Substance Use Disorders and ASAM Patient Placement Criteria

Substance Use Disorders and ASAM Patient Placement Criteria Rochelle Head-Dunham, MD, FAPA Medical Director/Chief of Adult Services DHH/Office for Behavioral Health

Objectives 1. Discuss defining criteria for Substance Use Disorders 2. Highlight General Principles of the Neurobiology of Addiction 3. Review the American Society of Addiction Medicine s (ASAM) Patient Placement Criteria

SUBSTANCE USE DISORDERS 4

Terminology Dual-disorders vs Co-occurring Disorders Use vs Misuse vs Abuse Tolerance vs Physiological Dependence Physiological Dependence vs Addiction Pseudo-addiction Assessment vs Patient Placement Criteria 5

General Principles & Considerations Heterogeneity of the addiction populations Diagnosing with expectation not exception Holistic evaluations and comprehensive treatment planning Unique person-centered and family focused treatment approaches are required to enhance outcomes Significant predictors of treatment success are continuous, empathic relationships and coordination of care 6

Axis I: Axis II: Diagnostic Statistical Manual (DSM) Multi-Axial System Clinical Disorders (Mental Illness and Addictive Disorders) Other Conditions That may be a Focus of Clinical Attention Personality Disorders; Developmental Disabilities Axis III: General Medical Conditions Axis IV: Psychosocial and Environmental Problems ( Stressors ) Axis V: Global Assessment of Functioning (GAF) 7

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Interrelationship of Substance Use and Mental (Psychiatric) Disorders Psychiatric disorders and substance use disorders can evolve independently through different, unrelated processes Symptoms of psychiatric and substance use disorders can be expressed independently or simultaneously Both disorders can mimic or mask symptoms of the other, i.e., cocaine intoxication can mimic schizophrenic; depression can mimic cocaine induced mood disorder. A relapse of one disorder can precipitate acute symptoms of the other disorder. Psychiatric symptoms may emerge with cessation of alcohol/drug use (i.e., first break schizophrenic).

Commonly Co-Occurring Mental Disorders (Axis I) 1. Mood Disorders are disorders that present with a disturbance in mood as a predominant feature; Major Depressive Disorders, Bipolar Disorders, substance Induced Mood Disorders, commonly co-occur with addictive disorders 2. Anxiety Disorders are disorders that present with anxiety (fear) as the predominant feature. Panic disorder, Social Anxiety Disorder, Generalized Anxiety Disorder, and Post-Traumatic Stress Disorder, commonly co-occur with addictive disorders. 3. Psychotic Disorders are disorders which typically present with psychosis or gross impairment in reality testing evidenced by delusional thinking, disorganized speech, or disorganized/ catatonic behavior. Schizophrenia, Schizoaffective disorder, and Delusional disorder, co-occur with addictive disorders. 10

Personality Disorders Co-occur with Substance Use (Axis II) A Personality Disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment, and is manifested in at least two of the following areas: Cognition, Affectivity, Interpersonal functioning or Impulse Control. DSM-IV TR

Medical Co-morbidity and Substance Use (Axis III) Inhalant use among 12 17 year olds and depression are increasing; Patients in chemical dependency programs are 18 times more likely to have major psychosis, 15 times more likely to have depression and 9 times more likely to have an anxiety disorder; Substance use increases the risk for hypertension (x2), congestive heart failure (x9) and pneumonia (x12); HIV patients with a substance use disorder are more likely to be non-adherent; Medicaid patients with a substance use disorder are more likely to be readmitted to a hospital within 30 days; 12

Medical Co-morbidity and Substance Use (Axis III) Substance use creates increased rates of complications with hip replacements; Patients treated with medication for alcoholism had fewer detoxification, alcohol related inpatient days and emergency room visits; High cost Medicaid recipients with HIV had an average annual cost of $157,000, with 40% higher costs for treatment of co-morbid MH/SU disorders, the most common co-morbidities Treating patients with substance use related medical disorders in an integrated setting can achieve cost savings; 13

Definition of Substance Related Disorders Substance Related Disorders are disorders resulting from ingestion of a drug of abuse (including alcohol), along with the development of the side effects of a medication, or from toxin exposure. Substance can refer to a drug of abuse, a medication, or a toxin. Patterns of use have been researched for eleven substances: Alcohol, Amphetamine, Caffeine, Cannabis, Cocaine, Hallucinogens, Inhalants, Nicotine, Opioids, Phencyclidines and Sedative hypnotics/benzodiazepines.

Diagnoses Associated With Classes Of Substances Table 1. Diagnoses associated with class of substances Dependence Abuse Intoxication Withdrawal Intoxication Delirium Withdrawal Delirium Dementia Amnestic Disorder Psychotic Disorders Mood Disorders Anxiety Disorders Sexual Dysfunctions Sleep Disorders Alcohol x x x x I W P P I/W I/W I/W I I/W Amphetamines x x x x I I I/W I I I/W Caffeine x I I Cannabis x x x I I I Cocaine x x x x I I I/W I/W I I/W Hallucinogens x x x I I I I Inhalants x x x I P I I I Nicotine x x Opioids x x x x I I I I I/W Phencyclidine x x x I I I I Sedatives, hypnotics, or anxiolytics Polysubstance x x x x I W P P I/W I/W W I I/W x Other x x x x I W P P I/W I/W I/W I I/W *Also Hallucinogen Perception Disorder (Flashbacks). Note: X, I, W, I/W, or P indicates that the category is recognized in DSM-IV. In addition, I indicates that the specifier With Onset During Intoxication may be noted for the category (except for Intoxication Delirium); W indicates that the specifier With Onset During Withdrawal may be noted for the category (except for Withdrawal Delirium); and I/W indicates that either With Onset During Intoxication or With Onset During Withdrawal may be noted for the category. P indicates that the disorder is Persisting.

Diagnoses Associated With Classes Of Substances (Illustrated) Table 1. Diagnoses associated with class of substances Classes of Substances Dependence Abuse Intoxication Withdrawal Intoxication Delirium Withdrawal Delirium Dementia Amnestic Disorder Psychotic Disorders Mood Disorders Anxiety Disorders Sexual Dysfunctions Sleep Disorders Alcohol x x x x I W P P I/W I/W I/W I I/W Amphetamines x x x x I I I/W I I I/W I I x Caffeine Cannabis x x x I I I Cocaine x x x x I I I/W I/W I I/W Hallucinogens x x x I I I I Inhalants x x x I P I I I Nicotine x x Opioids x x x x I I I I I/W Phencyclidine x x x I I I I Sedatives, hypnotics, or anxiolytics x x x x I W P P I/W I/W W I I/W Polysubstance x Other x x x x I W P P I/W I/W I/W I I/W

Diagnostic Considerations DSM IV-TR The Diagnostic and Statistical Manual (DSM-IV) has established two broad categories for the distinction of Addictive Disorders: A. Use Disorders are those diagnostic states which name the substance of abuse and assign severity (i.e., alcohol abuse or dependence ) or acuity (cocaine intoxication or withdrawal). B. Induced Disorders are those diagnostic states which occur as a result of the psychological consequences of ingested chemicals (i.e.., cocaine induced psychosis, methamphetamine induced mood disorder ). 17

Diagnostic Determinants Diagnostic determinants of Abuse versus Dependence, Withdrawal versus Intoxication are drug pharmacology and behavioral patterns/consequences of use Rationale for appropriate placement decisions must take into consideration, all of the above as determinants of severity and acuity.

Diagnostic Determinants Use Disorders Intoxication and Withdrawal

Diagnoses Associated With Classes Of Substances: Use Disorders (Illustrated) Table 1. Diagnoses associated with class of substances Dependence Abuse Intoxication USE DISORDERS Withdrawal Intoxication Delirium Withdrawal Delirium Dementia Amnestic Disorder Psychotic Disorders Mood Disorders Anxiety Disorders Sexual Dysfunctions Sleep Disorders Alcohol x x x x I W P P I/W I/W I/W I I/W Amphetamines x x x x I I I/W I I I/W I I x Caffeine Cannabis x x x I I I Cocaine x x x x I I I/W I/W I I/W Hallucinogens x x x I I I I Inhalants x x x I P I I I Nicotine x x Opioids x x x x I I I I I/W Phencyclidine x x x I I I I Sedatives, hypnotics, or anxiolytics x x x x I W P P I/W I/W W I I/W Polysubstance x Other x x x x I W P P I/W I/W I/W I I/W

Diagnoses Associated With Classes Of Substances: Diagnostic Possibilities (Illustrated)

Diagnoses Associated With Classes Of Substances: Diagnostic Possibilities (Illustrated) Table 1. Diagnoses associated with class of substances Dependence Abuse Intoxication Withdrawal Intoxication Delirium Withdrawal Delirium Dementia Amnestic Disorder Psychotic Disorders Mood Disorders Anxiety Disorders Sexual Dysfunctions Sleep Disorders Alcohol x x x x I W P P I/W I/W I/W I I/W Amphetamines x x x x I I I/W I I I/W I I x Caffeine Cannabis x x x I I I Cocaine x x x x I I I/W I/W I I/W Hallucinogens x x x I I I I Inhalants x x x I P I I I Nicotine x x Opioids x x x x I I I I I/W Phencyclidine x x x I I I I Sedatives, hypnotics, or anxiolytics x x x x I W P P I/W I/W W I I/W Polysubstance x Other x x x x I W P P I/W I/W I/W I I/W

Medication Options Induced Disorders

Medication Considerations Medications and Induced States Drugs and Alcohol induce a complex array of symptoms which are very similar to mental disorders in those who do not use drugs and alcohol. Use of psychotropic medications is therefore indicated to manage the psychiatric symptoms, independent of the cause for their expression. (Some cautions are necessary.) 24

Diagnoses Associated With Classes Of Substances: Induced Disorders (Illustrated) Table 1. Diagnoses associated with class of substances Dependence Abuse Intoxication Withdrawal Intoxication Delirium Withdrawal Delirium Dementia Amnestic Disorder Psychotic Disorders Mood Disorders INDUCED DISORDERS Anxiety Disorders Sexual Dysfunctions Sleep Disorders Alcohol x x x x I W P P I/W I/W I/W I I/W Amphetamines x x x x I I I/W I I I/W I I x Caffeine Cannabis x x x I I I Cocaine x x x x I I I/W I/W I I/W Hallucinogens x x x I I I I Inhalants x x x I P I I I Nicotine x x Opioids x x x x I I I I I/W Phencyclidine x x x I I I I Sedatives, hypnotics, or anxiolytics x x x x I W P P I/W I/W W I I/W Polysubstance x Other x x x x I W P P I/W I/W I/W I I/W

DSM V Eliminates the Multi-Axial System Axis I, II, and III (all diagnosis) are combined Axis IV Stressors are eliminated, replaced by ICD-9-CM V codes ICD-10-CM Z codes after October 2014 Axis V GAF is eliminated-new options are World Health Organization Disability Assessment Schedule (WHO-DAS 2.0) 26

DSM-V Diagnostic Considerations Substance-Related and Addictive Disorders Substance Abuse and Substance Dependence now consolidated into Substance Use Disorder, with severity continuum of mild, moderate, or severe Legal consequences criterion removed and craving criterion added to Substance Use Disorder Tolerance and Withdrawal criteria are not counted if the substance is prescribed by a physician Gambling Disorder has been moved from the Impulse-Control Disorders chapter in DSM-IV to this chapter in DSM-5 27

NEUROBIOLOGY OF ADDICTION 28

What is Addiction? The repetitive compulsive use of anything in spite of adverse consequences and ineffectiveness. This is regardless of the drug or behavior used.

What are we Addicted to? Below the level of the cortex the brain has a reward center. This center is necessary for us to learn what we should do again. It is a necessary survival mechanism. It can go awry and when it does we can be addicted. The main neurotransmitter active at this site is DOPAMINE. Wetsman, 2007

The Dopamine Spike

Anatomy of the Reward System

Dopamine Spike Electrical stimulation of the MFB in humans Electrical self stimulation of the MFB in mammals Degree of reward varies with rate of rise Craving starts on the way down Everyone has enough at the peak Wetsman, 2007

The Reward System Non-selective and Indiscriminant

Addiction Definitions ASAM Impaired control Preoccupation with the drug Use despite adverse consequences Distortions in cognition (denial and others) APA Addiction can be defined as compulsive drug seeking and drug taking, with a loss of control over drug use. DSMIV Maladaptive pattern of use Significant impairment or distress Three or more of the following within any 12 month period: 35

Definitions DSMIV (cont d) Tolerance Withdrawal Broken limits Persistent desire or unsuccessful efforts Excessive time spent Important activities given up Use despite adverse consequences 36

Why Addiction, Not Dependence? History of the term Dependence and the APA. WHO and physically vs psychologically addicting. Addiction without physical dependence. Dependence without addiction. Dependence vs. Tolerance Wetsman, 2007

So What About Abuse? Addiction is a sick brain doing it s best to feel better. Abuse is a healthy brain doing stupid things with drugs. There is no evidence of one leading to the other. You can have one or the other first and then develop the other one. Wetsman, 2007

So What About Abuse Abuse is to won t -- as addiction is to can t. Abuse is a normal brain needing no medicines (other than for whatever else is wrong with it) and addiction is an ill brain that often needs medical help. Treatments for Abuse vs Dependence are Different! Wetsman, 2007

DSM IV-TR Abuse (Cont) Key Point: THE SYMPTOMS HAVE NEVER MET THE CRITERIA FOR SUBSTANCE DEPENDENCE FOR THIS CLASS OF SUBSTANCE. Wetsman, 2007

American Society of Addiction Medicine - Patient Placement Criteria (ASAM PPC) 41

What is happening in some programs in America? Clients are being referred to the wrong levels of care. Clients are often referred to, and treated in the agency conducting the assessment. Clinical Assessments do not justify the recommendations being made. Clinical Justifications are not required. If provided clinical justifications do not include clinical rationale / evidence supporting the recommendation. There are little to no policies or procedures that address the format and or quality of assessments, patient placement decisions, and clinical justifications 42

Why Do We Need to Improve Patient Placement and Clinical Justifications? Improved Performance and Treatment Outcomes Increase Initiation, Engagement & Retention Rates More Efficient & Effective Utilization of Resources Shift to Performance Based Contracting Positions Organizations for Medicaid and Private Insurance Reimbursement 43

Question QUESTION: How does this lack of consistency interpreting clinical information impact treatment? 44

Treatment Implications Answer: Client s receive the Wrong 1. Diagnosis or Diagnostic Impression 2. Level of Care Recommendation 3. Services and Interventions As a result, the client s chances of being successful in treatment are compromised right from the beginning of the treatment process. 45

Question QUESTION: What Does Research Say About Mismatching Clients to Treatment? 46

Treatment Implications ANSWER: Clients that are mismatched to treatment have lower retention rates and poorer outcomes. Less treatment is NOT Good. More treatment is NOT Good. One study found that No Treatment was better than the wrong treatment. (Knight, K., 2009) Louisiana Department of Health and 47

Uniform Patient Placement Criteria Defined Uniform Patient Placement Criteria (e.g., ASAM, LOCUS ) describe in detail the levels of care along the continuum of care, and provide specific guidelines for Patient Placement Decisions, a.k.a., Level of Care recommendations. General Components of UPPC Level of Care Continuum Dimensions of Assessment Criteria (e.g., admission, continued stay & discharge) 48

ASAM Dimensions ASAM Six (6)Dimensions: The client s risk status in each of the six dimensions collectively inform the patient placement decision. 1. Acute Intoxication and/or Withdrawal Potential. 2. Biomedical Conditions and Complications. 3. Emotional, Behavioral, or Cognitive Problems and Complications. 4. Readiness to Change. 5. Relapse, Continued Use, or Continued Problem Potential 6. Recovery Environment. 49

Benefits of UPPC Uniform Patient Placement Criteria: 1. Guides proper patient placement. 2. Promotes individualized care. 3. Identifies critical information to be collected during an assessment. 4. Influences multidimensional treatment planning. 5. Establishes a common language. 6. Identifies gaps in a continuum of care. 50

IMPORTANT!!! Criteria are NOT substitutes for GOOD Clinical Judgment. Tools, and Criteria s support, guide and enhance GOOD Clinical Judgment! 51

ASAM Historical and Theoretical Foundations The ASAM PPC 2 is published by the American Society of Addiction Medicine. Used as a clinical guide in matching patients to the correct level of care. Expands use of multidimensional assessments in developing objective patient placement decisions at various levels of care. Emphasis on intensities of along a continuum, in a variety of program types and levels of care ASAM PPC - 2R 52

ASAM Historical and Theoretical Foundations The continuing development and refinement of the criteria continue a shift from: Uni-dimensional to multidimensional assessment. Program-driven to clinically driven treatment. Fixed length of service to variable length of service. A limited number of discrete levels of care to a continuum of care. ASAM PPC - 2R 53

Theoretical Foundations of the Goals of Treatment: ASAM PPC Tailored to individuals needs (length, choice) Guided by individualized treatment plan. Client directed treatment plan. Based on comprehensive bio-psychosocial assessment of person and when possible, family. Should list problems, strengths, priorities, goals, methods or strategies. Safety first ASAM PPC - 2R 54

ASAM Placement Considerations Placement decisions are determined based upon consideration of: Level of Service/Care most appropriate to meet the clinical needs Dimensional Assessments Primary and Secondary Determinants Louisiana Department of Health and Hospitals 55

Exceptions to PPC There are 3 exceptions which override the PPC match: Lack of the availability of the appropriate selected care. Failure of a patient to progress at a given level of care so as to warrant a reassessment of the treatment plan with a view to modification of the treatment approach. State laws regulating requiring different criteria. ASAM PPC - 2R 56

ASAM Levels of Service Levels of Care: Level 0.5 Level I Level II Level III Level IV Early Intervention Outpatient Treatment Intensive Outpatient / Partial Hospitalization Residential/Inpatient Treatment Medically Managed Intensive Hospital/Inpatient Treatment (Note:.1 to.9 represents graduated intensity within an existing level of care.) ASAM PPC - 2R 57

Levels of Care ASAM PPC - 2R Levels 0.5 Early Intervention Prevention Focus Staffing (Essential) Partnerships Individuals at risk for developing substance-related problems or Those without sufficient information to document a substance use disorder. Licensed Prevention Professionals Department of Education

Levels of Care ASAM PPC - 2R Levels I Outpatient Care (<9hrs/week Adults <6hrs/week Adols) Staffing (Essential) Organized services delivered in a wide variety of outpatient settings. Prescriptive services, regularly scheduled sessions, a defined set of policies and procedures or medical protocols. Accommodates high severity D4, unmotivated mandated persons; expanded for COD MD, Nurse, Clinicians/ Counselors, Care Coordinator, Peer Mentors (strongly recommended)

Levels of Care ASAM PPC - 2R Level II Intensive Outpatient/Partial Hospitalization (>9hrs/wk) Staffing (Essential) Partial 9-20hrs/wk; IOP 20hrs/</wk Organized, clinically intensive services delivered during the day, before or after work/school, in the evening or on weekends. Provides essential education and treatment components while allowing patients to apply their newly acquired skills within real world environments. MD, Nurse, Clinicians/ Counselors, Care Coordinator, Peer Mentors (strongly recommended

Levels of Care ASAM PPC - 2R Level III Residential/Inpatient Treatment Organized, 24hr services, staffed by trained medical and counseling staff to stabilize multidimensional problems, as prep for outpatient treatment. Defined set of policies and procedures foster reliance on the treatment community as a therapeutic agents. Designed to treat person who have significant social and psychological problems Staffing (Essential) MD(s), Nurse(s), Psych Techs Clinicians/ Counselors, Care Coordinator Staffing (Optional) Psychologist, Occupational Therapist, Peer Mentors Housed in or affiliated with permanent residential facilities. Generally provide access to on-site self-help meetings.

Levels of Care ASAM PPC - 2R Level III. 7D Residential Medically Monitored/Supported Detox Staffing (Essential) Staffing (Optional) Organized 24 hour nursing care and daily physician care for severe, unstable problems in Dimensions 1, 2 or 3. Counselors available. Appropriate for patients whose subacute biomedical, emotional, behavioral and cognitive problems are so severe that they require residential care not a full service hospital. MD(s) (AD Psych/Primary Care w/ ASAM); APRN/NP/RN; Psych Techs; Clinicians/ Counselors, Care Coordinator, Peer Mentor

Levels of Care ASAM PPC - 2R Level IV.D Medically Managed Intensive Hospital/ Inpatient Treatment Organized 24 hour nursing care and daily physician care for severe, unstable problems in Dimensions 1, 2 or 3. Counselors available. Appropriate for patients whose acute biomedical, emotional, behavioral and cognitive problems are so severe that they require primary medical and nursing care Full resources of a general acute care psychiatric hospital are available. Staffing (Essential) MD(s) (AD Psych/Primary Care w/ ASAM); APRN/NP/RN; Psych Techs; Clinicians/ Counselors, Care Coordinator, Staffing (Optional) Peer Mentor

Levels of Care ASAM PPC - 2R Opioid Maintenance Therapy Staffing (Essential) Best conceptualized as a separate service that can be provided at any level of care but typically, Level I Outpatient in an ambulatory setting. Daily or several times weekly opioid medication and counseling available to maintain multidimensional stability for those with opioid dependency. MD, Nurse, Clinician or Counselor

Dimensional Criteria ASAM s 6 assessment dimensions allow for multidimensional considerations in the determination of best level of care placements. Primary Determinants Acute Detox Medical Complications Psychiatric Difficulties Secondary Determinants Change readiness Relapse, continued use, continued problem potential Recovery/Living Environment

Summary Addiction populations are heterogeneous Neurobiology of addiction supports a chronic, relapsing condition and the disease concept Diagnose with expectation not exception Holistic evaluations and comprehensive treatment planning with care coordination are critical Appropriate dosing of care is critical to successful outcomes Unique person-centered, family focused empathic treatment approaches are required to enhance outcomes 66

References American Psychiatric Association, Diagnostic and Statistical manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC, American Psychiatric Association, 2000. Carroll, K.M. Methodological issues and problems in the assessment of substance use. Psychological Assessment 7:349 358, 1995. Donovan, D.M., and Marlatt, G.A., eds. Assessment of Addictive Behaviors. New York: Guilford Press, 1988. McLellan, A.T.; Kushner, H.; Metzger, D.; Peters, R.; Smith, I.; Grissom, G.; Pettinati, H.; and Argeriou, M. The fifth edition of the Addiction Severity Index. J Substance Abuse Treat 9:199 213, 1992b. Louisiana Department of Health and Hospitals 67

References Mee-Lee, D.; Shulman, G.D.; Fishman, M.; Gastfriend, D.R.; and Grifith, J.H. Patient Placement Criteria for the Treatment of Substance-Related Disorders. 2d ed., rev. Chevy Chase, MD: American Society of Addiction Medicine, 2001. Meyers, A. Thomas McLellan, J. Jaeger, H. Pettinati,The development of the comprehensive addiction severity index for adolescents (CASI-A) An interview for assessing multiple problems of adolescents. Journal of Substance Abuse Treatment, Volume 12, Issue 3, Pages 181-193 K. Spitzer, R.L., Williams, J.B.W., Gibbon, M. & First, M.B. Structured Clinical Interview for DSM- III-R-Patient Version. New York: New York State Psychiatric Institute, Biometrics Research Department, 1988. Sheehan, D.V., Lecrubier, Y., Sheehan, K.H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., & Dunbar, G.C. The mini-international neuropsychiatric interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-1V and ICD-10. Journal of Clinical Psychiatry, 59 (suppl. 20), 1998. Louisiana Department of Health and Hospitals 68

Questions and Discussion Rochelle Head-Dunham, MD rochelle.dunham@la.gov 225.342.8916 69