Assessment Dimensions by pengtt


									                                                                              SD Depart of Human Services
                                                                        Division of Alcohol and Drug Abuse

Assessment Dimensions
The ASAM criteria identify the following problem areas (dimensions) as the most important in
formulating an individualized treatment plan and in making subsequent patient placement decisions.
The ASAM Form is an ASSESSMENT tool as well as a PLACEMENT tool and seeks to match
intensity of treatment to severity of illness. It is also a method for justifying clinical decisions
Common Errors
   Summaries are generalized and insufficient
   Client does not meet criteria but is “forced” into specific level of care

Dimension 1: Acute Intoxication and/or Withdrawal Potential. What risk is associated with the
patient's current level of acute intoxication? Is there significant risk of severe withdrawal symptoms or
seizures, based on the patient's previous withdrawal history, amount, frequency, and recency of
discontinuation or significant reduction of alcohol or other drug use? Are there current signs of
withdrawal? Has the patient been using multiple substances in the same drug class? Is there a
withdrawal scale score available?

Dimension 2: Biomedical Conditions and Complications. Are there current physical illnesses,
other than withdrawal, that need to be addressed because they are exacerbated by withdrawal,
create risk or may complicate treatment? Are there chronic conditions that affect treatment? Is there
need for medical services that might interfere with treatment?

Dimension 3: Emotional, Behavioral or Cognitive Conditions and Complications (diagnosable
mental disorders or mental health problems that do not present sufficient signs and symptoms to
reach the diagnostic threshold). Are there current psychiatric illnesses or psychological, behavioral,
emotional or cognitive problems that need to be addressed because they create or complicate
treatment? Are there chronic conditions that affect treatment? Do any emotional, behavioral or
cognitive problems appear to be an expected part of the addictive disorder, or do they appear to be
autonomous? Even if connected to the addiction, are they severe enough to warrant specific mental
health treatment? Is the patient suicidal, and if so, what is the lethality? Is the patient able to manage
the activities of daily living? Can he or she cope with any emotional, behavioral or cognitive
problems? If the patient has been prescribed psychotropic medications, is he or she compliant?

Dimension 4: Readiness to Change. Is the patient actively resisting treatment? Does the patient
feel coerced into treatment? How ready is the patient to change? If he or she is willing to accept
treatment, how strongly does the patient disagree with others' perception that she or he has an
addictive or mental disorder? Does the patient appear to be compliant only to avoid a negative
consequence, or does he or she appear to be internally distressed in a self-motivated way about his

                                                                           SD Depart of Human Services
                                                                     Division of Alcohol and Drug Abuse

or her alcohol or other drug use or mental health problem? At what point is the patient in the stages of
change? Is there leverage for change available?

Dimension 5: Relapse, Continued Use or Continued Problem Potential. Is the patient in
immediate danger of continued severe mental health distress and/or alcohol or drug use? Does the
patient have any recognition or understanding of, or skills in, coping with his or her addictive or
mental disorder in order to prevent relapse, continued use or continued problems such as suicidal
behavior? How severe are the problems and further distress that may continue or reappear if the
patient is not successfully engaged in treatment at this time? How aware is the patient of relapse
triggers, ways to cope with cravings to use, and skills to control impulses to use or impulses to harm
self or others? What is the patient’s ability to remain abstinent or psychiatrically stable based on
history? What is the patient’s current level of craving and how successfully can he or she resist
using? If on psychotropic medications, is the patient compliant? If the patient has another chronic
disorder (e.g., diabetes), what is the history of compliance with treatment for that disorder?

Dimension 6: Recovery Environment. Do any family members, significant others, living situations,
or school or work situations pose a threat to the patient's safety or engagement in treatment? Does
the patient have supportive friendships, financial resources, or educational or vocational resources
that can increase the likelihood of successful treatment? Are there legal, vocational, social service
agency or criminal justice mandates that may enhance the patient's motivation for engagement in
treatment? Are there transportation, child care, housing, or employment issues that need to be
clarified and addressed?

The initial placement for recovery services should reflect an assessment of the patient's status in all
six dimensions. The principle here is that the highest severity problem (particularly those in
Dimensions 1, 2 or 3) should determine the patient's initial placement. Subsequent resolution of this
problem creates an opportunity to transfer the patient to a less intensive level of care. Addressing the
individual's recovery needs thus may involve a sequence of services across several levels of care
(involving a "step down" or "step up process").

What should be avoided is the notion of "averaging" severity across dimensions to arrive at a
placement determination.

                                                                            SD Depart of Human Services
                                                                      Division of Alcohol and Drug Abuse

Co-occurring Disorders and ASAM Assessment Dimensions

The ASAM PPC-2R thus incorporates criteria that address the large subset of individuals who present
for treatment with co-occurring Axis I substance-related disorders and Axis I/Axis II mental disorders.
Individuals with such co-occurring disorders (often referred to as "dual diagnoses") can be
conceptualized as belonging to one of two general categories:

Moderate Severity Disorders: Such persons present with stable mood or anxiety disorders of
moderate severity (including resolving bipolar disorder), or with personality disorders of moderate
severity (although some persons with severe levels of antisocial personality disorder may be
appropriately placed in this group), or with signs and symptoms of a mental health disorder that are
not so severe as to meet the diagnostic threshold.

High Severity Disorders: Such persons present with schizophrenia-spectrum disorders, severe mood
disorders with psychotic features, severe anxiety disorders, or severe personality disorders (such as
fragile borderline conditions).

Individuals whose co-occurring mental disorders best fit within the category of moderate severity
disorders are appropriately treated in programs designed to treat primary substance use disorders.
Those with concurrent high severity mental disorders, on the other hand, generally are best managed
in dual diagnosis specialty programs that can offer integration mental health and addiction treatment
approaches. Some patients may require immediate stabilization of their psychiatric symptoms before
they can be engaged in ongoing addiction treatment and recovery. Depending on the severity of their
symptoms, such patients may require referral to medical and/or psychiatric services outside the
ASAM PPC-2R levels of care (see Table 1).

Patients whose biomedical or psychiatric disorders are so severe that stabilizing them is the highest
priority are most appropriately treated in a medical or psychiatric facility or unit before addiction
treatment is initiated.

                                                                               SD Depart of Human Services
                                                                         Division of Alcohol and Drug Abuse

Sample One:

Santa 1

16-year-old young woman brought to emergency room of acute care hospital. She had gotten into an
argument with parents and ended up throwing a chair. Some indication she was intoxicated at the time
and parents have been concerned about her coming home late and mixing with wrong crowd. A lot of
family discord and mutual anger and frustration between Santa 1 and especially father. No previous
psychiatric or addiction treatment

Dimension 1-Intoxication/Withdrawal: though intoxicated at home not long before the chair throwing
incident, she is no longer intoxicated and has not been using alcohol or other drugs in large enough
quantities for long enough to suggest any withdrawal danger.

Dimension 2-Biomedical Conditions/Complications: she is not on any medications, has been healthy
physically and has no current complaints

Dimension 3-Emotional/Behavioral/Cognitive: complex problems with the anger, frustration and family
discord; chair throwing incident this evening, but is not impulsive at present in the ER.

Dimension 4-Readiness to Change: willing to talk to therapist; blames her parents for being overbearing
and not trusting her; agrees to treatment, but doesn’t want to be at home at least for tonight.

Dimension 5-Relapse/Continued Use/Continued Problem Potential: high likelihood that if released to
go back home immediately, there would be reoccurrence of fighting and possibly violence again, at least
with father.

Dimension 6-Recovery Environment: parents frustrated and angry too; mistrustful of patient; and want
her in the hospital to cut down on the family fighting

                                                                             SD Depart of Human Services
                                                                       Division of Alcohol and Drug Abuse


Santa 2:

Santa 2 is a 33 y/o male, referred to residential treatment from JMH detox. Santa 2 reported a 6yr history
of cocaine use at approx. 5g of cocaine 3x/day. Santa 2 also reported that he drinks a 6pk of beers and 3
magnum bottles of vodka per day. Santa 2 stated that his last use was 5 days ago prior to detox at JMH.
Santa 2 denied any medical problems. Santa 2 denied history of psychiatric treatment. Santa 2 is married
with 2 kids but was kicked out of the house 3 months ago due to his use. Santa 2 was oriented to all
spheres at the time of assessment. Based on the information provided, Santa 2 meets ASAM criteria for
Residential Substance Abuse Treatment.

D1 –
D2 –
D3 –
D4 –
D5 –
D6 -

Example of client summary: Dimension Format
D1 – Client reported smoking 1 joint of marijuana and drinking 4-6 beer 2/wk and reported last used 7
days ago.
D2 – Client stated that he suffers from hypertension and is compliant with medication.
D3 – Client stated that he feels depressed due to his drug use but has never see a psychiatrist or treated
with medication.
D4 – Client appears to be in the contemplation stage of change due to his DUI charge and court order
D5 – Client is not aware of his triggers and is predisposed to continued use due to his cycle of substance
D6 – Client stated that he has been staying with a friend b/c mother does not want him at her house.
Client meets the criteria for outpatient treatment and his appointment is next Wednesday.

                                                                                     SD Depart of Human Services
                                                                               Division of Alcohol and Drug Abuse

LEVEL OF FUNCTIONING/SEVERITY: Using assessment protocols that address all six dimensions, assign a
severity rating of High, Medium or Low for each dimension that best reflects the client’s functioning and severity.
Place a check mark in the appropriate box for each dimension.

Level of                   Intensity of Service         1.Intox/   2.          3.       4.        5.           6.
Functioning/Severity       Need                         With       Bio-        Emot     Read      Relapse      Rec.
                                                                   med         /        i-ness                 Envir

Low Severity –             L No immediate
Minimal, current           services or low
difficulty or              intensity of services
impairment. Absent,        needed for this
minimal, or mild signs     Dimension. Treatment
and symptoms. Acute        strategies usually
or chronic problem         able to be delivered in
mostly                     outpatient settings
stabilized; or soon
able to be stabilized
functioning restored
with minimal difficulty
Medium Severity -          M Moderate intensity
Moderate difficulty or     of services, skills
impairment. Moderate       training, or supports
to serious signs and       needed for this
symptoms. Difficulty       Dimension. Treatment
coping or                  strategies
understanding, but         may require intensive
able to function with      levels of outpatient
clinical and other         care
support services and
High Severity -            H High intensity of
Severe difficulty or       services, skills
impairment.                training, or supports
Serious, gross or          needed. More
persistent signs and       immediate, urgent
symptoms.                  services may require
Very poor ability to       inpatient or residential
tolerate & cope with       settings; or closely
problems.                  monitored case
                           management services
                           at a frequency greater
                           than daily

                                                                             SD Depart of Human Services
                                                                       Division of Alcohol and Drug Abuse


Name: __________________________________________ Date: ______________________

Immediate Need Profile: Assessor considers each dimension and with just sufficient data to
assess immediate needs, checks “yes” or “no” in the following table:

Dimension                       Questions                                        Yes          No
1. Acute Intoxication and/or    1(a) Past history of serious withdrawal, life-
Withdrawal Potential            threatening symptoms or seizures during
1. as above                     1(b) Currently having similar withdrawal
2. Biomedical                   2 Any current severe physical health
Conditions/Complications        problems?
3.                              3(a) Imminent danger of harming self or
Emotional/Behavioral/Cognitive  someone else?
3. as above                     3(b) Unable to function and safely care self?
Yes to questions 1a, 1b, 2 and/or 3a, 3b requires that the client immediately be referred for
medical and/or mental health evaluation, depending on which dimension(s) involved.

Dimension                Questions                                             Yes       No
4. Readiness to Change   4(a) Does client appear to need alcohol or other
                         drug treatment/ recovery, but ambivalent or feels it
                         unnecessary? e.g., severe addiction, but client feels
                         controlled use still OK
4. as above              4(b) Client been coerced, mandated or required to
                         have assessment and/or treatment?
Yes to questions 4a and/or to 4b alone, requires staff to begin immediate intervention and
motivational strategies appropriate to client’s stage of readiness to change.

Dimension                Questions                                               Yes     No
5. Relapse/Continued     5(a) Is client currently under the influence or
Use Potential            intoxicated?
5. as above              5(b) Is client likely to continue use of alcohol and/or
                         other drugs, or to relapse, in an imminently
                         dangerous manner?
Yes to question 5a requires client be considered for withdrawal potential. Yes to question 5a
and/or 5b, individual may need to be considered for 24-hour structure or care.

Dimension                Questions                                          Yes           No
6. Recovery              6. Are there any dangerous family, sig. others,
Environment              living/work/school situations threatening client’s
                         safety, immediate well-being, and/or sobriety?
Yes to Dimension 6, without any Yes in questions 1, 2 and/or 3, requires that the client be
assessed for the need of a safe or supervised environment.

                                                                               SD Depart of Human Services
                                                                         Division of Alcohol and Drug Abuse

Placement in High Intensity Levels of Care

Before admission into a medically monitored intensive inpatient program, the client shall:
1. Meet diagnostic criteria for a substance dependence disorder of the DSM IV; and
2. Meet specifications in at least two of the six ASAM dimensions, at least one of which is in dimension
one, two, or three as in the following criteria:
        a. The client is experiencing signs and symptoms of acute withdrawal
                 or there is evidence that a severe withdrawal syndrome is imminent
                 or there is a strong likelihood that the client who requires medication will not complete
                 detoxification at another level of care and enter continued treatment or self-help recovery;
        b. The client has a physical condition or complication impacting immediate safety or well-being;
        c. The client has a psychiatric condition or complication impacting immediate safety or well-being;
        d. The client exhibits severe impairment in significant life areas such as legal, family, or work;
        e. The client exhibits significant loss of control and relapse symptoms; or
        f. The client has had multiple attempts at treatment programs of lower intensity with an inability to
        stay sober.

“Imminent Danger”
    1. A strong probability that certain behaviors will occur (e.g., continued alcohol or drug use or
        relapse or non-compliance with psychiatric medications)
    2. The likelihood that these behaviors will present a significant risk of serious adverse
        consequences to the individual and/or others (as in a consistent pattern of driving while
    3. The likelihood that such adverse events will occur in the very near future

In order to constitute “imminent danger” ALL THREE ELEMENTS must be present

Level of Care Placement after relapse should be based on an assessment of history and “here & now”
and NOT on the assumption that if a patient relapsed after having been treated, then the previous level of
care was not intense enough!

HOMELESSNESS alone is NOT sufficient reason for Level III Placement!


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