Vol. 11, No. 7
Welcome to the October edition of Tips and Topics. Thanks for reading.
David Mee-Lee M.D.
This week, the American Society of Addiction Medicine (ASAM) will release the new edition of ASAM’s criteria: “The ASAM Criteria – Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions.” As Chief Editor, I am especially excited as October 24, 2013 culminates over two years of direct work on the new edition. (It has been 12 years since the last edition of ASAM’s criteria.)
For those of you familiar with The ASAM Criteria, you’ll be pleasantly surprised once you get your hands on the new manual. It is attractive, user-friendly and leaps and bounds ahead of previous editions. There is new content and it helps you apply the criteria in a variety of clinical settings and for different populations.
Both for long-time Criteria users and for readers who do not know The ASAM Criteria, here are highlights of what you will see in the new edition. (There is also more information about what’s new in this year’s May 2013 edition of Tips and Topics.)
Expand your knowledge about multidimensional assessment and the levels of care.
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’tmanage 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 everyday in a high intensity hospital-based service.
*Level 1, Outpatient Services
- 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.
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.
If you are not familiar with the ASAM Criteria dimensions, take a look at last month’s edition: http://changecompanies.net/tipsntopics/?s=The+ASAM+Criteria+six+dimensions
The new edition uses regular Arabic numerals- for Levels of Care.
So Level III is now Level3. Level IV is now Level 4 etc.
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
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 predesigned breaks.”
–> I’m still looking for the program that has the cocaine, heroin, marijuana or Xanax gazebo for the patients not ready to quit all those drugs at once!! <–
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.
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:
—-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.
Many clients come from criminal justice drug courts, probation and parole or even still reside in prison treatment settings.
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
Here are the facts:
- There are millions more people who after January 1, 2014will now be covered by health insurance and have access to addiction treatment
- 23.1 million people 12 years and older needed treatment for an illicit drug or alcohol use problem and only 2.5 million receive specialty addiction treatment (2012 National Survey on Drug Use and Health, NSDUH, September 2013)
How will addiction treatment agencies increase access to care when we already have waiting lists and can’t even meet treatment-on-demand?
The new edition addresses the need to reach out to other health systems where most people withaddiction first show up:
- Integration of addiction treatment services with mental health- co-occurring capable; co-occurring enhanced; complexity capable programs
- Increasing Screening, Brief Intervention, Referral and Treatment (SBIRT) in Level 0.5, Early Intervention
- Integration of addiction and general healthcare services – Patient Centered Health Care Homes
- Integration of primary care into addiction treatment settings
Learn how to manage care yourself
A new section on working effectively with managed care and healthcare reform helps everyone manage care to “bend the cost curve” – meaning reducing the rate of healthcare inflation and costs. This is a responsibility of ALL if we are to eliminate waiting lists and make way for the millions of potential new patients who deserve and need addiction treatment.
When asking a managed care utilization reviewer to authorize payment for your treatment services, go over in your clinical head the following steps in the information and be ready to communicate/convey them to the care manager on the phone:
1. What are the problems and priorities you are concerned about?
2. Which ASAM Criteria dimensions do they belong to?
3. What are you going to do in the treatment plan for those problems? What services? How much and how frequently does the client need those services?
4. What is the level of care that is the least intensive, but safe level to provide the treatment plan?
Here is an example that follows those steps: (Clinician response in italics)
Q1. What are the problems and priorities you are concerned about?
” The patient has impulses and cravings to continue using.”
Q2. Which ASAM Criteria dimensions do they belong to? –
“Dimension 5, Relapse, Continued Use or Continued Problem Potential”
Q3. What are you going to do in the treatment plan for those problems? What services? How much & how frequently does the client need those services? “Cognitive behavioral therapy, peer refusal skill building, medication management and relaxation and contingency management strategies – throughout the day, on a daily basis, for several hours a day, because the client’s cravings and impulses are intense, frequent and daily. Without this dose and frequency of services, my client will have a significant flare-up of liver problems and psychosis.”
Q4. What is the level of care that is the least intensive, but safe level to provide the treatment plan?
“Level 2.5 partial hospital combined with Level 3.1 supportive living”
Some clinicians request payment authorization by saying such things as:
“We need another week because the patient is at high relapse potential.” Such clinicians will need to be prepared to answer some more searching questions from the authorizer like:
What do you mean by “high relapse potential”?
What are you doing in the treatment plan for the high relapse potential?
What about the relapse prevention plan you say you are developing with the patient can only be done in your level of care?
Why cannot those same strategies be delivered safely in a less intensive setting?
If all a clinician can say is to repeat the statement that the patient’s potential for relapse is very high, then you can be assured that the managed care utilization reviewer will consider that as inadequate information to explain why further treatment is needed in your program. Most likely payment for those services will be denied.
Learning to manage care yourself means:
- To be good stewards of resources so we can increase access to care
- Stretching limited resources to provide all the levels of care a person needs for recovery
Malala Yousafzai is now 16 years old. She teaches and travels the globe talking about the importance of education, especially for girls and women. The Pakistani girl, shot by the Taliban for her efforts, has been hailed as the youngest person ever nominated for the Nobel Peace Prize.
When I was a 11 year old boy in Australia, I was writing little stories for the Sunday paper trying to win a prize. I even got to go on television to receive my prize of a watch for my essay. Malala blogged for the BBC in 2009 as she defied a Taliban edict banning girls from going to school. She was also 11.
Malala was targeted and shot in the head and neck October 9, 2012 – a year ago this month – following all the publicity she received for opposing that Taliban campaign to close schools. She continues to speak out eloquently and courageously.
I am proud to speak out and advocate for a broad range of effective and efficient services for people with addiction and co-occurring conditions, which I have trumpeted since the 1980’s. I will be especially gratified to hold the new edition of The ASAM Criteria and introduce it to everyone on Thursday, October 24.
Then I think of Malala Yousafzai.
No pressure – but I really don’t want you to miss out on the special preorder offer when you buy the new edition of The ASAM Criteria. Go to www.ASAMcriteria.org to order and get the offer that is in it last days until the end of October.
Until next time
See you again in late November. Thanks for reading.