1.2: ASAM Dimensions and Levels of Care

ASAM CRITERIA^[1]

The ASAM Criteria: Treatment Criteria for Addictive Substance-Related and Co-Occurring Conditions^[2] (called the ASAM Criteria) contain the most recent set of industry guidelines released on the treatment of SUDs. This resource provides a brief overview of the key provider competencies described in the ASAM Criteria. The Medicaid IAP appreciates the informal review, edits, and contributions provided by ASAM to the clinical summaries included below.

The content included in this document is an abbreviation of the full principles, concepts, and process described within the ASAM Criteria. Furthermore, the summary information in this document is based on the latest science available at the time of its release.

The ASAM Criteria describe five broad levels of care (Levels 0.5–4) with specific service and recommended provider requirements to meet those needs. These levels of care (Levels 0.5–4) span a continuum of care that represent various levels of care. A full list of the levels of care is provided in Figure 1, with more in-depth descriptions following this section.^[3]

Definition of Treatment Terms

Throughout the ASAM Criteria, the following treatment terms are used to describe services within a specified level of care:

• Clinically managed services are directed by nonphysician addiction specialists rather than medical personnel. They are appropriate for individuals whose primary problems involve emotional, behavioral, cognitive, readiness to change, relapse, or recovery environment concerns. Intoxication, withdrawal, and biomedical concerns, if present, are safely manageable in a clinically managed service. This type of care is described under Level 3.1, 3.3, and 3.5 residential programs.

• Medically monitored services are provided by an interdisciplinary staff of nurses, counselors, social workers, addiction specialists, or other health and technical personnel under the direction of a licensed physician. Medical monitoring is provided through an appropriate mix of direct patient contact, review of records, team meetings, 24-hour coverage by a physician, 24-hour nursing, and a quality assurance program. This type of care is described under Level 3.7 inpatient programs.

• Medically managed services involve daily medical care and 24-hour nursing. An appropriately trained and licensed physician provides diagnostic and treatment services directly, manages the provision of those services, or both. This type of care is described under Level 4 medically managed intensive inpatient programs.

levels of care

Level 0.5: Early Intervention

Professional services targeting individuals who are at risk of developing a substance-related problem but may not have a diagnosed SUD are provided in Level 0.5. These early intervention services—including individual or group counseling, motivational interventions, and Screening, Brief Intervention, and Referral to Treatment (SBIRT)—seek to identify substance-related risk factors to help individuals recognize the potentially harmful consequences of high-risk behaviors. These services may be coverable under Medicaid as stand-alone direct services or may also be coverable as component services of a program, such as driving under the influence or driving while intoxicated programs and Employee Assistance Programs (EAPs). Length of service may vary from 15 to 60 minutes of SBIRT, provided once or over five brief motivational sessions, to several weeks of services provided in programs. Medicaid coverage of services and component services, whether provided directly or through programs, must comport with all applicable rules, such as state plan benefit requirements.

• Setting: Early intervention services are often provided in nonspecialty settings, including primary care medical clinics, hospital emergency departments, community centers, worksites, or an individual’s home. SBIRT may be conducted in a primary care physician’s office, mental health practice, trauma center, emergency department, school setting, or other non-addiction treatment environments.
• Provider Type: Appropriately credentialed and/or licensed treatment professionals, including addiction counselors, social workers, or health educators may offer early intervention services. SBIRT activities are often provided by generalist health care professionals or addiction counselors who are knowledgeable about substance use and addictive disorders, motivational counseling, and the legal and personal consequences of high-risk behavior.
• Treatment Goal: Individual, group, or family counseling and SBIRT services should educate individuals about the risks of substance use and help them avoid such behavior. SBIRT services aim to intervene early, linking individuals with SUDs to appropriate formal treatment programs.

Level 1: Outpatient Services

Level 1 is appropriate in many situations as an initial level of care for patients with less severe disorders; for those who are in early stages of change, as a “step down” from more intensive services; or for those who are stable and for whom ongoing monitoring or disease management is appropriate. Adult services for Level 1 programs are provided less than 9 hours weekly, and adolescents’ services are provided less than 6 hours weekly; individuals recommended for more intensive levels of care may receive more intensive services.

• Setting: Outpatient services are often delivered in a wide variety of settings such as offices, clinics, school-based clinics, primary care clinics, and other facilities offering additional treatment or mental health programs.
• Provider Type: Appropriately credentialed and/or licensed treatment professionals, including counselors, social workers, psychologists, and physicians (whether addiction-credentialed or generalist) deliver outpatient services, including medication and disease management services.
• Treatment Goal: Outpatient services are designed to help patients achieve changes in alcohol and/or drug use and addictive behaviors, and often address issues that have the potential to undermine the patient’s ability to cope with life tasks without the addictive use of alcohol, other drugs, or both.
• Therapies: Level 1 outpatient services may offer several therapies and service components, including individual and group counseling, motivational enhancement, family therapy, educational groups, occupational and recreational therapy, psychotherapy, MAT, or other skilled treatment services.

Level 2: Intensive Outpatient and Partial Hospitalization Programs

Level 2 programs provide essential addiction education and treatment components and have two gradations of intensity.

Level 2.1: Intensive Outpatient Programs

Level 2.1 intensive outpatient programs provide 9–19 hours of weekly structured programming for adults or 6–19 hours of weekly structured programming for adolescents. Programs may occur during the day or evening, on the weekend, or after school for adolescents.

• Setting: Intensive outpatient programs are primarily delivered by substance use disorder outpatient specialty providers, but may be delivered in any appropriate setting that meets state licensure or certification requirements. These programs have direct affiliation with programs offering more and less intensive levels of care as well as supportive housing services.
• Provider Type: Interdisciplinary team of appropriately credentialed addiction treatment professionals including counselors, psychologists, social workers, addiction-credentialed physicians, and program staff, many of whom have cross-training to aid in interpreting mental disorders and deliver intensive outpatient services.
• Treatment Goal: At a minimum, this level of care provides a support system including medical, psychological, psychiatric, laboratory, and toxicology services within 24 hours by telephone or within 72 hours in person. Emergency services are available at all times, and the program should have direct affiliation with more or less intensive care levels and supportive housing.
• Therapies: Level 2.1 intensive outpatient services include individual and group counseling, educational groups, occupational and recreational therapy, psychotherapy, MAT, motivational interviewing, enhancement and engagement strategies, family therapy, or other skilled treatment services.

Level 2.5: Partial Hospitalization Programs

Level 2.5 partial hospital programs differ from Level 2.1 intensive outpatient programs in the intensity of clinical services that are directly provided by the program, including psychiatric, medical and laboratory services. Partial hospitalization programs are appropriate for patients who are living with unstable medical and psychiatric conditions. Partial hospitalization programs are able to provide 20 hours or more of clinically intensive programming each week to support patients who need daily monitoring and management in a structured outpatient setting.

• Setting: Structured outpatient setting that offers direct access to psychiatric, medical, and laboratory services. Such programs may be freestanding or located within a larger healthcare system so long as the partial hospitalization unit is distinctly organized from the rest of the available programs. These programs have direct affiliation with programs offering more and less intensive levels of care as well as supportive housing services.
• Provider Type: Similar to Level 2.1, partial hospitalization services are delivered by an interdisciplinary team of providers, with some cross-training to identify mental disorders and potential issues related to prescribed psychotropic drug treatment in populations with SUD. Additionally, these programs must support access to more and less intensive programs as well as supportive housing services. One major distinction from Level 2.1 is the requirement for qualified practitioners in partial hospitalization programs to provide medical, psychological, psychiatric, laboratory, toxicology and emergency services.
• Treatment Goal: At a minimum, this level of care meets the same treatment goals as described for Level 2.1, with psychiatric and other medical consultation services available within 8 hours by telephone or within 48 hours in person.
• Therapies: Level 2.5 intensive outpatient services include individual and group counseling, educational groups, occupational and recreational therapy, psychotherapy, MAT, motivational interviewing, motivational enhancement and engagement strategies, family therapy, or other skilled treatment services.

Level 3: Residential or Inpatient Programs

Level 3 programs include four sublevels that represent a range of intensities of service. The uniting feature is that these services all are provided in a structured, residential setting that is staffed 24 hours daily and are clinically managed (see definition of terms above). Residential levels of care provide a safe, stable environment that is critical to individuals as they begin their recovery process.

Level 3.1: Clinically Managed Low-Intensity Residential Programs

Level 3.1 programs are appropriate for patients whose recovery is aided by a time spent living in a stable, structured environment where they can practice coping skills and self-efficacy, and make connections to the community including work, education, and family systems.

• Setting: Services are provided in a 24-hour environment, such as a group home. Both clinic-based services and community-based recovery services are provided. Clinically, Level 3.1 requires at least 5 hours of low-intensity treatment services per week, including medication management, recovery skills, relapse prevention, and other similar services. In Level 3.1, the 5 or more hours of clinical services may be provided onsite or in collaboration with an outpatient services agency.
• Provider Type: Team of appropriately credentialed medical, addiction, and mental health professionals provide clinical services. Allied health professional staff, including counselors and group living workers and some clinical staff knowledgeable about biological and psychosocial dimensions of SUD and psychiatric conditions, support the recovery residence component of care.
• Treatment Goal: Patients receive individual, group, or family therapy, or some combination thereof; medication management; and psychoeducation to develop recovery, relapse prevention, and emotional coping techniques. Treatment should promote personal responsibility and reintegrate the patient to work, school, and family environments. At a minimum, this level of care provides telephone and in-person physician and emergency services 24 hours daily, offers direct affiliations with other levels of care, and is able to arrange necessary lab or pharmacotherapy procedures.
• Therapies: Level 3.1 clinically managed low-intensity residential services are designed to improve the patient’s ability to structure and organize the tasks of daily living, stabilize and maintain the stability of the individual’s substance use disorder symptoms, and to help them develop and apply recovery skills. The skilled treatment services include individual, group, and family therapy; medication management and medication education; mental health evaluation and treatment; motivational enhancement and engagement strategies; recovery support services; counseling and clinical monitoring; MAT; and intensive case management, medication management and/or psychotherapy for individuals with co-occurring mental illness.

Level 3.3: Clinically Managed Population-Specific High-Intensity Residential Programs (specified for adults only)

This gradation of residential treatment is specifically designed for specific populations of adult patients with significant cognitive impairments resulting from substance use or other co-occurring disorders. This level of care is appropriate when an individual’s temporary or permanent cognitive limitations make it unlikely for them to benefit from other residential levels of care that offer group therapy and other cognitive-based relapse prevention strategies. These cognitive impairments may be seen in individuals who suffer from an organic brain syndrome as a result of substance use, who suffer from chronic brain syndrome, who have experienced a traumatic brain injury, who have developmental disabilities, or are older adults with age- and substance-related cognitive limitations. Individuals with temporary limitations receive slower paced, repetitive treatment until the impairment subsides and they are able to progress onto another level of care appropriate for their SUD treatment needs.

• Setting: Services are often provided in structured, therapeutic rehabilitation facilities and traumatic brain injury programs located within a community setting, or in specialty units located within licensed healthcare facilities where high-intensity clinical services are provided in a manner that meets the functional limitations of patients. Such programs have direct affiliation with more or less intensive levels of care as well as supportive services related to employment, literacy training, and adult education.
• Provider Type: Physicians, physician extenders, and appropriately credentialed mental health professionals lead treatment. On-site 24-hour allied health professional staff supervise the residential component with access to clinicians competent in SUD treatment. Clinical staff knowledgeable about biological and psychosocial dimensions of SUD and psychiatric conditions who have specialized training in behavior management support care. Patients have access to additional medical, laboratory, toxicology, psychiatric, and psychological services through consultations and referrals.
• Treatment Goal: Specialized services are provided at a slower pace and in a repetitive manner to overcome comprehension and coping challenges. This level of care is appropriate until the cognitive impairment subsides, enabling the patient to engage in motivational relapse prevention strategies delivered in other levels of care.
• Therapies: Level 3.3 clinically managed population-specific high-intensity residential services may be provided in a deliberately repetitive fashion to address the special needs of individuals for whom a Level 3.3 program is considered medically necessary. Daily clinical services designed to improve the patient’s ability to structure and organize the tasks of daily living and recovery, to stabilize and maintain the stability of the individual’s substance use disorder symptoms, and to help them develop and apply recovery skills are provided. The skilled treatment services include a range of cognitive, behavioral, and other therapies administered on an individual and group basis; medication management and medication education; counseling and clinical monitoring; educational groups; occupational and recreational therapies; art, music, or movement therapies; physical therapy; clinical and didactic motivational interventions; and related services directed exclusively toward the benefit of the Medicaid-eligible individual.

Level 3.5: Clinically Managed Residential Programs (high intensity for adults, medium intensity for adolescents)

This gradation of residential programming is appropriate for individuals in some imminent danger with functional limitations who cannot safely be treated outside of a 24-hour stable living environment that promotes recovery skill development and deters relapse. Patients receiving this level of care have severe social and psychological conditions. This level of care is appropriate for adolescents with patterns of maladaptive behavior, temperament extremes, and/or cognitive disability related to mental health disorders.

• Setting: Services are often provided in freestanding, licensed facilities located in a community setting or a specialty unit within a licensed health care facility. Such programs rely on the treatment community as a therapeutic agent.
• Provider Type: Interdisciplinary team is made up of appropriately credentialed clinical staff, including addictions counselors, social workers, and licensed professional counselors, and allied health professionals who provide residential oversight. Telephone or in-person consultation with a physician is a required support, but on-site physicians are not required.
• Treatment Goal: Comprehensive, multifaceted treatment is provided to individuals with psychological problems, chaotic or unsupportive interpersonal relationships, criminal justice histories, and antisocial value systems. The level of current instability is of such severity that the individual is in imminent danger if not in a 24-hour treatment setting. Treatment promotes abstinence from substance use, arrest, and other negative behaviors to effect change in the patient’s lifestyle, attitudes, and values, and focuses on stabilizing current severity and preparation to continue treatment in less intensive levels of care.
• Therapies: Level 3.5 clinically managed residential services are designed to improve the patient’s ability to structure and organize the tasks of daily living, stabilize and maintain the stability of the individual’s substance use disorder symptoms, to help them develop and apply sufficient recovery skills, and to develop and practice prosocial behaviors such that immediate or imminent return to substance use upon transfer to a less intensive level is avoided. The skilled treatment services include a range of cognitive, behavioral, and other therapies administered on an individual and group basis; medication management and medication education; counseling and clinical monitoring; random drug screening; planned clinical activities and professional services to develop and apply recovery skills; family therapy; educational groups; occupational and recreational therapies; art, music or movement therapies; physical therapy; and related services directed exclusively toward the benefit of the Medicaid-eligible individual.

Level 3.7: Medically Monitored Inpatient Programs (intensive for adults, high-intensity for adolescents)

This level of care is appropriate for patients with biomedical, emotional, behavioral, and/or cognitive conditions that require highly structured 24-hour services including direct evaluation, observation, and medically monitored addiction treatment. Medically monitored treatment is provided through a combination of direct patient contact, record review, team meetings, and quality assurance programming. These services are differentiated from Level 4.0 in that the population served does not have conditions severe enough to warrant medically managed inpatient services or acute care in a general hospital where daily treatment decisions are managed by a physician.

Level 3.7 is appropriate for adolescents with co-occurring psychiatric disorders or symptoms that hinder their ability to successfully engage in SUD treatment in other settings. Services in this program are meant to orient or re-orient patients to daily life structures outside of substance use.

• Setting: Services are provided in freestanding, appropriately licensed facilities located in a community setting or a specialty unit in a general or psychiatric hospital or other licensed health care facility.
• Provider Type: Interdisciplinary team is made up of physicians credentialed in addiction who are available on-site 24 hours daily, registered nurses and additional appropriately credentialed nurses, addiction counselors, behavioral health specialists, and clinical staff who are knowledgeable about biological and psychosocial dimensions of SUD and psychiatric conditions and who have specialized training in behavior management techniques and evidence-based practices.
• Treatment Goal: Patients with greater severity of withdrawal, biomedical conditions, and emotional, behavioral, or cognitive complications receive stabilizing care including directed evaluation, observation, medical monitoring, 24-hour nursing care, and addiction treatment.
• Therapies: Daily clinical services, which may involve medical and 24-hour nursing services; individual, group, family and activity services; pharmacological, cognitive, behavioral, or other therapies; counseling and clinical monitoring; random drug screening; health education services; evidence-based practices, such as motivational enhancement strategies; medication monitoring; daily treatment services to manage acute symptoms of the medical or behavioral condition; and related services directed exclusively toward the benefit of the Medicaid-eligible individual.

Level 4: Medically Managed Intensive Inpatient Programs

This level of care is appropriate for patients with biomedical, emotional, behavioral, and/or cognitive conditions severe enough to warrant primary medical care and nursing care. Services offered at this level differ from Level 3.7 services in that patients receive daily direct care from a licensed physician who is responsible for making shared treatment decisions with the patient (i.e. medically managed care). These services are provided in a hospital-based setting and include medically directed evaluation and treatment.

• Setting: Services may be provided in an acute care general hospital, an acute psychiatric hospital, or a psychiatric unit within an acute care general hospital, or through a licensed addiction treatment specialty hospital.
• Provider Type: Interdisciplinary team is made up of appropriately credentialed clinical staff, including addiction-credentialed physicians who are available 24 hours daily, nurse practitioners, physicians’ assistants, nurses, counselors, psychologists, and social workers. Some staff are cross-trained to identify and treat signs of comorbid mental disorders.
• Treatment Goal: Addiction services, including medically directed acute withdrawal management, are provided in conjunction with intensive medical and psychiatric services to alleviate patients’ acute emotional, behavioral, and cognitive distresses associated with the SUD when those problems are so severe that they require primary medical and 24-hour nursing care. Because the length of stay in a Level 4 program typically is sufficient only to stabilize the individual’s acute signs and symptoms, a primary focus of the treatment plan is case management and coordination of care to ensure a smooth transition to continuing treatment at another level of care.
• Therapies: Cognitive, behavioral, motivational, pharmacologic, and other therapies provided on an individual or group basis; physical health interventions; health education services; planned clinical interventions; and services for the patient’s family, guardian, or significant others.

WITHDRAWAL MANAGEMENT LEVELS OF CARE

The ASAM Criteria includes five levels of withdrawal management services, which are described as if they were provided separately from the aforementioned level-of-care services available to manage SUDs. However, these services are routinely provided concurrently with other addiction services, by the same clinical staff, and in the same treatment setting. A brief description of withdrawal management services is provided below.

Level 1-WM: Ambulatory Withdrawal Management Without Extended On-Site Monitoring

• Organized outpatient services delivered in a physician’s office, addiction treatment facility, or patient’s home
• Services provided in regularly scheduled sessions
• Services include individual assessment, medication/nonmedication withdrawal management, education, clinical support, and discharge planning

Level 2-WM: Ambulatory Withdrawal Management With Extended On-Site Monitoring

• Organized outpatient services delivered in a physician’s office, general/mental health care facility, or addiction treatment facility
• Services are provided in regularly scheduled sessions on a daily basis with extended on-site services
• Services are identical to those provided in Level 1

Level 3.2-WM: Clinically Managed Residential Withdrawal Management

• Organized services are delivered in a social setting with an emphasis on peer support
• Services provide 24-hour structure and support
• Services include daily therapies to assess progress, medical services, individual and group therapy, withdrawal support, and health education services

Level 3.7-WM: Medically Monitored Inpatient Withdrawal Management

• Services are delivered in a freestanding withdrawal management center with inpatient beds
• Services are provided daily with observation, monitoring, and treatment
• Services include specialized clinical consultation; supervision for cognitive, biomedical, emotional, and behavioral problems; medical nursing care; and direct affiliation with other levels of care

Level 4-WM: Medically Managed Intensive Inpatient Withdrawal Management

• Services are provided in an acute care or psychiatric hospital inpatient unit
• Services are provided 24 hours daily with observation, monitoring, and treatment
• Services include specialized medical consultation, full medical acute services, and intensive care

Key Takeaways

Withdrawal Management

• Withdrawal management can occur at all levels of care
• Withdrawal management is not confined to hospital-based programs and should be based on individual client needs

Query \(\PageIndex{1}\)

Patient Placement Criteria^[4]

For many years, addiction treatment providers predominantly assumed that people with drinking problems were a homogeneous group that could be treated optimally with only one treatment modality. This modality involved inpatient care with a fixed length of stay and a treatment approach based on the 12­-step model of Alcoholics Anonymous. In recent years, however, both assumptions—that of patient homogeneity and treatment uniformity—have been abandoned. Researchers and clinicians now recognize that those with substance use disorder (SUD) are a diverse group and differ substantially in the causes and manifestations of their problems. Furthermore, most researchers now believe that no single form of treatment is effective for all people presenting with alcohol or drug-­related problems (Hester and Miller, 1989). Consequently, researchers now are conducting many studies designed to determine what types of interventions are most effective for what types of patients. This approach is founded on the “matching hypothesis,” which states that an optimal matching of patients and treatments will produce the greatest overall treatment effectiveness.

The need to formally acknowledge the unique treatment needs among people with addiction-related problems recently has received additional support from the proliferation of managed care systems that seek to control healthcare costs. With the widespread use of managed care in treating alcohol and other drug (AOD) abuse in both the private and public sectors, the demand for specific types or levels of treatment (ex: outpatient or residential) now depends on more than just the patient’s wishes or the physician’s perceptions of what the patient needs. Patients now must meet utilization review criteria set by the managed care providers in order to be eligible for treatment reimbursement. In addition to controlling costs, the development of such criteria will enable healthcare delivery systems to account for meaningful and valid differences among problem drinkers and to determine more accurately the mix of treatment services the patients need. Ultimately, the improved match between patient needs and the types of services avail­able within the system will enhance the efficiency and effectiveness of the alcoholism treatment system. This matching process likely will focus on selecting specific treatment modalities rather than on the settings in which these modalities are provided.

ASAM Criteria

The ASAM criteria were developed from numerous and widely dissemi­nated drafts and revisions and were evaluated in field tests at 15 different sites (Mee­Lee, 1993). The primary goal of the criteria was to provide a common language for both providers and payers when determining the severity of a patient’s problems, the different levels or settings of the treatment modalities offered, and the criteria for patient placement within the continuum of AOD treatment. These criteria not only described patient characteristics that might warrant inpatient care but also provided guidelines for different types of outpatient treatment and outlined the process of moving across different levels of care.

The ASAM system is built around criteria dimensions that are used to place patients in one of four levels of care originally presented in an Institute of Medicine report (1990) describing transitions in the alcoholism treatment field. The levels of care are as follows:

• Level 0.5: Early Intervention
• Level I: Outpatient Treatment
• Level II: Intensive Outpatient and Partial Hospitalization Treatment
• Level III: Residential and Medically Monitored Inpatient Treatment
• Level IV: Medically Managed In­patient Treatment

Assessment Dimensions

Under ASAM guidelines, patients are assigned to one of the four levels of care after being evaluated along six criteria dimensions reflecting the severity of the patient’s problems. Each dimension contains several criteria, and the number of specific criteria that must be met depends on the level of care. These six dimensions are described in the following paragraphs.

Dimension 1: Acute Intoxication and/or Withdrawal Potential.

The ASAM criteria assume that a person who is acutely intoxicated cannot be monitored adequately as an outpatient and should receive more intensive care. When assessing withdrawal potential, one of the most important considerations is whether the patient is at risk of experiencing life­threatening withdrawal symptoms or requires medication or other support services to cope with or reduce the discomfort of withdrawal, which otherwise might cause him or her to terminate treatment.

Dimension 2: Biomedical Conditions or Complications.

Higher levels of care are indicated when continued AOD use would put the patient in danger of health complications. For example, an alcohol­ dependent woman who is pregnant might benefit from a higher level of care. Similarly, problem drinkers with cardiovascular, liver, or gastrointestinal diseases requiring medical monitoring or treatment should receive a higher level of care.

Dimension 3: Cognitive, Emotional, and Behavioral Conditions and Complications.

A wide range of emotional and behavioral conditions and com­plications exist in problem drinkers, either as manifestations of alcohol abuse or as independent, coexisting psychiatric disorders. These conditions (e.g., debilitating anxiety, guilt, or depression) deserve special attention during treatment and therefore may necessitate a higher level of clinical care. Moreover, problem drinkers exhibiting signs of an imminent risk of harming themselves (e.g., attempting suicide) or others may re­quire 24-­hour monitoring, thus justifying a higher level of clinical care. The same holds true for problem drinkers whose mental status does not allow them to understand the nature of the disorder or the treatment process.

Dimension 4: Readiness to Change.

Patients in addiction treatment vary greatly in their willingness to comply with treatment regimens. Patients who seek treatment and cooperate by following clinical instructions typically require a lower level of care. However, alcohol dependence often compromises a person’s capacity to cooperate with treatment protocols. Patients often present for treatment with some level of understanding that AOD are responsible for their problems but are still unwilling to participate in the clinical process. Other patients may deny that they have a alcohol or drug problem. Thus, some may be unlikely to enter the treatment system without first receiving some form of therapeutic preparation directed at addressing their denial and their resistance to treatment. Under these conditions, a high level of clinical care may be appropriate.

Dimension 5: Relapse/Continued Use Potential.

Because drug-­related problems involve recurrent patterns of behavior, relapse is a frequent and integral part of the natural history of the disorder. Two major sets of factors that derive from the patient’s personal (i.e., psychological and biological) background and social environment contribute to relapse potential. This dimension addresses the personal factors that influence the extent to which people can control their environments (environmental factors are addressed in dimension 6). Accordingly, when these elements impede a patient’s control over his or her behavior in the current environment, a higher level of care (e.g., a halfway house rather than out­ patient care) may be justified to minimize the relapse risk. For example, if a patient experiences marked and persistent cravings for alcohol and thus has higher relapse potential, treatment success may be less likely in an outpatient than in an inpatient setting.

Dimension 6: Recovery Environment.

The patient’s environment can facilitate recovery or increase the risk of relapse. When the social setting is supportive (e.g., family members and friends agree with and encourage recovery) or the patient seeks out social surroundings that discourage alcohol­ abusing behavior patterns, a lower level of clinical care may be justified. How­ever, when a recovering person’s social setting is compromised—for example, by inadequate transportation to the treatment provider, a higher level of family stress, or friends and coworkers who regularly use alcohol—a higher level of care may be required.

Key Takeaways

• Patients are assigned to one four levels of care after being evaluated along six criteria dimensions.
• Greater severity of problems corresponds to higher levels of care.

Query \(\PageIndex{2}\)

linking assessment and placement

Once the counselor has completed a thorough biopsychosocial assessment following the ASAM dimensions, the next step is to recommend placement in a level of care. One of the most important guidelines provided by ASAM is that counselors should recommend the least restrictive effective level of care. In general, this means that for a person without medical necessity for level III or IV treatment, and who has not had previous treatment, we would recommend a lower level of care such as outpatient or intensive outpatient. As always, the counselor must consider the full picture that includes biological, psychological, and social issues.

The table below summarizes the correlations between the treatment settings and criteria dimensions specified by the ASAM guidelines. The actual criteria for placing an individual into a given level of care vary according to the care level, and placement ultimately depends on the combination of patient characteristics in the six assessment dimensions.

For example, treatment in an outpatient setting (i.e., level I) requires that the patient meets level I criteria in all six assessment dimensions, whereas treatment in an inpatient setting (i.e., level III or IV) requires that the patient meets the corresponding severity criteria in at least two of the six dimensions. Furthermore, not all dimensions are relevant to all placement decisions. For example, treatment resistance, relapse potential, and recovery environment are not used to distinguish between patients requiring level III and level IV care.

Figure 1: Summary of ASAM Criteria Dimensions of Assessment

Criteria Dimension	Level I: Outpatient Treatment	Level II: Intensive Outpatient or Partial Hospitalization Treatment	Level III: Medically Monitored Inpatient (Residential) Treatment	Level IV: Medically Managed Inpatient Treatment
Acute Intoxication/ Withdrawal Potential	Minimal to no risk of severe withdrawal; will enter detoxification if needed.	Minimal risk of severe withdrawal; will enter detoxification if needed and responds to social support when com- bined with treatment.	Risk of severe but manageable withdrawal, or has failed detoxification at lower levels of care.	Risk of severe withdrawal; detoxification requires frequent monitoring.
Biomedical Conditions	None or noninterfering with treatment.	May interfere with treatment but patient does not require inpatient care.	Continued use means imminent danger, or complications or other illness requires medical monitoring.	Complications (e.g., recurrent seizures or disulfiram reactions) that require medical management.
Cognitive/Emotional/ Behavioral Conditions	Some anxiety, guilt, or depression related to abuse, but no risk of harm to self or others. Mental status permits treatment comprehension and participation.	Inability to maintain behavioral stability, abuse/neglect of family, or mild risk of harm to self or others.	Symptoms require structured environment, moderate risk of harm to self or others, or history of violence during intoxication.	Uncontrolled behavior, confusion/disorientation, extreme depression, thought disorder, or alcohol hallucinosis/psychosis.
Readiness to Change	Willing to cooperate and attend treatment; admits problem.	Attributes problems externally; not severely resistant.	Does not accept severity of problems despite serious consequences.	Any difficulties noted in levels I, II, or III.
Relapse Potential	Able to achieve goals with support and therapeutic contact.	Deteriorating during level I treatment, or will drink without close monitoring and support.	Deteriorating and in crisis during outpatient care, or at- tempts to control drinking without success.	Any difficulties noted in levels I, II, or III.
Recovery Environment	Supportive social environment or motivated to obtain social support.	Current job environment disruptive, family/support system nonsupportive, or lack of social contacts.	Environment disruptive to treatment, logistic impediments to outpatient care, or occupation places public at risk if patient continues to drink.	Any difficulties noted in levels I, II, or III.
ASAM = American Society of Addiction Medicine

The video below summarizes key elements of the ASAM criteria for counselors.

One or more interactive elements has been excluded from this version of the text. You can view them online here: cod.pressbooks.pub/addictionscounseling/?p=5#oembed-1

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1. The ASAM information comes from a set of guidelines published by the Medicaid Innovation Accelerator Program.
2. Mee-Lee D, ed. The ASAM Criteria: Treatment Criteria for Addictive Substance-Related, and Co-Occurring Conditions. Chevy Chase, MD: American Society of Addiction Medicine; 2013. www.asam.org/quality- practice/guidelines-and-consensus-documents/the-asam-criteria/text. Accessed March 18, 2016.
3. The ASAM Criteria discuss their application to adolescents in some detail, although they are not specified completely for adolescents as a separate population. The book includes a matrix for matching adolescent severity and level of function with type and intensity of service.
4. Morey, L. (1996). ASAM Patient Placement Criteria: Linking typologies to managed care. Alcohol Health and Research World, 36-44.