MODULE 15
BIOPSYCHOSOCIAL AND THE BIOPSYCHOSOCIAL DIMENSIONS OF SUBSTANCE ABUSE
Title 450 Chapter 18
Standards and Criteria for Alcohol and Drug Treatment Programs
450:18-1-2. Definitions "Biopsychosocial assessment" means face-to-face interviews conducted by a qualified service
provider designed to elicit historical and current information regarding the behaviors, experiences, and support systems of a
consumer, and identify the consumer’s strengths, needs, abilities, and preferences for the purpose of guiding the consumer’s
recovery plan.
450:18-7-23. Biopsychosocial assessment
(a) All programs shall complete a Biopsychosocial assessment which gathers sufficient information to assist the consumer in
developing an individualized service plan. The program shall develop a Biopsychosocial evaluation which contains, but is not
limited to, the following:
(1) Identification of the consumer’s strengths, needs, abilities, and preferences;
(2) History of the presenting problem;
(3) Previous treatment history to include substance abuse and mental health;
(4) Health history and current biomedical conditions and complications;
(5) Alcohol and drug use history;
(6) History of trauma;
(7) Family and social history, including family history of alcohol and drug use;
(8) Educational attainment, difficulties, and history;
(9) Cultural and religious orientation;
(10) Vocational, occupational and military history;
(11) Sexual history, including HIV, AIDS and STD at-risk behaviors;
(12) Marital or significant other relationship history;
(13) Recreational and leisure history;
(14) Legal history;
(15) Present living arrangement;
(16) Economic resources;
(17) Level of functioning;
(18) Current support system including peer and other recovery supports;
(19) Current medications, if applicable, and shall include obtainable information regarding the name of prescribing physician,
name of medication, strength and dosage, and length of time consumer was on the medication;
(20) Consumer’s expectations in terms of service; and
(21) Assessment summary or diagnosis, and signature of the assessor and date of the assessment.
450:18-7-24. Biopsychosocial assessment, time frame
(a) The assessment shall be completed during the admission process and within specific timelines established by the facility but
no later than the following time frames:
(1) Residential services, seven (7) days [168 hours];
(2) Halfway house services, seven (7) days [168 hours];
(3) Intensive outpatient services, by the fourth visit;
(4) Outpatient services, by the end of the fourth visit.
(b) In the event of a consumer re-admission after one (1) year of the last Biopsychosocial assessment, a new Biopsychosocial
assessment shall be completed. If readmission occurs within one (1) year after the last Biopsychosocial assessment, an update
shall be completed.
The Biopsychosocial Assessment is an important document that sets up the rationale for all the work to follow in
the clinical setting. All areas of this document need to be addressed in full. There are to be no blanks left on this
document, as blank space suggests the writer did not address the information in that section. Full completion of
the assessment is also an expectation from reviewers. One will need to enter "none reported" in any area where
no check box is available – this indicates that there is no issue or need to be addressed.
CITATION” www. mc708.org/Committees/.../Completing_the_Biopsychosocial_Assessment.doc
A biopsychosocial assessment is a collaborative process that aims to identify the important factors that are
relevant to creating a plan of psychopharmacological and psychotherapeutic treatment. Since every person is
unique, every assessment is unique. As the assessment process unfolds it may become clear that more attention
needs to be paid to one area (for instance, medical illnesses, or cognitive functioning) and this may lead to
consultation with other experts. Nevertheless, there are some key elements of a biopsychosocial assessment that
are appropriate for almost everyone, these include –
A history of mood symptoms - factors that lead to worsened symptoms, and those that alleviate symptoms; a
history of treatment and response to treatment; the relationship of mood symptoms to other symptoms (such as
anxiety, physical symptoms, etc.).
o A general medical history
o A developmental, social and cultural history – particularly paying attention to patterns and
recurring experiences in relationships.
o A history of school and work
o A review of psychiatric and medical symptoms
o An assessment of cognitive functioning
o Identification of strengths and problems
For many people it will also be useful to do a detailed history of mood episodes over time, what is called a
retrospective mood chart. This not only clearly identifies the person’s unique pattern of mood variation, but it is
also a very effective way of summarizing past treatment and response. Often a very detailed retrospective mood
chart makes it clear what combination of treatment is most likely to be useful.
Assessment of the most appropriate treatment options will include an assessment for specialized treatment and
treatment setting. If treatment is needed that is not provided by the assessor, then appropriate referrals will be
provided.
When there is a need for more information we will use other sources including –
o
Past psychiatric, psychotherapy or medical records
o
Pharmacy records
o
Information from diaries, other records
o
Collateral history
When specialized assessments are indicated we will arrange for –
o
Substance abuse assessment
o
Psychological assessment
o
Nutritional assessment
CITATION: http://www.bipolaradvantage.com/AdvantageProgram/Assessment/Biopsychosocial.php
BIOPSYCHOSOCIAL MODEL OF ADDICTION
BIOPSYCHOSOCIAL-BPS
The biopsychosocial model of addiction is the result of additional work and an enhanced understanding of the
reasons for addiction and addictive behavior.
This model was developed to include models related to addiction that were developed and researched over the
past fifty years. It is a distillation of all other models. The biopsychosocial model of addiction does consider
addiction to be an illness, but also includes perspectives of psychological, cognitive, social, developmental,
environmental and cultural nature related to substance addiction. Hence, this model recognizes the fact that
substance addiction is more than a mere disease and that the use of drugs is induced as a result of factors
existing in the society, the peer group, a cultural tendency for substance abuse and has genetic links. In this
model of addiction, the degradation of the body as a result of substance abuse causes disease which has to be
treated along with the addiction.
TREATMENTS-MEDICATION
Medication and behavioral therapy, especially when combined, are important elements of an overall therapeutic process that
often begins with detoxification, followed by treatment and relapse prevention. Easing withdrawal symptoms can be
important in the initiation of treatment; preventing relapse is necessary for maintaining its effects. And sometimes, as with
other chronic conditions, episodes of relapse may require a return to prior treatment components. A continuum of care that
includes a customized treatment regimen—addressing all aspects of an individual's life, including medical and mental health
services—and follow–up options (e.g., community – or family-based recovery support systems) can be crucial to a person's
success in achieving and maintaining a drug–free lifestyle.
Treatment. Medications can be used to help reestablish normal brain function and to prevent relapse and diminish
cravings. Currently, we have medications for opioids (heroin, morphine), tobacco (nicotine), and alcohol addiction
and are developing others for treating stimulant (cocaine, methamphetamine) and cannabis (marijuana) addiction.
Most people with severe addiction problems, however, are polydrug users (users of more than one drug) and will
require treatment for all of the substances that they abuse.
Opioids: Methadone, buprenorphine and, for some individuals, naltrexone are effective medications for the treatment of
opiate addiction. Acting on the same targets in the brain as heroin and morphine, methadone and buprenorphine suppress
withdrawal symptoms and relieve cravings. Naltrexone works by blocking the effects of heroin or other opioids at their
receptor sites and should only be used in patients who have already been detoxified. Because of compliance issues,
naltrexone is not as widely used as the other medications. All medications help patients disengage from drug seeking and
related criminal behavior and become more receptive to behavioral treatments.
Tobacco: A variety of formulations of nicotine replacement therapies now exist—including the patch, spray, gum, and
lozenges—that are available over the counter. In addition, two prescription medications have been FDA–approved for
tobacco addiction: bupropion and varenicline. They have different mechanisms of action in the brain, but both help prevent
relapse in people trying to quit. Each of the above medications is recommended for use in combination with behavioral
treatments, including group and individual therapies, as well as telephone quit lines.
Alcohol: Three medications have been FDA–approved for treating alcohol dependence: naltrexone, acamprosate, and
disulfiram. A fourth, topiramate, is showing encouraging results in clinical trials. Naltrexone blocks opioid receptors that are
involved in the rewarding effects of drinking and in the craving for alcohol. It reduces relapse to heavy drinking and is highly
effective in some but not all patients—this is likely related to genetic differences. Acamprosate is thought to reduce
symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria (an unpleasant or
uncomfortable emotional state, such as depression, anxiety, or irritability). It may be more effective in patients with severe
dependence. Disulfiram interferes with the degradation of alcohol, resulting in the accumulation of acetaldehyde, which, in
turn, produces a very unpleasant reaction that includes flushing, nausea, and palpitations if the patient drinks alcohol.
Compliance can be a problem, but among patients who are highly motivated, disulfiram can be very effective.
The often painful symptoms of drug withdrawal may last for several days and can stand as a barrier to the treatment of a
drug abuse problem. Some practitioners use "rapid" or "ultra rapid" detoxification methods to condense the withdrawal
process into a considerably shorter period of time, about two hours, while the addict is asleep. Rapid detox patients placed
under anesthesia while given treatment drugs, such as naltrexone, can avoid the extreme pain associated with such
treatments, say proponents, and bypass the major effects of withdrawal. Critics argue that the treatments can be very
expensive and that safety has not been sufficiently demonstrated.
A 2005 clinical study on "ultra rapid detox" for heroin addicts, comparing buprenorphine-assisted or clonidine-assisted
opioid detoxification to anesthesia-assisted detoxification, reported that anesthesia patients commonly underwent withdrawal
when they awoke from, had a similar study dropout rate (approximately 80%), and some anesthesia patients experienced
severe medical complications. Another 2005 study compared clonidine-assisted detoxification to (rapid) clonidine-naloxone
precipitated withdrawal under anesthesia, reporting no significant differences in degree or duration of pain, withdrawal
severity, or drug craving, with similar withdrawal sequelae, oral naltrexone compliance levels, and abstinence from
heroin four weeks following detoxification.
What if science made a pill to protect us from addiction — keeping us from smoking cigarettes, getting fat or
abusing drugs and alcohol? They are working on that right now. It's is called TA-CD.
TREATMENT-BEHAVIORAL
Cognitive Behavioral Therapy. Seeks to help patients recognize, avoid, and cope with the situations in which they
are most likely to abuse drugs. H.A.L.T HIGH RISK SITUATIONS - People, Places and Things.
Cognitive behavior therapy is based on the idea that feelings and behaviors are caused by a person's thoughts,
not on outside stimuli like people, situations and events. People may not be able to change their circumstances,
but they can change how they think about them and therefore change how they feel and behave. The goal of
cognitive behavior therapy is to get the person to learn or relearn better coping skills.
Motivational Incentives. Uses positive reinforcement such as providing rewards or privileges for remaining drug
free, for attending and participating in counseling sessions, or for taking treatment medications as prescribed.
Motivational Interviewing. Employs strategies to evoke rapid and internally motivated behavior change to stop
drug use and facilitate treatment entry.
Group Therapy. Helps patients face their drug abuse realistically, come to terms with its harmful consequences,
and boost their motivation to stay drug free. Patients learn effective ways to solve their emotional and
interpersonal problems without resorting to drugs.
Recovery is about change!
NOTHING CHANGES IF NOTHING CHANGES
QUITTING: It’s easy, I have done it hundreds of times.
Mark Twain
INSANITY: repeating the same actions over and over but expecting different results.
Albert Einstein.
The benchmark for the theory of change is: “Substance Abuse Treatment and the Stages of Change” by Dr.
Gerard J. Connors-PhD, Dr. Dennis M. Donovan-PhD and Carlo C. Diclemente-PhD. They propose there are
five stages of change:
 Pre contemplation- the person denies there is a problem and is resistant to change.
 Contemplation- person begins to reevaluate self- maybe my behavior is causing all these negative
outcomes and begins to concede there might be a problem.
 Preparation-Acknowledges there is a problem and wants to do something about it and makes plans to do
so.
 Action- implements plan.
 Maintenance- working the action plan, learning from success and failures.
 Some people have a problem with the "higher power" idea to which Kahil Gibran-18th century
philosopher/poet responded:
I was too smart to believe in a power greater than me. What I started to realize was that if I was the greatest
power in my life, I was in deep, trouble....Kahlil Gibran
"There is no chemical solution for a spiritual problem."
RELAPSE
THE FIRST RULE OF RECOVERY
You don't recover from an addiction by stopping using. You recover by creating a new life where it is easier to not
use. If you don't create a new life, then all the factors that brought you to your addiction will eventually catch up
with you again.
RECOVERY SKILLS
Relaxation is not an optional part of recovery. It's essential to recovery. There are many ways to relax. They range
from simple techniques like going for a walk, to more structured techniques like meditation. Meditation is an
important part of that mix because the simple techniques don't always work. If you're under a lot of stress, you
may need something more reliable like meditation. Use any of these techniques, or any combination. But do
something every day to relax, escape, or reward yourself, and turn off the chatter in your mind.
Healthy ways to relax and recharge
Go for a walk.
Spend time in nature.
Call a good friend.
Sweat out tension with a good workout.
Write in your journal.
Take a long bath.
Light scented candles
RELAPSE PREVENTION
Don't look where you fall, but where you slipped. ~African Proverb
The Stages of Relapse
Relapse is a process, it's not an event. In order to understand relapse prevention you have to understand the
stages of relapse. Relapse starts weeks or even months before the event of physical relapse. In this page you will
learn how to use specific relapse prevention techniques for each stage of relapse. There are three stages of
relapse.
• Emotional relapse
• Mental relapse
• Physical relapse
EMOTIONAL RELAPSE
In emotional relapse, you're not thinking about using. But your emotions and behaviors are setting you up for a
possible relapse in the future.
The signs of emotional relapse are:
• Anxiety
• Intolerance
• Anger
• Defensiveness
• Mood swings
• Isolation
• Not asking for help
• Not going to meetings
• Poor eating habits
• Poor sleep habits
MENTAL RELAPSE
In mental relapse there's a war going on in your mind. Part of you wants to use, but part of you doesn't. In the
early phase of mental relapse you're just idly thinking about using. But in the later phase you're definitely thinking
about using.
The signs of mental relapse are:
 Thinking about people, places, and things you used with
 Glamorizing your past use
 Lying
 Hanging out with old using friends
 Fantasizing about using
 Thinking about relapsing
 Planning your relapse around other people's schedules
EARLY RELAPSE PREVENTION
Practice self-care. The most important thing you can do to prevent relapse at this stage is take better care of
yourself. Think about why you use. You use drugs or alcohol to escape, relax, or reward yourself. Therefore you
relapse when you don't take care of yourself and create situations that are mentally and emotionally draining that
make you want to escape.
Techniques for Dealing with Mental Urges
 Play the tape through
 Tell someone that you're having urges to use
 Distract yourself
 Wait for 30 minutes
 Do your recovery one day at a time
 Make relaxation part of your recovery.
Physical Relapse
Once you start thinking about relapse, if you don't use some of the techniques mentioned above, it doesn't take
long to go from there to physical relapse. Driving to the liquor store. Driving to your dealer.
THOSE WHO FORGET THE PAST ARE CONDEMMED TO REPEAT IT
SANTAYANA
CONCLUSIONS
Hedonism... an axiom of our present age, leads us to some unrealistic expectations. We muster most of our time
and resources trying to avoid any unpleasant experiences. We seek the ultimate "Happy Pill" but this might be
purely mythical.
There is a genetic condition where the individual never feels pain. The Riley Day syndrome.
Humans who cannot feel pain
So what would happen if people could take a drug that relieved all emotional and physical pain and distress? The
answer is that the person would not survive long.
There is a very severe inherited condition, the Riley-Day Syndrome, where the child is born with damaged
sensation so he or she can hardly feel any pain. Pain is a normal warning sign of slight injury and is first felt as
mild discomfort. You are experiencing it as you read this page. Every few minutes your senses tell you to shift
position slightly to even up the blood circulation in the skin. If you did not you would very quickly land up with
pressure sores. We automatically turn over when asleep and make hundreds of other postural adjustments,
shifting weight from one leg to another when standing, and resting weary muscles after an energetic day.
When someone lacks this continuous feedback from skin, muscles and bones to the brain, the result is that they
burn, cut, and bruise themselves. So pain keeps us healthy, constantly disciplining our daily lives. Relieve all pain,
and risk your whole future. And the same is true of emotional pain. Happiness and sorrow in our relationships are
vital to healthy community life.
You cannot have love without grief. It has been said that the greatest gift you can possibly give to someone who is
dying is the knowledge that you will miss him or her when they are gone. Grief is a direct expression of our love,
of missing the person. On a day to day basis, grief caused by separation is what drives the engine to invest time
and energy in a relationship. Marriages where spouses never miss the other's absence are at high risk of divorce.
What happens to humans able to live in constant ecstasy?
So what happens to people who are able to live (hypothetically perhaps) in constant ecstasy? They will never be
distressed by the lack of anything. They will forget to eat, won't pay bills, won't worry about whether friendships or
relationships are falling apart - in fact they won't be able to focus on any problem in life, until the nightmare
moment arrives when the dose wears off.
12 years in recovery, following 30 years of abuse/addiction have taught me to be grateful for the hard lessons and
coping skills I've learned, given the tenor of our present age... 2012, economic turmoil, environmental...global
warming, over population, resource depletion all very stressful issues; sure to create the "Perfect Storm" for desire
to escape and increase addiction potential for the unprepared. I cringe when I see our college students on "Spring
Break" competing in "chugging" contests or hear mantra's that glamorize risky behavior-What happens in Vegas,
stays in Vegas? Rehab is a good business to be in!!
http://www.yourrecoveryinfo.com/M11.html
DIMENSIONS OF SUBSTANCE ABUSE
The Patient Placement Criteria (PPC) are guidelines developed by the American Society of Addiction Medicine (ASAM) that
can be accurately used to assess the severity of patients' problems so that they can be admitted to the most appropriate
level of care (admission criteria), remain in that level of care (continuing care criteria) and be discharged from that level of
care (discharge criteria). These guidelines are divided into six assessment dimensions, as follows:
The Department of Mental Health & Substance Abuse (DMHSA) uses the American Society of Addiction Medicine Patient
Placement Model-2R (ASAM PPC-2R) as the primary reference source for substance treatment Continuum of Care. The
Patient Placement Criteria (PPC) are guidelines developed by the American Society of Addiction Medicine (ASAM) that can
be accurately used to assess the severity of patients' problems so that they can be admitted to the most appropriate level of
care (admission criteria), remain in that level of care (continuing care criteria) and be discharged from that level of care
(discharge criteria). These guidelines are divided into six assessment dimensions, as follows:
1. Acute Intoxication and/Withdrawal Potential: What risk is associated with the patient’s level of acute
intoxication? Is there serious risk of withdrawal symptoms based on the patient’s withdrawal history? Are there
signs of withdrawal? Does patient need acute inpatient detoxification services or can he be served in an Outpatient
detoxification setting?
2. Biomedical Stabilization: Are there current physical illnesses other than withdrawal, that need to be addressed or
which complicate treatment? Are there chronic conditions that affect treatment? e.g., chronic pain with narcotic
analgesics.
3. Behavioral Stabilization: Are there psychiatric illnesses or psychological, behavioral or emotional problems that
need to be addressed or which complicate treatment? Are there chronic conditions that affect treatment? Do any
emotional/behavioral problems appear to be an expected part of addiction illness or do they appear to be separate?
Even if connected to addiction, are they severe enough to warrant specific mental health treatment?
4. Readiness to Change: Does the patient feel coerced into treatment or actively object to receiving treatment? How
ready is the patient to change? If willing to accept treatment, how strongly does the patient disagree with others’
perception that she/he has an addiction problem? DMHSA has opted to use the “Stages of Change” by Prochaska
and Diclemente to determine patient’s readiness of change (See figure 1, Stages of Change). If patient is
diagnosed with alcohol dependence but does not believe he has an alcohol problem, he would be placed in the
Pre-contemplation Stage. Patient must then be placed in an ASAM Level 0.5 or I with the aim to raise awareness
that a substance problem exists, with the use of motivational strategies. When patient moves to the Preparation
Stage, then it will warrant a referral to a more intensive level of care for treatment.
5. Relapse Potential: Is the patient in immediate danger of continued severe distress and drinking/drugging
behavior? Does the patient have any recognition and understanding of, and skills for how to cope with his/her
addiction problems and prevent relapse or continued use? How aware is the patient of relapse triggers, ways to
cope with cravings to use and skills to control impulses to use?
6. Recovery Environment: Are there any dangerous family, significant others, living or school/working situations
threatening engagement and success? Does the patient have supportive friendship, financial or
educational/vocational resources to improve likelihood of successful treatment? Are there legal, vocational, social
service agency or criminal justice mandates that may enhance motivation for engagement into treatment?
Figure 1. Stages of Change by Prochaska and DiCemente
PPCs also describe the level of care. It includes the distinct characteristics of each treatment modality, as
indicated in the table below. DMHSA is aware that although many placement models exists in the Nation (US), the
cry for standardization and the aim to have common language in the treatment field is essential in order to
develop a broader continuum of care, has led many providers to use the ASAM PPC-2R model. In addition, the
principle author and chief editor, Dr. Mee-Lee had visited three times and provided extensive training on the
model to DMHSA staff as well as community providers, with his last visit in September 2006. This ensured that
treatment will have common knowledge of the different levels of care, develop skills to conduct thorough
assessments and thus strengthen referral system. Therefore, DMHSA defines Continuum of Care Levels, as
follows [ next page ]:
Chart 1. Substance Treatment Levels of Care
ASAM Level
Reference
No.
Treatment Modality
Name
Clinical Needs and Treatment Setting
Examples
Level of Intensity By
Number of Hours
Level 0.5
Drug Education/Early Intervention
Risk Factors or problems, No DSM-IV
diagnosis, Psycho-education, monitoring
Minimum of two hours
weekly
Level I
Outpatient
DSM-IV diagnosis
Low severity of problems, Low-intensity
outpatient
Minimum of four hours and
less than 9 hours weekly
Level I-D
Outpatient Detoxification
Ambulatory Detoxification
without Extended Onsite Monitoring
DSM-IV diagnosis
Medically Supervised, in Office or clinic
setting or treatment facility
One hour, two to three times
weekly, or regularly
scheduled sessions
Level II
Intensive Outpatient
DSM-IV diagnosis
Intensive Outpatient treatment, structured
evening program
Minimum of nine hours
weekly
Level II.5
Day Treatment/Partial Hospitalization
Clinically-managed structured day
program
Minimum of eight hours a
day, five days a week
Level III.2-D
Social Detox./Clinically Managed
Social setting detoxification, may be
residential
24 hours, 2 - 7 days
Level III.5
Residential<30 days
Residential treatment, structured
therapeutic community
24 hours daily, up to 30
days
Level III.5
Residential>30 days
Significant problems with living skills,
antisocial
traits
24 hours daily, more than
30 days to 6 mos.
Level III.7
Inpatient Semi-medically managed, or
Medically-monitored, Severe problems with
ASAM Dimension 3
Withdrawal symptoms or potential severe
enough to require 24 hours inpatient
monitoring
24 hours Inpatient, 2 - 5
days
Level IV
Full Medically-managed Intensive Inpatient
Treatment, Hospital Setting
Withdrawal symptoms or potential severe
enough to require inpatient care,
physician management, Hospital
24 hours, Emergency
Services, 1-5 days
Drug Education and Early Intervention- ASAM Level 0.5:
Drug Education and Early Intervention is a crucial part of the continuum of care, but remains one of the most under-funded
and under-developed part of the continuum. Drug Education is the least intensive outpatient service, totaling fewer than four
(4) hours a week. It is designed for patients mainly with problems or risk factors related to substance use and needing drug
and alcohol education. In addition, when an initial assessment is completed, an immediate Substance Related Disorder
(DSM-IV substance abuse or dependence criteria) cannot be confirmed. Further assessment is warranted to rule in or out an
addiction problem. Core service elements include, but not limited to, formal group drug education on the dynamics of
addiction and the addiction process, medical aspects of addiction, drug-related legal aspects, and community resource
awareness of available drug and alcohol service providers. Patients receive a minimum of twenty (20) drug education hours.
The Superior Court of Alcohol Treatment Program (ATP) and Drug Education Program (DEP) are equivalent to this level of
care.
DMHSA has begun exploring new motivational strategies and engagement as part of the Early Intervention component of
the continuum of care. Motivational Interviewing (MI-By Miller and Rollnick) is an effective evidence-based approach to
overcoming the ambivalence that keeps people from making desired changes in their lives. Research supports evidence that
early identification and intervention is cost-effective and yields positive results for the entire health system. As Alcohol and
Other Drugs (AOD) early identification and intervention become a greater part of the continuum, prevention of the more
serious complications of AOD problems can be minimized or avoided.
DMHSA defines indicated prevention, which concentrates on individuals who are at very high risk and may be
using or experimenting with AOD, as early intervention. It goes on to define early intervention as targeting, in the
early stages, individuals who have been assessed as having an AOD problem, as well as interventions at all
levels of the continuum, which intervene at the earliest point, to produce the most effective results. Education and
screening, which are components of each part of the continuum of care, are the first steps for assessing the need
for early intervention and can occur in any environment - the doctor’s office or health clinic, school, mayor’s office,
criminal justice system, or a number of community settings. Families, friends, and workplace colleagues are often
the first to notice that a problem might exist, although they may not initially recognize it as an AOD problem. The
easier the access to more formal screening and assessment (discussed in more detail later in this section), the
easier it is to provide appropriate intervention services.
Because intervention may need to occur more than once, a continuum of education, outreach, case management,
and drop-in facilities such as mayor’s offices are crucial. DMHSA recently funded Drug Education services as one
of the means that can be used to educate individuals about AOD issues and engage pre-treatment ready
individuals in intervention and treatment. Intervention success is often difficult to measure. It will work with its
partners, using some of the same principles outlined in the drug education/early intervention section, to adopt and
develop science-based models and best practices for the intervention component. DMHSA wants to emphasize
that the prevention, intervention, treatment and recovery system is not a linear system, but a circular system.
Individuals with AOD problems have a variety of needs that may reoccur at any point in the recovery process. This
is an important concept in the early intervention models that DMHSA is considering. For instance, outreach and
care/case management intervention is part of the continuum in the early, middle and aftercare/continued care
components of the continuum, and links all aspects of the continuum. An individual may require outreach and
case/care management to bring him/her into the system, but may also require these service elements to support.
Screening and Assessment: Identifying individuals who may need assistance with an AOD problem is an
important component of Early Intervention. The DMHSA will work with substance treatment providers to identify
and to develop screening potential in the settings, which they already provide forms/levels of prevention or
treatment services. Once an individual has been identified as having a possible AOD problem, the individual
needs an appropriate assessment done to determine if the person 1) has an AOD problem, 2) the level of
severity, 3) the required level of intervention or care, and 4) the appropriate intervention or treatment referral.
Again, DMHSA requires and supports the use of the ASAM six assessment dimensions, when conducting
appropriate screenings/assessments.
Screening and assessing individuals throughout the lifespan is an important function of developing a standardized
process. The use of additional screening and assessment tools must be age and developmentally appropriate, as
well as the range of responses to the screening/assessment outcomes. Children, youth, young adults and elders
need screening instruments that take into consideration variables such as age, level of maturity, gender, culture,
and family and peer environment. Standardized AOD screening and assessment tools used by all programs are
part of the development of a Territory-wide treatment system intended to help patients move through the
continuum of care seamlessly. Always adhering to federal and territory confidentiality regulations, programs can
more readily exchange information as patients move from one level of treatment to another, without requiring
patients to repeat the same process at every juncture.
Substance treatment providers will work with the DMHSA and its partners to identify essential elements, proven
screening and assessment tools, and best practices, in order to ensure accurate and quality screening and
assessment. The process will include age/developmentally, gender, race, ethnicity, and sexual orientation
appropriate screening and assessment.
Outpatient Treatment – ASAM Level I:
The next level of care is Outpatient Treatment. These services function under a defined set of policies and
procedures. This is a nonresidential organized group service or office visits, totaling fewer than nine (9) hours and
a minimum of four hours a week, in which directed treatment and recovery services are provided by addictioncredentialed clinicians that help patients cope with life tasks without non-medical use of psychoactive substances.
Clinicians provide directed evaluation, treatment and recovery services to patients with substance-related
disorders. Core services elements include, but not limited to, referral for TB testing, treatment planning, drug
education, minimal individual, group, or family counseling, drug testing, and ongoing bio-psychosocial
assessment. Patients provisionally diagnosed with substance abuse (DSM-IV abuse criteria), or unmotivated
patients diagnosed with substance dependence (DSM-IV dependence criteria) but are in early stages of change
(Prochaska and DiClemente) and who are not yet ready to commit to full treatment and recovery are placed in this
level of care. A primary objective with dependent patients is to engage resistant individuals in treatment and work
towards securing a referral to the next appropriate level of care.
Outpatient Detoxification – ASAM Level I-D:
Level I-D is an organized outpatient service which may be delivered in an office setting, healthcare or addiction
treatment facility, or in a patient’s home, by trained and licensed clinicians who provide medically supervised
evaluation, detoxification and referral services according to a predetermined schedule. Such services are provided
in regularly scheduled sessions. They should be delivered under a defined set of policies and procedures or
medical protocols. Outpatient services should be designed to treat the patient’s level of clinical severity and to
achieve safe and comfortable withdrawal from mood-altering drugs (including alcohol and tobacco) and to
effectively facilitate the client’s transition into ongoing treatment and recovery, such as a referral to an Intensive
Outpatient Program, as stated below.
Intensive Outpatient Treatment – ASAM Level II:
A programmatic therapeutic milieu consisting of regularly scheduled sessions for a minimum of nine (9) hours a
week in a structured program, which provides patients with the opportunity to remain in their own environment
and/or retain their employment. It is designed for individuals needing multidimensional services that cannot be met
at an Outpatient level of care and who do not need primary medical and nursing services at a partial
hospitalization, or medically monitored intensive inpatient level of care. The patients need for psychiatric and
medical services are addressed through consultation or referral arrangement. Patients diagnosed with substance
dependence and not needing withdrawal monitoring are placed in this level of care. Core services elements
include, but not limited to, referral for TB testing, ongoing bio-psychosocial assessment, treatment planning, drug
testing, drug education, intensive individual/group/family psychosocial therapy, and intensive case management.
Optimal elements include family support group, spirituality, AA/NA 12-step support groups, pre-employment skills
training, nutrition education, and issuance of vouchers for childcare and transportation services. Enhancing
elements include techniques to address relapse prevention, stress, anger, and self-esteem issues.
Partial Hospitalization (Day Treatment) – ASAM Level II.5:
The components of the partial hospitalization (Day Treatment) level of care include all cores, optimal, and
enhancing multidimensional elements provided in an Intensive Outpatient level of care. DMHSA use to operate
this level of care from Mondays through Fridays, from 7:30 am to 4:30 pm. Day treatment usually provides 20 or
more hours of clinically intensive programming per week based on individual treatment plans. It is designed to
provide patients who need a more structured care and environment, in comparison to Intensive Outpatient, but not
severe enough to require 24 hours inpatient or residential services. Additional elements include easy access to
psychiatric and medical services, recreational therapy, with basic nurse’s aide services available.
Clinically-Managed Residential Detox. (Social Detoxification) – ASAM Level III.2-D:
ASAM level III.2-D is sometimes referred to as “Social Setting Detoxification.” It is an organized service that may
be delivered by appropriately trained and certified staff, who provides 24-hour supervision, observation and
support for patients who are intoxicated or experiencing withdrawal, with the aim for them to achieve initial
recovery from the effects of AOD. Prior to admission patients must provide a medical clearance document, to
validate that there are no medical complications needing urgent attention. Social Detoxification is characterized by
its emphasis on peer and social support. This level provides care for patients whose intoxication/withdrawal signs
and symptoms are severe to require 24-hour structure and support, but the full resources of a medically monitored
inpatient detoxification are not necessary. A social detoxification facility must have an agreement with local
medical providers to ensure readily accessible emergency care when needed. Hospital affiliation providing 24hour medical backup is a must. Staff members must be trained in admission, monitoring skills, including signs and
symptoms of alcohol and other drug intoxication and withdrawal, as well as appropriate treatment of those
conditions, supportive care, basic cardiopulmonary resuscitation technique, assessment and referral procedures.
These services function under a defined set of policies and procedures.
Residential/Inpatient Services – ASAM Level III.5:
Residential treatment is a broad category that consists of many different treatment models. This is the most
developed and supported part of the continuum. DMHSA defines this level as a 24-hour Inpatient program in a
planned regimen of observation, monitoring, and treatment. It utilizes a multidisciplinary staff for patients whose
biomedical, emotional, and/or behavior problems are severe enough to require inpatient services. It also includes
all cores, optimal, and enhancing multidimensional elements provided in an Intensive Outpatient level of care. It
serves patients who need a safe and stable living environment in order to develop their recovery skills. Mutual and
self-help group meetings generally are available on-site. In order to assist its partners in understanding this part of
the AOD system, DMHSA is using two categories to define AOD residential treatment: residential treatment less
than 30 days and residential treatment more 30 days.
Residential treatment (sometimes referred as Rehabilitation) < 30 days includes several treatment modalities
designed to assist individuals who need brief residential treatment interventions that address AOD problems. For
most individuals who are physically addicted or otherwise determined dependent, this is the first part of entering
the treatment process, but individuals may enter at any point on the continuum and/or may need to utilize this
particular component more than once. Some of the residential treatment models that are considered part of this
component are: detoxification, stabilization, observation, and transitional services, and short-term specialized
treatment programs. The main goal of residential treatment < 30 days is to medically detoxify and/or stabilize
individuals, to assess the exact nature of the AOD problem, to assist individuals with case management needs,
and to access next-step treatment and support systems at the appropriate level of care. Furthermore, intense
psychosocial therapy may be considered depending on the patient’s level of severity. Research supports that a
significant number of patients have benefited from this level of care and were referred to less intense programs,
such as Intensive Outpatient or Outpatient, and thus showed successful or favorable treatment outcomes.
Residential treatment >30 days: The residential treatment >30 days is the only part of the system that is supported by
funding from the Substance Abuse Treatment Prevention (SAPT) Federal Block Grant, through DMHSA. DMHSA is working
with its partners to broaden funding opportunities to increase the availability of beds and bed days to the system. This
category consists of several different long-term treatment models. These models are designed to assist individuals and
families in a safe, long-term, stabilized, therapeutic living situation to learn more about their AOD problems; strategies for
relapse prevention; interpersonal, social, and life skills necessary to form productive personal relationships,
career/work/educational opportunities, and community support systems. These models have individual treatment plans
and/or case management plans that assist patients in maintaining sobriety and developing self-supportive, independent
lives. Models included in the residential> 30 days include residential recovery homes, therapeutic communities, social
rehabilitation models, youth residential programs, and family shelters. The Salvation Army’s Lighthouse Recovery Center for
men and the Oasis Empowerment Center for women both fall under this level of care, as well as, any adult or adolescent
clinically managed, 24-hour residential treatment program. Treatment capacity for both Centers is limited and needing
expansion. Substance treatment providers are expected to have knowledge of the different elements of the residential
system and linkages to each component.
Medically-Monitored Inpatient Detoxification – ASAM Level III.7-D:
Level III.7-D is sometimes referred to as “Semi-Medically-Managed” service. It is an organized service delivered
by medical and nursing professionals, which provides 24-hour medically supervised evaluation and withdrawal
management in a permanent facility with inpatient beds. Services are delivered under a defined set of physicianapproved policies and physician-monitored procedures or clinical protocols. This level provides care for patients
whose withdrawal signs and symptoms are sufficiently severe to require 24-hour inpatient care. DMHSA further
defines this service, as indicated treatment, which concentrates on patients who are experiencing high-risk ASAM
dimension 3 problems.
Medically Managed 24-hour Intensive Inpatient – ASAM Level IV:
This level of care has primary medical and nursing services and the full resources of a general hospital available
on a 24-hour basis with multidisciplinary staff to provide support services for both alcohol/other drug treatment and
coexisting acute biomedical, emotional, and behavioral conditions that need to be addressed. It is staffed by
designated addiction-credentialed physicians, psychiatrists, as well as other mental health and addictioncredentialed clinicians. Such services are delivered under a defined set of policies and procedures and have
permanent facilities that include inpatient beds. The treatment is specific to mental and substance-related
disorders; however, the skills of the interdisciplinary team and the availability of support services allow the conjoint
treatment of any co-occurring biomedical conditions that needs to be addressed.
Ambulatory Treatment: Ambulatory AOD treatment refers to the available outpatient services for the
continuum of care, such as Drug Education, Outpatient, or Intensive Outpatient. Individuals can utilize these
services at any point in the continuum. Some individuals may need only the support and guidance of outpatient
counseling, others may need outpatient counseling after a short-term or long-term residential stay for support and
maintenance of recovery. Some individuals need to begin treatment at the least intensive level to find that they
need a more intensive program or environment to maintain sobriety. Ambulatory services have the flexibility of
providing individual and group counseling one to two times a week, day treatment, acupuncture services, psychoeducational groups, youth services, case/care management, and opiate maintenance. Ambulatory services are
paired with residential services in the family shelters. Ambulatory settings can provide and support many of the
service needs of the AOD continuum, including outreach, early intervention, central intake, case/care
management, and aftercare and recovery support. Substance treatment providers are expected to have
knowledge of the different elements of ambulatory services and have linkages to each service
Aftercare/Continued Care and Recovery:
The aftercare and recovery AOD service, as a distinct component, is another underfunded and underdeveloped part of the
continuum. AOD is a chronic condition, similar to other chronic health conditions that require constant support and attention
to prevent relapse. Relapse can occur at any point in the recovery process. Individuals and families who have completed a
treatment regimen will have been exposed to relapse prevention strategies. However, even with this knowledge, relapse can
occur due to a myriad of biological, physiological, psychological, emotional, life circumstance, societal or peer pressure,
including thinking that time has cured the AOD problem. Because of the stigma attached to AOD problems, it is difficult at
any point for individuals and families to seek assistance, but after any length of recovery, it may be even harder. This
component needs to be especially sensitive to the way in which shame and embarrassment can be attached to relapse, and
must have services that are non-judgmental, welcoming, flexible, supportive, and easily accessible and available. These
services can take the form of case/care management, outreach, drop-in centers, or informal and formal support networks.
The treatment system currently utilizes self-help programs to provide recovery support. However, the aftercare and recovery
AOD component is a newer part of the formal system of care. This component can provide a much-needed support
mechanism for sobriety and provide cost savings as well preventing the serious human complications of relapse, including
death. Continued Care programs can operate one to two sessions, for one to two hours, on a weekly basis. Primary focus is
for providers to facilitate recovery plans, to further stability in patient lives. Treatment providers are expected to work with the
DMHSA in the planning, design, implementation, and evaluation of aftercare and recovery models. The DMHSA and its
partners will utilize science-based models and best practices in designing and evaluating this component. Providers are
expected to have strong linkages with this system.
Reference Sources: 1) American Society of Addiction Medicine (ASAM) Patient Placement Criteria 2nd Revision.
2) The Massachusetts Department of Public Health Bureau of Substance Abuse Services Fiscal Year 2006,
Terms and Conditions and Standards of Care, For the Alcohol and Other Drugs Service System.
CITATION: http://dmhsa.guam.gov/services/substance_abuse/
MORE INFORAMTION:
http://coce.samhsa.gov/cod_resources/PDF/ASAMPatientPlacementCriteriaOverview5-05.pdf