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Exploring ASAM Levels and Criteria 20-860013 Back to Course Index

EXPLORING ASAM LEVELS AND CRITERIA

The ASAM Criteria is the most widely used and comprehensive set of guidelines for placement, continued stay, transfer, or discharge of patients with addiction and co-occurring conditions. (asam.org 2021)  This course explores the criteria and levels of care but it does not provide these in their entirety.  For a more in-depth education on criteria and levels please read The ASAM Criteria:  Treatment for Addictive, Substance-Related, and Co-Occurring Conditions. Much of this course is taken from and based on excerpts from the ASAM book and website.

The ASAM Criteria is a collection of objective guidelines that give clinicians a way to standardize treatment planning and where patients are placed in treatment, as well as how to provide continuing, integrated care and ongoing service planning. The criteria were developed by the American Society of Addiction Medicine (ASAM), and presented in a book written by a group of well-known and highly regarded doctors and professionals, working in a variety of mental health and addiction treatment fields. The ASAM Criteria has become the most widely used set of criteria in the United States for the treatment of substance-use issues, and it has been continually revised and updated over the years with the newest science in the field of addiction. Currently, in its third edition (2013), The ASAM Criteria has been in use since 1991, and its foundations extend back even further into history.

Treatment professionals use a lot of information to decide how to best provide care to their patients. They rely on clinical knowledge, their experience in the field, and, perhaps most importantly, the direction and goals developed collaboratively with the patient him or herself. Many professionals use The ASAM Criteria to assist them in filtering all of this knowledge and data, and in determining what kind of services can be provided to the patient at the least intensive, but safe, level of care.

One important aspect of The ASAM Criteria is that it views patients in their entirety, rather than a single medical or psychological condition. This means that, when determining service and care recommendations, The ASAM Criteria pay attention to the whole patient, including all of his or her life areas, as well as all risks, needs, strengths, and goals.

Keep in mind that The ASAM Criteria is an educational tool. It does not dictate a particular standard of care or specific treatment decisions.  Treatment professionals are responsible for the care of their patients and must make independent judgments about whether and how to use The ASAM Criteria in their treatment decisions.

Adolescent and adult treatment plans are developed through a multidimensional patient assessment over five broad levels of treatment that are based on the degree of direct medical management provided, the structure, safety, and security provided, and the intensity of treatment services provided.

Acute Intoxication and/or Withdrawal Potential

The first dimension explores an individual’s past and current experiences of substance use and withdrawal. No longer called “detoxification,” withdrawal management encompasses a range of services designed to meet a person’s biopsychosocial needs.

 

Biomedical Conditions and Complications

The second dimension explores an individual’s health history and current physical condition. The goal is to determine whether the person needs additional physical health services, from acute stabilization to ongoing management of a chronic condition.

 

Emotional, Behavioral, or Cognitive Conditions and Complications

The third dimension explores an individual’s thoughts, emotions, and mental health issues. This may include cognitive, behavioral, psychiatric, and trauma-related conditions.

When considering the third dimension, it’s important to determine whether signs and symptoms can be addressed safely through addiction treatment (i.e., mood swings due to drug use) or warrant additional mental health services (i.e., mood swings due to concurrent bipolar disorder).

Dimension 3 also identifies five subcategories known as risk domains. These include dangerousness/lethality, interference with addiction recovery efforts, social functioning, the ability for self-care, and the course of illness.

 

Readiness to Change

The fourth dimension explores an individual’s readiness and interest in change. This dimension helps clinicians develop individualized care for people based on their readiness to change. The goal is to engage people in their behavior change, providing motivational enhancement services as necessary.

It’s important to recognize people may show different levels of readiness to change for different issues. An individual may be already making changes in one area of his or her life while still seeing no problem with another self-destructive behavior.

 

Relapse, Continued Use, or Continued Problem Potential

The fifth dimension explores an individual’s unique relationship with relapse, continued use, or continued problems. This dimension is relevant at any stage of treatment – even if a person has not achieved a level of recovery that would seem to allow for relapse.

 

Recovery Environment

The sixth dimension explores an individual’s recovery or living situation, including the surrounding people, places, and things. A person’s needs could include housing, financial, vocational, educational, legal, transportation, or childcare services. Clinicians also examine whether family members, significant others, or school, work, and living situations pose a threat to the person’s treatment and recovery.

 

Many principles guided the development of The ASAM Criteria. Some of these principles can better explain the mindset of the care provider, and help the patient understand how these criteria are used in determining the best treatment services for them.

 

Using the Criteria to Make Decisions About Care


The ASAM Criteria provide treatment professionals with objective standards they can use to help identify the least intensive treatment services that can help keep a participant safe as he or she works to make personal life changes. But identifying the most appropriate services is just one step in a much more intricate process. The ASAM Criteria outlines a detailed flowchart that treatment providers and professionals can use to assist them in their clinical decisions.

This “decisional flowchart” has been provided here, and each of its three main components (Assessing, Identifying, and Providing/Evaluating) is discussed below.  These are steps providers and professionals work through together when discussing what type of care to offer—and fund—for an individual. Following this decisional flow helps ensure that treatment is being effectively managed and that patients receive the appropriate intensity of care.

 

What are the Levels of Care?

The ASAM Criteria’s strength-based multidimensional assessment takes into account a patient’s needs, obstacles, and liabilities, as well as their strengths, assets, resources, and support structure. This information is used to determine the appropriate level of care across a continuum.

 

Assessing
The “assessment” phase of treatment represents the early information-gathering phase, in which the patient and physician work together to determine what signs and symptoms are present, and what they point to.

The ASAM Criteria begins this phase by asking “What does the patient want?” and “Why now?” If there isn’t good agreement and understanding of these early questions, it can significantly impact the later stages of treatment.

The ASAM Criteria is also unique in how it guides treatment professionals to conduct assessments.  Rather than simply focusing on a diagnosis or an isolated symptom, The ASAM Criteria uses what’s called a “multidimensional” assessment. This assessment is a way to see how treatment might affect multiple life areas of an individual.

There are six major life areas (or “dimensions”) detailed in The ASAM Criteria, and each one influences the others. Treatment providers look at these dimensions from every angle, considering them separately and together, and exploring both risks and strengths in each.

Physicians use their clinical knowledge to gather information about these dimensions and combine this with any other diagnoses (such as a substance use disorder) to complete the “Assessing” phase. Some levels of care require that a patient have a specific diagnosis to be admitted. The ASAM Criteria specify that a professional can use a reference tool such as the DSM5 or ICD-10 to help determine a diagnosis.

 

Identifying

Once the information about a patient’s wants, immediate needs, and different life areas have been gathered, treatment professionals move into the second phase of the decision-making process. This phase helps them identify what issues are of the highest severity, and of the highest priority, to address in treatment.  Treatment professionals rely on their clinical knowledge and training to help determine which issues and which life areas pose the biggest challenges. The ASAM Criteria help them rank these areas and choose which ones to target during treatment. From here, professionals and providers can work with the patient to figure out the specific services needed, and what goals to set. No services are recommended that do not refer back to the patient’s needs and goals.

 

Providing/Evaluating

The final phase of The ASAM Criteria treatment process takes the assessment information, and the identified priorities and services, and establishes what intensity of services should be provided. In other words, this is where service providers and patients decide how much and how often treatment is needed.  Patients may require weekly, daily, or even hourly services which might require a residential program or hospital stay. Again, this intensity is determined by a patient’s unique, individual needs, and provided in the least intensive, but safe treatment setting. Once this has been done, the final step is to track the progress of treatment, including any recommendations for discharge, transfer, or continuing service

 

Discharge, Transfer, and Continuing Service

All decisions about when to end services, when to change services, and when to continue services are based on the progress the patient is making. The ASAM Criteria does not support any treatment that has dates of “graduation” or “completion” that can be assigned before treatment has even begun. The length of treatment depends upon the progress made, in clearly defined and agreed-upon goals, rather than a result of a program’s preset structure.

 

The ASAM Criteria text describes the treatment as a continuum marked by four broad levels of service and an early intervention level. Within the five broad levels of care, decimal numbers are used to further express gradations of the intensity of services. These levels of care provide a standard nomenclature for describing the continuum of recovery-oriented addiction services. With the ASAM CONTINUUM™, clinicians can conduct a multidimensional assessment that explores individual risks and needs, as well as strengths, skills, and resources. ASAM CONTINUUM then provides clinicians with a recommended ASAM Level of Care that matches the intensity of treatment services to identified patient needs. 

 

ASAM Level 0.5

Called Early Intervention for Adults and Adolescents, level 0.5  constitutes a service for individuals who, for a known reason, are at risk of developing substance-related problems, or a service for those for whom there is not yet sufficient information to document a diagnosable substance use disorder. 

 

ASAM Level 1

Called Outpatient Services for adolescents and adults, level 1 typically consists of less than 9 hours of service/per week for adults or less than 6 hours a week for adolescents for recovery or motivational enhancement therapies and strategies. Level 1 encompasses organized services that may be delivered in a wide variety of settings.

 

ASAM Level 2

Called Intensive Outpatient Services for adolescents and adults, level 2 typically consists of 9 or more hours of service a week or 6 hours for adults and adolescents respectively to treat multidimensional instability. Level 2 encompasses services that are capable of meeting the complex needs of people with addiction and co-occurring conditions. It is an organized outpatient service that delivers treatment services during the day, before or after work or school, in the evening, and/or on weekends.

 

ASAM Level 2.5

Called Partial Hospitalization Services for adolescents and adults, level 2.5 typically provides 20 or more hours of service a week for multidimensional instability that does not require 24-hour care. Level 2 encompasses services that are capable of meeting the complex needs of people with addiction and co-occurring conditions. It is an organized outpatient service that delivers treatment services usually during the day as day treatment or partial hospitalization services. 

ASAM 3.1

Called Clinically Managed Low-Intensity Residential Services, this adolescent and adult level of care typically provides 24-hour living support and structure with available trained personnel and offers at least 5 hours of clinical service a week. Level 3 encompasses residential services that are described as co-occurring capable, co-occurring enhanced, and complexity capable services, which are staffed by designated addiction treatment, mental health, and general medical personnel who provide a range of services in a 24-hour living support setting.

 

ASAM Level 3.3

Called Clinically Managed Population-Specific High-Intensity Residential Services, this adult-only level of care typically offers 24-hour care with trained counselors to stabilize multidimensional imminent danger along with less intense milieu and group treatment for those with cognitive or other impairments unable to use full active milieu or therapeutic community. Level 3 encompasses residential services that are described as co-occurring capable, co-occurring enhanced, and complexity capable services, which are staffed by designated addiction treatment, mental health, and general medical personnel who provide a range of services in a 24-hour treatment setting.

 

ASAM Level 3.5

Called Clinically Managed Medium-Intensity Residential Services for adolescents and Clinically Managed High-Intensity Residential Services for adults, this level of care provides 24-hour care with trained counselors to stabilize multidimensional imminent danger and prepare for outpatient treatment. Patients at this level can tolerate and use a fully active milieu or therapeutic community. Level 3 encompasses residential services that are described as co-occurring capable, co-occurring enhanced, and complexity capable services, which are staffed by designated addiction treatment, mental health, and general medical personnel who provide a range of services in a 24-hour treatment setting.

 

ASAM Level 3.7

The Medically Monitored High-Intensity Inpatient Services for adolescents and Medically Monitored Intensive Inpatient Services Withdrawal Management for adults provide 24-hour nursing care with a physician’s availability for significant problems in Dimensions 1, 2, or 3. Patients in this level of care require medication and have a recent history of withdrawal management at a less intensive level of care, marked by past and current inability to complete withdrawal management and enter into continuing addiction treatment. This is the appropriate setting for patients with subacute biomedical and emotional, behavioral, or cognitive problems that are so severe that they require inpatient treatment. Level 3 encompasses residential services that are described as co-occurring capable, co-occurring enhanced, and complexity capable services, which are staffed by designated addiction treatment, mental health, and general medical personnel who provide a range of services in a 24-hour treatment setting.

 

ASAM Level 4

Called Medically Managed Intensive Inpatient Services for adolescents and adults, this level of care offers 24-hour nursing care and daily physician care for severe, unstable problems in ASAM Dimensions 1, 2, or 3. Counseling is available 16 hours a day to engage patients in treatment. 

 

Though treatment intensity is often split into “levels” of care, these levels connect, acting more like “benchmarks” along a single spectrum. Patients can move between levels, depending on their unique needs. ASAM also uses separate criteria and levels of care benchmarks for adult patients and adolescent patients. This is because adolescents can be in different stages of emotional, mental, physical, and social development than adults. For this reason, certain adolescent services, such as withdrawal management, are bundled together with the rest of their treatment, whereas adults can enter into withdrawal management treatment separately.

 

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