Addiction Assessment and Evaluation
DSM-IV-TR Diagnosis Substance Abuse Recurrent use leading to consequences Criteria for dependence must not be met Substance Dependence What is commonly referred to as addiction Typically involves tolerance and/or withdrawal
Substance Abuse One or more of the following symptoms Use leading to failure to fulfill major role obligations at work, school or home Use in situations that are physically hazardous Substance-related legal problems Use despite persistent social/interpersonal problems caused or worsened by the use.
Tolerance Substance Dependence: 3 or more symptoms Need for more to get the same effect Less effect from the same amount Withdrawal characteristic syndrome of the substance Same or similar substance is taken to relieve or prevent withdrawal symptoms
Substance Dependence Cont d More use than intended (loss of control) Unsuccessful efforts to cut down or stop (loss of control) Significant time spent procuring, using, or recovering from the use of the substance Important social, work, fun activities are given up Continued use despite knowledge of physical or psychological symptoms caused by use
Substance Dependence Specifiers Early Full Remission 1< >12 months no symptoms Early Partial Remission 1< >12 months 1-2 symptoms Sustained Partial Remission 1-2 symptoms for more than 12 months Sustained Full Remission No symptoms for more than 12 months
Abuse and Dependence Once criteria for dependence have been met, an abuse diagnosis cannot be made! Consider In a Controlled Environment Prison or residential treatment Do not confuse substance-related disorders with substanceinduced disorders
ASAM The American Society of Addiction Medicine Patient Placement Criteria First version in 1991 To establish a shared understanding between providers about clinically-appropriate level of care Also influenced by managed-care industry Justification of treatment and measuring outcomes ASAM PPC-2 published in 1996 ASAM PPC-2R published in 2001 (current)
ASAM Dimensions Dimension 1: Acute intoxication and/or withdrawal potential Dimension 2: Biomedical conditions and complications Dimension 3: Emotional, behavioral or cognitive conditions and complications Dimension 4: Readiness to change Dimension 5: Relapse, continued use, and continued problem potential Dimension 6: Recovery environment
ASAM Levels of Care Range from 0.5 (Early Intervention) to IV (Medically Managed Intensive Inpatient) LOC assessments used for referrals to higher or lower levels and to justify continuing care at current level The complexity of this system is a significant weakness and creates barriers to the effective, reliable use of ASAM-PPC-2R across settings
ASAM LOC Assessment A level of care must be assessed for each dimension Determine low, moderate, or high severity for each dimension Consider how the risk or severity level in a given dimension is impacted by other dimensions Take into account available resources and barriers to certain levels of care. Goal is to recommend the least-restrictive LOC that will still meet the needs of the individual Important for individual rights and funding-efficiency
Stages of Change The Transtheoretical Model (TTM) was developed by Prochaska & DiClemente in 1983 Stages of Change (SOC) Processes of Change Core Constructs One of the most widely-used and intuitively-appealing models for understanding and facilitating intentional behavioral change As one progresses through the stages, the process generally moves from cognitive to behavioral Fits nicely with Motivational Interviewing
Stages of Change (SOC) Pre-contemplation Contemplation Preparation Action Maintenance Relapse Termination
TTM Stages of Change Not distinct stages but fluid and overlapping Not linear: people often move back and forth and recycle through the process Understanding where the individual is in the process can guide interventions