Rehab 4 Addiction

The American Society of Addiction Medicine (ASAM) was created during the 1950s to help establish a high degree of medical expertise regarding addiction.

Its aim is to develop and recommend effective working practices for all medical professionals working in the field of addiction.

 ASAM is heavily invested in the latest research findings relevant to all aspects of addiction and regularly updates all medical professionals on current research findings.

The ASAM Criteria

Doctor testing

The ASAM criteria is used to assess clients who have been identified as needing treatment to help them recover from a substance misuse disorder or addiction. 

Over the years medical practitioners specialising in the addiction field have found that there are several separate areas of support people can receive to help them recover, depending on their own individual circumstances. 

These separate areas can be biological, psychological or social in nature, so this is referred to as taking a biopsychosocial approach to devising treatment.

Biopsychosocial Assessment

Doctor and patient

This involves a comprehensive assessment of all the biological, psychological and social factors that can contribute to a person’s treatment plan.

The biopsychosocial assessment will cover all 6 ASAM dimensions to ensure all the areas in the patient’s life are fully reviewed to identify any areas where specific interventions may be needed.

For example, they may require detoxification treatment to help them biologically withdraw from a particular substance, or they may require the support of psychological therapists so they can develop the necessary skills to cope with stressful situations instead of using substances.

The ASAM criteria can identify a client’s individual strengths and the positive aspects in their life which can be valuable resources, as well as identifying any barriers to them fully engaging with treatment.

Who uses the ASAM criteria?

Doctor Clipboard

The ASAM criteria is a set of guidelines regarding the management, referral, treatment, placement and discharge of patients with substance misuse disorders

The ASAM criteria can be used by any medical professionals working in the field to support them with their decision-making processes.

ASAM developed 6 dimensions which they propose medical professionals use to assess people referred to them. 

The outcome of this assessment will dictate each patient’s treatment plan.

The 6 dimensions are listed below:

  • Dimension 1 – Acute intoxication and/or withdrawal 
  • Dimension 2 – Biomedical conditions and complications
  • Dimension 3 – Emotional, behavioural, or cognitive conditions and complications
  • Dimension 4 – Readiness to change
  • Dimension 5 – Relapse, continued use, or continued problem potential
  • Dimension 6 – Recovery/living environment

Dimension risk ratings

Risk

Each dimension is assigned a risk rating by assessors ranging from 0, (low risk) to 4, (high risk).

The risk rating attributed to each dimension will help medical practitioners develop a course of treatment to address this area (if necessary).

If a person is attributed a higher rating, then extra consideration should be given to this dimension when formulating their treatment plan.

The risk rating categories are as follows;

  • 4 – Utmost severity, the threat of imminent danger
  • 3 – Serious issue that needs addressing
  • 2 – Moderate difficulty in functioning efficiently
  • 1 – Mildly difficult
  • 0 – No issue, very low risk

Dimension 1 – Acute intoxication and/or withdrawal 

Withdrawal

This dimension is concerned with assessing the client’s current level of substance use and whether they are vulnerable to experiencing severe withdrawal symptoms, or if their physical health is in danger of rapidly deteriorating.

It will be necessary to measure the level of consumption of all the substances that the person has a history of consuming and their current level of use over recent weeks.

It is important to know of any withdrawal symptoms the client is experiencing and the severity of such symptoms.

The client can report to the assessor the severity of any withdrawal symptoms, or it may be that such symptoms are observable.

Particular care must be noted with patients who have alcohol dependence due to the potentially dangerous and life-threatening consequences of alcohol withdrawal

It’s important to assess for severe alcohol withdrawal if there are any suspicions that alcohol is a substance that the client consumes at high levels on a regular basis.

The assessment process in this dimension may result in the client being referred to a detoxification treatment in an inpatient setting if their risk rating is too high. 

Dimension 2 – Biomedical conditions and complications

Medical Assessment

This element of the assessment focuses on enquiring about any physical illnesses or conditions a person may be diagnosed with that could negatively impact their ability to engage with treatment.

It is important to assess the type and intensity of treatment they would need to manage this area and ensure that any ongoing medical treatment is taken into account when composing a treatment plan. 

This is essential, as being physically unwell affects people’s mental health and reduces their ability to show the psychological resilience needed to maintain recovery.

Particular areas of interest would be whether any female clients are pregnant and if there are any chronic medical conditions that the patient is managing, such as diabetes or asthma.

A suitable care plan can then be developed to minimise the negative effects of these medical conditions on their substance misuse treatment plan.

It may well be that a person is receiving medical treatment that may interfere with their substance misuse treatment, or that any withdrawal symptoms they may experience could negatively impact their physical health conditions.

Dimension 3 – Emotional, behavioural, or cognitive conditions and complications

Emotional Conditions

The third dimension is concerned with assessing the emotional and psychological state of the client. 

Psychological problems can play a key role in the development of an addiction and also create barriers to the therapeutic process.

Therefore, it is extremely important that medical practitioners identify any emotional, behavioural or cognitive complications which may require specific interventions.

For example, it may be that a patient is showing signs that indicate an as yet undiagnosed mental health condition such as Bipolar Disorder or Obsessive Compulsive Disorder.

If this was the case medication or a specific psychological therapy may be prescribed.

For example, if the assessment reveals a client is finding it difficult to deal with previous traumatic experiences, it may be decided that they would benefit from trauma therapy.

It will be necessary to establish the severity of such symptoms and whether they will affect the client’s engagement with treatment.

Another aim of the assessor is to investigate if any mental health concerns are related to their substance misuse disorder and whether any such concerns require specific treatment.

An important part of the assessment for this dimension is to establish whether there is any aspect of their mental health that could negatively impact their day-to-day functioning. 

This includes their ability to demonstrate adequate levels of self-care. A patient could be identified as high risk if it appears they have:

  • Neglected their own personal hygiene
  • Have been unable to hold down a job
  • Cannot maintain positive relationships

Another area to consider is whether the person is a suicide risk or is vulnerable to self-harm, or it could be they may be showing signs of aggressive and impulsive tendencies and therefore be a risk to others.

Dimension 4 – Readiness to change

Ready to Change

In this dimension, the aim is to identify how ready the client is to change and whether they are seen to possess the necessary motivation to fully engage with treatment.

It could be that the client may not think that they have a problem.

It is important to evaluate if the client is fully aware of their substance misuse behaviour and the consequences that it has had for them.

 To be ready to change and engage with the treatment they should be able to reflect on, accept their situation, realising that they need to change in order to lead a more fulfilling life.

A person with a low-risk rating in this area would exhibit a high level of motivation reflected in their regular attendance at relevant appointments.

They are actively involved in, and committed to, following their own treatment plan.

The assessor will look for evidence that they are talking about making positive progress in key areas of their lives, such as:

  • Finding employment
  • Studying for a new course
  • Improving their physical health

If it seems apparent to the assessor that the client feels like they are being pressured into treatment and are only there because they have to be, then this could be a red flag for a higher risk rating. 

This could occur for example if the person feels coerced into receiving treatment as part of a condition imposed by the criminal justice system.

For this criterion, the assessor may well refer to The Stages of Change Model developed by Prochaska and DiClemente to establish which stage the client is in. 

If they are assessed as being in the pre-contemplation stage then they may require specific motivational counselling sessions to help them move through the stages and engage more fully with treatment.

Dimension 5 – Relapse, continued use, or continued problem potential

Relapse

The pressing concern here is whether the client is vulnerable in the short term to continue taking substances and experiencing any mental distress.

The risk rating attributed to this dimension needs to reflect how much of a relapse risk the client is.

The risk rating will be high for this dimension if it is judged that not engaging with treatment may lead to a severe risk of relapse and high levels of distress for the patient

The assessor will be required to judge if the client has developed the psychological coping skills to successfully manage:

  • Negative thoughts and emotions,
  • Social pressures,
  • Cravings
  • Setbacks

A person who is able to reflect upon what their triggers for relapse might be and has strategies to implement when such triggers appear would receive a lower risk rating.

Someone who is still unable to resist any impulses may be seen as a greater risk and in need of improving their cognitive skills through a course of Cognitive Behavioural Therapy.

Another aspect to investigate is how compliant the patient is with adhering to any mediation they have been prescribed for any mental health conditions.

An inability to do so could indicate a higher vulnerability to relapsing. 

Dimension 6 – Recovery/living environment

Recovery

Dimension 6 relates to the social element of the patient’s life.

ASAM criteria deems it important to investigate whether any aspect of the patient’s social environment may derail their attempts to engage with treatment. 

This includes:

  • Their living circumstances
  • Their work situation
  • Any social and legal issues in their lives

If there is a lot of discord prevalent with family members, or if a person is leading a chaotic life with no fixed address, then the assessor may allocate a high-risk rating score of 3 or 4.

If, however, a client was surrounded by supportive and caring family and friends, this would be seen as a positive resource in their recovery and they would receive a lower risk score.

The client’s work situation also comes under scrutiny as it is potentially a high source of stress.

Whether it is because of difficult relationships with colleagues, fear of redundancies, changes to work patterns or tight deadlines, many people take substances to cope with the stress of work.

It is important to establish whether their workplace is a significant risk factor for having a negative impact on their well-being. 

Assessing a client’s financial situation is also an important consideration. Finance and debt is frequent cause of stress and worry for people. 

Debt could also be linked to other stressors in a person’s life, such as homelessness or unemployment.

The assessor would be keen to note if there are any legal disputes affecting the client’s ability to focus on their recovery, this may include:

  • A custody rights battle,
  • A criminal record complicating the search for work
  • If they are currently facing criminal proceedings

 If, however, the patient needs to demonstrate significant improvements in their life in order to see their children, then this could provide the necessary motivation for the client to fully engage with treatment.

Conclusion

Support

The six dimensions of the ASAM criteria relate to different elements of the biopsychosocial approach to treating individuals for substance misuse.

Experts in the addiction field have recognised the importance of considering the needs of patients in all of the six dimensions, in order to help them achieve a positive outcome. 

 Each patient will have an individual treatment plan, each of which will serve different therapeutic needs in all six dimensions.

References

(1) American Society of  Addiction Medicine (2021) ASAM: Quality and Science

available @ASAM Home Page 

(2) McBride, A. (2002) Client Assessment in Peterson, T. & McBride, A. (ed) Working with Substance Misusers: A Guide to Theory and Practice London. Routledge.

(3) Mee-Lee, D. (2013) The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related and Co-occurring Conditions

(4) Miller, S., Fiellin, D., Rosenthal, R., Saitz, R. (2019) The ASAM Principles of Addiction Medicine (Sixth edition) Wolters Kluwer. London

(5) Miller, W., Rollnick, S. (1991) Motivational Interviewing: Preparing people to change addictive behaviour. Guildford Press. London

(5a) Mullins, L.J. (2010) Management and Organisational Behaviour. Pearson Education. Harlow

(6) Shapiro, F. (2018)  Eye Movement Desensitisation and Reprocessing Therapy (EMDR): Basic Principles, Protocols and Procedures (Third Edition). The Guildford Press. London

(7) Summers, Z. (2002) Coercion and the Criminal Justice System in Peterson, T. & McBride, A. (ed) Working with Substance Misusers: A Guide to Theory and Practice London. Routledge.

boris

Boris is our editor-in-chief at Rehab 4 Addiction. Boris is an addiction expert with more than 20 years in the field.  His expertise covers a broad of topics relating to addiction, rehab and recovery. Boris is an addiction therapist and assists in the alcohol detox and rehab process. Boris has been featured on a variety of websites, including the BBC, Verywell Mind and Healthline.