UNDERSTANDING THE AMERICAN SOCIETY OF ADDICTION …



UNDERSTANDING THE AMERICAN SOCIETY OF ADDICTION MEDICINE’S PATIENT PLACEMENT CRITERIA

By Michelle Tooker

The American Society of Addiction Medicine’s (ASAM) Patient Placement Criteria (PPC) has become a national model for treatment matching in addiction care. Andrea G. Barthwell, MD, founder of EMGlobal LLC, Arlington, VA, explained how the ASAM PPC seeks to reduce over- and undertreatment, objectively articulate clinical needs, conserve resources, and diminish adverse outcomes caused by mismatched treatment.1-6 She also discussed how the ASAM PPC model may be applied to the field of pain management to treat prescription opioid misusers.

History of PPC

To address third-party payers’ reluctance to support the continuum of services necessary to manage the heterogeneous addiction population, partly due to a lack of evidence for effectiveness and the stigma surrounding this disease, an objective guideline for matching patients to levels of care (LOC) became necessary.4,7 In 1991, the first version of the ASAM PPC was developed based on the clinical experience of a respected group of physicians rather than empiric evidence.7,8 The ASAM PPC-2 followed in 1996 and the most recent edition—ASAM PPC-2R—was published in 2001.8 The ASAM PPC-2R assesses patients along 6 dimensions (Table 1) and subsequently assigns them to 1 of 5 levels of service (LOS) (Table 2). This format clarifies for both payers and clinicians what types of treatment are clinically necessary, and justifies the need for financial support.5,6,9,10 As of 2005, all but 8 states[1] required state-funded providers to comply with some type of PPC, and 31 states[2] specifically used the ASAM PPC guidelines.11

Table 1. Six Dimensions of the ASAM PPC4,6,8,11

|1. Acute intoxication and/or withdrawal potential |

|2. Biomedical conditions and complications |

|3. Emotional, behavioral, or cognitive conditions and complications |

|4. Readiness to change |

|5. Relapse, continued use, or continued problem potential |

|6. Recovery/living environment |

Table 2. Levels of Service in the ASAM PPC-2R8

|Level of service |Description of treatment |

|0.5: Early intervention |Organized services designed to explore and address problems or risk factors that are related to substance use |

| |and help individuals recognize the consequences associated with substance abuse. |

|I: Outpatient treatment |Outpatient services that are professionally directed by addiction treatment staff and physicians. Provided |

| |regularly in scheduled sessions for generally fewer than 9 contact hours per week. A defined set of policies |

| |and procedures or clinical protocols is followed. |

|II: Intensive outpatient |Outpatient services that accommodate people by offering treatment services at many different times. Provides |

|treatment/partial hospitalization |essential education and treatment components in a “real world” setting. |

|III: Residential/inpatient treatment |Staffed services in a 24-hour live-in setting. For individuals who need safe and stable living environments to|

| |develop their recovery skills. |

| |Encompasses 4 types of programs: |

| |III.1: Clinically managed low-intensity residential treatment |

| |III.3: Clinically managed medium-intensity residential treatment |

| |III.5: Clinically managed high-intensity residential treatment |

| |III.7: Medically monitored inpatient treatment |

|IV: Medically managed intensive inpatient|Planned regimen of 24-hour medically directed evaluation, care, and treatment of mental and substance-related |

|treatment |disorders in an acute care inpatient setting. For individuals whose problems are so severe that biomedical, |

| |psychiatric, and nursing care are essential. |

Treatment Goals

The PPC-2R’s 5 LOS allow patients to receive appropriate treatment based on clinical necessity and severity of disease. Each LOS helps individuals meet their treatment goals, which Dr Barthwell described as:8,12

• Acknowledging that addiction exists

• Committing to recovery

• Reducing or eliminating inducements to use (eg, craving, inadequate support environment)

“Ideally, the patient’s first contact with the treatment system . . . would convey some hope of recovery,” Dr Barthwell stated. To help increase the likelihood of success, the updated edition added a LOC—Level 0.5—which serves as a pretreatment/prediagnosis service to screen for or rule out substance-related disorders in at-risk patients.8 It offers therapies such as 1-on-1 counseling and educational programs for first-time driving under the influence (DUI) offenders.8

Informed consent can also help patients reach their treatment goals. “You make the patient aware of the modalities that you’re going to use, the risks and benefits associated with those modalities, [and] whether there are alternatives,” she said. This includes a discussion of the risk of forgoing treatment.

Ultimately, the goal is for patients to sustain gains made during treatment and to continue to progress on their own. This requires the establishment of an internal locus of control, so patients believe they have power over their behavior, in contrast to an external locus where people feel they have no control over their circumstances (eg, fate, luck).13 It can take 2 years to establish an internal locus of control and during this the time the use of management tools (eg, urine drug testing) and counseling may be required. “You want to have an external locus of control operative in that person’s life until they’re able to build in a self-directed way on the gains made in treatment,” Dr Barthwell said.

PPC-2R Assessment Dimensions

Patients are evaluated along 6 dimensions to determine which LOC or intensity of services they should receive.6,8,11 Clinicians individualize goals for each person, guided by a tailored treatment plan that identifies and addresses the patient’s problems and the methods that will be used. While all 6 dimensions are important, Dr Barthwell emphasized that readiness to change, relapse/continued use potential, and recovery/living environment are the “heart and soul” of addiction treatment. Living environment relates to the setting in which the patient resides and whether it is structured and supportive of or detrimental to recovery. The individual’s external relationships with family and larger social groups and a controlled, encouraging environment are the keystones to success. “Structure without support feels punitive,” she said. “Support without structure is enabling.”

These guidelines allow providers to identify necessary treatment, where those services should occur, and an ideal level of intensity and duration. “It declares a timetable for achieving your goals and objectives,” Dr Barthwell explained. Health care professionals want patients in the least intensive and restrictive LOC, while maintaining their safety, security, and success. Finally, she advised clinicians to reevaluate a patient’s LOC if predicted responses do not occur after a dose of service at a certain level.

Validity of the ASAM

The Substance Abuse and Mental Health Services Administration (SAMHSA) has funded the evaluation and validation of the ASAM PPC, with 7 studies conducted to date.14 Within most of the studies, patients who were matched (recommended and actual LOC were the same) generally experienced greater treatment success than those who were mismatched (recommended level was higher or lower than actual LOC).1 A study examining the predictive validity of the ASAM PPC using both a computer algorithm and clinical-evaluation protocol found that 3 months after intake, mean days of alcohol consumption in undertreated patients was higher than in those who were matched (Figure 1).1,15

Figure 1. Mean Days of Alcohol Use Adjusted for Level of Care1,15

[pic]

A cross-state prospective study compared data from 240 adults in Oregon (where PPC was recently implemented) to 287 adults in Washington (no method of PPC was in use) who presented for addiction treatment.12 “When it [ASAM PPC] was used, they got a better length-of-stay determination . . . better use of their facilities and better outcomes,” said Dr Barthwell. The study found that 95% of the matches in the Oregon sample corresponded with clinical recommendations and treatment focus shifted from being program-driven to patient-driven.12

Finally, The Boston Target Cities Project modified the ASAM PPC into a 1-page summary.15,16 The study aimed to enhance publicly funded substance abuse treatment in Boston, particularly for minorities, women, the homeless, and those with a dual diagnosis.16 Compared to direct self-referred admission, patients assigned via centralized intake centers, which involved in-depth clinical assessments by nurses or nurse practitioners, were 36% more likely to transition to treatment following their initial match than those who engaged in the self-selection process without case management.15,16 In addition, prescreened patients were less likely to return for detoxification within 90 days.15,16 “[Patients] in the self-selection process either failed to show, failed to stay, failed to complete, or didn’t follow the recommendation to move to another LOC after treatment,” explained Dr Barthwell.

Clinical Challenges and Treatment Barriers

Responding to patient urgency with an appropriate match of services is a clinical challenge associated with PPC. Dr Barthwell explained the difficulty in matching appointment response time with patient urgency in a publicly funded system. “A number of patients wander off and lose their need to be seen in response to the multiple mini-crises that occur in their lives,” she said. Another concern is that treatment failure in a lower LOC is often a prerequisite for getting into an appropriate LOC. These challenges are partly addressed by the ASAM PPC-2R, but barriers to treatment—patient reluctance, insurance issues, work conflicts, and interference with personal relationships—may hinder response time and success of service matching.2

Overtreatment

There is no evidence that overtreatment produces better results than matched treatment.1 “Sometimes people get overmatched because they’ve got the coverage . . . to pay for it, so there’s a push administratively to put people in the higher-cost facility,” Dr Barthwell said. One study of 281 alcoholics in an urban addiction treatment program offering a continuum of LOC found that overtreatment occurred in 59% of unmatched patients.2 Of these, 93% were mismatched to overtreatment simply because Medicaid covered inpatient care.2

Undertreatment

Undertreatment may result in increased adverse outcomes, rapid relapse, or the inability to overcome addiction. “There are lots of things that cause people to not accept the match and put themselves in a lower LOC,” Dr Barthwell said. Patients often select outpatient care instead of a rehabilitation program because the latter is inconvenient. In one study, 20 out of 29 mismatched alcoholics were undertreated due to conflicts with their work schedules.2

Opioid Maintenance Therapy

Opioid Maintenance Therapy (OMT) is built into the second edition of the ASAM PPC.8 OMT is an umbrella term that encompasses a number of pharmacologic and nonpharmacologic treatment modalities, including the therapeutic use of specialized opioid compounds such as methadone and buprenorphine to occupy opioid receptors in the brain, extinguish drug craving, and establish a maintenance state.8,18,19 It is usually offered in the context of ambulatory services, although it can be provided under other LOC, and delivered by addiction-credentialed clinicians or addiction-trained personnel.8,18,19 Therapies include individualized assessment and treatment, monitored urine drug testing, counseling, case management, and psychoeducation.8

OMT may be warranted for individuals at high-risk of relapse due to a lack of awareness of triggers, difficulty postponing instant gratification, or treatment resistance.19 Dr Barthwell said that OMT is designed to address loss of function in work, family, and social roles caused by misusing opioids. It is recommended for opioid-addicted patients who demonstrate physiologic craving, intensification of addiction symptoms, and continued high-risk behaviors with deteriorating function despite nonmaintenance treatments and adjustments to their treatment plan.19

Prescription Opioids and PPC

Although not developed to understand or define subtypes of prescription opioid abusers, Dr Barthwell sees potential in using the ASAM PPC model to treat these patients. Prescription opioid misusers have different demographic, personal, and clinical characteristics. Defining subtypes among these patients will help clinicians to determine proper treatment matching.17 For example, someone who abuses opioids casually (eg, only at parties) requires much different treatment than someone who suffers from addiction. Splitting and relumping patients into clinically manageable groups will help answer the myriad of questions surrounding prescription opioid abuse and determine which type of prevention message will resonate with which type of patient. Examples of questions to help understand different patients are outlined in Table 3.

Table 3. Suggested Questions to Help Identify Patient Subtypes Along the 6 Dimensions

|Dimension |Questions |

|1. Acute intoxication/withdrawal |What is the risk of intoxication? |

| |Withdrawal risk? |

| |Signs of withdrawal? |

| |Support to assist with ambulatory withdrawal? |

|2. Biomedical conditions |Physical illnesses? |

| |Chronic conditions? |

|3. Emotional/behavioral complications |Current psychiatric illnesses? |

| |Chronic conditions? |

| |Are they an expected part of addiction illness or are they autonomous? |

| |Do they require specific mental health treatment? |

|4. Treatment acceptance or resistance |Is the patient objecting to treatment? |

| |Does the patient feel coerced? |

| |If willing to accept treatment, how strongly does the patient disagree with others’ |

| |perception that he or she has a problem? |

| |Does the patient appear to be compliant only to avoid a negative consequence, or does he|

| |or she appear to be internally distressed in a self-motivated way? |

|5. Relapse potential |Is the patient in immediate danger of continued severe distress and drinking/drug |

| |behavior? |

| |Does the patient have any recognition or understanding of skills with which to cope with|

| |his or her addiction problem in order to prevent relapse or continued use? |

| |What severity of problems and further distress will potentially continue or reappear if |

| |the patient is not successfully engaged in treatment at this time? |

| |How aware is the patient of relapse triggers, ways to cope with cravings, and skills to |

| |control impulses to use? |

|6. Recovery/living environment |Are there dangerous family members, significant others, living situations, or |

| |school/work situations that pose a threat to treatment engagement and success? |

| |Does the patient have supportive friendships, financial resources, or |

| |educational/vocational resources? |

| |Are there legal, vocational, social service agency, or criminal justice mandates that |

| |may enhance the patient’s motivation for engagement in treatment? |

Future Generations of PPC

According to Dr Barthwell, the next generation of the ASAM PPC should focus on patient needs instead of fixed-level program needs. “Rather than have the setting drive what you give [a patient], you have the individualized assessment drive what you give,” she stated. More individualized treatment and an unbundling of services will ensure patient success and effective use of resources.

Additionally, the complexity of the criteria should be addressed so that it can be used in everyday clinical practice.5 “We’ve got to do some parsing of the language that we’re using to describe these things,” Dr Barthwell said. Finally, new strategies that overcome patient resistance to clinical recommendations for more intensive treatment are vital.2,5

Conclusion

While the ASAM PPC show promise for reducing detrimental undertreatment, minimizing cost-inefficient overtreatment, and improving patient results, more research and subsequent revisions are needed to maximize its effectiveness.1,3,14 Such a model could prove valuable in developing interventions for prescription opioid abusers. Pain expert and conference chair Nathaniel P. Katz, MD, from Tufts University School of Medicine, Boston, MA, concluded, “the consequences to the pain management profession for not having a treatment-matching algorithm like this have been absolutely devastating.”

References

(1) Magura S, Staines G, Kosanke N et al. Predictive validity of the ASAM Patient Placement Criteria for naturalistically matched vs. mismatched alcoholism patients. Am J Addict. 2003;12:386-397.

(2) Kosanke N, Magura S, Staines G, Foote J, DeLuca A. Feasibility of matching alcohol patients to ASAM levels of care. Am J Addict. 2002;11:124-134.

(3) Shulman, Gerald D. Upgrading the ASAM Criteria. Behavioral Health Management . 9-1-1994.

(4) McKay JR, Cacciola JS, McLellan AT, Alterman AI, Wirtz PW. An initial evaluation of the psychosocial dimensions of the American Society of Addiction Medicine criteria for inpatient versus intensive outpatient substance abuse rehabilitation. J Stud Alcohol. 1997;58:239-252.

(5) Turner WM, Turner KH, Reif S, Gutowski WE, Gastfriend DR. Feasibility of multidimensional substance abuse treatment matching: automating the ASAM Patient Placement Criteria. American Society of Addiction Medicine. Drug Alcohol Depend. 1999;55:35-43.

(6) Mee-Lee D. Patient Placement Criteria: A Critical Tool for Achieving Quality Care. 1995. SAMHSA Center for Substance Abuse Treatment. TIE Communique.

(7) Gastfriend DR. Addiction Treatment Matching Research Foundations of the American Society of Addiction Medicine (ASAM) Criteria. Binghamton: The Haworth Medical Press; 2003.

(8) Mee-Lee D. ASAM PPC-2R ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders. Second edition, revised ed. Chevy Chase: American Society of Addiction Medicine, Inc.; 2001.

(9) McKay JR, McLellan AT, Alterman AI. An evaluation of the Cleveland criteria for inpatient treatment of substance abuse. Am J Psychiatry. 1992;149:1212-1218.

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

(11) Kolsky, Gretchen D. Current State AOD Agency Practices Regarding the Use of Patient Placement Criteria (PPC)- An Update. 2006. Washington, DC, The National Association of State Alcohol and Drug Abuse Directors (NASADAD).

(12) Deck, Dennis, Gabriel, Roy, Knudsen, Jeff, and Grams, Gwen. Impact of Patient Placement Criteria on Substance Abuse Treatment Under the Oregon Health Plan. Gastfriend, D. R. Addiction Treatment Matching Research Foundations of the American Society of Addiction Medicine (ASAM) Criteria. 27-44. 2003. Binghamton, NY, The Haworth Medical Press.

(13) Marchiori E, Loschi S, Marconi D, Mioni D, Pavan L. Dependence, Locus of Control, Parental Bonding, and Personality Disorders: A Study in Alcoholics and Controls. Alcohol Alcohol. 1999;34:396-401.

(14) Gastfriend, DR, Mee-Lee David. The ASAM Patient Placement Criteria: Context, Concepts and Continuing Development. Gastfriend DR. Addiction Treatment Matching Research Foundations of the American Society of Addiction Medicine (ASAM) Criteria. 1-8. 2008. Binghamton, The Haworth Medical Press.

(15) Sharon, Estee, Krebs, Chris, Turner, Winston et al. Predictive Validity of the ASAM Patient Placement Criteria for Hospital Utilization. Gastfriend, DR. Addiction Treatment Matching Research Foundations of the American Society of Addiction Medicine (ASAM) Criteria. 79-93. 2003. Binghamton, The Haworth Medical Press.

(16) Shwartz M, Gastfriend DR, Mulvey K et al. The Boston Target Cities Program: Overview and Evaluation Results. J Psychoactive Drugs. 1999;31:265-72.

(17) Barbor TF, Caetano R. Subtypes of substance dependence and abuse: implications for diagnostic classification and empirical research. Addiction. 2006;101:104-110.

(18) New Mexico Health Policy Commission. Required Levels of Care & Assessment/Reassessment Dimensions For Developing Clinical Criteria for Admission, Continuation and Discharge. 2000.

(19) Gastfriend, D. R., Rubin, Amy, Sharon, Estee, and et al. New Constructs and Assessments for Relapse and Continued Use Potential in the ASAM Patient Placement Criteria. Gastfriend DR. Addiction Treatment Matching Research Foundations of the American Society of Addiction Medicine (ASAM) Criteria. 2003. Binghamton, The Haworth Medical Press.

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[1]Alabama, California, Indiana, Kentucky, Louisiana, Maine, Vermont, and Virginia.

[2] Alaska, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Iowa, Maryland, Massachusetts, Michigan, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Washington, West Virginia, and Wyoming.

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