TIPS and TOPICS
Vol 1, No.11
March 2004

In this issue
– SAVVY
– SKILLS
– SOUL
– Until next time

WELCOME!

Recently I was training on the ASAM Criteria. I was surprised by some fundamental misunderstandings even from people using the criteria for many years. As you may know, I have been involved with, and chaired the development of the Patient Placement Criteria (PPC) for the Treatment of Substance Related Disorders of the American Society of Addiction Medicine (ASAM) since its beginning in the late 1980’s. For those of you who do not know the ASAM PPC, these are consensus criteria that match people with substance use problems to the appropriate level of care within a broad continuum of services.

There are separate criteria for adults and adolescents.
There have been three editions:
1991: ASAM PPC-1
1996: ASAM PPC-2
2001: The Revised Second Edition, ASAM PPC-2R.
Go to ASAM PPC-2R to learn more. 

SAVVY

My professional involvements have steeped me in the concepts and content of the criteria. I recognize others obviously are not as familiar with a number of aspects of the ASAM PPC.
So here is a potpourri of information about the ASAM Criteria. It barely scratches the surface, but adds to information available in previous TIPS and TOPICS too. Item 1 in Savvy though is brand new information.

Tips:

• Your program survival may be associated with the use of the ASAM Criteria.

The Clinical Trials Network (CTN) is a program of the National Institute on Drug Abuse (NIDA). The CTN Bulletin is the official newsletter of the NIDA CTN. It is closely read at 17 academic centers and 118 treatment programs, nationally.

The March 10, 2004 Volume 04 – 05 of the CTN Bulletin featured an important report from the CTN Treatment Matching Interest Group (TMIG).

The report was titled:
“Study Finds Growing Use of Placement Criteria & an Association with Program Survival.”

Here is an excerpt:
“The TMIG is working with the National Treatment Center Study, which surveyed 450 private substance abuse treatment programs in 1995-96.
The joint study examined program awareness of the ASAM Patient Placement Criteria.
With an 89% overall response rate, the survey found that over 70% of respondents were already using the ASAM Criteria, although the manner of use remains unclear.
For-profits were 54% less likely to have adopted and single-level programs were 34% to 42% less likely than multi-level ones.
Programs that accepted and referred dually diagnosed patients were 3.4 times more likely to be adopters than non-dual diagnosis capable ones.
Programs that had not survived 24 months after the initial survey were less likely to be ASAM adopters in 1996, and those that closed within 6 months of the initial survey had even lower adoption rates.
These are the first nationally representative findings regarding use of the ASAM Criteria model and they indicate widespread penetration, with greater prevalence in systems that have more challenging level-of-care placement options.
The association of this model with program survival is intriguing and the study interest group will propose more detailed, longitudinal follow-up, including a study of the impact on treatment quality and outcomes.”

Did you digest that? In a quick read of those findings, you might miss some of the implications this study raises.

These are the questions provoked from that report.

>>Is the use of the ASAM Criteria and a program’s survival merely a coincidental association?
>>Or does use of the ASAM Criteria actually help a program survive?
>>Or is adoption of the ASAM Criteria really a marker of something else about the survivability of the program?

Click Here for more information on the CTN including summaries of all the protocols.

Click Here for information on all federally sponsored clinical trials, including study sites and restrictions.

• Do you really know the ASAM Criteria? Here’s ASAM 101 in one page or less.

It is sometimes amusing and alarming what workshop participants really know about the ASAM PPC.

>>>If you say you use the ASAM Criteria, it would be good to actually own and read the ASAM PPC manual. Some people have seen a two page summary crosswalk; or their agency has an intake form where they check off the ASAM level of care to which the patient is assigned. They are surprised to discover that there is an actual book.
ASAM PPC-2R (2001) is a 380-page book.

>>>If you are using the 1991 or 1996 editions, that is better than nothing. However there are a number of innovations in the latest edition. For example, there are new criteria and program descriptions for people with co-occurring mental and substance criteria; and new assessment dimension names for Dimensions 3, 4 and 5. And all of the adolescent criteria were updated for the first time in ten years.

>>>People sometimes confuse dimensions and levels of care. There are six assessment dimensions, and four broad levels of service. Within the 4 Levels of Care, there are more specific levels of care.

A quick refresher

Here are the assessment dimensions:
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

Here are the four Levels of Service:
I Outpatient Services
II Intensive Outpatient/Partial Hospitalization Services
III Residential/Inpatient Services
IV Medically-Managed Intensive Inpatient Services

Extra Comments

Within these four broad levels of service there are:
** many other levels of care
**an additional five levels of detoxification intensity for adults
**opioid maintenance therapy (OMT)
**early intervention services for people who have not yet crossed the line into a substance use disorder.

The Criteria authors intended to create a common, clear language in the use of the dimensions and levels of care, to enhance consistency in communication throughout the field.
In this respect, note that the Assessment Dimensions use regular Arabic numbers- 1, 2, 3,4, 5, 6.
Note that the Levels of Service use Roman numerals- I, II, III, IV.

For example- if you say “Level 2” when you mean “Dimension 2” that can be confusing. If you write “Level 1” when you mean “Level I”, it is not a big deal, but Roman numerals will more readily be recognized as Levels of Care.

ASAM, the organization

Many do not know that ASAM is an organization of about 3,000 physicians interested in people who are sick and suffering with addictive disorders. These can range from psychiatrists to internal medicine doctors. The professional organization does many things, one of which is to publish the “Patient Placement Criteria for the Treatment of Substance Related Disorders of the American Society of Addiction Medicine”. With that mouthful, I understand why people say: “Do you use the ASAM?” But just so you know – ASAM is an organization too, not just a set of criteria.

For more tidbits on the ASAM Criteria

Read previous editions of my Tips & Topics.
> April 03: in Savvy & Skills
> June 03: in Savvy & Skills
> Sept 03: in Stump the Shrink
> Nov 03: in Skills
> Jan 04: in Stump the Shrink

SKILLS

Here are some frequently asked questions about using the ASAM Criteria, along with tips.

FAQ 1. How do you decide how long to keep a person in a level of care, or discharge or transfer to another level of care?

TIP 1: Use the Continued Service and Discharge/Transfer criteria to guide those decisions.
Base your decisions on the progress (or not) of the client’s response to the individualized treatment plan. Another way to understand those guidelines is to ask yourself or the team the following question:

“Does the client’s severity or level of function in any or all of the assessment dimensions require a dose or intensity of service which can only safely be delivered in the current level of care?”

If the answer is yes, then the client stays in the current level of care.

If the answer is no:
“No – the client’s functioning has deteriorated to such an extent that they now require a dose and intensity of service which can only safely be delivered in a more intensive level”, then transfer them to that more intensive level of care.

If the answer is no:
“No- the client’s functioning has progressed and improved to such an extent that they now can be managed with a dose and intensity of service which can safely be delivered in a less intensive level”, then transfer them to that level of care.

For example:
A client has developed non-suicidal depression in addition to a currently stabilized substance use problem. He now requires medication. This may seem clear indication of a new problem or worsening function that justifies continued stay in a residential level of care. When the program is asked how the depression is being treated and monitored, their response is they take the client to see the psychiatrist twice per week. These twice- weekly psychiatric visits are not a dose or intensity of service which can only safely be delivered by continued stay in the residential level. Medication monitoring can safely be delivered in outpatient care. The client can thus be transferred.

Second example:
A client exhibits withdrawal signs and symptoms, which have deteriorated to such an extent that she requires detoxification services. The dose and intensity of service this client requires can only safely be delivered with 24 hour nursing and physician availability. This person should now be transferred to a medically-monitored intensive detoxification level, III.7-D.

FAQ 2: Why are there no recommended lengths of stay for each level in the ASAM Criteria?

TIP 2: Pay attention to the client’s progress in treatment.

How long someone stays in a level of care depends on their severity of illness or level of function plus their progress and response to treatment. A client may appear to need a medically managed intensive inpatient level of detoxification (Level IV-D) due to apparently impending seizures.

However, after 24 hours the client has responded sufficiently to medication to now be safely monitored in Level III.7-D. (some progress)

Then after another 24 hours, it is clear they are doing so well that transfer to Level II-D (Ambulatory Detoxification with Extended On-site Monitoring) can safely provide the intensity of detoxification service needed. (more progress)

The result:
Using the ASAM PPC continuum of detox levels, this particular patient is able to receive seven days of detox support, and using fewer resources than would be consumed in three days of Level IV-D care. Compare 7 with 3.

FAQ 3. All that is fine, but what if you don’t have all the levels of care available or there are waiting lists?

TIP 3: Do the best you can. Be sure to document the “gaps” in your service delivery system.

Use what resources you can creatively piece together that will safely provide the intensity of care needed. Then take the 30 seconds to document the level or kind of service you ideally would have liked to provide for the client; the service the client actually received; and the reason for the difference.

A simple data-gathering Placement Summary is below.

PLACEMENT SUMMARY

Even though you can’t give the client what they ideally need, do not lose the opportunity to record the “gaps” in your service delivery system. The accumulated data will document how many services or patient days were unnecessarily provided, or withheld from people. Combine this with other tracking data on readmission rates or early departure rates. Eventually patterns will emerge; gaps will become apparent. But what you will have is objective data to help change the system’s continuum of care to serve your clients better.

SOUL

I am no scholar of Greek mythology. But I recently heard psychoanalyst, Jean Shinoda Bolen, M.D., explain the difference between the two types of time – Cronos and Kairos time. Cronos was a Greek god determined not to be overcome by his own son. He got rid of his children by swallowing each child immediately after the birth. Cronos (as in chronometer, chronology) time is time that eats you up. This is the kind of time when you have one eye on the clock, when you are on a schedule, and “putting in time” or “doing time”.

By contrast, Kairos time is “participating in time”. This is psychologically-nourishing time, the kind that nurtures you as evident in those experiences where we lose track of time. No matter what you are doing – running group, seeing families, supervising team members, developing a service plan, working on a budget – in Kairos time you feel unhurried, peaceful absorption in each task. (Dr. Shinoda Bolen has authored many books on this if you want to learn more.)

I don’t know about you, but I’m interested in moving more and more to that Kairos time, away from the type that eats you up. Have you seen the billboard advertising for vocational assistance? It says: “Find a job you love and you’ll never work another day in your life”. The other day at the airport, I overheard a woman joking with her work colleagues about how short her retirement lasted. “How many times a week can you play golf?” she laughed. She was back on the job wanting to participate again in nourishing time- for her.

Staying in Kairos time is essential if we are to be present and centered in working with clients, families and team members. Cronos time only eats you up. If that is happening too much, you may agree with my witty colleague who jokes: “Time to get out of counseling and into food service!”

Until next time

Thanks again to all of you who send comments and questions. Feel free to forward TIPS and TOPICS to a colleague and invite them to sign up for themselves. I look forward to being with you in April.

David