The ASAM Criteria

ASAM Textbook Chapter 4-5

Article Index

Research on the ASAM Criteria

Since the publication of the first edition, there has been over a decade of experience with the ASAM criteria. Use of the second edition (ASAM PPC-2; Mee-Lee, Shulman et al., 1996) has been mandated or recommended to publicly funded treatment programs in nearly 30 states, by the U.S. Department of Defense, and by two large health maintenance organizations. While this does not constitute universal acceptance, there clearly is movement toward the common language they provide to the providers and managers of care, as well as a strong focus on multidimensional assessment and individualized care.

Formal research into the criteria also is encouraged. In the earliest such study (Plough, Shirley et al., 1996), counselors used a simple, one-page summary of the criteria. The results suggested that use of even a primitive version of the ASAM criteria is associated with improved treatment retention.

In 1994, the National Institute on Drug Abuse (NIDA) funded the first randomized controlled trial using the ASAM criteria, and it is hoped that clinical outcomes research will drive future revisions of the criteria. There also have been two retrospective studies: one applied an abbreviated PPC-1 algorithm to telephone survey data (Morey, 1996), while the other implemented only the psychosocial dimensions (McKay, Cacciola et al., 1997). A solution has been developed to address the problem of interviewer ease of use of criteria, and this solution has been tested in three prospective studies. It consists of a comprehensive implementation designed by Gastfriend and his associates to offer the counselor a sequence of questions and scoring options on the screen of a microcomputer (Turner, Turner et al., 1999).

There have been two naturalistic studies and one randomized controlled trial of placement criteria (the results of which are not yet published). Overall, the early studies have shown adequate reliability, good concurrent validity, and some degree of predictive validity (Gastfriend, Lu et al., 2000).

 

Conclusions

Four important missions underlie the ASAM criteria: (1) to enable patients to receive the most appropriate and highest quality treatment services, (2) to encourage the development of a broad continuum of care, (3) to promote the effective, efficient use of care resources, and (4) to help protect access to and funding for care. The use of placement criteria in treatment planning thus represents far more than a narrow utilization review or case management process. Correctly applied and implemented, the ASAM criteria can assist in improving the “placement match” by redesigning the place of treatment and the level of care.

Effective implementation of the newest version of the ASAM criteria (ASAM PPC-2R) will require a shift in thinking toward outcomes-driven case management. A variety of treatment agencies will need to make this shift, including regulatory agencies, clinical and medical staff, and referral sources (such as courts, probation officers, child protective services, employers, and employee assistance professionals (Heatherton, 2000).

The ASAM criteria offer a system for improving the “modality match” through the use of multidimensional assessment and treatment planning that permits more objective evaluation of patient outcomes. With improved outcome analysis driving treatment decisions, the problem of access to care and funding of treatment can be championed more effectively.

 

 


References

American Psychiatric Association (APA) (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Washington , DC : American Psychiatric Press.

Gartner L & Mee-Lee D, eds. (1995). The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders (Treatment Improvement Protocol No. 13). Rockville , MD : Center for Substance Abuse Treatment.

Gastfriend DR (1994). Anticipated problems facing ASAM patient placement criteria. Presented at the CSAT TIP Meeting, April 21, 1994 .

Gastfriend DR (1999). Placement Matching: Challenges and Technical Progress. Proceedings of the AAAP Tenth Annual Meeting & Symposium. Kansas City , MO : AmericanAcademy of Addiction Psychiatry, 19-20.

Gastfriend DR, Lu S & Sharon E (2000). Placement matching: Challenges and technical progress. Substance Use & Misuse 35(12-14):2191-2213.

Gastfriend DR & McLellan AT (1997). Treatment matching: Theoretic basis and practical implications. Medical Clinics of North America 81(4):945-966.

Gastfriend DR, Najavits LM & Reif S (1994). Assessment instruments. In N Miller (ed.) Principles of Addiction Medicine, First Edition. Chevy Chase , MD : American Society of Addiction Medicine.

Gregoire TK (2000). Factors associated with level of care assignment in substance abuse treatment. Journal of Substance Abuse Treatment 18:241-248.

Heatherton B (2000). Implementing the ASAM criteria in community treatment centers in Illinois : Opportunities and challenges. Journal of Addictive Diseases 19(2):109-116.

Harrison PA, Hoffmann NG, Hollister CD et al. (1988). Determinants of chemical dependency treatment placement: Clinical, economic, and logistic factors. Psychotherapy 25:356-364.

Hoffmann NG, Floyd AS, Zywiak WH et al. (1999). Strategies for Case-Mix Adjustments in Addictions Treatment Evaluations: Prognostic Indicators in Public Sector Populations. Report prepared for the State of Wisconsin under CSAT Contract 270-95-0023.

Hoffman NG, Halikas JA, Mee-Lee D et al. (1991). Patient Placement Criteria for the Treatment of Psychoactive Substance Use Disorders (PPC-1). Washington , DC : American Society of Addiction Medicine.

Institute of Medicine (IOM) (1990). Broadening the Base of Treatment for Alcohol Problems. Washington , DC : National Academy Press.

Institute of Medicine (IOM) (1989). Controlling Cost and Changing Patient Care: The Role of Utilization Management. Washington , DC : National Academy Press.

May WW (1998). A field application of the ASAM Placement Criteria in a 12-step model of treatment for chemical dependency. Journal of Addictive Diseases 17(2):77-91.

McKay JR, Cacciola JS, McLellan AT et al. (1997). An initial evaluation of the psychosocial dimensions of the American Society of Addiction Medicine criteria for inpatient vs. intensive outpatient substance abuse rehabilitation. Journal of Studies on Alcohol 58(5):239-252.

McLellan AT & Alterman AI (1991). Patient-treatment matching: A conceptual and methodological review, with suggestions for future research. In RW Pickens, CG Leukefeld & CR Schuster (eds.) Improving Drug Abuse Treatment (Research Monograph 106). Rockville , MD : National Institute on Drug Abuse.

Mee-Lee D (1994). Placement criteria and patient-treatment matching. In N Miller (ed.) Principles of Addiction Medicine, First Edition. Chevy Chase , MD : American Society of Addiction Medicine.

Mee-Lee D (2001a). Persons with addictive disorders, system failures, and managed care. In EC Ross (ed.) Managed Behavioral Health Care Handbook. Gaithersburg , MD : Aspen Publishers, Inc., 225-266.

Mee-Lee D (2001b). Treatment planning for dual disorders. Psychiatric Rehabilitation Skills 5(1):52-79.

Mee-Lee D (1998). Use of patient placement criteria in the selection of treatment. In AW Graham & TK Schultz (eds.) Principles of Addiction Medicine, Second Edition. Chevy Chase , MD : American Society of Addiction Medicine.

Mee-Lee D, Shulman GD, Fishman M et al. (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.

Mee-Lee D, Shulman GD & Gartner L (1996). ASAM Patient Placement Criteria for the Treatment of Substance Related Disorders, Second Edition (ASAM PPC-2). Chevy Chase , MD : American Society of Addiction Medicine.

Miller WR & Rollnick S (1991). Motivational Interviewing: Preparing People to Change Addictive Behavior. New York , NY : Guilford Press, 1991.

Morey LC (1996). Patient placement criteria: Linking typologies to managed care. Alcohol Health & Research World 20(1):36-44.

National Institute on Drug Abuse (1999). Principles of Drug Addiction Treatment—–A Research Based Guide. Rockville , MD : NIDA (NIH Publication # 99-4180).

National Institute on Drug Abuse (NIDA) (1994). Mental Health Assessment and Diagnosis of Substance Abusers (Clinical Report Series). Rockville , MD : NIDA, National Institutes of Health.

National Institute on Drug Abuse (NIDA) (1999). Principles of Drug Addiction Treatment: A Research-Based Guide. Rockville , MD : NIDA, National Institutes of Health.

National Institute on Drug Abuse (NIDA) (1997). Treatment of Drug-Dependent Individuals With Comorbid Mental Disorders (Research Monograph 172). Rockville , MD : NIDA, National Institutes of Health.

Plough A, Shirley L, Zaremba N et al. (1996). CSAT Target Cities Demonstration Final Evaluation Report. Boston , MA : Office for Treatment Improvement.

Prochaska JO, DiClemente CC & Norcross JC (1992). In search of how people change: Applications to addictive behaviors. American Psychologist 47:1102-1114.

Project MATCH Research Group (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol 58:7-29.

Rawson RA & Ling W (n.d.). American Society of Addiction Medicine Patient Placement Criteria for the Treatment of Psychoactive Substance Use Disorders: An Analysis. Unpublished paper prepared for the California Office of Alcohol and Drug Programs.

Shulman GD (1993). The ASAM Criteria: A benefit to EAPs. EAP Digest 13(4):26-28.

Turner WM, Turner KH, Reif S et al. (1999). Feasibility of multidimensional substance abuse treatment matching: Automating the ASAM Patient Placement Criteria. Drug and Alcohol Dependence 55:35-43.

TABLE 1.

Matching Patients with Co-Occurring Disorders to Services

 

Patients

Services

Addiction-Only Patients: Individuals who exhibit substance abuse or dependence problems without co-occurring mental health problems or diagnosable Axis I or II disorders.

 

 

Addiction Only Services (AOS):Services are directed toward the amelioration of substance-related disorders. No services are available the treatment of co-occurring mental health problems or diagnosable disorders. (Such a program is clinically inappropriate for dually diagnosed individuals.)

 

Patients with Co-Occurring Mental Health Problems of Mild to Moderate Severity: Individuals who exhibit (1) sub-threshold diagnostic (traits, symptoms) Axis I or II disorders or (2) diagnosable but stable Axis I or II disorders (for example, bipolar disorder but compliant with and stable on medication).

 

 

 

Dual Diagnosis Capable (DDC): The primary focus is on substance use disorders, but the program is capable of treating patients with sub-threshold or diagnosable but stable Axis I or II disorders. Psychiatric services are available on-site or by consultation; at least some staff are competent to understand and identify signs and symptoms of acute psychiatric conditions.

 

 

 

Patients with Co-Occurring Mental Health Problems of Moderate to High Severity: Individuals who exhibit moderate to severe diagnosable Axis I or II disorders, who are not stable and require mental health as well as addiction treatment.

 

 

 

Dual Diagnosis Enhanced (DDE): Psychiatric services are available on-site or closely coordinated; all staff are crosstrained in addiction and mental health disorders and are competent to understand and identify signs and symptoms of acute psychiatric conditions and to treat mental health problems along with the substance use disorders. Treatment for the mental and substance disorders is integrated (similar to a traditional “dual diagnosis” program).


 

 

SOURCE: Mee-Lee D, Shulman GD, Fishman M et al. (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.

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