How to Really Use the New Edition of The ASAM Criteria: What to Do and What Not to Do

Since 1991, The American Society of Addiction Medicine (ASAM) has published the most comprehensive set of guidelines for assessment, service planning, placement, continued stay, and transfer/discharge of individuals with addiction and co-occurring conditions. There are a lot of people in over thirty states and in the Department of Defense addiction programs around the world—as well as payers and managed care organizations—that say they “use” ASAM’s criteria. If you are one of those people, you will want to have the new third edition: The ASAM Criteria—Treatment Criteria for Substance-Related, Addictive, and Co-Occurring Conditions (Mee-Lee et al., 2013).

If you do not yet use ASAM’s criteria, this edition is where you will want to start, because this is the most well-formatted, attractive, and user-friendly edition yet published. The chapters and sections walk the reader through a process that parallels how assessment, service planning, placement, and continuing services really happen. Beginning with some brief history and underlying goals and principles of The ASAM Criteria, the flow of the book helps counselors, clinicians, care managers, and supervisors understand that ASAM’s criteria is much more than just initial “placement” in your treatment program.

In fact, if you truly embrace the spirit and content of The ASAM Criteria, it will change how you use the criteria to engage people into recovery, collaborate on treatment planning, design and deliver levels of care and the continuum of services, and manage and pay for care from acute services to ongoing disease management.

This article aims to help you really “use” The ASAM Criteria. 

What The ASAM Criteria is not  

• The ASAM Criteria is not just admission criteria to get a client into your level of care and program.

Each edition of the criteria since 1991 (ASAM, Hoffmann, Halikas, Mee-Lee, & Weedman, 1991; ASAM, 1996; Mee-Lee et al., 2001) has had “patient placement” in the title. It is understandable then that people and programs have focused more on “placing” a person in a circumscribed level of care program, rather than individualizing treatment—matching a person’s needs and strengths to the best intensity of services in a continuum of levels of care.  This is one of the reasons the title of this new edition does not have “patient placement” any more, because these guidelines are to be used for doing much more than just placing a person in your program.

• The ASAM Criteria is not just a checklist of criteria to justify why you put the client in your program because your state or county requires you to use ASAM’s criteria.

Some counselors and programs didn’t even know that there was an actual book of principles, guidelines, and criteria because they have a two-page crosswalk that says “ASAM Patient Placement Criteria” at the top. The new edition is a hardcover book of 460 pages with adult and adolescent criteria and guidelines on matching to level of care, but also much more. I have had counselors ask me to fax them the latest copy of The ASAM Criteria thinking it is a two-page document.

• The ASAM Criteria is not just a paperwork exercise you tolerate every thirty or ninety days depending on when your licensing authority requires you to review and update the treatment plan.

Reviewing a client’s multidimensional assessment should be a regular part of the ongoing evaluation of the client’s progress and outcomes in treatment. This is not something to be done at thirty or sixty-day intervals. Looking at a client’s progress in treatment helps clinicians decide what needs to be done next if outcomes are good. Or, if the client is not doing well and progress has stalled, reviewing The ASAM Criteria’s six dimensions guides the use of the continued service or transfer/discharge criteria. The new edition provides clinical vignettes and guidelines to improve your assessment on when to keep a client longer in treatment in your level of care, or when it is time to transfer the client to a different setting or level.

• The ASAM Criteria is not promoting fixed length-of-stay, residential treatment as the only level of care where addiction recovery should start.

In fact, what level of care a person needs and how long they stay depends on that person’s particular severity of illness, level of function, and what progress they are making in treatment.  If residential twenty-four-hour services are needed because the client would be in imminent danger if not treated within that time frame, then they should be able to access that level of care without having to fail at a less intensive level first. We don’t require someone with severe suicidal impulses to try outpatient treatment first, or someone with a severe heart attack to start exercising and stop smoking before being admitted.  

On the other hand, if a person can safely and effectively receive the intensity of services they need in an outpatient or intensive outpatient setting, that should be tried first rather than to use more resources than they need, which deprives others of access to care due to limited funds and waiting lists. The new edition explains further what residential levels of care are matched for what severities of illness and levels of function so that we increase access to care, instead of waiting lists, and stretch resources to give people the best chance of recovery by giving them all the care they need in a broad continuum of care. But to stretch resources, the whole continuum of care has to be used flexibly in an overlapping and seamless manner, which The ASAM Criteria encourages.

• The ASAM Criteria is not something you do along with the Addiction Severity Index (ASI), or other biopsychosocial assessments, and then move onto business as usual in your program.

For most clients, addiction and co-occurring conditions are chronic illnesses that need person-centered services, not program-driven care that they complete and from which they graduate. The new edition promotes a disease management approach that encourages better integration with general and mental health care. Level 1, outpatient services, is not just the entry point for addiction services; it is where ongoing disease monitoring and maintenance of recovery occurs.  Some patients may never graduate or complete treatment if they need ongoing professional monitoring of their addiction, just as few people graduate or complete treatment for hypertension, asthma, diabetes, or bipolar disorders.

So what does “using” The ASAM Criteria really mean?

What Using The ASAM Criteria Is  

• Using The ASAM Criteria is an opportunity to rethink how to engage people into treatment and attract them into ongoing recovery and wellness.

Most people with addiction do not wake up one day and declare “My life is unmanageable and I want serenity and sobriety one day at a time and am ready to do whatever it takes. Where’s the AA meeting tonight?” Most feel they have been forced into treatment, if not formally mandated by a judge or child protective services, but by a relative or spouse or partner or an employer. The ASAM Criteria has always had Dimension 4, “Readiness to Change”—which before 2001 was called “Treatment Acceptance/Resistance”—and has always advocated for motivational enhancements strategies for Dimension 4 services.

In the new edition, we added to that approach by changing any terminology like “resistant” or “unmotivated” to language that recognized people as being at different stages of change and level of interest in treatment and recovery. The third edition of Motivational Interviewing (Miller & Rollnick, 2013) even refers to “resistance” as a term previously used in Motivational Interviewing, not even present in their new edition. This is because “resistance” places the pathology in the patient and client rather than in the interaction between counselor and client, where it rightfully belongs.  

Like any chronic illness where the outcomes depend significantly on self-propelled lifestyle change, addiction especially needs to attract people into self-change rather than force compliance in services they feel cornered into accepting. Use Dimension 4 of The ASAM Criteria to guide your assessment and stage-matched interventions that promote accountable self-change in order to reach sustainable, lasting, and positive outcomes.

• Using The ASAM Criteria is viewing multidimensional assessment using the six assessment dimensions as not only an initial process, but ongoing throughout a person’s lifelong recovery process.

In case you are not as familiar with the dimensions here they are and what they focus on:

1. Acute Intoxication and/or Withdrawal Potential:Assessment for intoxication and/or withdrawal management, withdrawal management in a variety of levels of care, and preparation for continued addiction services
2. Biomedical Conditions and Complications:Assess and treat co-occurring physical health conditions or complications. Treatment provided within the level of care or through coordination of physical health services
3. Emotional, Behavioral or Cognitive Conditions and Complications: Assess and treat co-occurring diagnostic or sub-diagnostic mental health conditions or complications. Treatment provided within the level of care or through coordination of mental health services 
4. Readiness to Change: Assess stage of readiness to change. If not ready to commit to full recovery, engage into treatment using motivational enhancement strategies. If ready for recovery, consolidate and expand action for change
5. Relapse, Continued Use or Continued Problem Potential: Assess readiness for relapse prevention services and teach where appropriate.  If still at early stages of change, focus on raising consciousness of consequences of continued use or problems with motivational strategies.  
6. Recovery Environment: Assess need for specific individualized family or significant other, housing, financial, vocational, educational, legal, transportation, childcare services

In the new edition, there have been improvements in Dimensions 1 and 5. The name of the dimensions remains the same, but for Dimension 1, “detoxification” service has been changed to “withdrawal management” because the liver detoxifies alcohol and other drugs, but clinicians manage withdrawal. The five levels of withdrawal management are now renamed from Level I-D. Ambulatory Detoxification Without Extended On-Site Monitoring to as follows plus the four other WM levels. Also note the change from Roman numerals to Arabic numerals:

• Level 1-WM: Ambulatory Withdrawal Management without Extended On-Site Monitoring
• Level 2-WM: Ambulatory Withdrawal Management with Extended On-Site Monitoring
• Level 3.2-WM: Clinically-Managed Residential Withdrawal Management
• Level 3.7-WM: Medically-Monitored Inpatient Withdrawal Management
• Level 4-WM: Medically-Managed Intensive Inpatient Withdrawal Management

The clinical implication of the change to “withdrawal management” is that a patient is often admitted to a Level 3.7-WM or 4-WM at $600-800/day for a few days to prevent withdrawal seizures and then is discharged. Within a week a person may start using substances again, which is seen as noncompliance because they have already been detoxified. However, they were actually treated for a few days to prevent seizures, but their withdrawal syndrome was not managed as it could have been by using the full range of five levels of withdrawal management that are in the adult criteria. By managing withdrawal in a continuum of WM services, a person could get two weeks of support through withdrawal for what is now spent in three or four days in the most intensive and expensive levels of WM (e.g., Level 3.2-WM may cost $100-200/day, which could give a person three or four days in twenty-four-hour support for every one day that Level 4-WM costs). Thus, without spending more resources and maybe even less than what is spent for a few days of the most intensive and expensive levels of WM, the patient could receive much longer lengths of withdrawal management in the five levels of WM.

• Using The ASAM Criteria is taking Dimension 5, Relapse, Continued Use or Continued Problem Potential seriously as a dimension to be assessed and treated, not as a behavior problem warranting discharge.

In Appendix B, Special Considerations for Dimension 5, this new edition gives guidance not only on the constructs that make for a comprehensive assessment of Dimension 5, but also on how to deal with the common situation of a client using substances while in treatment. Instead of telling a client to come back when they are stable or even actually discharging them from treatment, there are guidelines and an example of a policy and procedure on how to handle substance use while in treatment.  

Of course, if a client is not interested in treatment and uses and influences others to use trying to disrupt treatment, then discharge is certainly to be considered. If the client is not willing to change his or her treatment plan in a positive direction—staying away from drug using friends or going to more support groups—then it would be considered “enabling” to continue treatment as if progress was being made. However, if the client is willing to make changes, even tiny steps, then treatment is about “progress not perfection” as said in Alcoholics Anonymous. The new guidelines in Appendix B really help clinicians use the spirit and content of The ASAM Criteria.

• Using The ASAM Criteria is understanding the residential levels of care as twenty-four-hour treatment services for people whose continued use or relapse would place them in imminent danger.

The new edition explains more about what is meant by “imminent danger” as there has been misunderstanding in the past. It does not restrict the meaning to just traditional managed care medical necessity of seizure dangers in Dimension 1, or severe physical or mental health life-threatening problems in Dimensions 2 and 3. This edition explains further “imminent danger” in Dimensions 4, 5, and 6. For example, a client may not even think he or she has an addiction problem, is intoxicated but not in withdrawal, and is intent on driving when it is clear they are impaired. Such a person needs twenty-four-hour stabilization in a residential setting. Or, a client has overwhelming impulses to continue drinking or drugging and is in imminent danger of worsening liver or psychotic illness thus needing twenty-four-hour treatment to prevent acute flare-up.

There may be danger in the future that is not imminent, such as the person may drink and drive sometime in the coming weeks and months, and/or the client has great difficulty stopping substance use because of homelessness or a toxic recovery environment. However, this person’s relapse potential and dangerous behavior would not warrant twenty-four-hour residential treatment levels of care, especially if the clinician is willing to put the person on a waiting list. Such a person may benefit from Level 3.1, Clinically Managed Low Intensity Residential Treatment, which provides for twenty-four-hour supports with a minimum of five hours of clinical services per week. This is a twenty-four-hour supportive living environment, not a twenty-four-hour treatment setting.

An additional change in the adult residential levels of care is that Level 3.3 has been renamed to match its originally intended setting; Clinically Managed Population-Specific High-Intensity Residential Services is designed to serve people with cognitive difficulties. Level 3.3 programs were always meant to deliver high-intensity services, which may be provided in a deliberately repetitive fashion to address the special needs of individuals for whom a Level 3.3 program is considered medically necessary. 

Such individuals may be elderly, cognitively impaired, developmentally delayed, or those in whom the chronicity and intensity of the primary disease process requires a program that allows sufficient time to integrate the lessons and experiences of treatment into their daily lives. Typically, they 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). The decimal point of 3.3 was retained to indicate the slower pace, but the name change indicates that this level is for a specific population and that high intensity work still is needed but at a slower pace. 

• Using The ASAM Criteria is working effectively to manage care whether you are a provider or a care manager for a payer or managed care organization.

Both addiction treatment clinicians and payers spend significant amounts of time and resources communicating back and forth in the treatment payment approval process. One of the goals of the new edition is to have The ASAM Criteria enhance assessment, placement, and the care management processes for providers and payers. So, there is a section on “Understanding how to Effectively Work with Managed Care and Health Care Reform.” 

When focused on assessing all six assessment dimensions of The ASAM Criteria and planning an individualized collaborative plan, clinicians are in fact managing care if the treatment level selected is the least intensive but safe level of care for the person. This isn’t about just placing a person in the least intensive level until they “fail” that level. This is about making sure we give people all the care they need, but not in a more intensive level than is clinically safe as that is wasteful of scarce resources. But also not to place them in a less intensive level of care that matches their severity and level of function. If they go to a less intensive level than is needed and end up getting worse that is not good for the patient and his or her family, but also not good for budgets as the person then ends up in emergency rooms or more acute care again.

• Using The ASAM Criteria is applying the guidelines to a wide range of populations in a variety of settings.

Counselors have had difficulty knowing how to apply the criteria to older adults, parents with children who are with them in treatment, people in safety sensitive occupations, and clients in criminal justice settings. The new edition goes a long way to help the field recognize the unique assessment and treatment issues for these special populations. Because many clients are referred for addiction treatment mandated from criminal justice drug courts, probation, and parole, or are even in prison treatment settings, this new edition addresses the challenges and special issues in applying the guidelines to this large population of people in addiction treatment.

For example, judges often mandate clients to a specific level of care and length of stay, which is not based on an assessment of what will achieve good outcomes, but rather based on public safety reasons. The ASAM Criteria recommends that judges mandate assessment and treatment adherence that places the responsibility on clients to “do treatment and change” rather than give the impression that they can “do time” in a program for a fixed length of stay. 

A Manual You Can Really Use  

“Using” The ASAM Criteria has meant many things to different people in different settings. Once you get your hands on the new book released on October 24, 2013, you’ll not only be able to explore the issues discussed in this article for yourself, but there is something else you will notice. You will be pleasantly surprised how user-friendly it is. Run your fingers along the edge of the pages of this attractive manual and the tabs will tell you exactly where you are in the book. If you’d like to see more about the new edition, you can visit www.ASAMcriteria.org for additional information. You can even download some PowerPoint slides and other articles on what’s new.

References  

American Society of Addiction Medicine. (1996). Patient placement criteria for the treatment of substance-related disorders (ASAM PPC-2) (2nd ed.). Chevy Chase, MD: The Society.

Hoffmann, N. G., Halikas, J. A., Mee-Lee, D. & Weedman, R. D. (1991). Patient placement criteria for the treatment of psychoactive substance use disorders. Washington, DC: American Society of Addiction Medicine, Inc. 

Mee-Lee, D., Shulman, G. D., Fishman, M., Gastfriend, D. R., & Griffith, J. H. (Eds.). (2001). ASAM patient placement criteria for the treatment of substance-related disorders, revised (ASAM PPC-2R) (2nd ed.). Chevy Chase, MD: American Society of Addiction Medicine, Inc.

Mee-Lee D., Shulman, G. D., Fishman, M. J., Gastfriend, D. R., & Miller, M. M. (Eds.). (2013). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring conditions (3rd ed.). Carson City, NV: The Change Companies.

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing—Helping people change (3rd ed.). New York, NY: Guilford Press.