Assessment Dimensions
The ASAM criteria identify the following problem areas (dimensions) as the most important in formulating an individualized treatment plan and in making subsequent patient placement decisions. (Note that the information given here is for the adult criteria only. A detailed discussion of the adolescent criteria is found in Section 13 of this text.)
Dimension 1: Acute Intoxication and/or Withdrawal Potential. What risk is associated with the patient's current level of acute intoxication? Is there significant risk of severe withdrawal symptoms or seizures, based on the patient's previous withdrawal history, amount, frequency, and recency of discontinuation or significant reduction of alcohol or other drug use? Are there current signs of withdrawal? Does the patient have supports to assist in ambulatory detoxification, if medically safe? Has the patient been using multiple substances in the same drug class? Is there a withdrawal scale score available?
In the adult ASAM Placement Criteria, detoxification services can be provided at any of five levels of care. Specific criteria, organized by drug class (alcohol, sedative-hypnotics, opioids, et al.) guide the decision as to which detoxification level is safe and efficient for a patient in withdrawal.
Dimension 2: Biomedical Conditions and Complications. Are there current physical illnesses, other than withdrawal, that need to be addressed because they are exacerbated by withdrawal, create risk or may complicate treatment? Are there chronic conditions that affect treatment? Is there need for medical services that might interfere with treatment?
Dimension 3: Emotional, Behavioral or Cognitive Conditions and Complications (diagnosable mental disorders or mental health problems that do not present sufficient signs and symptoms to reach the diagnostic threshold). Are there current psychiatric illnesses or psychological, behavioral, emotional or cognitive problems that need to be addressed because they create or complicate treatment? Are there chronic conditions that affect treatment? Do any emotional, behavioral or cognitive problems appear to be an expected part of the addictive disorder, or do they appear to be autonomous? Even if connected to the addiction, are they severe enough to warrant specific mental health treatment? Is the patient suicidal, and if so, what is the lethality? Is the patient able to manage the activities of daily living? Can he or she cope with any emotional, behavioral or cognitive problems? If the patient has been prescribed psychotropic medications, is he or she compliant?
Dimension 4: Readiness to Change. Is the patient actively resisting treatment? Does the patient feel coerced into treatment? How ready is the patient to change? If he or she is willing to accept treatment, how strongly does the patient disagree with others' perception that she or he has an addictive or mental disorder? Does the patient appear to be compliant only to avoid a negative consequence, or does he or she appear to be internally distressed in a self-motivated way about his or her alcohol or other drug use or mental health problem? At what point is the patient in the stages of change? Is there leverage for change available?
Dimension 5: Relapse, Continued Use or Continued Problem Potential. Is the patient in immediate danger of continued severe mental health distress and/or alcohol or drug use? Does the patient have any recognition or understanding of, or skills in, coping with his or her addictive or mental disorder in order to prevent relapse, continued use or continued problems such as suicidal behavior? How severe are the problems and further distress that may continue or reappear if the patient is not successfully engaged in treatment at this time? How aware is the patient of relapse triggers, ways to cope with cravings to use, and skills to control impulses to use or impulses to harm self or others? What is the patient’s ability to remain abstinent or psychiatrically stable, based on history? What is the patient’s current level of craving and how successfully can he or she resist using? If on psychotropic medications, is the patient compliant? If the patient has another chronic disorder (e.g., diabetes), what is the history of compliance with treatment for that disorder?
Dimension 6: Recovery Environment. Do any family members, significant others, living situations, or school or work situations pose a threat to the patient's safety or engagement in treatment? Does the patient have supportive friendships, financial resources, or educational or vocational resources that can increase the likelihood of successful treatment? Are there legal, vocational, social service agency or criminal justice mandates that may enhance the patient's motivation for engagement in treatment? Are there transportation, child care, housing, or employment issues that need to be clarified and addressed?
The prognosis for resolution of problems in the various dimensions depends on the clinician's knowledge of problem severity and the level of difficulty in resolving these problems. This knowledge then forms the basis for the clinician and patient participating together in establishing a mutually agreeable treatment plan. The goals for each problem may need to be reviewed from the standpoint of resolution of the acute crisis and/or alteration of the course of the chronic illness.
Interactions Across Dimensions in Assessing for Level of Care. The ASAM criteria function best when individuals are assessed in each dimension independently and also in terms of the interaction across dimensions. For example, when assessing an individual for severity, a history of moderate or severe withdrawal without any current intoxication or withdrawal, or current intoxication without a history of significant withdrawal problems should generate a lesser level of concern than a combination of a history of moderate or severe withdrawal with current symptoms of intoxication or withdrawal.
In reality, there is considerable interaction across dimensions. For example, significant problems with readiness to change (Dimension 4), coupled with a poor recovery environment (Dimension 6) or moderate problems with relapse or continued use (Dimension 5), may increase the risk of relapse. Another commonly seen combination involves problems in Dimension 2 (such as chronic pain which distract the patient from the recovery process) coupled with problems in Dimensions 4, 5 or 6.
The converse also is true. For example, problems with relapse potential (Dimension 5) may be offset by a high degree of readiness to change (Dimension 4) or a very supportive recovery environment (Dimension 6). The interaction of these factors may result in a lower level of severity than is seen in any dimension alone.
The lesson here is that assessments are most accurate when they take into account all of the factors (dimensions) that affect each individual's receptivity and ability to engage in treatment at a particular point in time.
Continued Service and Discharge Criteria. In a departure from earlier editions, the current edition of the criteria (ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition-Revised [ASAM PPC-2R]; Mee-Lee, Shulman et al., 2001) contains only admission criteria, leaving the decisions about continued service, transfer, or discharge to general guidelines and the judgment of the treatment professional. This change was made in recognition of the fact that, in the process of patient assessment, certain problems and priorities are identified as justifying admission to a particular level of care. It is the resolution of those problems and priorities that determines when a patient can be treated at a different level of care or discharged. The appearance of new problems may require services that can be provided effectively at the same level of care, or transfer of the patient to a more or less intensive level of care.
The assessment process for continued service or discharge/transfer is the same as for admission, with the reassessment of multidimensional severity determining the treatment priorities, intensity of needed services and the decision about ongoing level of care. Decisions concerning continued service, transfer, or discharge involve review of the treatment plan and assessment of the patient’s progress. That is, they involve the same type of multidimensional assessment process that led to admission to the current level of care.