Referral to Treatment:Utilizing the ASAM Criteria

Stephen A. Wyatt, DO

Medical Director, Addiction Medicine

Behavioral Health Service

Carolinas HealthCare System

AOAAM Essentials in Addiction MedicineOctober 22, 2016East Lansing, MI

Disclosure

• American Society of Addiction Medicine publishes the Patient Placement Criteria 2nd Edition Revised.

• This publication is used for initial evaluation, placement, continued stay, transfer and discharge planning.

• ASAM PPC-II-R AND THE ASAM CRITERIA (2013)

Historical Approach to Treatment

• Complications Driven Approach

• Diagnosis, Program-driven Treatment

• Individualized, Clinically driven Treatment

• Biopsychosocial Needs

• Addiction

• Mental Health

• Social

• Participant-Directed, Outcome-informed Treatment

ASAM criteria driven treatment

• Enhances use of limited resources

• Increase ability to maintain treatment

• Improves outcomes to help prevent relapse

• Fixed length to flexible length of stays

• Chronic disease management

Collaboration

• Understand their understanding of the problem

• Agreement on Goals

• Agreement on Treatment Methods

• Establishes a Therapeutic Alliance

Development of the Treatment Plan

• Patient Centered Treatment.

• What?

• Why?

• How?

• Where?

• When?

Initial Assessment

• Step by Step Approach

• Not always in the same order due patient needs

• Assess:

• Risks

• Needs

• Strengths & Resources

Multi-Dimensional Assessment

Dimensions

1. The acute intoxication and/or withdrawal potential

2. Biomedical conditions and complications

3. Emotional, behavioral or cognitive conditions and complications

4. Readiness to change

5. Relapse, continued use or continued problem potential

6. Recovery and living environment

FIRST STEP

• IMMINENT DANGER

• A high probably that certain behaviors will occur

• The likelihood that such behaviors will present a significant risk of serious adverse consequences to the individual and/or others

• The likelihood adverse events will occur in the very near future

Stages of Change

• Pre-contemplation

• Contemplation

• Preparation

• Action

• Maintenance

• Relapse or return to old behavior/patterns

(Prochaski and DiClemente, 1996).

Dimension 1: The acute intoxication and/or withdrawal potential.

• Processing current levels of acute intoxication

• Previous withdraw history and management

• Current signs of withdrawal and participants them available support networks

Dimension 2: Biomedical conditions/complications

• How does the participants health impact his or her treatment?

• Assessing for ”physical health services”

• Any and all physical conditions and complications should be considered

• Severity

• Medication management

• Any treatment issues

• This includes current and acute ailments to chronic conditions

Dimension 3: Emotional/Behavioral/ Cognitive condition/ complications

• Assessed for any “mental health services” needed

• Make sure to address these symptoms appropriately

• Violence potential

• Ability to function

• Include; Thought, Mood, and/or Personality Disorders

Dimension 4: Readiness to Change

• Addresses ”Motivational services” needed.

• Stages of change found in the trans-theoretical model of change

• This includes his or her level of understanding, commitment, and ability to follow through

Dementia 5: Relapse/Continued use/Continued problem potential

• Assessed for any “relapse prevention services” needed• Accounts for participants who:

• continue to use

• continue to experience mental health concerns

Dimension 5: Relapse/ Continued use/ Continued problem potential

• Substance use patterns

• Physical and mental health conditions

• Relapse triggers

• Coping skills and other demographic factors

Dimension 6:Recovery/Living environment

• Help provide “recovery support services”

• Tries to get an accurate picture of where the patient lives or plans to live

• Family, friends and support

• How he or she is doing at work or school

• Finances

• Transportation

• Legal mandates and requirements

Levels of Care

• 0.5 Prevention & Early Intervention

• 1 Outpatient Services

• 2 Intensive Outpatient Services

• 3 Residential Treatment

• 4 Inpatient Hospitalization

Treatment Models

Motivational Interviewing

• Extrinsic & intrinsic motivation

• Enlightened self-interest

• Developing discrepancy

• Rolling with resistance

• Supportive&strategicinterventions

• Decisional balance

• Change plan worksheet

(Miller and Rollnick, 2002).

Matrix Model

• The model integrates treatment elements from a number of strategies, including relapse prevention, motivational interviewing, psycho-education, family therapy, and 12-Step program involvement.

• Combines Evidence Based Practices: • Motivational Interviewing

• CBT & Classic Conditioning

• Drug & Alcohol Education

• Brain Chemistry

• Stages of Recovery

• The basic elements are group sessions, individual sessions, along with encouragement to participate in 12-Step activities, delivered over a 16-week intensive treatment period

(Obert, Rawson, McCann, & Ling, 2006).

Dialectic Behavioral Therapy

• Learn and practice skills in the areas of:

• Mindfulness

• EmotionalRegulation

• Distress Tolerance

• InterpersonalEffectiveness

• Diary Cards

• Chain Analysis

• Ultimate goal to build a life worth living

(Linehan, 2008).

12-Step Facilitation

• Encourages acceptance of the addiction, commitment to abstinence and willingness to participate actively in 12-step fellowships as a means of establishing recovery.

• Evaluate the substance use problems and advocate abstinence.

• Explain basic 12-step structure and concepts.

• Encourage client to engage in 12-Step meetings

• Facilitate ongoing participation

• Discuss and support client working each of the 12-Steps

• Include support system in the therapeutic process

• Utilizing 12-Step network when in crisis

• Assist the client making a moral inventory and engaging in amends

• Encourage involvement in 12-Step beyond formal therapy

Coordinating/Collaborating Care

• Regular conversations with treatment program

• Collaborative treatment planning

• Include ancillary providers such as PCP & dentist

• On the same pages with community support meetings

Revised title

• patient placement

• Matching patients to individually assessed needs

• Derive a collaborative treatment decision and service plan

Co-Occurring Disorders

• Integration treatment services

• Providers

• Needs of individuals

• Subdiagnostic code current conditions

• or

• Call occurring formal psychiatric diagnoses

Acute intoxication and withdrawal potential• Detoxification

• Done by the liver

• Clinicians and practitioners “manage withdrawal”

Opioid treatment services

• Opioid treatment programs (OTP)

• Agonist medications

• Methadone

• buprenorphine

• Antagonist Medications

• Naltrexone

• Office based Opioid Treatment (OBOT)

• buprenorphine

• Naltrexone

• Psychosocial Services

Added Adult Special Populations• Older Adults:

• Diagnostic criteria

• Prospective parents or parents receiving addiction treatment with their children

• A continuum of treatment needs

• Persons in Safety Sensitive Occupations

• Longer closer monitoring

• Persons in criminal justice settings.

• Adherence to treatment

Unique Descriptors

Settings, support systems, staff, diagnostic criteria, therapies, assessment and treatment planning, documentation, dimensional criteria.

Dimension Risk Rating

• 0 Rating

• Non-issue, Very low-risk

• No current risk

• Acute and chronic problems have been stabilized

Dimension Risk Rating

• #1 Rating

• Experiencing mild discomfort or difficulty

• Able to function with minimal impairment

• Able to stabilize any acute and chronic problems quickly

Dimension Risk Rating

• #2 rating

• Experience a moderate risk or difficulties

• Noticeable impairment in functioning

• Still able to cope with and understand support services

Dimension Risk Rating

• #3 Rating

• Serious difficulties and impairment

• Difficulty coping with and understanding issues

• Near imminent danger high!

Dimension Risk Rating

• #4 Rating - IMMINENT DANGER

• Severe difficulties or impairment

• Serious, persistent signs and symptoms

• Very for ability to cope with or tolerate illness

3 H’s

• History

• Here and now

• How concerned?

Dimension One: Example

Dimension Risk Rating

• Severity

• Risk

• Concern

Level of risk will change and should be continually assesed.

Matching services to need

• Risk is multidimensional and biopsychosocial

• e.g. Stabilizing psychosis or managing of patients withdrawal while addressing and an unstable or dangerous living environment)

• Risk relates to the patient’s history

• e.g. The patients whose withdrawal always results in seizures as a different treatment needs from the patient this withdrawlinvolves only mild symptoms of anxiety

• Risk is expressed in current status

• How acute, Unstable and active is the patient’s current clinical presentation?

• Risk involves a degree of change

• From baseline or premorbid functioning

Organizing Information

Assessment dimensions

Risk:0

Risk:1

Risk:2

Risk:3

Risk:4

Priority dimension

Services needed

Intensity of services and LOC in setting

1

2

3

4

5

6 I

• Moderate risk rating of two or higher should be considered a priority

dimension

• Is zero rating would indicate an low level of risk

• A single risk rating in the assessment dimension can then be isolated to

determine the priority dimension