Vol.12 , No. 7
Welcome to the October edition of Tips and Topics (TNT). I’m glad you could join us.
David Mee-Lee M.D.
It was a year ago this month the latest edition of The ASAM Criteria was released. If you haven’t been briefed on what’s new in the 2013 edition, you can take a look at the October 2013 edition of Tips and Topics http://www.tipsntopics.com/2013/10/
or even do a two-hour eTraining module for continuing education credits on an “Introduction to The ASAM Criteria”. Check it out at http://www.asamcriteria.org and click on Resources & Training. There’s lots of other resources on bringing you up to speed.
I am often asked whether The ASAM Criteria can be used in mental health treatment systems as well as for addiction treatment. I’m biased of course. Not only is it useful in mental health, but also in this era of healthcare reform where integratedcare is increasingly necessary, The ASAM Criteria can help general health teams as well.
The ASAM Criteria six dimensional assessment provides a comprehensive structure to provide and manage addiction, mental and general health care.
Here is an update on what I reviewed in the Volume 4, No. 10 edition in March 2007 http://www.tipsntopics.com/2007/03/march-2007/#more-81
The common language of the six assessment dimensions of The ASAM Criteria can be used to determine multidimensional assessment (MDA) of severity and level of function of any health care 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
(The ASAM Criteria 2013, pp 43-53)
For each dimension, I’ll outline how why it is useful and important to consider each assessment dimension if you are:
- A general health clinician – whether in the emergency room, primary care, health clinic or specialty practice
- A mental health clinician – whether in emergency psychiatric services, private practice or a mental health clinic
- An addiction treatment counselor or clinician – whether in outpatient or residential services or private practice
- A care manager – whether in a managed care company or treatment agency
Dimension 1: Acute intoxication and/or withdrawal potential
- Emergency room personnel too often treat the complications of addiction and take care of the broken leg or head trauma from a drunk driving accident, but don’t link the patient to needed addiction treatment. They would never simply stabilize a patient’s asthma attack or diabetic coma without linking them to ongoing asthma or diabetes care.
- Surgeons may do a successful appendectomy for acute appendicitis only to find the patient agitated and in delirium tremens (DTs) three days later. Nobody checked the patient’s alcohol history to discover he/she is a daily heavy drinker and needed withdrawal management along with the appendectomy.
- 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?
- Addiction clinicians are checking the person’s recent substance use history to assess the need for withdrawal management; and in ongoing care using urine drug screen monitoring and other tests to check for use and intoxication.
- Care managers can use the five levels of withdrawal management (WM) to provide and pay for a flexible continuum of WM services that not only uses resources efficiently, but can provide at least two weeks of WM support for what is often spent in 3-4 days at an acute care “detox” unit.
Dimension 2: Biomedical conditions and complications
- All clinicians assess a person’s physical health needs, which are the focus of this dimension.
- But emergency personnel and primary care workers can easily become entangled in a chronic pain patient’s use of medication, which may now have crossed the line into addiction.
- Mental health and addiction clinicians also often struggle with the interface between a person’s chronic pain and their depression, anxiety or substance use disorder. How much does the patient’s pain need better pain management? Or are the frequent requests for more pain medication simply addiction?
- Care managers in managed care companies will frequently authorize huge sums of money for expensive medications, physical health tests or procedures while micromanaging and denying payment for needed outpatient sessions or inpatient and residential levels of care in addiction treatment.
- Care managers in treatment now work in an era of healthcare reform that now requires good linkage with primary care physicians and ongoing disease management.
Dimension 3: Emotional/behavioral/cognitive conditions and complications
- Mental illness suffers nearly the same discrimination and stigma as addiction. Emergency room personnel can easily treat the acute suicidal overdose or self-inflicted cutting lacerations, but fall down on linking the patient to ongoing mental health services.
- Primary care physicians prescribe the majority of antidepressants and anti-anxiety medications more than psychiatrists. But what about the psychosocial aspects? How well can they collaborate with therapists to provide whole care?
- What about all those family members who present with somatic complaints when what is really fueling the headaches, stomach upsets and pain are family behavioral health problems?
- There is now more attention on co-occurring disorders. Both mental health and addiction personnel are more fully embracing at least the need to ask questions about addiction and mental health, as well as coordinate care for any co-occurring disorders.
- If not already doing this, Care managers in managed care should support funding for integrated care rather than create the dilemma clinicians have traditionally faced: Which diagnosis to make the primary one to ensure payment – mental disorder or substance use disorder?
Dimension 4: Readiness to Change
- For many health care workers this is the less understood and more neglected assessment dimension of all. This dimension is as important to assess and treat as whether a patient is having a withdrawal seizure, bleeding to death,or suicidal or homicidal.
- Millions of dollars are wasted in unfilled or partially used prescriptions. No client will adhere to a medication, lifestyle or cognitive change if the treatment plan is driven only by what the clinician, counselor or doctor wants for them.
- Even in general health care, the rhetoric has shifted to the importance of patient-centered care and shared decision-making. What are the person’s priorities and goals? What quality of life do they want? What treatment strategies are a good fit for them and what ones are not?
- 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
- Dimension 5 is not just about drinking and drugging relapse or continued use.Oncologists, internists, and family physicians, focus on how to prevent a cancer recurrence; or another diabetic coma or heart attack. Judges, probation and parole officers, and police are concerned with how to prevent another arrest, probation violation or some illegal activity.
- Addiction and mental health too often see treatment as isolated episodes of acute care for withdrawal management or crisis intervention.
- Nowadays mental health clinicians however are thinking more about how to prevent that psychotic or manic episode, or another suicidal or self-mutilation injury, or another domestic violence situation. Increasingly the focus is on such methods as a Wellness Recovery Action Plan (WRAP).
- The addiction field has long talked about relapse prevention. Where addiction treatment still struggles is in what to do with flare-ups of addiction and substance use while a person is in treatment. I have written about this before- most recently in the July 2014 edition of Tips and Topics. Check it out if you missed it at http://www.tipsntopics.com/2014/07/
- Care managers in addiction managed care and treatment could learn more from chronic disease management of physical health and of severe mental illness. Much can be learned from community-oriented supports and outreach, which proactively prevents deterioration or intervenes early with flare-ups and worsening outcomes.
Dimension 6: Recovery Environment
- With changes in how healthcare is being financed, hospitals are now penalized if a patient returns for readmission within 30 days. Previously, a returning patient filled a bed and generated revenue. What is critical now is that a patient’s family supports, living situation and environmental vulnerabilities and resources are assessed and addressed. This is part of the shift from acute care to ongoing disease management and health and wellness.
- Addiction and mental health professionals are well aware of the following recovery environment issues: Who does a person live with? Is there even a place to live? Who is the financial and emotional support -or not? Are there transportation, childcare, criminal justice, work, school or financial problems? It is important to assess and service these issues.
- Even general healthcare knows that 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.
- The environment makes a big difference to patient comfort and recovery. Birthing centers now look more like a hotel suite than a cold sterile labor and delivery room.
- Care managers in managed care companies and insurance benefit plans still don’t give the financial support and respect for the necessary recovery support services inherent in Dimension 6. Care managers on treatment teams too often can feel like second-class citizens on the treatment team hierarchy.In fact their work is so critical to success. Fortunately also peer specialists are now joining the team.
What about the LOCUS (Level of Care Utilization System) versus The ASAM Criteria?
This is a question I hear from time to time. The LOCUS evaluation parameters were influenced by the ASAM multidimensional assessment and other placement tools. In 1998 the LOCUS was introduced by the American Association of Community Psychiatrists (AACP) and was designed more specifically for mental health treatment systems.
The ASAM Second Revised Edition (ASAM PPC-2R) was published in 2001 containing criteria for co-occurring disorders. It was specifically broadened and updated to allow the assessment dimensions to apply to both mental health and addiction.
Both sets of criteria focus on a multidimensional assessment of the client. Both assess severity and level of function in a variety of important clinical and psychosocial areas. If this is a question that your treatment system is facing, you can see more about this in the March 2008 edition of Tips and Topics.
The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.
The field has had no standardized assessment tool to implement the ASAM Criteria. The multidimensional assessment is a powerful structure and clinical guide as discussed in SAVVY above. Furthermore, coming in 2015 will be a whole new opportunity for the field to unite around The ASAM Criteria Software.
Arising out of the research of David Gastfriend, M.D. (when he was Associate Professor of Psychiatry, Harvard Medical School and led millions of dollars of research on the ASAM Patient Placement Criteria for over a decade) the ASAM Criteria Software fills an important void.
The new software is based on research software extensively tested in Norway, other countries and US agencies.The Substance Abuse and Mental Health Services Administration (SAMHSA) invested millions of dollars to make the software compatible with all the major Electronic Healthcare Record systems.
Get acquainted with what is coming in 2015 to provide a standardized assessment to implement The ASAM Criteria.
The ASAM Criteria Software provides counselors, clinicians and other treatment team members with a computer-guided, structured interview for assessing and caring for adult patients with addictive, substance-related and co-occurring conditions.While the research has been done with adults, there is nothing to stop its being used with youth.
The software offers:
- Data entry screens
- Data management and clinical decision support (CDS) software
- Outputs of an electronic and hard copy of treatment priorities and the least intensive, but safe, efficient and effective placement setting.
- Research-quality questions (including tools such as the Addiction Severity Index (ASI), the Clinical Institute Withdrawal Assessment for AlcoholRevised, CIWA-Ar, and the Clinical Institute Narcotic Assessment, CINA instruments) and extensive algorithmic branching
- An output of a 3-5 page report detailing a patient’s Diagnostic and Statistical Manual (DSM) substance use disorder diagnoses, severity and imminent risks and the recommended levels of care.
How does The ASAM Criteria book relate to The ASAM Criteria Software?
The ASAM Criteria book and The ASAM Criteria Software are companion text and application.
- The book delineates the dimensions, requirements and decision rules that comprise ASAM’s criteria.
- The software provides the approved structured interview to guide the assessment and calculate the complex decision tree to yield suggested levels of care.
- The book and the software should be used in tandem, the book to provide the background and guidance for proper use of the software, and the software to enable comprehensive, standardized evaluation.
- Effective, reliable treatment planning for adults is enhanced by using the book and software together.
Stay tuned at http://www.ASAMcriteria.org and click on the Software tab. We’ll let you know as soon as there are more specifics on how to access The ASAM Criteria Software. It won’t be free, but it will be affordable.
There was absolutely no doubt what I would write for SOUL this month. I was getting ready to complete this month’s edition when the message from my very pregnant daughter was that contractions had started and were intensifying.
It was SUNday morning as the SUN was rising when Miya and Paulo scurried to the hospital – contractions now spiking every three minutes. Even with all their preparation for a calm, all natural birth event, labor pains are just what they’re called….labor.
Two hours after arriving at the hospital Miya’s labor of love was successful and we are all blessed to have grandchild and granddaughter #2 to beam about. Big sister, Luna, now two and a half welcomed her baby sister, not yet fully aware that she will now have to share the attention.
It is always curious as to what inspires parents to name their children. One day I’ll explain why we named our three children Miya, Taylor and Mackenzie. But for SOUL this month the spotlight is on Luna and baby Sol – our own Moon and Sun.
At the risk of being too cute, it was auspicious that:
- Sol arrived on a SUNday
- As the SUN was rising – what would have really been a surprise was if Sol wasn’t a daughter but a son!
- Just earlier in the month I clicked this photo knowing that Sol was the intended name
- In Portuguese Sol is pronounced SOUL
And to top it off, the rental car I was assigned on my business trip this week was an Hyundai Soul model.
Here comes the sun…welcome to the world, Sol.
Until next time
I’m glad you could join us this month. See you again in late November.
Thanks for reading.