Hello, my name is Julie Kmic and today I'm going to be talking about level of care assessment and the ASAM criteria. So I'm an addiction psychiatrist and I work at the University of Pittsburgh Medical Center. I'm an associate professor of psychiatry and I'm the medical director at our ambulatory detox program as well as our narcotic addiction treatment program, which is a licensed opioid treatment program. I have no financial conflicts of interest to report and I'm not going to be discussing any off-label use of medications during this talk. Here are the objectives for today's lecture. At the end of the course, I'm hoping that you're going to be able to describe the importance of level of care assessment, discuss the ASAM criteria, multidimensional assessment, describe the six dimensions of an assessment and how they can interact and determine need priorities, understand the continuum of the levels of care for treatment of substance use disorders and how one can move through these levels, and then be aware of some of the changes in the fourth edition of the ASAM criteria. This was just published back in October of 2023 and I don't think that it's been widespread adapted by institutions and states for use. So what you're probably going to run into more so is still the ASAM criteria from the third edition. So what I want to talk about are the ASAM criteria first. So what are they? Well, the ASAM criteria is an assessment tool. It was published several years back. We're on the third, well, we're on the fourth edition, but we were on the third edition where it was substantially changed. And what is done is a face-to-face interview, but these can also be done through telemedicine now since we have adapted telemedicine since COVID, and we want to use these assessments to determine which level of substance use treatment is the most appropriate for a patient. And this is referred to as the level of care. So when does somebody need to have a level of care assessment? Well, typically it's when they are being admitted to a substance use treatment program, and we want to make sure that the level of care that is offered by a program is appropriate for the needs of the patient. And insurance companies often are requiring preauthorization for certain levels of care like residential programs, opioid treatment programs, intensive outpatient, and so on. They're also needed to continue treatment. So a level of care assessment is required at different points of treatment to demonstrate that the person still meets criteria for that level of care and doesn't need either higher or a lower level of care. And sometimes, too, people will need one of these assessments to comply with a court order. So judges, magistrates, sometimes parole or probation officers require that an individual receives a care assessment and then that the patient would comply with the recommended level of care because of some legal involvement. So who uses the ASAM criteria? Clinicians, regulators, payers, so insurance companies, and the states. About two-thirds of the states in the United States, or 43 states throughout the United States, use a standard patient placement criteria, and two-thirds of them are using the ASAM criteria. So there are some other different level of care assessments that a state might require. For example, I'm in Pennsylvania, and Pennsylvania adapted the ASAM criteria, I'm going to say maybe like six, seven, eight years ago. And then before that, we were using something called the PCPC. And it changed. So what's the purpose of the ASAM criteria? We want to have one set of criteria, basically a consensus nationally. So we have a common language to discuss level of care assessments and placement guidelines so you can assign patients to different levels of care and treatment, but still be talking about the same thing. And we want to have an assessment-based, clinically-driven, outcome-oriented continuum of care. We don't want this just to be, well, you're coming to rehab because that's the only thing we offer, or you're getting outpatient treatment because that's the only thing we offer, when the patient actually might need a higher or lower level of care. And we also want to move from a diagnosis-based treatment to addressing multiple needs that are assessed in these level of care assessments. We want to have an outcome and clinically-driven treatment that's individualized for patients and not just based on what the program offers. And also we want to be able to provide different lengths of service based on the patient's needs and outcomes rather than just have a fixed length. For example, okay, well, we have an intensive outpatient program that lasts for six weeks, so patients stay in this program for six weeks and then they're discharged whether they need to stay, whether they've made some improvement or if they haven't. So we want to make sure to do these assessments and then make recommendations based on how they're doing in treatment. And we also want to have a broad continuum of care rather than just a limited number of levels of care or discrete options for care. So this is the evolution of treatment matching. So we could have complication-driven treatment, we could have diagnosis or program-driven treatment, or we could have an individualized assessment-driven treatment or an outcome-driven treatment. So the guiding principles of the ASAM criteria are to individualize treatment plans for people that are presenting for care and having a choice of treatment levels, as well as a whole continuum of care throughout the range of outpatient to inpatient. And patients can progress through levels of care, going up a level or down level as needed, and then also length of stay. And then we want to also, the guiding principle for ASAM is also clinical versus reimbursement considerations. We don't want things to be recommended just because they're going to be reimbursed. We want to make clinical decisions. Here's the assessment dimensions. First is the acute intoxication and withdrawal potential, biomedical complications and conditions, emotional, behavioral, and cognitive conditions, as well as complications, readiness to change, the relapse potential or continued use or continued problem potential, and then the person's recovery environment. So for dimension one, the acute intoxication and withdrawal potential, what we're looking at here is what is the individual's past and current experience with substance use and withdrawal? The goal of this level of care is to avoid consequences that could be hazardous because of abrupt discontinuation of substance use and apply criteria across the five levels of withdrawal management. And we want to engage the patient in withdrawal management and link them to care afterwards, plus or minus mutual support groups. And we want to be able to ease the discomfort during withdrawal so that they're going to be able to stop using the substance. So in this assessment, some of the considerations are what risk is associated with the current level of intoxication. So for example, if somebody came into your treatment program and they were nodding off because they recently used an opioid and then were worried about them leaving, like in that kind of state, or let's say somebody gets admitted to the emergency department and their alcohol level is 450. So what is the level of risk there? And then what services do we have that can manage intoxication and what's needed to manage this intoxication level? So sometimes if somebody is intoxicated with opioids, we might be concerned about the potential for overdose-slowed respirations. And what do we have on site to be able to address this? And as far as like alcohol, when somebody has a really high level, what do we need to do to address this level, get some laboratories, maybe do some IV hydration. And so if somebody is in an outpatient type of setting, you would hold their keys if they drive to the assessment and they're intoxicated, or what if somebody is using methamphetamine and they had some psychotic symptoms, then you'd want to address that too. Are they safe to go like this? Or is this really going to severely impact their safety if you were to let them leave? The other question that you have, is there a significant risk of withdrawal or medical complications based on their withdrawal history? And also based on their recent substance use or the chronicity of their substance use. So somebody who's been drinking alcohol on a regular daily basis for years, months or years, what's their withdrawal potential for that? And what was their history of withdrawal? Have they had withdrawal seizures or withdrawal delirium? So we want to consider that. And are there current signs of withdrawal? So if somebody comes in and you get a breathalyzer on them and it's, let's say 0.18, and they're already showing some signs of withdrawal, then that might make you think that they're going to have more severe withdrawal, even while they're still intoxicated and showing some symptoms. And if you do a withdrawal rating scale, like the cows or the Siwa, what are they scoring on that if you're looking at those withdrawal rating scores? What are their vital signs? We want to look at that too. And then if the patient doesn't want to do an inpatient kind of withdrawal management program, do they have supports to support ambulatory withdrawal if it's medically appropriate for them? So in that case, we'd want to make sure that somebody can get a ride to appointments or can log on to telemedicine appointments or somebody staying with them. So if their condition worsens that they can, somebody can summon help or get the patient to the emergency department for further treatment. Okay. So dimension two, to consider our biomedical conditions and complications. So in this one, we're thinking, is there a need for stabilization of either an acute or chronic medical condition? So for example, if somebody came into the ED and they had some cellulitis from injection drug use and they needed to be admitted for IV antibiotics. So that's one of the considerations that you might take into consideration there. And so you can think about current physical illness that needs to be addressed that could potentially complicate treatment if it's not addressed, chronic conditions that need stabilization or ongoing management. So sometimes we'll have people that have diabetes that's not well controlled or their blood pressure. They haven't been taking medicines, or maybe they have a seizure disorder and they need to get stabilized or have ongoing management that can't be provided in an outpatient setting, or maybe it can. So then you make the determination based on this. And then do they have any kind of communicable disease that could affect other patients that are staffed or any kind of infectious disease? So the big one that we think about was COVID was really affecting rehabs and admissions to different programs back, especially in 2020, 2021. But I'm sure that a lot of programs have developed protocols revolving around this as well. And then the other thing that you want to consider too is, is the patient pregnant? So that might lead you to recommend a different level of care for the, for the individual. Dimension three are the emotional, behavioral or cognitive conditions and complications. So you, in this dimension, what we're doing is we're assessing for the need for mental health services. So if somebody has some kind of emotional, behavioral or cognitive signs and symptoms are part of addiction, they'd be addressed as part of the addiction treatment. But if they're part of a mental health disorder, like bipolar disorder or depression, then they should be addressed, you know, hopefully within the same program that the person is getting referred to. Spiritual aspects should be assessed here. So that would be including what gives the person purpose and meaning and what's their connection to a higher power. Those things can be addressed in this dimension. And then you need to address both the addictive disorder as well as the mental health disorder as primary disorders. There's been lots of research that's looked at, you know, if we do parallel treatment, meaning you get some mental health treatment and then you get addiction or substance use disorder treatment at two different places at the same time. Sometimes people do sequential. So they say, okay, I'm going to take care of my addiction first and then I'll get my mental health treatment. And then there's co-occurring. So at the same place, they're getting treatment for their addiction and for their mental illness. That co-occurring treatment has been shown to be more effective than either parallel or sequential. So just a few other assessment considerations that are included. Are these psychiatric or behavioral cognitive conditions that do they need to be addressed because they're going to complicate treatment or create some kind of risk, especially with mental health? We're thinking about suicide risk or risk to harm others. So we've got to consider that. Are there chronic conditions that need stabilization or ongoing treatment? So let's think, you know, if somebody has schizophrenia, maybe they're having an exacerbation and they haven't been taking their antipsychotic medicine. And so that needs to be stabilized. Are there any kind of emotional, cognitive, or behavioral signs or symptoms that are part of the substance use disorder? Or are they an independent psychiatric disorder? So that can help determine where they should be addressed. And if the symptoms are related to a substance use disorder, do they warrant mental health treatment? So if somebody is having suicidal ideation or psychosis symptoms. The other thing to think about is the patient able to manage their activities of daily living and can they cope with these conditions? So in dimension three, you want to think about different risk domains. So the first one I want to talk about is dangerousness and lethality. And I have referred to this before. So this is the ideation, like suicidal ideation, homicidal ideation. Also, if somebody is engaging in non-suicidal self-injurious behavior or harming other people. Also think about their impulsivity too. They might have some suicidal thoughts, but be able to, you know, they're not wanting to act on them. They have reasons for living and they're just kind of passing thoughts. They have been, they think that if they're in treatment, life's going to get better. So they have hope for the future. So you do a suicide risk assessment for this individual, but also you've got to consider, okay, how impulsive are they in the past? Maybe they've engaged in some kind of self-harm in the past when they said, you know, I wasn't really trying to hurt myself or I wasn't planning on it, but I just kind of got the impulse and I did it and I acted on it. Or perhaps they might be impulsive when they're intoxicated. And then do they have the ability to act on any of these thoughts that they may or may not be having? Also, how much are these problems interfering with their recovery from addiction? So this is the degree to which someone who's is going to be distracted from working on the recovery because of their psychiatric or cognitive problems. The other thing to think about is how the substance use disorder can interfere with them enacting mental health recovery efforts when they're in a co-occurring program. And then you want to think about how well are they socially functioning? So how are their relationships affected by their substance use or other cognitive or emotional problems? So is the person able to care for themselves? So are they so depressed that they can't get out of bed? They can't get dressed. They're not showering or feeding themselves. That's something that you can consider. Or is their substance use affecting their ability to perform their active days of daily living, like having food, shelter and able to groom themselves? And what's the course of illness? So if they've had this kind of problem in the past, how does the history of the illness and response to treatment influence your thinking on how they might respond in addition to their current signs and symptoms of the disorder that they have? How is that going to predict their response to treatment now? And so you also want to think about the chronicity of the condition as well as the acuity of it to predict their response to treatment. The fourth dimension in this third ACM criteria are going to be the readiness to change. So you want to assess in this dimension the need to which motivational enhancement is needed to engage or attract the individual into the recovery process. And a person might be in different stages of change for different reasons. They might be able to get into treatment for anxiety, but they might not want to stop drinking alcohol or stop using benzos. They might be ready to get treatment for their physical health conditions like hypertension, but they're not ready to quit smoking. And so you might think about the different stages of change using that trans-theoretical model that's by Procheska and DiClemente rather than just saying that they're in denial or resistant to treatment. So you want to think about these different stages of change. When you're doing an assessment, some of the considerations are going to be the awareness that the patient has of the relationship between their substance use and their negative consequences. How willing is the individual and ready to make changes? Do they have the ability to make those changes in their substance use? And how much control does the individual feel that they have over their treatment services? So the motivation could be legal. It could be related to their family problems or their employment issues. And it doesn't really matter what the reason is, but the goal is to, because research has shown no matter why, no matter what reason that people get into treatment, they can still respond to treatment and recover. But hopefully we can attract people into recovery over time. Dimension five is the relapse, continued use, or continued problem potential. So you want to assess the need for relapse prevention or continued use if there hasn't been a period of recovery. And you want to assess the need for continued problem potential if there's a co-occurring condition with mental health or cognitive or trauma conditions that are going to add to their ability to stabilize and make progress in recovery. And assigning the level of care depends on both their history and their current problems. So some of the considerations you take into account are, is the individual in immediate danger of having a physical or mental health condition deteriorate from their substance use? Do they have skills to cope with addictive or co-occurring disorders to prevent relapse or continued use? And have medications aided in their recovery in the past, so psychiatric medicines or meds psychiatric medicines or meds for craving like acamprosate or naltrexone, or think about medications for opioid use disorder like buprenorphine and methadone. So some other assessment considerations include, does the individual have the skills for dealing with cravings, impulses, or protracted withdrawal? And does the individual have skills to deal with peer pressure, having a negative affect or emotions and stress? And then think about how severe are the problems and the distress that the person might have that could return if the person doesn't engage in treatment and continues to have engage in the addictive behavior or has continued mental health problems? And what's the person's awareness of triggers and do they have skills to control impulses? And the last dimension is the recovery or living environment. So you want to assess the need for individualized family or concern significant other support and services. And then assess the need for housing, financial, educational, vocational, legal, childcare, and transportation services. So there's a lot of stuff here to think about in terms of the recovery environment. And then also it's important to identify who are some recovery supports or what are some supports in the environment for each condition that the person's experienced, if it's substance use disorder, if it's a co-occurring psychiatric disorder. So some assessment considerations are going to include what situations pose a threat to the person's engagement and treatment and recovery. So is it perhaps they have a significant other that they live with that's using or a family member? What resources do they have that's going to increase their likelihood of recovery? So do they have supportive relationships? Do they know other people that are in recovery? Is their job like a reason for them to get into recovery? They don't want to lose their job or they really enjoy their job and that gives them a sense of meaning. Are there any mandates that might enhance somebody's motivation for treatment like legal or maybe their job's telling them they have to go? Sometimes child protective services. And what issues need to be addressed to increase somebody's ability to engage in treatment? Like do they have trouble getting to the clinic because of transportation? Do they need childcare? Are they unhoused and so housing needs to be addressed? Or are they working and can't get to treatment or need to have treatment outside of normal business hours? So in this level of care assessment too, you want to assess risk. So risk assessment is going to be multi-dimensional and each dimension is going to be assessed independently and it's going to have its own risk rating. And the patient's history is going to impact the risk assessment. So do they have a history of complicated withdrawal, suicide attempts? And then also you can think about what their history has been like in terms of kind of successful treatment. So if they've been able to complete an ambulatory withdrawal management program in the past successfully, that's a good predictive factor. And risk is going to be expressed with regard to their current status. So their medical stability, their psychiatric stability and their living environment. And the risk is going to involve the degree of change from their baseline functioning. So let's say somebody goes from being able to take care of themselves and their ADLs to needing assistance with this versus somebody who continues to have the same level of lower functioning. So maybe somebody wasn't able to take care of as many things at home or with themselves and needed prompting. And that hasn't really changed. They still have that same low baseline. So here's the risk rating here on a scale of zero to four. And you can see the risk rating of zero is very low risk or it's a non-issue. And then we've got one is a minor issue or minor signs and symptoms. And the chronic issues can be resolved pretty quickly. Risk rating of two is a moderate issue or difficulty with moderate impairment or persistent chronic issues. But individual has some skills or supports to help cope with them and mitigate the risks. And then we've got a rating of three. And this could be a serious issue and the patient could have difficulty with coping. They might be considered to be in or near imminent danger. And then a risk rating of four is the most severe. And this person has severe impairments in coping and functioning with signs and symptoms indicating imminent danger. It could be like suicidal or it could be overdose risk. Could be a lot of different things here. So when you're doing this risk rating, you want to assess barriers as well as strengths and skills and resources that the person does have. So the interventions can interact. For example, the biomedical problems can interact with the recovery environment and problem potential that's associated with relapse or continued use. So for example, if somebody has a problem, an alcohol use disorder, and they have, let's say they have a history of withdrawal seizures, that could be a biomedical problem or they have a seizure disorder or some other medical condition and with the recovery environment. So let's say there's nobody at home to support them during withdrawal management. And then the problem potential associated with relapse or continued use is that they could end up having complications of that medical problem. So the interactions between the different dimensions can increase or decrease the severity of risk in a dimension. And some problem dimensions can be offset by other dimensions. For example, withdrawal potential can be offset by a supportive recovery environment and no biomedical complications. So this would be the person who doesn't have any medical conditions, no co-occurring psychiatric conditions, and they live at home with somebody who doesn't drink and is supportive of their recovery. And so perhaps they'd be okay for withdrawal management in an ambulatory setting versus having to go into a hospital setting. So you want to take care of the priority needs and these are indicated by a risk rating of four and indicate a need for immediate services. It doesn't necessarily mean if they have a risk rating of four that they have to be in a level four level of service. So there are levels of care and that's what I was just referring to in terms of level four. So they range from zero to four in the third edition of the ASAM criteria. And within the five levels of care, there's some decimal numbers that are used to express creations of service intensity. So patients can move up and down in intensity of services without a change in their level of care. So it could be a 3.7 and it moves down to a lower three level. Slight differences between adult and adolescent levels of care on a couple of different levels that I'll point out. So you can see level 0.5 in the third edition of the ASAM criteria is early intervention for both adults and adolescents. Level one for adults and adolescents is outpatient services. And there's the OTP, which is within the level one outpatient care opioid treatment program. So that's going to be the methadone program. And that level of care is not specified for adolescents because not too many adolescents get admitted to OTPs. Maybe things would change because there are some changes with OTP guidelines, federal regulations, but still I think most of the time people, adolescents might get referred to buprenorphine or naltrexone versus methadone for opioid use disorder. Moving on level two is intensive outpatient or hospitalization. So here's where there's some decimal places. So you can see somebody might move from 2.5 partial down to 2.1, which is intensive outpatient. So partial is five days a week or four days a week. Whereas intensive outpatient is usually like three days a week for three hours a day. Level three is residential or inpatient services. And you can see that there's different gradations here. So there's the highest of the level threes is 3.7, medically monitored intensive inpatient services for adults. And you can see the difference for adolescents there for 3.7 is medically monitored high intensity inpatient services. So there's a little bit of a difference in wording here. So 3.1 is the same between adolescents and adults. And then 3.3, there's not any kind of designated level of care for adolescents, but in adults, 3.3 is clinically managed population specific high intensity residential services. And we're going to talk about these things further in the next slides. And then there's level 3.5, which is clinically managed high intensity residential services. Whereas in adolescence, the 3.5 is clinically managed medium intensity. And then there's level four. And for both adults and adolescents, this is going to be medically managed intensive inpatient services. So typically like hospital, hospital based. So here's level 0.5 early intervention. So the purpose of this level is to explore and address problems and risk factors associated with substance use or addictive behaviors to help the individual recognize the harmful consequences of those behaviors. So some interventions that might take place are SBIRT or screening brief intervention and referral treatment, one-on-one counseling with people who are at risk, educational programs like DUI programs. And then the setting that this could take place in our clinical offices, schools, work settings, community centers, emergency departments, mental health settings, primary care, or somebody's home. And the focus is going to be on psychoeducation, on the risks of substance use and how to avoid substance use engagement. So we want to prevent people from developing a substance use disorder. Level one services are outpatient, and this is going to be counselors or healthcare providers that provide screening, evaluation, treatment, and ongoing recovery and disease management. So this could be the level of the initial level of care, or it could be a step down from a higher level of care. So ongoing services for these individuals is going to be less than nine hours per week for adults and less than six hours a week for adolescents. And the length of service depends on the severity of the substance use and the response to treatment. People can be engaged in this ongoing to maintain the recovery. So in these outpatient services, individuals can enter treatment while they're actively using substances or while they're in recovery to support and maintain their recovery. The treatment services that are offered typically are counseling, so it could be individual, group, or family, psychoeducation, occupational or recreational therapy, as well as pharmacotherapy. So it could be meds for addiction or medications for psychiatric conditions. And the setting can be in an outpatient health clinic, school-based programs. This can happen in a primary care setting, substance use treatment programs, mental health clinics, and then also child and adolescent behavioral health clinics, as well as opioid treatment programs. And the focus is going to be to enact change in substance use and related behavioral issues. So like they said at the beginning, that somebody can come in while they're actively using substances. So if you think about it, like if somebody joined an OTP and started treatment on methadone, they're going to actively be using for a while until they get on a stable dose of methadone typically. Oh, and here we're going to talk about the opioid treatment program. So this level of care involves daily or several times weekly opioid agonist medication. With methadone, it's pretty much daily. There was a different medication that was available a long time ago. It's not on the market now, but you could maybe do several times weekly. Counseling is available in OTP, and this is usually for people with moderate to severe opioid use disorder. And you're going to have outpatient services with the addition of the medication. And then opioid treatment programs, they could use methadone. That's typically a medicine that's used, but they can also provide buprenorphine and also can provide naltrexone. So moving on to intensive outpatient, this is a level 2.1, and these programs provide counseling and education about addiction and mental health related problems. And the hours of service are typically 9 to 19 hours a week of structured programming for adults. And for adolescents, it's going to be 6 to 19 hours per week. And a majority of the programming is going to be group counseling. And this can occur during the day, evening, or on the weekends, depending on the person's schedule. And when somebody completes, they typically step down to outpatient services. When an individual can be in an OTP, which remember is level 1, and in IOP. And the treatment services that are provided here in an IOP are counseling, med management, psychoeducation, and occupational and recreational therapy. Setting can be any kind of appropriate setting that meets state licensure and certification criteria. So typically it's going to be some kind of outpatient treatment program. It could be a mental health program, or a drug and alcohol program, or a co-program. Focus is going to be on structured support to assist in the individuals in gaining insight and the motivation to change. Level 2.5 is partial hospitalization. So these are often PHP or can be called day treatment. And these are going to be pretty much more intensive. It's going to be 20 or more hours per week. So the individual needs more than the nine hours that they're getting an IOP, but they don't require 24-hour care. And typically you're going to have some kind of in-house services like psychiatry, medical, or laboratory. And if not, they've got medical and psychiatric consultation available within eight hours by phone or within 48 hours face-to-face. For adolescents, the educational needs have to be addressed by the treatment provider. So they have to have some kind of plan for how are they going to complete their schoolwork or not missing out on their education. As far as treatment services in this level of care, people are going to do a lot of counseling, group counseling, or it could be individual or family. And then motivational interviewing can be part of this, psychoeducation, and then that occupational recreational therapy. And then as with all the other levels, pharmacotherapy could be part of it. Setting could be any appropriate setting that's going to meet state licensure and certification criteria. And then the focus is going to be on a more intense provision of services at a lower level of care, but with increased multidisciplinary treatment. So it's going to be obviously higher than an IOP, so you might have more people involved in treatment providing more treatments because you do have some psychiatry. You might have psychiatry or maybe family medicine involved to address some of the needs of the individuals in this program. Moving up to level 3.1, this is clinically managed low-intensity residential services. So these programs offer five or more hours per week of low-intensity treatment of substance use disorders for people who need time and a structured environment to practice their coping skills and recovery. So they live and receive clinical services on site, but they're not involved all day long in groups, basically. The treatment services include counseling, med management, psychoeducation, mental health treatment, voc rehab, job placement, and life skills. So a little bit more advanced than what you would get in an IOP or a partial in terms of adding on to these life skills and job placement. And they can have additional peer or self-help groups in addition to the professional services. And these residential services at this level can be combined with IOP under certain circumstances because you can see that they might not have any more than five hours of low-intensity treatment. Maybe somebody needs a little bit more than that, so they need to do IOP with it. These programs are staffed 24 hours with allied health professionals and mental health professionals. So these would be like a halfway house or a group home with a treatment component or supportive living environment. These wouldn't be considered sober or recovery houses, or in my state they're called three-quarter houses because they're not staffed. And the setting is usually a freestanding facility that's going to meet state licensing criteria. So moving up to 3.3, this is a clinically managed population-specific high-intensity residential service. So this is for adults, there's not any kind of adolescent equivalent. So this is a structured recovery environment and they have high intensity clinical services to meet the limitations of the individuals or to support recovery from substance use disorder or co-occurring disorders. And so it's thought that the substance use disorder or the co-occurring disorder are significant and result in cognitive impairment that makes outpatient treatment or relapse prevention efforts unfeasible. So the patients live and receive clinical services on site. There's alternative residential levels of care that are unlikely to be effective for the person because of their cognitive limitations, so they need to be in this level of care. And these cognitive limitations can contribute to problems with interpersonal relationships, coping skills, and comprehension. Now sometimes the cognitive limitations can be temporary, could be because of substance use, or they could be longer term like somebody has a history of a TBI. So level 3.3 is a clinically managed population-specific high-intensity residential service. So again, this is that adult-only, highly structured program. So they're going to have daily clinical services to improve their ability to complete their ADLs, they can have cognitive and behavioral therapies, counseling, pharmacotherapy, somebody's going to make sure that they're adherent to their medicines, they can get toxicology testing, and they can have daily addiction and mental health treatment services as well as treatments, medical treatments, motivational interventions, and then also get the family involved with family services. So people, the transition out of level 3.3 usually includes some ancillary services or like wraparound services that include housing, folk services, or transportation assistance. So an example of this level of care could be a therapeutic rehab facility or a traumatic brain injury program. Okay, now we have level 3.5, which is a clinically managed high-intensity residential service for adults, and for adolescents it's a clinically managed medium-intensity residential service. So this level of care serves individuals who need to have a safe and stable living environment to develop their recovery skills so they don't immediately relapse or return to use and or continue substance use. And they need to have 24-hour supportive care and to be able to initiate the recovery process. So patients will live in the program and receive clinical services on-site, and they have 24-hour support because of the lack of progress with prior recovery attempts. So sometimes patients might try to stop using on their own, maybe they go to a level one, but they aren't having any success with that level of care, so they get referred up a level, maybe up two levels depending on how dangerous their substance use is. And there's an emphasis on the treatment community as a therapeutic agent, so they connect with others who are around them and seeking treatment as well. And patients typically lack stable and supportive healthy relationships and support, so getting involved in this therapeutic environment can be helpful for that. And this level of care is going to assist patients in building a support system and addressing their basic needs like housing and employment. So in the same level, patients that are involved in the criminal justice system, they might have extensive history of previous treatment, and they typically have experienced significant mental health issues and trauma. And so effective treatment is thought to be habilitative rather than rehabilitative, meaning you can't rehabilitate something that somebody has never learned in the first place. And the treatment services that they offer at this level are activities to bolster their activities of daily living, their recovery and interpersonal skills, also bolster up relapse prevention skills. And then these programs are going to offer toxicology testing, motivational enhancement, counseling, pharmacotherapy, and all the things that were in that level 3.3 like met adherence and occupational and recreational therapy. The setting for this is usually a freestanding licensed facility in a community setting, or it could be a specialty unit within a licensed healthcare facility. And this could also be offered in a prison or a secure community setting for somebody who's involved in the criminal justice system. So level 3.7 is a structured regimen of 24-hour evaluation, observation, medical monitoring, and addiction treatment in an inpatient setting for people who don't need whole resources that an acute hospital or medically managed inpatient program offers. And this level is appropriate for people who need inpatient care for withdrawal or biomedical or emotional or cognitive problems. And what's different in this level, this medically monitored intensive inpatient services for adults, is that there's going to be physician monitoring, nursing care, psych services, counseling, as well as recreational activities, med management, and withdrawal symptom management. And the focus is to stabilize somebody's physical and emotional health so that they can eventually transition to a lower level of care. And you're going to focus on stabilizing their overall health so that they can work on their recovery. And usually a level 3.7 is a freestanding licensed facility in the community, or it could be a specialty unit in a licensed healthcare facility. And then we've got level 4. So this is the medically managed intensive inpatient services. So these are services for people with acute and severe biomedical, emotional, behavioral problems, which require medical nursing care and the medically directed treatment services deliver 24 hours. So you need the full resources of an acute general hospital or a psychiatric hospital. And the setting is usually going to be a licensed acute care setting that offers addiction treatment with intensive medical or psychiatric services. And you're going to have some focus on physical health, including their potentially severe withdrawal symptoms and their mental health. And that's going to take precedence over enacting change towards recovery. So if somebody is very sick, let's say somebody has severe withdrawal and they just had a withdrawal seizure. They need to be stabilized. We're not going to be talking to them about going to group therapy at that point. And then as far as treatment services, we're getting daily physician monitoring, 24 hour nursing care and monitoring. There's going to be a physician on call typically 24 seven, and then you're going to have psychiatric services, counseling, recreational activities when people are doing a little bit better and stabilized and then medication management and then withdrawal symptom management. So the physician's going to make daily decisions regarding treatment as the patient ready to be discharged to a lower level of care. And the focus is going to just be primarily on stabilization of the acute symptoms with an emphasis on coordinating care so they can go to a lower level of care. So when I work at our inpatient withdrawal management unit, we're getting people stabilized so they're not having severe symptoms of alcohol, benzo or opioid withdrawal. And then right away, you know, as soon as they're able to participate in an interview with some therapist, they're going to start working on their after care plans or where they're going to go after they're done with the withdrawal management. So speaking of withdrawal management, there's these different levels of withdrawal management to that coordinate with those levels of care. So the level one is outpatient, remember, and so you can have ambulatory withdrawal management without extended onsite monitoring. So this is somebody who has mild withdrawal and you have daily or a little bit less outpatient supervision. So in the program I work in, we see people Monday through Friday on a daily basis to make sure that they're progressing towards recovery and making sure that on Friday that they're set for the weekend. If there's any problems, they can go to our emergency department to be followed up. So that's our level. We have a level one withdrawal management program there. People in this level have a supportive living environment and they're likely to complete withdrawal management and continue treatment. With any of these withdrawal managements, you're going to want to think about where somebody's going to go for treatment afterwards or what's the next step. Because withdrawal management alone isn't going to do much for the individual's substance use disorder. It might make them feel better for a little while, but the risk of having a return to use is very high. So level two withdrawal management is ambulatory as well, but they have extended onsite monitoring. So this is usually for somebody who has moderate withdrawal and they stay on site all day with supervision and support for their withdrawal. They're going to go home at the end of the day and they have a supportive living environment and they're going to complete withdrawal management and continue some level of treatment. So they might continue with like partial program. Level 3.2 withdrawal management is clinically managed. So somebody here has moderate withdrawal. They need that 24 hour nursing support to complete withdrawal and to increase their likelihood of continued treatment. Level 3.7 is medically monitored inpatient withdrawal management. So they have more severe withdrawal. They need 24 hour nursing care and physician visits as needed. And without this, they're unlikely to complete withdrawal management. And level four, that's what I was talking about a little bit before where I work. It's a medically managed intensive inpatient withdrawal management program. So it's somebody with severe unstable withdrawal. They need that 24 hour nursing care and daily physician visits. There's a physician on call as well to modify the regimen and manage the instability that the patient may have. Okay. So we've talked about this different levels of care. So next we want to talk about the transfer or discharged criteria. So how do you transfer somebody from one level of care to another or discharge them from a level of care? So letter A, we have the patient has achieved their goals in the treatment plan and you have a problem justifying admission to the program or the problem that justified their admission to the program has resolved. And they, you want to continue chronic disease management at a less intensive level of care. Transfer or discharge criteria B, the patient's been unable to resolve the problem that justified their admission to the program despite changes to the treatment plan. So you tried some different things there, but the patient's not responding. And you've think that the patient achieved maximum benefit at that current level of care. And so we're going to transfer to another level of care, either up or down or discharge them for treat from treatment because they're no longer benefiting. Criteria C, the patient had a lack of capacity due to either a diagnostic or co-occurring disorder that limited their ability to resolve problems. And so the treatment at a different level of care or discharge from this level of care is indicated. And then criterion D is the patient's problem intensified or the patient developed new problems and can only be effectively treated at a more intensive level of care. So they're moving up in their level of care. So for example, you might think about somebody who's maybe in a ambulatory withdrawal management program, but they start, they're not responding to the medication. Their symptoms are worsening. Maybe they had a withdrawal seizure. They need to be admitted to a level four withdrawal management program. Okay. So that's it for the third edition. I wanted to talk about some of the changes that have been, that took place in the fourth edition, volume one. So that's one of the big differences. There's going to be several different volumes for the ASAM criteria, fourth edition. These came out in October of 2023, this volume one edition. So volume one is going to be on adults. It's going to be focused on adults or it is focused on adults. And there's some forthcoming volumes. There's one that's supposed to come up this year on adolescents and transition aged youth. And then in 2025, there's going to be a volume on addiction treatment within jails and prisons. And then in 2026, there's hopefully going to be one on behavioral addictions. So they're going to focus on things like gambling, internet and gaming addiction, sex addiction addiction. And so that's anticipated to be in 2026. So with this volume one, this focus on adults, the continuum of care has been updated to promote a chronic care model of treatment. So you remember when we were talking about level one, people could stay in treatment even though they're in remission or they need for relapse prevention. So this level 1.0 in the fourth edition is going to be ongoing monitoring for those who are in stable remission, including ongoing management. So somebody could be in stable remission from opioid use disorder or sustained remission if you're using DSM criteria in terminology on maintenance treatment. So let's say somebody is on buprenorphine and they can, they just stay in this level one. They're doing fine. They have monthly or visits to get their buprenorphine refills, for example. And we're also, another focus is going to be on the integration of care. So withdrawal management and biomedical services are integrated in the continuum with psychosocial services. And then we're also going to have co-occurring care. And we're going to integrate care for co-occurring psychiatric disorders by incorporating standards for something called co-occurring capable care into all different levels of care. So right now, like within the treatments that we have available or different programs that are available for people, they differ state by state, region by region. But the hope is that more programs are going to become co-occurring capable, and they can offer co-occurring care at all different levels of care, you know, from anywhere from level one to level four. And also the continuum of care has been updated to promote recovery support services. So this is going to include standards for recovery support, either directly or through a partnership at each level of care. So recovery support services could be recovery housing, in addition to outpatient level of care, but we could also have peer recovery support services too. And then it's also going to include harm reduction. So this wasn't talked about in the third edition, but it's going to encourage the consideration of harm reduction needs of the patients in order to be responsive to the patient's goals and preferences. So you might remember that, you know, somebody might be wanting to get treatment for their anxiety, but they don't want to stop using alcohol, was the example before. So we want to honor the patient's goals and preferences. So maybe somebody doesn't necessarily want to stop using opioids, but they want to stop, they want to get treatment for their depression. So then we want to make sure to provide harm reduction, so some education about overdose and naloxone and prescribes and naloxone for that individual. And also this harm reduction focus is going to incorporate low threshold addiction medication access. So not setting such high barriers for somebody to get treatment with buprenorphine, for example. The other thing is this readiness to change has been integrated across the dimensions. So you're going to be assessing readiness for change across all the different dimensions. And there's a new dimension six, and this is considered, this is called person-centered considerations. So you want to consider barriers to care. So this was addressed in the third edition, but it was just called something different. So you want to think about social determinants of health, but also, so that could include like housing, transportation, employment, things like that, that could be barriers to care or maybe facilitate care, patient preferences, and then also a need for motivational enhancement is considered under this dimension. So this is just a figure looking at the third edition versus the fourth edition dimensions of care. So remember there were six, there's still six in the fourth edition, but this is how they changed. So level one is pretty much the same, acute intoxication and withdrawal potential. In the fourth edition, it's called intoxication withdrawal and addiction medication. So they added in there just basically, you know, like you can have buprenorphine, methadone, naltrexone, I can't proceed, disulfiram. But level two or dimension two is biomedical conditions and complication. And level two and the fourth is biomedical conditions. Dimension three, emotional, behavioral, cognitive conditions and complication has been renamed to psychiatric and cognitive conditions. Dimension four, readiness to change, that's not going to be in this new edition. And dimension five is relapse or continued use or continued problem potential. And so now that's basically been put, renamed and reconsidered. There's like some additional considerations here and it's substance use related risks is what is going to be called in the fourth edition. And then dimension six was recovery environment in the third edition. And that's going to be recovery environment interactions. And then remember, I already talked to you about this new dimension for the fourth edition, person-centered considerations, which I talked about on the previous slide. So just a brief overview, dimension one, intoxication withdrawal and addiction medications. So you want to think about intoxication and associated risks, like we were talking about before withdrawal and associated risks and then addiction medicine needs or medication needs. So do they need to get started on something for cravings or do they need to get started on an opioid like buprenorphine or methadone to help suppress withdrawal and help with cravings. And so the person can stop using heroin or fentanyl, whatever it may be. Dimension two, biomedical conditions. So we think about their physical health concerns, pregnancy related concerns, and then sleep problems. Because a lot of times our patients do have some sleep issues. Dimension three is that renamed psychiatric and cognitive conditions. So we want to think about their active psychiatric concerns, whether it be depression, anxiety, schizophrenia, persistent disability from one of these conditions, their cognitive functioning, trauma, exposure, and related needs. And then their psychiatric and cognitive history is going to be addressed here. Dimension four is going to be substance use related risks. So this is the likelihood of risky substance use or risky substance related behaviors. Perhaps that might be revolving around injection drug use, sharing injection equipment, or maybe trading sex for drugs, things like that. Dimension five is recovery environment interactions. So we're going to think about the individual's ability to function in their current environment. Are they safe in their current environment? Do they have supports? And also in their current recovery environment, what is the cultural perception? So this is something new of substance use. As far as dimension six, we want to think about person-centered considerations. So their preference, sometimes, you know, patients, when you do a level of care assessment, it might be pretty obvious that they need inpatient level of care, but they don't want that. So then what do you do? So you've got to take into consideration what they want and then barriers to care. So that could be transportation, could be financial, like they don't have insurance and want to go to an inpatient program. And then the need for motivational enhancement. So sometimes individuals, they are pre-contemplative about change, so perhaps they need some motivational enhancement. So as far as the continuum of care, it still has four broad treatment levels, levels one through four. The other one had zero through four. Remember those 0.5 was prevention. Within each level, decimal numbers are going to denote those gradations of intensity and types of care. So level one is long-term remission monitoring for patients with sustained remission, and that's going to allow for patients to have checkups and then also to rapidly re-engage with care if needed. The medically managed levels of care are going to be integrated into the main care continuum. So medical management for intoxication, withdrawal, and biomedical and psychiatric comorbidities is integrated. You're going to have programs with enhanced biomedical capabilities. So that's level 3.7, bio is this new level here. So for example, that could be one of those rehab program, you know, that's 3.7 was that 24 hour service, but they're going to have ability to treat some biomedical problems or more severe illnesses, or perhaps like some of these manage some of these diabetes. And then you have programs that have enhanced capabilities to treat patients with co-occurring mental health conditions. So these are called co-occurring enhanced or COE level of care. So you could have a level 1.7 co-occurring enhanced. So that's, they're probably going to have a psychiatrist or psychiatric nurse practitioner on board. So here's a table looking at this continuum of care. One of the other things that's new is this recovery residence. So it's not one of these levels, but it is something to consider. So it's RR or recovery residence. And then we've got level 1 outpatient. So we can have long-term remission monitoring in this, and then there's level 1.5, which is outpatient therapy. And then there's 1.7 medically managed outpatient. So this might be where my buprenorphine patients fall. Level two is intensive outpatient or high intensity outpatient. So level 2.1 is intensive outpatient. So that's going to be similar to back when we were talking about intensive outpatient before about nine hours a week of treatment. And then level 2.5 is high intensity. So that's going to be similar to the partial level. And then there's medically managed intensive outpatient. So you're going to have some medical treatments in that intensive outpatient setting as well. Level 3 residential, similar to what we had before. So there's that clinically managed low intensity residential. And then there's the clinically managed high intensity residential. And then that 3.7 is that medically managed residential where there's going to be a physician on staff to be able to assess the patients and provide treatment for them. And then there's level four inpatient. So this is medically managed inpatient. So typically that's like an acute general hospital or psychiatric hospital setting. Okay. So this is the reference for this talk. So we have the ASAM criteria, the third edition, and then also the fourth edition that's available now. And that's the end of the presentation for today. Good luck with studying and good luck with your exam.

ASAM criteria

level of care assessment

substance use disorders

individualized treatment plans

continuum of care

chronic care model

co-occurring psychiatric disorders

recovery support services

harm reduction

transfer and discharge criteria