The
common language of the six assessment dimensions
of the ASAM Patient Placement Criteria can be used
to determine multidimensional assessment of severity
and level of function of any healthcare 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
Dimension
1: Acute intoxication and/or withdrawal potential
Who
should be thinking about Dimension 1?
-->•
Emergency room personnel should be thinking: Is
this patient with a broken leg someone who was simply
in a car accident? Or was this person driving under
the influence, and is someone who has an addiction
problem that needs treatment?
-->• Surgeons may do a successful appendectomy
for acute appendicitis only to find the patient
agitated and in the DTs three days later. Nobody
checked the patient’s alcohol history. They
would have discovered a daily heavy drinker at risk
of severe alcohol withdrawal, needing detox medication.
-->• 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?
-->• And of course, addiction clinicians
are assessing the client’s substance use perhaps
via drug screen monitoring. They are also checking
Dimension 1 for any need for detox services.
Dimension
2: Biomedical conditions and complications
Who
should be thinking about Dimension 2?
-->•
There usually isn’t much dispute about checking
whether someone has any physical health needs. Every
client and patient receives some assessment of their
Dimension 2 status.
Dimension
3: Emotional/behavioral/cognitive conditions and
complications
Who
should be thinking about Dimension 3?
-->•
With Dimension 3, we are usually back to some ambivalence.
Mental health people are ready to assess Dimension
3. Only more recently is there the attention on
co-occurring disorders and dual diagnosis. Addiction
personnel are more fully embracing the need to at
least ask questions about mental health and to coordinate
care for any co- occurring disorder.
-->• Unfortunately for the rest of healthcare
staff, mental illness suffers nearly the same discrimination
and stigma as addiction clients. Emergency room
personnel should be savvy enough to tell the difference
between a heart attack and a panic attack. Or the
difference between a substance induced psychosis
and a schizophrenic break.
-->• Family physicians can limit a variety
of laboratory and exploratory tests by tuning into
the patient who is dealing with depression; or exhibiting
stress from family addiction and presenting with
somatic complaints.
Dimension
4: Readiness to Change
Who
should be thinking about Dimension 4?
-->•
No treatment session, medication, or lifestyle change
will be adhered to if the treatment plan is driven
only by what the clinician, counselor or doctor
wants for the client, instead of being focused on
what the client wants for him or herself ,and is
invested in.
-->• Every branch of health care faces
people who are ambivalent about their health status
and following through on treatment and lifestyle
change.
-->• 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
Who
should be thinking about Dimension 5?
-->•
Dimension 5 is not just about drinking and drugging
relapse or continued use (for people who have not
yet decided to commit to abstinence).
-->• Mental health clinicians are thinking
also about how to prevent that psychotic or manic
episode; or another suicidal or self-mutilation
injury; or another domestic violence situation
-->• Oncologists, internists, family physicians,
judges, probation and parole officers, and police
are all thinking how to prevent a cancer recurrence;
or another diabetic coma or heart attack. Or how
to prevent another arrest or probation violation
or some illegal activity.
Dimension
6: Recovery Environment
Who
should be thinking about Dimension 6?
-->•
Addiction and mental health professionals well know
that all the following recovery environment issues
are important to assess and service- i.e. who a
person lives with; whether there is even a place
to live; who is the financial and emotional support
or not; whether there are transportation, childcare,
criminal justice, work, school or financial problems.
-->• But even in general healthcare, 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.
-->• Or if you have an older adult likely
to be confused when in hospital, then having photographs
around and other familiar objects or reminders of
loved ones can enhance recovery.
-->• Birthing centers now look more like
a hotel suite than a cold sterile labor and delivery
room.
For
more information and references on the ASAM Patient
Placement Criteria:
Mee-Lee
D, Shulman GD, Fishman M, Gastfriend DR, and Griffith
JH, eds. (2001). ASAM Patient Placement Criteria
for the Treatment of Substance-Related Disorders,
Second Edition-Revised (ASAM PPC-2R). Chevy Chase,
MD: American Society of Addiction Medicine, Inc.
To
purchase the ASAM PPC:
American
Society of Addiction Medicine - 4601 Nth. Park Ave.,
Arcade Suite 101, Chevy Chase, MD 20815. (301) 656-3920;
Fax: (301) 656-3815; www.asam.org; To order ASAM
PPC- 2R: (800) 844- 8948.
References:
Mee-Lee D, Shulman GD (2003): “The ASAM Patient
Placement Criteria and Matching Patients to Treatment",
Chapter 5 in Section 4, Overview of Addiction Treatment
in "Principles of Addiction Medicine”
Eds Graham AW, Schultz TK, Mayo- Smith MF, Ries
RK, Wilford BB, Third Edition. American Soc. of
Addiction Medicine Inc., Chevy Chase, MD.
Gastfriend,
D.R. & Mee-Lee, D. (2003): “The ASAM Patient
Placement Criteria: Context, Concepts and Continuing
Development” in “Addition Treatment
Matching – Research Foundations of the American
Society of Addiction Medicine (ASAM) Criteria.”
Journal of Addictive Diseases, 22, Supplement
Number 1, 2.
Mee-Lee,
David (2005): “ASAM’s placement criteria:
What’s new” Behavioral Health Management
Volume 25, No. 3. May/June 2005
Miller,
S.D., Mee-Lee, D., Plum, B. & Hubble, M (2005):
“Making Treatment Count: Client-Directed,
Outcome Informed Clinical Work with Problem Drinkers.”
In J. Lebow (ed.). Handbook of Clinical Family
Therapy. New York: Wiley.
Mee-Lee,
David (2005): “ASAM Patient Placement Criteria:
Implications for Assessment and Treatment of Patients
with Co-Occurring Disorders” Counselor
Magazine. Volume 6, No. 5 pp. 28-33.
Mee-Lee,
David (2006): “Development and Implementation
of Patient Placement Criteria” in “New
Developments in Addiction Treatment”. Academic
Highlights. J Clin Psychiatry 67:11: 1805-1807.
For more tidbits on the ASAM Criteria, refer
to previous editions:
April
2003: in Savvy & Skills
June 2003: in Savvy & Skills
Sept 2003: in Stump the Shrink
Nov 2003: in Skills
Jan 2004: in Stump the Shrink
Mar 2004: in Savvy & Skills
Oct 2004: in Savvy
Dec 2005: in Savvy, Skills & Stump the Shrink
Oct-Nov 2006: in Savvy & Skills
Select
the Best Answer:
1. The best treatment system for addiction is:
(a) A 28-day stay in inpatient rehabilitation
with much education.
(b) A broad continuum of care with all levels of
care separated to maintain group trust.
(c) Not possible now that managed care has placed
so much emphasis on cost-containment.
(d) A broad range of services designed to be as
seamless as possible for continuity of care.
(e) Short stay inpatient hospitalization for psychoeducation.
2. The six assessment dimensions
of the ASAM Criteria:
(a) Help assess the individual’s
comprehensive needs in treatment.
(b) Provide a structure for assessing severity of
illness and level of function.
(c) Requires that there be access to medical and
nursing personnel when necessary.
(d) Can help focus the treatment plan on the most
important priorities.
(e) All of the above.
3. A multidimensional assessment
in behavioral health treatment:
(a) Should include psychosocial
factors such as readiness to change.
(b) Is ideal, but not necessary within a managed
care environment.
(c) Should include biomedical and psychiatric problems,
but not motivation or relapse potential.
(d) Is best done after detoxification is completed.
(e) Should be completed by the primary therapist
only.
Indicate True or False:
4. It is not the severity or functioning
that determines the treatment plan, but the diagnosis,
preferably in DSM terms. (T) (F)
5. The level of care placement is
the first decision to make in the assessment. (T)
(F)
Here are the answers and some implications
Question
1 – (d). Even though there are many levels
of care described in the ASAM Criteria, they do
not need to be all discrete programs with their
own assessment and service menu in a separate treatment
setting, clinician team and administrative structure.
In fact if you chose (b) as the answer because of
your concern for group trust, consider how Alcoholics
Anonymous can create a healing and welcoming environment.
Yet you can never guarantee that there will be the
same group members at a meeting from one day to
the next. A person with three hours of abstinence
may be sitting next to someone with thirty years
of grateful recovery sitting next to someone who
is ambivalent about sobriety sitting next to someone
who is absolutely committed to recovery.
Question
2 – (e). The ASAM MDA addresses all of
these issues and is useful not just in addiction
treatment, but also in mental health and healthcare
in general.
Question
3 – (a). Focus is often placed just on
the first three dimensions to determine Medical
Necessity. But the last three dimensions are just
as important to assess and service because they
are just as influential on influencing treatment
outcomes as the first three dimensions. As a result,
in the ASAM Criteria, Medical Necessity has been
broadened to “Clinical Necessity”.
Question
4 – F. In fact it is the other way around.
In the old days of addiction treatment, the diagnosis
determined the treatment plan. If you had alcohol
dependence, the placement and length of stay was
automatically 28 days of residential treatment.
In applying the ASAM PPC, it is the individual’s
unique MDA needs that determines the level of care
and length of stay, not their diagnostic label.
Question
5 – F. Again, it is the other way around.
You may feel you have the need to triage a person
to a level of care as the first decision. However
you cannot know where to refer or link a person
until you have done enough assessment and service
planning to know what is the least intensive, but
safe level of care that can provide the mix of services
needed. For example, you would need to know what
is the person’s severity of withdrawal to
determine what mix of detoxification services (medication,
nursing care, doctor visits, psychosocial support,
24 hour structure or not etc.) is needed. Only then,
as the last decision, could you decide on a level
of care in hospital versus social detox versus outpatient
detox level of care. (There are five levels of detox.
in the ASAM PPC)
SOUL
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
At a workshop recently, I was introducing myself.
As I was explaining about graduating from specialist
psychiatry training and entering private practice,
I realized I was talking about 30 years ago---1977----
last century. For a person who feels sometimes that
I am still in my 30’s, that was a sober reminder
of the aging process. My mother turned 92 in January,
and is still quite mentally alert and active. I
hope I got her genes. Her sister, whom she visits
every day in the nursing home, is 94. While the
sister is not quite as sharp, she still has a sense
of humor and surprising wit at times. I hope I got
her genes too.
My mother tells me about all the nursing home patients
she sees come and go. And before they die, many
of them suffer the indignities of yelling aggressively
in their senile distress with such venom they would
never have imagined in their better years. There’s
the pastor who takes off his clothes, and invites
female patients into his bed: “It’s
clean” he says. There’s Edna (we’ll
call her) who carries her toy doll, and hits people
for sitting in “her” chair.
“If
I get like that”, my mother says, “shoot
me.” I say: “It won’t matter because
you probably won’t know you are like that
anyway.” The comedians joke that’s the
beauty of Alzheimer’s---every day is a new
day with opportunities to meet new people and new
things to do. Then I thought, maybe that’s
another way to view the meaning of living one-day-at-a-time----to
embrace each day as if it’s an opportunity
for exciting new people, places or things. I know
I don’t want the sad regressive behavior devoid
of social judgment and sensibility. But a little
bit of the ability to forget the regrets of the
past and the worries of the future might be a nice
gift! As they say, that’s why they call living
today is a present.
Until
Next Time
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Thanks for joining us. See you in April.
David
Contact Information
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
email: info@dmlmd.com
phone: 530-753-4300 PACIFIC
web: http://www.dmlmd.com
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Copyright
2007 DML Training & Consulting | 4228 Boxelder
Place | Davis | CA | 95618
