Are We Ready for ASAM? Does the ASAM Level of Care Designa:ons Correspond to Clinical Judgment? Desirée A. Crevecoeur-MacPhail, PhD UCLA Integrated Substance Abuse Programs Semel Ins@tute for Neuroscience and Human Behavior David Geffen School of Medicine at UCLA AHSR 2016, SeaLle WA
Disclosures No disclosures to report No relevant financial rela@onships with commercial interests exist between the author of this PPP and the creators of the ASAM This project was funded solely by the Los Angeles County Department of Public Health Substance Abuse Preven@on and Control
Select the Best Answer The best treatment system for addic:on is: a. A 28 day stay in inpa@ent with educa@on b. A broad con@nuum 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 con@nuity of care e. Short stay inpa@ent hospitaliza@on for psychoeduca@on
How do professionals working with pa:ents diagnosed with substance use disorders determine the appropriate level of care they need?
The Crystal Ball Method
The Magic Eight-Ball Method
Different Parameters to Determine Level of Care Court mandated What is available at site where client presents for treatment What the client wants to do Determined by counselor judgment Subject to biases (MAT, own tx program, own recovery) Recent educa@on/training experiences
How Did We Get Here? No standard assessment for substance use disorders - intui@ve Addic@on Severity Index (ASI) and other tools Changes in SUD tx system require EBPs, use of DSM criteria, and demonstra@on of medical necessity ASAM s Solu@on: ASAM Criteria (1991, 2001, 2013)
Paradigm ShiN ASAM criteria have evolved over @me to reflect current scien@fic research One dimension to mul@dimensional Program-driven to clinically driven treatment Fixed length of stay to variable length Limited number of discrete levels of care to a con@nuum of care
A LiOle About Los Angeles County 10+ Million Residents 50 65K Treatment Admissions ~ 200 Agencies Centralized assessments (Community Assessment Service Centers) Most operated by treatment agencies Favori@sm regarding referrals
Training on ASAM Criteria UCLA conducted 13, day-long training sessions in FY 2015-2016 with 562 alendees Sessions included case presenta@ons and other processes to give providers experience with the ASAM criteria Ques@ons addressed during sessions and included on sa@sfac@on forms collected aler the training
Understanding and U@lizing the ASAM Criteria
Six dimensions ASAM Criteria Refer to numerous levels of care (OP, IOP, RS, WM, OTP) Used to help determine level of care for SUD and MH Assist clinician in determining the appropriate level of care for both SUD and MH Suggested level of care clinician may override
ASAM PLACEMENT CRITERIA LEVELS OF 1. OUTPT 2. INTENSIVE 3. MED 4. MED OF CARE OUTPT MON INPT MGD INPT CRITERIA Intoxication/ Withdrawal no risk minimal some risk severe risk medical 24-hr acute monitoring med. care required required Medical Complications no risk manageable Psych/Behav Complications no risk mild severity moderate cooperative high resist., Readiness but requires needs 24-hr For Change cooperative structure motivating Relapse Potential Recovery Environment maintains abstinence supportive more symptoms, needs close monitoring less support, w/ structure can cope unable to control use in outpt care danger to recovery, logistical incapacity for outpt 24-hr psych. & addiction Tx required
ASAM Dimensions Acute Intoxica@on and/or Withdrawal Poten@al Biomedical Condi@ons and Complica@ons Emo@onal, Behavioral, or Cogni@ve Condi@ons and Complica@ons Readiness to Change Relapse, Con@nued Use, or Con@nued Problems Poten@al Recovery and Living Environment ASI Domains Alcohol, Drugs Medical Psychiatric Alcohol, Drugs Employment support, Legal, Family social
Is there disagreement? YES! But why?
Some Sources of Disagreement Fear of change Lack of interest in doing something different Slow adopters
Other Sources of Disagreement 1. Counselor recognizes signs that are not reported by the client A. Symptoms of withdrawal B. Dishonest report of substance use palerns 2. Lacking familiarity with ASAM criteria A. Focus on both SUD and MH (and some medical) B. Sugges+ons for level of care 3. Training issues
Addressing Areas of Disagreement Encourage clinician to make notes Nota@ons made on assessment form, progress notes, or elsewhere in pa@ent file Did pa@ent report significant MH issues / or limited substance use Remind clinician that, in some cases, overrides of LOC suggested by ASAM are ok Addi@onal training or more prac@ce needed?
Conclusions Some engage/make changes immediately, some resist, others are simply confused Significant changes take @me to implement Do not assume that resistance is the only reason for slow adop@on of new tools Encourage discussion of problems, areas of disagreement
Acknowledgements For allowing the use of their slides, thanks to Tom Freese, PhD, UCLA ISAP PSATTC Albert Hasson, MSW, UCLA ISAP Lynn Posze, MA, LPCC Kentucky Division of Behavioral Health
Questions?
THANK YOU! Desiree A. Crevecoeur-MacPhail, Ph.D. Principal Investigator/Research Psychologist UCLA Integrated Substance Abuse Programs (310) 267-5207 email: desireec@ucla.edu