The addiction treatment field has evolved considerably over the past twenty years as our country has worked to respond to an epidemic of overdose deaths. In my training with SUD treatment professionals, I like to describe the ASAM 4th edition Criteria as a disruptive force that promotes change and transformation and will invariably help us to save lives.
Take a moment and ask yourself what events in the last 10-20 years have transformed the way we live and move about in the world.
What made Fast Food even faster? The drive through.Simple but disruptive, fast became even faster.
What revolutionized the way we move and communicate across the planet? The Internet, email, cellphones, texting, FaceTime, ZOOM, Microsoft Teams and social media.
What about traveling? Now we have Trip Tiks, MapQuest, WAZE, Google Maps or your car’s built in navigation system, the CLEAR program of facial and fingerprint recognition at airports.
These events have arguably created disruption to our otherwise normal routines.
Don’t let the term “disruption” throw you off. The 4th Edition of The ASAM Criteria still follows the same guiding principles as previous editions:
Patient admission into treatment is based on needs rather than arbitrary prerequisites
Patients receive multidimensional assessments that address the broad range of factors that contribute to substance use and co-occurring disorders.
Treatment plans are individualized based on these multidimensional assessments.
Reassessments drive patients’ movement along the clinical continuum of care based on their progress and outcomes rather than arbitrary predetermined lengths of stay.
Care is interdisciplinary, evidence-based, and patient-centered, with informed consent and shared decision-making at the center of treatment decisions.
The ASAM Criteria also recognizes that many patients with SUD have co-occurring conditions. They are the expectation, not an exception. And this is a foundational concept.
One of main goals of the ASAM 4th edition criteria is to reflect the current state of science and practice. The dimensions were updated to simplify the language and to align with the updated dimensional admission criteria framework. Now each Dimension is broken down into actionable subdimensions.
Subdimensions can be found in Dimensions 1-5 and are used to develop the level of care recommendation as well as assist in the development of the treatment plan. A new dimension was added Person-centered consideration that considers barriers to care, patient preferences, and need for motivational enhancement services.
There is the explicit consideration of addiction medication needs now in Dimension 1. The Readiness to Change dimension has been removed and is considered throughout each Dimension. The previous Dimensions 4, 5 and 6 shifted to the new Dimension 4 – substance use related risks and Dimension 5 – recovery environment interactions
Let’s take a closer look at the changes within the six dimensions and their accompanying subdimensions.
Dimension 1: Intoxication, Withdrawal, and Addiction Medications
Subdimensions:
- Intoxication and withdrawal associated risks
- Addiction medication needs
Practical Application:
When assessing a client, consider both their immediate intoxication state and potential withdrawal risks. For example, a client with severe alcohol dependence may require gabapentin, diazepam or clonidine as a part of their detoxification protocolto manage potentially life-threatening withdrawal symptoms.
Additionally, evaluating the need for addiction medications may be critical. A client with opioid use disorder might benefit fromusing buprenorphine or methadone for a determinant time period. By addressing these subdimensions, you can ensure a safer and more comfortable start to the recovery process.
Dimension 2: Biomedical Conditions
Subdimensions:
Physical health concerns
Pregnancy-related concerns
Sleep problems
Practical Application:
Medical staff should develop treatment plans for Dimension 2 concerns that are addressed directly by a medically managed program. Clinical staff may support management of Dimension 2 issues by providing referrals for care when needed, supporting the patient to effectively engage in treatment and adhere to the treatment plan, and by providing psychoeducation and other psychosocial services to address health behaviors, including treatment adherence.
All patients should have a physical exam within a reasonable timeframe of admission to treatment. The recommended timing of the physical exam for each level of care is outlined in the service characteristic standards.
For pregnant clients, develop a treatment plan that prioritizes both maternal and fetal health. This might involve coordinating care with obstetricians and using pregnancy-safe treatment modalities.
Address sleep issues, which are common in early recovery. Implement sleep hygiene education and consider non-addictive sleep aids when appropriate.
Dimension 3: Psychiatric and Cognitive Conditions
Subdimensions:
Active psychiatric concerns
Persistent disability
Cognitive functioning
Trauma exposure and related needs
Psychiatric and cognitive history
Practical Application:
The goals of the Dimension 3 assessment are to identify the patient’s treatment needs including:
Medically managed care
Psychiatrically managed care
Skilled mental health treatment
Enhanced staff support
And to determine the interactions between the patient’s substance use and mental health concerns. Medically managed care is care that is directly managed by a physician or advanced practice provider.
Medical management is provided by Levels 1.7, 2.7, 3.7, and 4. Psychiatric management is care that is directly managed by a psychiatrist or psychiatric specialty advanced practice provider. Psychiatric management is provided by Levels 1.7 Co-Occurring Enhanced (COE), 2.7 COE, 3.7 COE, and Level 4 Psych. The level of care assessment is focused on assessing active psychiatric symptoms and persistent impairment to determine what level of support, supervision and monitoring the patient needs.
Consider cognitive functioning when designing treatment interventions. A client with cognitive impairments may require simplified educational materials or more frequent, shorter therapy sessions.
For clients with trauma history, incorporate trauma-informed care principles into your treatment approach. This might include offering EMDR or other trauma-specific therapies alongside addiction treatment.
Dimension 4: Substance Use Related Risks
Subdimensions:
Likelihood of substance use
Likelihood of substance use related behaviors
Practical Application:
Risky substance use refers to any use with significant risk for adverse medical, psychological, emotional, social, financial and/or legal outcomes. The goals of the Dimension 4 assessment include determining the patient’s current risks related to substance use and SUD-related behaviors, identifying the need for supervision and the need to build insight and skills needed to support recovery.
The subdimensions include the likelihood of engaging in risky substance use and likelihood of engaging in risky SUD-related behaviors, such as driving while intoxicated and problem gambling.
The level of care assessment for Dimension 4 considers both the likelihood of continued substance use and the level of harm associated with that risk. Does the patient’s substance use or behaviors pose a significant risk for:
• Serious harm
• Destabilizing loss
• Negative but not destabilizing consequences
The clinician should focus on harms that are likely to occur or become imminent in hours or days, not weeks or months.
Dimension 5: Recovery Environment
Subdimensions:
Ability to function in current environment
Safety in current environment
Support in current environment
Cultural perceptions of substance use
Practical Application:
Evaluate the client's living situation and its impact on recovery. For a client living in an environment where substance use is prevalent, consider recommending sober living arrangements or developing strategies to create a substance-free space within their current home.
Assess the client's support system and cultural context. For example, if a client comes from a culture where substance use is stigmatized, incorporate culturally sensitive education for both the client and their family members.
Dimension 6: Person-Centered Considerations
Subdimensions:
Patient preferences
Barriers to care
Need for motivational enhancement
Practical Application:
Dimension 6 supports a shared decision-making process. Motivational interviewing can be used during the Dimension 6 assessment to better understand a patient’s reservations about treatment and encourage participation in the recommended level of care. It should also be used to consider strategies to overcome obstacles to care.
Involve the client in treatment planning by discussing their preferences and goals. For instance, if a client expresses interest in holistic approaches, consider incorporating mindfulness or yoga into their treatment plan.
Identify and address barriers to care, such as transportation issues or childcare needs. This might involve connecting the client with community resources or offering telehealth options when appropriate.
Assess the client's motivation for change and incorporate motivational interviewing techniques when needed. For a client in the precontemplation stage, focus on building rapport and providing education rather than pushing for immediate abstinence.
Conclusion
By thoroughly assessing and addressing each dimension and its subdimensions, addiction counselors can create more comprehensive, individualized treatment plans. This approach ensures that we consider the full spectrum of our clients' needs, from medical and psychiatric concerns to environmental and personal factors.
Remember, the ASAM criteria are not meant to be a rigid checklist but rather a framework to guide our clinical decision-making. By combining these criteria with our clinical expertise and the client's own input, we can provide truly client-centered care that addresses the complex nature of addiction and supports long-term recovery.
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