostic and treatment services are directly provided an/or managed by an appropriately trained and licensed physician.an appropriately trained and licensed physician.

Dimensional Criteria AssessmentDimensional Criteria Assessment

Dimension 1:Dimension 1: Acute Intoxication/Withdrawal PotentialAcute Intoxication/Withdrawal Potential

Dimension 2:Dimension 2: Biomedical Conditions and Complications Biomedical Conditions and Complications Dimension 3:Dimension 3: Emotional/Behavioral/Cognitive Conditions and Complications Emotional/Behavioral/Cognitive Conditions and Complications Dimension 4:Dimension 4: Readiness to Change Readiness to Change Dimension 5:Dimension 5: Relapse/Continued Use/Continued Problem Potential Relapse/Continued Use/Continued Problem Potential Dimension 6:Dimension 6: Recovery Environment Recovery Environment

ASAM Criteria should be utilized to:ASAM Criteria should be utilized to:1. Assign the appropriate level of service and level of care1. Assign the appropriate level of service and level of care

2. Do effective treatment planning and documentation2. Do effective treatment planning and documentation

3. Make decisions about continued service or discharge by ongoing assessment and 3. Make decisions about continued service or discharge by ongoing assessment and review of progress notes review of progress notes

Relationship Between ASAM PPC-2R and ASI-MVRelationship Between ASAM PPC-2R and ASI-MV

ASAM PPC-2RASAM PPC-2R

DimensionsDimensions

ASI-MV DomainsASI-MV Domains

*ASAM Dimension 1:*ASAM Dimension 1:

Acute Acute

Intoxication/WithdrawalIntoxication/Withdrawal

PotentialPotential

*Drug/Alcohol Use*Drug/Alcohol Use

*ASAM Dimension 2:*ASAM Dimension 2:

Biomedical Conditions & Biomedical Conditions &

ComplicationsComplications

*Medical Status*Medical Status

*ASAM Dimension 3:*ASAM Dimension 3:

Emotional, Behavioral & Emotional, Behavioral &

Cognitive Conditions &Cognitive Conditions &

Complications Complications

*Psychiatric Status*Psychiatric Status

Relationship Between ASAM PPC-2R and ASI-MVRelationship Between ASAM PPC-2R and ASI-MV

ASAM PPC-2RASAM PPC-2R

DimensionsDimensions

ASI-MV DomainsASI-MV Domains

*ASAM Dimension 4:*ASAM Dimension 4:

Readiness To ChangeReadiness To Change

*Legal System?*Legal System?

*ASAM Dimension 5:*ASAM Dimension 5:

Relapse, Continued Use, Continued Relapse, Continued Use, Continued Problem Potential Problem Potential

*Drug/Alcohol Use*Drug/Alcohol Use

*Psychiatric Status*Psychiatric Status

*ASAM Dimension 6:*ASAM Dimension 6:

Recovery EnvironmentRecovery Environment

*Employment/Support*Employment/Support

*Legal System*Legal System

*Family/Social Relationships*Family/Social Relationships

ASAM PPC-2RASAM PPC-2R((Dimension 1- Detoxification Services)Dimension 1- Detoxification Services)

Level I.D: Ambulatory Detoxification without Extended Level I.D: Ambulatory Detoxification without Extended On-site Monitoring (e.g., physician office practice/home On-site Monitoring (e.g., physician office practice/home health care)health care)

Level II-D: Ambulatory Detoxification with Extended On-Level II-D: Ambulatory Detoxification with Extended On-site Monitoring (e.g., detoxification on partial site Monitoring (e.g., detoxification on partial hospitalization program)hospitalization program)

Level III-D: Residential/Inpatient DetoxificationLevel III-D: Residential/Inpatient Detoxification Level III.2D: Clinically Managed Residential Level III.2D: Clinically Managed Residential

Detoxification (e.g., social detox)Detoxification (e.g., social detox) Level III.7D: Medically Monitored Inpatient Level III.7D: Medically Monitored Inpatient

DetoxificationDetoxification Level IV-D: Medically Managed Inpatient DetoxificationLevel IV-D: Medically Managed Inpatient Detoxification

Residential/Inpatient Levels of CareResidential/Inpatient Levels of Care Level III: Residential/Inpatient ServicesLevel III: Residential/Inpatient Services

Level III.1- Clinically Managed Low-Intensity Level III.1- Clinically Managed Low-Intensity Residential Services (Residential Services (e.g., halfway housee.g., halfway house))

Level III.3- Clinically Managed Medium- Intensity Level III.3- Clinically Managed Medium- Intensity residential Services (residential Services (e.g., Therapeutic Rehabilitation e.g., Therapeutic Rehabilitation FacilityFacility))

Level III.5- Clinically Managed High-Intensity Level III.5- Clinically Managed High-Intensity Residential Services (Residential Services (e.g., Therapeutic Community, e.g., Therapeutic Community, Residential Treatment CenterResidential Treatment Center))

Level III.7- Medically Monitored Intensive Inpatient Level III.7- Medically Monitored Intensive Inpatient TreatmentTreatment

Level IV: Medically Managed Intensive Inpatient Level IV: Medically Managed Intensive Inpatient TreatmentTreatment

The Differences Between Inpatient, Residential The Differences Between Inpatient, Residential and Outpatient with Supportive Livingand Outpatient with Supportive Living

InpatientInpatient ResidentialResidential O.P. w/SupportiveO.P. w/Supportive

LivingLiving

Provides 24-hour Provides 24-hour structure & supportstructure & support

Provides 24-hour Provides 24-hour access to medical & access to medical & nursing servicesnursing services

Patients in Patients in

““Imminent Danger” Imminent Danger”

Provides 24-hour Provides 24-hour structure & supportstructure & support

(except III.1<24 hrs)(except III.1<24 hrs)

Primary medical Primary medical services not services not necessarynecessary

Patients in Patients in

““Immienent Danger”Immienent Danger”

(except III.1)(except III.1)

Provides structure & Provides structure & SupportSupport

Primary medical Primary medical services not services not necessarynecessary

Patients not in Patients not in

““Imminent Danger”Imminent Danger”

Levels of Care (PPC-2R)Levels of Care (PPC-2R)Overall Structure of Levels of Care & ServicesOverall Structure of Levels of Care & Services

Level 0.5- Early InterventionLevel 0.5- Early Intervention Level I- OutpatientLevel I- Outpatient Level II- Intensive Outpatient/Partial Level II- Intensive Outpatient/Partial

HospitalizationHospitalization Level III- Residential/Inpatient TreatmentLevel III- Residential/Inpatient Treatment Level IV- Medically Managed Intensive Inpatient Level IV- Medically Managed Intensive Inpatient

TreatmentTreatment

Level 0.5 is NOT a level of care or treatment Level 0.5 is NOT a level of care or treatment but the combination of psycho-education but the combination of psycho-education

and assessment. If the assessment and assessment. If the assessment indicates the need for treatment, the indicates the need for treatment, the

individual may receive treatment at the individual may receive treatment at the conclusion of the 0.5 service or concurrentlyconclusion of the 0.5 service or concurrently

Outpatient Levels of Care & ServicesOutpatient Levels of Care & Services

Level 0.5- Early InterventionLevel 0.5- Early InterventionLevel I- OutpatientLevel I- Outpatient

Less that 9 contact Hours/WeekLess that 9 contact Hours/WeekLevel II- Intensive Outpatient/Partial Level II- Intensive Outpatient/Partial

HospitalizationHospitalizationLevel II.1- 9 or More Contact Hours/Week in a Level II.1- 9 or More Contact Hours/Week in a

Structured PStructured Program (6 hrs. for adolescents)rogram (6 hrs. for adolescents)Level II.5- 20 or More Contact Hours/Week in Level II.5- 20 or More Contact Hours/Week in

a a StructuredStructured Program Program

The CIWA-ArThe CIWA-Ar((Clinical Institute Withdrawal Assessment of Alcohol, Clinical Institute Withdrawal Assessment of Alcohol,

Revised)Revised)

It requires It requires under two minutesunder two minutes to administer to administer

It requires no medial knowledgeIt requires no medial knowledge

It provides you with a quantitative score It provides you with a quantitative score that predicts the severity of withdrawal that predicts the severity of withdrawal from alcoholfrom alcohol

Types of Managed Care ReviewsTypes of Managed Care Reviews

For the MCOFor the MCO For the ProviderFor the Provider

Pre-certificationPre-certification Intake & Initial Intake & Initial AssessmentAssessment

Concurrent ReviewConcurrent Review Treatment Plan UpdateTreatment Plan Update

Retrospective ReviewRetrospective Review Case ReviewCase Review

Managed CareManaged Care

A clinical Quality Process A clinical Quality Process

Rather than Simply A Way to Reduce Rather than Simply A Way to Reduce Treatment CostsTreatment Costs

Individualized TreatmentIndividualized Treatment

The four P’sThe four P’sPatient/Participant AssessmentPatient/Participant AssessmentProblems/PrioritiesProblems/PrioritiesPlanPlanProgressProgress

Match Match Severity or Level of Functioning Severity or Level of Functioning (Assets and Obstacles to Improvement) (Assets and Obstacles to Improvement) With With Intensity of Service Intensity of Service (Treatment (Treatment Modalities, Strategies and Site of Care)Modalities, Strategies and Site of Care)

Level of Care Placement afterLevel of Care Placement afterrelapserelapse

should be based on an assessment should be based on an assessment of history and “here & now” andof history and “here & now” and

NOTNOTon the assumption that if a patient on the assumption that if a patient relapsed after having been treated, relapsed after having been treated, then the previous level of care was then the previous level of care was

not intense enough!not intense enough!

HOMELESSNESSHOMELESSNESSalone alone is is

NOTNOTsufficient reason for Level III sufficient reason for Level III

Placement!Placement!

The more disadvantaged The more disadvantaged and complicated, and complicated,

the the more importantmore important is isCASE MANAGEMENTCASE MANAGEMENT

Co-occurring medical and psychiatric disordersCo-occurring medical and psychiatric disorders AdolescentsAdolescents Ex-FelonsEx-Felons Older AdultsOlder Adults Welfare/disability clientsWelfare/disability clients Financial problems needsFinancial problems needs Parenting needsParenting needs Pregnant WomenPregnant Women HIV- AIDSHIV- AIDS

The Three H’s of AssessmentThe Three H’s of Assessment

HistoryHistory

Here and NowHere and Now

How uncomfortable are you?How uncomfortable are you?

A Discharge PlanA Discharge PlanIs AIs A

Deferred Treatment PlanDeferred Treatment Planandand

Should Be As Should Be As Specific and ConcreteSpecific and ConcreteAs A Treatment PlanAs A Treatment Plan

““Discharge PlanningDischarge Planning” is part of ” is part of treatment planning, NOT a treatment planning, NOT a

discrete activitydiscrete activity

Assessing for “Lapse” vs. “Relapse”Assessing for “Lapse” vs. “Relapse”

LapseLapseImpulsiveImpulsiveShort DurationShort DurationAccompanied by GuiltAccompanied by GuiltSmall Amount of UseSmall Amount of UseRelatively Low Relatively Low Consequences Consequences Desire to Return to Desire to Return to AbstinenceAbstinence

RelapseRelapsePlannedPlannedLong Period of UseLong Period of UseHigh DefensivenessHigh DefensivenessLarge Amount of UseLarge Amount of UseRelatively High Relatively High ConsequencesConsequencesUncertainty About Uncertainty About Desire to Return to Desire to Return to AbstinenceAbstinence

““Imminent Danger”Imminent Danger”

1.1. A strong probability that certain behaviors will occur (e.g., A strong probability that certain behaviors will occur (e.g., continued alcohol or drug use or relapse or non-compliance with continued alcohol or drug use or relapse or non-compliance with psychiatric medications)psychiatric medications)

2.2. The likelihood that these behaviors will present a significant risk The likelihood that these behaviors will present a significant risk of serious adverse consequences to the individual and/or others of serious adverse consequences to the individual and/or others (as in a consistent pattern of driving while intoxicated)(as in a consistent pattern of driving while intoxicated)

3.3. The likelihood that such adverse events will occur in the very near The likelihood that such adverse events will occur in the very near futurefuture

In order to constitute “imminent danger” ALL THREE ELEMENTSIn order to constitute “imminent danger” ALL THREE ELEMENTSmust be presentmust be present

Immediate Need ProfileImmediate Need Profile

Dimension #1: Acute Intoxication/WithdrawalDimension #1: Acute Intoxication/Withdrawal

Potential:Potential:

(a) Have you ever has life-threatening(a) Have you ever has life-threatening

withdrawal signs or symptoms? ___ No ___Yeswithdrawal signs or symptoms? ___ No ___Yes

(b) If yes, are you currently having similar(b) If yes, are you currently having similar

withdrawal symptoms? ___No ___Yeswithdrawal symptoms? ___No ___Yes

Dimension #2: Biomedical Conditions and Complications:Dimension #2: Biomedical Conditions and Complications:

Do you have any current, untreated severeDo you have any current, untreated severe

physical problems? ___No ___Yesphysical problems? ___No ___Yes

Dimension #3: Emotional/Behavioral Conditions & Complications:Dimension #3: Emotional/Behavioral Conditions & Complications:

Do you feel that you are imminently in danger and could harm Do you feel that you are imminently in danger and could harm yourself or someone else? ___No ___Yesyourself or someone else? ___No ___Yes

Immediate Need Profile Immediate Need Profile (con’t)(con’t)

Dimension #4: Treatment Acceptance/Resistance:Dimension #4: Treatment Acceptance/Resistance:

(a) Do you feel that you are in immediate need of (a) Do you feel that you are in immediate need of alcohol/drug treatment? __No __Yesalcohol/drug treatment? __No __Yes

(b) Have you been referred or required to have an (b) Have you been referred or required to have an assessment and/or enter treatment by the criminal assessment and/or enter treatment by the criminal justice system, health or social services,justice system, health or social services, work/school, or family/significant other? __No __Yeswork/school, or family/significant other? __No __Yes

Immediate Need Profile Immediate Need Profile (con’t)(con’t)

Dimension #5: Relapse/Continued Use PotentialDimension #5: Relapse/Continued Use Potential

(a) Are you currently under the influence? __No __Yes(a) Are you currently under the influence? __No __Yes

(b) Are you likely to continue use of alcohol and/or other (b) Are you likely to continue use of alcohol and/or other drugs, or to relapse, in an imminently dangerous drugs, or to relapse, in an imminently dangerous manner? __No __Yesmanner? __No __Yes

Dimension #6: Recovery Environment:Dimension #6: Recovery Environment:

Are there any dangerous family, significant others, Are there any dangerous family, significant others, living/working situations threatening your safety, living/working situations threatening your safety, immediate well-being and/or sobriety? __No __Yesimmediate well-being and/or sobriety? __No __Yes

Responses to Immediate Need ProfileResponses to Immediate Need Profile

Yes to Dimension 1, 2, and/or 3 Questions:Yes to Dimension 1, 2, and/or 3 Questions:Requires that the caller/client immediately receive medial or Requires that the caller/client immediately receive medial or psychiatric carepsychiatric care

Yes to Dimension 4 Alone:Yes to Dimension 4 Alone:Caller/client to be seen for an assessment within 48 hours, and Caller/client to be seen for an assessment within 48 hours, and perferably earlier, for motivational strategies, unless patinet perferably earlier, for motivational strategies, unless patinet imminently likely to walk out and needs containment strategiesimminently likely to walk out and needs containment strategies

Yes to Dimension 5, Question (a):Yes to Dimension 5, Question (a):Requires the caller/client receive assessment for withdrawal Requires the caller/client receive assessment for withdrawal potentialpotential

Yes to Dimension 5 and/or 6 without Yes in Dimensions 1, 2, and/or 3:Yes to Dimension 5 and/or 6 without Yes in Dimensions 1, 2, and/or 3:Requires the caller/client be referred to a safe or supervised Requires the caller/client be referred to a safe or supervised environmentenvironment

Screening for Alcohol ProblemsScreening for Alcohol Problems

1.1. Have you ever felt the need to Have you ever felt the need to CUT CUT down on your down on your drinking? __Yes __Nodrinking? __Yes __No

2.2. Have you ever felt Have you ever felt ANNOYED ANNOYED by someone criticizing by someone criticizing your drinking? __Yes __Noyour drinking? __Yes __No

3.3. Have you ever felt Have you ever felt GUILTY GUILTY about your drinking? about your drinking?

__Yes __No__Yes __No

1.1. Have you ever felt the need for an Have you ever felt the need for an EYE OPENER EYE OPENER to to get you started in the morning? __Yes __Noget you started in the morning? __Yes __No

UNCOPEUNCOPE

UU “In the past year, have you ever drank or used drugs “In the past year, have you ever drank or used drugs more that you intended to?”more that you intended to?”

NN “Have you ever neglected some of your usual “Have you ever neglected some of your usual responsibilities because of using alcohol or drugs?”responsibilities because of using alcohol or drugs?”

CC “Have you felt you wanted or needed to cut down on your “Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?”drinking or drug use in the last year?”

O O “Has anyone objected to your drinking or drug use?”“Has anyone objected to your drinking or drug use?”P P “Have you ever found yourself preoccupied with wanting “Have you ever found yourself preoccupied with wanting

to use alcohol or drugs?”to use alcohol or drugs?”E E “Have you ever used alcohol or drugs to relieve “Have you ever used alcohol or drugs to relieve

emotional discomfort?”emotional discomfort?”

CraftCraftBrief Screening Test for AdolescentBrief Screening Test for Adolescent

Substance AbuseSubstance Abuse* 2 or more yes answers suggests a significant problem* 2 or more yes answers suggests a significant problem

C- C- Have you every ridden in a CAR when driven by Have you every ridden in a CAR when driven by someone (including yourself) who was “high” or had someone (including yourself) who was “high” or had been using alcohol or drugs?been using alcohol or drugs?

R- R- Have you ever used alcohol to RELAX, feel better Have you ever used alcohol to RELAX, feel better about yourself or fit in?about yourself or fit in?

A- A- Do you ever use alcohol/drugs while you are by Do you ever use alcohol/drugs while you are by yourself, ALONE?yourself, ALONE?

F- F- Do your family or FRIENDS ever tell you that you Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?should cut down on your drinking or drug use?

F- F- Do you ever FORGET things that you did while Do you ever FORGET things that you did while using alcohol or drugs?using alcohol or drugs?

T- T- Have you gotten into TROUBLE while you were Have you gotten into TROUBLE while you were using alcohol or drugs?using alcohol or drugs?

YesYes NoNo