The newly released fourth edition criteria from the American Society of Addiction Medicine (ASAM) has a renewed focus on holistic and patient-centered care for treating substance use disorders (SUD).
Some of the main topics included a focus on chronic care treatment, integrated care, treating co-occurring conditions, recovery support services and harm reduction models.
ASAM is a physician-led professional group for clinicians involved in the care of individuals with SUD. The criteria are a set of guidelines “for placement, continued stay, transfer or discharge of patients with addiction and co-occurring conditions.”
One of the most significant changes to the new edition is a new dimension focusing on patient-centered considerations. This replaced the “readiness to change” dimension, which industry insiders said is now woven through every other dimension.
The renewed focus on patient-centered care takes into account barriers to treatment access. It encourages providers to consider each patient’s social determinants of health and personal preferences when developing treatment plans.
“It’s really kind of a version of shared decision making,” Don Bartosik, master trainer consultant at the Hazelden Betty Ford Foundation, told Behavioral Health Business. “It’s not just as a clinician sitting down with a person and saying that they need X level of care based on other levels of severity. Well, that might be what is clinically indicated. But then you actually sit down with a patient and you say, ‘This is what you need. Does this fit with what you can actually do?’”
The Hazelden Betty Ford Foundation is an addiction treatment provider based in Center City, Minnesota. The nonprofit has eight locations and provides substance use disorder treatment through telehealth. ASAM worked with the foundation’s publishing arm, Hazelden Publishing, to produce the edition.
Bartosik gave the example of a working single mother who may clinically need residential treatment. If she has no one to take care of her children and would be missing work, she won’t be able to access that treatment.
“You might need to decide with that person what is more reasonable,” Bartosik said. “We still want you to get help; we still want to put you on the path to recovery. We want to wrap you with as many supports as possible, but maybe this residential option isn’t good for you right now.”
This new dimension could also focus on helping patients thrive in their community and care after an inpatient stay.
“It’s prompting [providers] to work with the patient more and use more evidenced-based assessments to determine where the patient needs to be and where the patient also wants to be, as opposed to just an authoritative set of rules for a level of care that the patient needs to be at,” Leah Kendall, chief compliance officer at Atlantic Health Strategies, told BHB.
Atlantic Health Strategies is a consulting and training organization focused on the behavioral health sector.
Part of the move towards individualized care is an emphasis on harm reduction and meeting the patients where they are, according to Bartosik. The new standards also include ways that medication-assisted treatment can be incorporated into care.
“There is an emphasis on harm reduction, and harm reduction being part of individualized care,” Bartosik. “One thing that has been more prominent is the support for broad access to addiction medication. So trying to remove a lot of those barriers to being able to get medication for folks who could really benefit when they have an addiction.”
A focus on recovery
Long-term recovery is a crucial part of the new edition. For example, ASAM added a new level of care for remission monitoring. Traditionally, the first level of care started at outpatient therapy, but that was moved up to level 1.5.
“Those are your patients that are not necessarily in active treatment, but maybe they’re having that long, ongoing case management for chronic care that’s going well,” Sariah Hopkins, CEO of Atlantic Health Strategies, told BHB. “Now we have a level that addresses that.”
This is one move the new guidelines make to acknowledge that SUD is a longer-term condition that patients and providers must manage over a long period.
“[ASAM] wanted to promote this chronic care model,” Bartosik said, “which really is a pretty widely accepted position that addiction is a chronic illness and folks need to be able to kind of move along that continuum of care.”
Part of the continuum of chronic care is taking into account a patient’s physical, mental and addiction conditions.
For example, in the new edition, ASAM spelled out ways that care could be more integrated in its biomedical conditions and complications dimension, according to insiders.
“That focuses on really digging deep into what other physical issues this person might be experiencing,” Bartosik said, “either that are contributing to a substance use issue or as a result of a substance use issue.”
This is a recognition that patients with SUD often have co-occurring disorders, according to Hopkins.
“ASAM has cleared up the mud and made it very visible what the requirements are for a provider to provide the level of services necessary to meet both the addictive disorders and the co-occurring medical disorders, with the recognition that they go hand in hand,” Hopkins said.
Did ASAM get rid of PHPs?
When ASAM first released the new guidelines in October, some confusion was expressed over social media about the absence of partial hospitalization programs (PHPs) as a level of care listed.
But Hopkins notes that it wasn’t so much that the guidelines eliminated PHPs, as renaming the service to high-intensity outpatient programs or HIOPs. The reasoning was to clarify the term since many PHP providers are not in a hospital.
Historically, the wording has created some friction between payers and providers. But this could help clear up the mud on what and where the care is given.
“All we have is ASAM changing the name of what we’re calling it, but they’ve done that very conscientiously because when we’re doing a PHP level of care, it is a confusing term,” Hopkins said. “The providers that are doing that aren’t part of a hospital generally, some joint ventures with hospitals, but most of the time it’s a freestanding facility or an outpatient-only program.”
