TIPS & TOPICS
Volume 4, No.10
March 2007

In this issue
— SAVVY
— SKILLS
— SOUL
— Until Next Time

Welcome to the March edition of TNT, especially if you are one of the many new subscribers.

SAVVY

I was recently training on the Patient Placement Criteria (PPC) for the Treatment of Substance-Related Disorders, Second Edition Revised, ASAM PPC-2R (2001). For those of you who use the ASAM Criteria, that is a mouthful and why many people just say: “Do you use the ASAM?” But you should know that ASAM is the American Society of Addiction Medicine, which is an organization of about 3,000 physicians interested in helping people with alcohol and other drug problems. The ASAM PPC is primarily designed for people with substance and co-occurring mental disorders. But the assessment dimensions of the ASAM Criteria are a good structure that all healthcare and mental health clinicians would find helpful, not just addiction treatment professionals.

Tips:

  • You may not be required to use the ASAM Criteria. Explore using the ASAM multidimensional assessment (MDA) as an efficient and comprehensive assessment of any person’s needs and resources…

The common language of the six assessment dimensions of the ASAM Patient Placement Criteria can be used to determine multidimensional assessment of severity and level of function of any healthcare client. Here are the six assessment dimensions of the MDA:

1. Acute intoxication and/or withdrawal potential
2. Biomedical conditions and complications
3. Emotional/behavioral/cognitive conditions and complications
4. Readiness to Change
5. Relapse/Continued Use/Continued Problem potential
6. Recovery environment

Dimension 1: Acute intoxication and/or withdrawal potential

Who should be thinking about Dimension 1?

–>Emergency room personnel should be thinking: Is this patient with a broken leg someone who was simply in a car accident? Or was this person driving under the influence, and is someone who has an addiction problem that needs treatment?

–>Surgeons may do a successful appendectomy for acute appendicitis only to find the patient agitated and in the DTs three days later. Nobody checked the patient’s alcohol history. They would have discovered a daily heavy drinker at risk of severe alcohol withdrawal, needing detox medication.

–>Mental health professionals should be checking: Is this major depression? Or is the person crashing from cocaine or other stimulants? Is this really anxiety disorder, or is the client in benzodiazepine or alcohol withdrawal? Is this really bipolar disorder, or is the person using uppers and downers and having mood swings as part of an addiction problem?

–>And of course, addiction clinicians are assessing the client’s substance use perhaps via drug screen monitoring. They are also checking Dimension 1 for any need for detox services.

Dimension 2: Biomedical conditions and complications

Who should be thinking about Dimension 2?

–>There usually isn’t much dispute about checking whether someone has any physical health needs. Every client and patient receives some assessment of their Dimension 2 status.

Dimension 3: Emotional/behavioral/cognitive conditions and complications

Who should be thinking about Dimension 3?

–>With Dimension 3, we are usually back to some ambivalence. Mental health people are ready to assess Dimension 3. Only more recently is there the attention on co-occurring disorders and dual diagnosis. Addiction personnel are more fully embracing the need to at least ask questions about mental health and to coordinate care for any co- occurring disorder.

–>Unfortunately for the rest of healthcare staff, mental illness suffers nearly the same discrimination and stigma as addiction clients. Emergency room personnel should be savvy enough to tell the difference between a heart attack and a panic attack. Or the difference between a substance induced psychosis and a schizophrenic break.

–>Family physicians can limit a variety of laboratory and exploratory tests by tuning into the patient who is dealing with depression; or exhibiting stress from family addiction and presenting with somatic complaints.

Dimension 4: Readiness to Change

Who should be thinking about Dimension 4?

–>No treatment session, medication, or lifestyle change will be adhered to if the treatment plan is driven only by what the clinician, counselor or doctor wants for the client, instead of being focused on what the client wants for him or herself ,and is invested in.

–>Every branch of health care faces people who are ambivalent about their health status and following through on treatment and lifestyle change.

–>Alliance building, engagement, and motivational enhancement is critical not just in addiction treatment, but also in mental health and healthcare in general.

Dimension 5: Relapse/Continued Use/Continued Problem potential

Who should be thinking about Dimension 5?

–>Dimension 5 is not just about drinking and drugging relapse or continued use (for people who have not yet decided to commit to abstinence).

–>Mental health clinicians are thinking also about how to prevent that psychotic or manic episode; or another suicidal or self-mutilation injury; or another domestic violence situation

–>Oncologists, internists, family physicians, judges, probation and parole officers, and police are all thinking how to prevent a cancer recurrence; or another diabetic coma or heart attack. Or how to prevent another arrest or probation violation or some illegal activity.

Dimension 6: Recovery Environment

Who should be thinking about Dimension 6?

–>Addiction and mental health professionals well know that all the following recovery environment issues are important to assess and service- i.e. who a person lives with; whether there is even a place to live; who is the financial and emotional support or not; whether there are transportation, childcare, criminal justice, work, school or financial problems.

–>But even in general healthcare, when a patient is recovering from a heart attack, the person who has family and supportive friends around will do better than the isolated person.

–>Or if you have an older adult likely to be confused when in hospital, then having photographs around and other familiar objects or reminders of loved ones can enhance recovery.

–>Birthing centers now look more like a hotel suite than a cold sterile labor and delivery room.

For more information and references on the ASAM Patient Placement Criteria:
Mee-Lee D, Shulman GD, Fishman M, Gastfriend DR, and Griffith JH, eds. (2001). ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition-Revised (ASAM PPC-2R). Chevy Chase, MD: American Society of Addiction Medicine, Inc.

To purchase the ASAM PPC:
American Society of Addiction Medicine – 4601 Nth. Park Ave., Arcade Suite 101, Chevy Chase, MD 20815. (301) 656-3920; Fax: (301) 656-3815; www.asam.org; To order ASAM PPC- 2R: (800) 844- 8948.

References:
Mee-Lee D, Shulman GD (2003): “The ASAM Patient Placement Criteria and Matching Patients to Treatment”, Chapter 5 in Section 4, Overview of Addiction Treatment in “Principles of Addiction Medicine” Eds Graham AW, Schultz TK, Mayo- Smith MF, Ries RK, Wilford BB, Third Edition. American Soc. of Addiction Medicine Inc., Chevy Chase, MD.

Gastfriend, D.R. & Mee-Lee, D. (2003): “The ASAM Patient Placement Criteria: Context, Concepts and Continuing Development” in “Addition Treatment Matching – Research Foundations of the American Society of Addiction Medicine (ASAM) Criteria.” Journal of Addictive Diseases, 22, Supplement Number 1, 2.

Mee-Lee, David (2005): “ASAM’s placement criteria: What’s new” Behavioral Health Management Volume 25, No. 3. May/June 2005

Miller, S.D., Mee-Lee, D., Plum, B. & Hubble, M (2005): “Making Treatment Count: Client-Directed, Outcome Informed Clinical Work with Problem Drinkers.” In J. Lebow (ed.). Handbook of Clinical Family Therapy. New York: Wiley.

Mee-Lee, David (2005): “ASAM Patient Placement Criteria: Implications for Assessment and Treatment of Patients with Co-Occurring Disorders” Counselor Magazine. Volume 6, No. 5 pp. 28-33.

Mee-Lee, David (2006): “Development and Implementation of Patient Placement Criteria” in “New Developments in Addiction Treatment”. Academic Highlights. J Clin Psychiatry 67:11: 1805-1807.

For more tidbits on the ASAM Criteria, refer to previous editions:

April 2003: in Savvy & Skills
June 2003: in Savvy & Skills
Sept 2003: in Stump the Shrink
Nov 2003: in Skills
Jan 2004: in Stump the Shrink
Mar 2004: in Savvy & Skills
Oct 2004: in Savvy
Dec 2005: in Savvy, Skills & Stump the Shrink
Oct-Nov 2006: in Savvy & Skills

SKILLS

Tips:

  • Use these test questions to see what you know about the ASAM Criteria and the implications for clinical skills and services design.

Select the Best Answer:

1. The best treatment system for addiction is:

(a) A 28-day stay in inpatient rehabilitation with much education.
(b) A broad continuum of care with all levels of care separated to maintain group trust.
(c) Not possible now that managed care has placed so much emphasis on cost-containment.
(d) A broad range of services designed to be as seamless as possible for continuity of care.
(e) Short stay inpatient hospitalization for psychoeducation.

2. The six assessment dimensions of the ASAM Criteria:

(a) Help assess the individual’s comprehensive needs in treatment.
(b) Provide a structure for assessing severity of illness and level of function.
(c) Requires that there be access to medical and nursing personnel when necessary.
(d) Can help focus the treatment plan on the most important priorities.
(e) All of the above.

3. A multidimensional assessment in behavioral health treatment:

(a) Should include psychosocial factors such as readiness to change.
(b) Is ideal, but not necessary within a managed care environment.
(c) Should include biomedical and psychiatric problems, but not motivation or relapse potential.
(d) Is best done after detoxification is completed.
(e) Should be completed by the primary therapist only.

Indicate True or False:

4. It is not the severity or functioning that determines the treatment plan, but the diagnosis, preferably in DSM terms. (T) (F)

5. The level of care placement is the first decision to make in the assessment. (T) (F)

Here are the answers and some implications

Question 1 – (d). Even though there are many levels of care described in the ASAM Criteria, they do not need to be all discrete programs with their own assessment and service menu in a separate treatment setting, clinician team and administrative structure. In fact if you chose (b) as the answer because of your concern for group trust, consider how Alcoholics Anonymous can create a healing and welcoming environment. Yet you can never guarantee that there will be the same group members at a meeting from one day to the next. A person with three hours of abstinence may be sitting next to someone with thirty years of grateful recovery sitting next to someone who is ambivalent about sobriety sitting next to someone who is absolutely committed to recovery.

Question 2 – (e). The ASAM MDA addresses all of these issues and is useful not just in addiction treatment, but also in mental health and healthcare in general.

Question 3 – (a). Focus is often placed just on the first three dimensions to determine Medical Necessity. But the last three dimensions are just as important to assess and service because they are just as influential on influencing treatment outcomes as the first three dimensions. As a result, in the ASAM Criteria, Medical Necessity has been broadened to “Clinical Necessity”.

Question 4 – F. In fact it is the other way around. In the old days of addiction treatment, the diagnosis determined the treatment plan. If you had alcohol dependence, the placement and length of stay was automatically 28 days of residential treatment. In applying the ASAM PPC, it is the individual’s unique MDA needs that determines the level of care and length of stay, not their diagnostic label.

Question 5 – F. Again, it is the other way around. You may feel you have the need to triage a person to a level of care as the first decision. However you cannot know where to refer or link a person until you have done enough assessment and service planning to know what is the least intensive, but safe level of care that can provide the mix of services needed. For example, you would need to know what is the person’s severity of withdrawal to determine what mix of detoxification services (medication, nursing care, doctor visits, psychosocial support, 24 hour structure or not etc.) is needed. Only then, as the last decision, could you decide on a level of care in hospital versus social detox versus outpatient detox level of care. (There are five levels of detox. in the ASAM PPC)

SOUL

At a workshop recently, I was introducing myself. As I was explaining about graduating from specialist psychiatry training and entering private practice, I realized I was talking about 30 years ago—1977—- last century. For a person who feels sometimes that I am still in my 30’s, that was a sober reminder of the aging process. My mother turned 92 in January, and is still quite mentally alert and active. I hope I got her genes. Her sister, whom she visits every day in the nursing home, is 94. While the sister is not quite as sharp, she still has a sense of humor and surprising wit at times. I hope I got her genes too.

My mother tells me about all the nursing home patients she sees come and go. And before they die, many of them suffer the indignities of yelling aggressively in their senile distress with such venom they would never have imagined in their better years. There’s the pastor who takes off his clothes, and invites female patients into his bed: “It’s clean” he says. There’s Edna (we’ll call her) who carries her toy doll, and hits people for sitting in “her” chair.

“If I get like that”, my mother says, “shoot me.” I say: “It won’t matter because you probably won’t know you are like that anyway.”

The comedians joke that’s the beauty of Alzheimer’s—every day is a new day with opportunities to meet new people and new things to do. Then I thought, maybe that’s another way to view the meaning of living one-day-at-a-time—-to embrace each day as if it’s an opportunity for exciting new people, places or things. I know I don’t want the sad regressive behavior devoid of social judgment and sensibility. But a little bit of the ability to forget the regrets of the past and the worries of the future might be a nice gift! As they say, that’s why they call living today is a present.

Until Next Time

Thanks for joining us. See you in April.
David