Download Understanding and Using ASAM PPC

Participant Handout
The American Society of Addiction Medicine (ASAM)
Patient Placement Criteria:
Understanding and Using ASAM PPC-2R
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Agenda
9:00 AM Underlying Concepts of the ASAM Criteria
• Pretest Questions
• Generations of Clinical Care in Addiction Treatment
• Paradigm shift and Brief History of PPC
• Principles Guiding ASAM PPC Development and Implications
• Assessment of Biopsychosocial Severity and Function
Levels of Care and Service in ASAM PPC-2R
I Outpatient Services
II Intensive Outpatient/Partial Hospitalization Services
III Residential/Inpatient Services
IV Medically-Managed Intensive Inpatient Services
10:30 AM Break
10:45 AM Content and Specifics about ASAM PPC-2R
• Terminology
• Improving Level I, Outpatient Services & Changes to Continued Service and Discharge Criteria
• ASAM PPC-2R’s Approach to Co-occurring Disorders
• Revised Constructs for Dimension 5: Relapse/Continued Use
• Adolescent Criteria
How to Organize Assessment Data to Focus Treatment
• Immediate Need Profile
12 Noon
Lunch
1:00 PM
How to Target and Focus Service Priorities
• Decision Tree to Match Assessment and Treatment/Placement Assignment
• Case exercises – Tracy and Ann
• 3 H’s
• Case Presentation Format
2:30 PM Break
2:45 PM
Engaging the Client as a Participant in Treatment
• Stages of Change and How People Change
• Developing the Treatment Contract – What Does the Client Want?
Improving the Range and Use of Treatment Services
• Dimension 4, Readiness to Change Assessment and Matching
• Example Policy and Procedure to Deal with Recovery and Psychosocial Crises
• The Coerced Client and Working with Referral Sources
• Gathering Data on Policy and Payment Barriers
3:50 PM
Wrap-Up
• What is one thing you have learned that you will do differently in your daily practice?
• Evaluation forms
4:00 PM
Adjourn
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Understanding and Using ASAM PPC-2R
A. Pretest Questions
Select the Best Answer:
1. The best treatment system for addiction is:
a. A 28-day stay in inpatient
rehabilitation with much education.
b. A broad continuum of care with all
levels of care separated to maintain group
trust.
c. Not possible now that managed
care has placed so much emphasis on
cost-containment.
d. A broad range of services designed to
be as seamless as possible for continuity
of care.
e. Short stay inpatient hospitalization for
psychoeducation.
3. A multidimensional assessment in behavioral
health treatment:
a. Should include psychosocial factors such
as readiness to change.
b. Is ideal, but not necessary within a
managed care environment.
c. Should include biomedical and
psychiatric problems, but not motivation or
relapse potential.
d. Is best done after detoxification is
completed.
e. Should be completed by the primary
therapist only.
4. Criteria for Co-occurring Mental and
Substance-Related Disorders:
a. Helps define the kinds of programs that
could meet the needs of dual diagnosis
patients.
b. Introduces a “future directions” matrix to
match services to individual needs.
c. Encourages addiction treatment providers
to broaden access to care for dual diagnosis.
d. Provides a common language for both
mental health and addiction treatment
systems.
e. All of the above.
2. The six assessment dimensions of the ASAM
Criteria:
a. Help assess the individual’s
comprehensive needs in treatment.
b. Provide a structure for assessing
severity of illness and level of function.
c. Requires that there be access to medical
and nursing personnel when necessary.
d. Can help focus the treatment plan on
the most important priorities.
e. All of the above.
Indicate True or False:
T F
5. It is not the severity or functioning that determines the treatment plan, but the diagnosis, preferably in DSM terms.
6. There are six broad levels of care in the ASAM Criteria.
7. Dimension 5 focuses on internal attitudes, beliefs and coping skills to deal with relapse.
8. The level of care placement is the first decision to make in the assessment.
9. All programs should at least be Dual Diagnosis Capable (DDC).
10.Dimension 4, Readiness to Change, applies only to motivation for abstinence.
11.Clients in early stages of change need relapse prevention strategies.
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Understanding and Using ASAM PPC-2R
B. Generations of Clinical Care in Addiction Treatment
1. Complications-driven Treatment
• No diagnosis of Substance Use
Disorder
• Treatment of addiction complications
with no continuing care
• Relapse triggers treatment of
complications only
No
diagnosis
Treatment of
complications
No continuing
care
Relapse
2. Diagnosis, Program-driven Treatment
• Diagnosis determines
treatment
Diagnosis
• Treatment is the primary
program and aftercare
• Relapse triggers a repeat of
the program
Program
Aftercare
Relapse
3. Individualized, Clinically-driven Treatment
PATIENT/PARTICIPANT
ASSESSMENT
PROGRESS
Response to Treatment
BIOPSYCHOSOCIAL Severity (SI)
and Level of Functioning (LOF)
Data from all
BIOPSYCHOSOCIAL Dimensions
PROBLEMS/PRIORITIES
BIOPSYCHOSOCIAL Severity (SI)
and Level of Functioning (LOF)
PLAN
BIOPSYCHOSOCIAL Treatment
Intensity of Service (IS) Modalities and Levels of Service
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Understanding and Using ASAM PPC-2R
4. Client-Directed, Outcome-Informed Treatment
PATIENT/PARTICIPANT
ASSESSMENT
PROGRESS
Treatment Response: Clinical
functioning,psychological, social/
interpersonal LOF
Proximal Outcomes e.g., Session
Rating Scale; Outcome Rating Scale
Data from all
BIOPSYCHOSOCIAL Dimensions
PROBLEMS/PRIORITIES
PLAN
Build engagement and alliance
working with multidimensional
obstacles inhibiting the client
from getting what they want.
What will client do?
BIOPSYCHOSOCIAL Treatment
Intensity of Service (IS) Modalities and Levels of Service
5. Paradigm Shift
The Criteria have evolved over time to reflect the current scientific research. For example, since the first
edition was published in 1991, the ASAM Criteria have evolved to encourage clinicians and programs
to move:
• from unidimensional to more multidimensional assessments;
• from program-driven to more clinically driven treatment;
• from a fixed length of stay to variable length of service; and
• from a limited number of discrete levels of care to a continuum of care.
(ASAM PPC-2R, p.1)
C. Brief History of the ASAM Patient Placement Criteria (ASAM PPC-2R pp 12-14)
• 1987 Cleveland Criteria and the NAATP Criteria published
• 1991 ASAM PPC-1 published
• 1992 Coalition for National Clinical Criteria established
• 1994 ASAM Criteria Validity Study funded by NIDA
• 1995 “The Role and Current Status of Patient Placement Criteria In the Treatment of Substance Use
Disorders” The Recommendations of a Consensus Panel. Co-Chairs: Lee Gartner and David MeeLee, M.D. Treatment Improvement Protocol. The Center for Substance Abuse Treatment.
• 1996 ASAM PPC-2 published
• 1998 – 1999 ASAM PPC endorsed by >20 states, DoD, VA, ValueOptions
• 1999 NIAAA funds Assessment Software project
• 2001 ASAM PPC-2R published
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Understanding and Using ASAM PPC-2R
D. Principles Guiding ASAM PPC Development and Implications (ASAM-PPC-2R pp 15 -17)
Principle
Objectivity
Choice of
Treatment Levels
Continuum of
Care
Treatment Failure
Length of Stay
(LOS)
Twelve Step/
Mutual/Self-Help
Recovery Groups
Implications
1. The criteria are as objective, measurable and quantifiable as possible.
2. Certain aspects of the criteria require subjective interpretation.
3. Like other medical or psychiatric conditions – diagnosis, assessment and treatment
is a mix of objectively measured criteria and experientially based professional
judgments.
1. Referral to specific level of care is based on a multidimensional assessment of the
patient.
2. The goal is a level of care that is least intensive that can accomplish the treatment
objectives while providing safety and security.
3. Levels presented as discrete, but represent benchmarks or points along a continuum
of treatment services used in a variety of ways depending on a patient’s needs and
response.
4. Patient enters the continuum at any level and moves through levels of care in
consecutive order or skipping levels as needed.
1. Within and across the levels of care, there is a continuum of the severity of illnesses
treated; and the intensities of services provided.
2. Funding and reimbursement needs to match this continuum of care and intensities
of service.
3. If only one of many levels of care is offered, movement between levels requires
linking patient with providers of other levels of care whenever indicated by the
assessment of the patient’s needs and progress.
1. A concern is the concept of “treatment failure,” which has been used by some
reimbursement or managed care organizations as a prerequisite for approving
admission to a more intensive level of care (e.g., “failure” in outpatient treatment as a
prerequisite for admission to inpatient treatment).
2. Because ASAM believes that individual treatment decisions should be based upon
an assessment of each patient, the requirements that a person fail one or more times
in outpatient treatment before he or she can be considered for inpatient treatment is
no more rational than treating every patient in an inpatient program or using a fixed
length of stay for all.
1. No fixed LOS
2. LOS depends on severity of illness and progress/response to treatment
1. Initial consideration was given to including self-help recovery groups such as
Alcoholics Anonymous, Narcotics Anonymous or Cocaine Anonymous as a formal
treatment level.
2. As valuable as they are, these recovery groups do not constitute a treatment level and
do not meet the criteria used to describe the programmatic aspects of different levels
of treatment. Rather, it is best to consider them “self problem identification, helpseeking options.”
3. Significant consideration was given to specific inclusion of spiritual parameters
as they relate to placement criteria. We acknowledge that spirituality is absolutely
inherent in the comprehensive biopsychosocial multidimensional assessment,
treatment, and continuity of care for substance-related disorders. Spiritual concepts,
ideas, and relationships are integral to all levels of care and, to a certain degree, even
transcend each level of care; nonetheless, they are difficult to define acceptably in
objective, behavioral and measurable terms. Spirituality is implied in all dimensions
and in all levels of care, and certainly is inherent in the Twelve Step philosophy.
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Understanding and Using ASAM PPC-2R
1. Assessment of Biopsychosocial Severity and Function (ASAM PPC-2R, pp 5-7)
The common language of the six assessment dimensions of the ASAM Patient Placement Criteria can be
used to determine multidimensional assessment of severity and level of function; needs and resources;
problems and strengths of people seeking addiction and mental health services.
1. Acute intoxication and/or withdrawal potential 2. Biomedical conditions and complications 3. Emotional/behavioral/cognitive conditions and complications
4. Readiness to Change
5. Relapse/Continued Use/Continued Problem potential
6. Recovery environment
Assessment Dimensions
Assessment and Treatment Planning Focus
1. Acute Intoxication and/
or Withdrawal Potential
Assessment for intoxication and/or withdrawal management.
Detoxification in a variety of levels of care and preparation for continued
addiction services.
2. Biomedical Conditions
and Complications
Assess and treat co-occurring physical health conditions or complications.
Treatment provided within the level of care or through coordination of
physical health services.
3. Emotional, Behavioral
or Cognitive Conditions
and Complications
Assess and treat co-occurring diagnostic or sub-diagnostic mental health
conditions or complications. Treatment provided within the level of care
or through coordination of mental health services.
4. Readiness to Change
Assess stage of readiness to change. If not ready to commit to full recovery,
engage into treatment using motivational enhancement strategies. If ready
for recovery, consolidate and expand action for change.
5. Relapse, Continued Use
or Continued Problem
Potential
Assess readiness for relapse prevention services and teach where
appropriate. If still at early stages of change, focus on raising consciousness
of consequences of continued use or continued problems as part of
motivational enhancement strategies.
6. Recovery Environment
Assess need for specific individualized family or significant other, housing,
financial, vocational, educational, legal, transportation, childcare services.
2. Biopsychosocial Treatment - Overview: 5 M’s
* Motivate - Dimension 4 issues; engagement and alliance building
* Manage - the family, significant others, work/school, legal
* Medication - detox; HIV/AIDS; anti-craving anti-addiction meds; disulfiram, methadone;
buprenorphine, naltrexone, acamprosate, psychotropic medication
* Meetings - AA, NA, Al-Anon; Smart Recovery, Dual Recovery Anonymous, etc.
* Monitor - continuity of care; relapse prevention; family and significant others
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Understanding and Using ASAM PPC-2R
3. Treatment Levels of Service (ASAM PPC-2R, pp 2-4)
I Outpatient Services
II Intensive Outpatient/Partial Hospitalization Services
III Residential/Inpatient Services
IV Medically-Managed Intensive Inpatient Services
Levels of Care and Service in ASAM PPC-2R: (ASAM PPC-2R, pp 2-4)
I - Outpatient Treatment (<9 hours/week for
Adults; <6 hours/week for Adolescents)
Level 0.5: Early Intervention Services (ASAM
PPC-2R, pp 41-44; pp 205-208) - Criteria for
assessment and education services for individuals
with problems or risk factors related to substance
use, but for whom an immediate Substance
Related Disorder cannot be confirmed. Further
assessment is warranted to rule in or out addiction.
Level II Intensive Outpatient/Partial
Hospitalization Services (ASAM PPC-2R, pp
55-69; pp 217-233)
II.1 - Intensive Outpatient Treatment (9 hours/
week for Adults; 6 hours/week for Adolescents)
Opioid Maintenance Therapy (OMT) (ASAM
II.5 - Partial Hospitalization Treatment
PPC-2R, pp 137-143) - Criteria for Level I
Outpatient OMT, with discussion that OMT can
be in all levels of service, and not restricted to only
being an outpatient treatment modality.
Level III Residential/Inpatient Services
(ASAM PPC-2R, pp 71-126; pp 235-269)
Detoxification Services for Dimension 1
III.1 - Clinically-Managed, Low Intensity
Residential Treatment (Halfway House; Support.
Living Envir.)
I-D - Ambulatory Detoxification without
Extended On-site Monitoring
III.3 - Clinically-Managed, Medium Intensity
Residential Treatment (Therapeutic Rehabilitation
Facility) (This level is not in the Adolescent
Criteria continuum of care)
(Adult Criteria only) (ASAM PPC-2R – pp
145-146)
II-D - Ambulatory Detoxification with Extended
On-site Monitoring
III.5 - Clinically-Managed, Medium/High
Intensity Residential Treatment (Therapeutic
Community, Residential Treatment Center)
III.2-D - Clinically-Managed Residential
Detoxification Services (Social Detoxification)
III.7 - Medically-Monitored Intensive Inpatient
Treatment (Inpatient Treatment Center)
III.7-D - Medically-Monitored Inpatient
Detoxification Services
Level IV Medically-Managed Intensive
Inpatient Services (ASAM PPC-2R, pp 127-135;
IV-D - Medically-Managed Inpatient
Detoxification Services
pp 271-278)
Level I Outpatient Services (ASAM PPC-2R,
IV - Medically-Managed Intensive Inpatient
Treatment
pp 45-56; pp 209-219)
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Understanding and Using ASAM PPC-2R
ASAM PPC-2R Level of
Detoxification Service for Adults
Ambulatory Detoxification without
Extended On-Site Monitoring
Ambulatory Detoxification with
Extended On-Site Monitoring
Clinically-Managed Residential
Detoxification
Medically-Monitored Inpatient
Detoxification
Medically-Managed Inpatient
Detoxification
ASAM PPC-2R Levels of Care
Early Intervention
Outpatient Services
Intensive Outpatient
Partial Hospitalization
Clinically-Managed Low-Intensity
Residential
Clinically-Managed Med-Intensity
Residential
Clinically-Managed High-Intensity
Residential
Note: There are no separate Detoxification
Services for Adolescents
Mild withdrawal with daily or less than daily outpatient
I-D supervision; likely to complete detox. and to continue
treatment or recovery
Moderate withdrawal with all day detox. support and
II-D supervision; at night, has supportive family or living situation;
likely to complete detox.
Moderate withdrawal, but needs 24-hour support to complete
III.2-D detox. and increase likelihood of continuing treatment or
recovery
Severe withdrawal and needs 24-hour nursing care and
III.7-D physician visits as necessary; unlikely to complete detox.
without medical, nursing monitoring
Severe, unstable withdrawal and needs 24-hour nursing
IV-D care and daily physician visits to modify detox. regimen and
manage medical instability
Level
Level
0.5
I
II.1
II.5
III.1
III.3
III.5
Medically-Monitored Intensive
Inpatient
III.7
Medically-Managed Intensive
Inpatient
IV
Same Levels of Care for Adolescents except Level III
Assessment and education for at risk individuals who do not
meet diagnostic criteria for Substance-Related Disorder
Less than 9 hours of service/week (adults); less than 6 hours/
week (adolescents) for recovery or motivational enhancement
therapies/ strategies
9 or more hours of service/week (adults); 6 or more hours/
week (adolescents) to treat multidimensional instability
20 or more hours of service/week for multidimensional
instability not requiring 24 hour care
24 hour structure with available trained personnel; at least 5
hours of clinical service/week
24 hour care with trained counselors to stabilize
multidimensional imminent danger. Less intense milieu
and group treatment for those with cognitive or other
impairments unable to use full active milieu or therapeutic
community
24 hour care with trained counselors to stabilize
multidimensional imminent danger and prepare for
outpatient treatment. Able to tolerate and use full active
milieu or therapeutic community
24 hour nursing care with physician availability for significant
problems in Dimensions 1, 2 or 3. Sixteen hour/day
counselor ability
24 hour nursing care and daily physician care for severe,
unstable problems in Dimensions 1, 2 or 3. Counseling
available to engage patient in treatment
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Understanding and Using ASAM PPC-2R
E. Terminology
• Decimal point system (ASAM PPC-2R, p.2)
• Assessment dimensions – use regular Arabic numbers
• Levels of Service - Levels I-IV since 1991 to maintain common language – Roman numerals
• Examples, Setting, Support Systems, Staff, Therapies, Assessment/Treatment Plan Review,
Documentation (ASAM PPC-2R, Adult Level II, pp.57-61; Adolescent Level III, p. 243-253)
• DSM-IV diagnoses - Substance-Induced and Substance Use Disorders; Diagnostic Admission
Criteria – Diagnostic Admission Criteria (ASAM PPC-2R, Adult Level III, p.98; Adolescent Level
III, p. 254)
• Dimensional Admission Criteria (ASAM PPC-2R, Adult Level I, p.50; Adult Level IV, p. 132)
• “Clinically-Managed” (ASAM PPC-2R, p. 360)
• “Residential” versus “Inpatient”
• “Length of Stay” (ASAM PPC-2R, p. 16); “Length of Service” (ASAM PPC-2R, p. 45)
F. Selected ASAM PPC-2R Changes
1. Improving Level I, Outpatient Services (ASAM PPC-2R, p. 52; p. 215)
The additional admission criteria for Dimension 4, Level I services (page 52, 2001) are as follows:
“(c) The patient is ambivalent about a substance-related and/or mental health problem. He or she requires
monitoring and motivating strategies, but not a structured milieu program. For example, the patient has
sufficient awareness and recognition of a substance use and/or mental health problems to allow engagement
and follow-through with attendance at intermittent treatment sessions as scheduled; or
(d) The patient may not recognize that he or she has a substance-related and/or mental health problem. For
example, he or she is more invested in avoiding a negative consequence than in the recovery effort. Such a
patient may require monitoring and motivating strategies to engage in treatment and to progress through the
stages of change.”
2. Changes to Continued Service and Discharge Criteria (ASAM PPC-2R, pp. 7, 35-40; pp
199-204)
In the process of patient assessment, certain problems and priorities are identified as justifying
admission to a particular level of care. The resolution of those problems and priorities determines
when a patient can be treated at a different level or discharged from treatment. The appearance of new
problems may require services that can be provided effectively at the same level of care, or they may
require a more or less intensive level of care.
After the admission criteria for a given level of care have been met, the criteria for continued service,
discharge or transfer from that level of care are as follows:
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Understanding and Using ASAM PPC-2R
Continued Service Criteria: It is appropriate to retain the patient at the present level of care if:
1. The patient is making progress, but has not yet achieved the goals articulated in the individualized
treatment plan. Continued treatment at the present level of care is assessed as necessary to permit the
patient to continue to work toward his or her treatment goals;
or
2. The patient is not yet making progress but has the capacity to resolve his or her problems. He or
she is actively working on the goals articulated in the individualized treatment plan. Continued
treatment at the present level of care is assessed as necessary to permit the patient to continue to
work toward his or her treatment goals;
and/or
3. New problems have been identified that are appropriately treated at the present level of care. This
level is the least intensive at which the patient’s new problems can be addressed effectively.
To document and communicate the patient’s readiness for discharge or need for transfer to another level
of care, each of the six dimensions of the ASAM criteria should be reviewed. If the criteria apply to the
patient’s existing or new problem(s), the patient should continue in treatment at the present level of
care. If not, refer the Discharge/Transfer Criteria, below.
Discharge/Transfer Criteria: It is appropriate to transfer or discharge the patient from the present level
of care if he or she meets the following criteria:
1. The patient has achieved the goals articulated in his or her individualized treatment plan, thus
resolving the problem(s) that justified admission to the current level of care;
or
2. The patient has been unable to resolve the problem(s) that justified admission to the present level of
care, despite amendments to the treatment plan. Treatment at another level of care or type of service
therefore is indicated;
or
3. The patient has demonstrated a lack of capacity to resolve his or her problem(s). Treatment at
another level of care or type of service therefore is indicated;
or
4. The patient has experienced an intensification of his or her problem(s), or has developed a new
problem(s), and can be treated effectively only at a more intensive level of care.
To document and communicate the patient’s readiness for discharge or need for transfer to another level
of care, each of the six dimensions of the ASAM criteria should be reviewed. If the criteria apply to the
existing or new problem(s), the patient should be discharged or transferred, as appropriate. If not, refer
to the Continued Service criteria.
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Understanding and Using ASAM PPC-2R
3. ASAM PPC-2R’s Approach to Co-occurring Disorders (ASAM PPC-2R, pp. 7-12)
(a) Historical context of the ASAM PPC
• Dimension 3 – 1991: “Emotional/Behavioral Conditions and Complications” versus “Psychiatric
Conditions”, which would keep Dimension 3 too focused on mental health treatment and dual
diagnosis; and diminish interest in mental health issues as an expected part of addiction and recovery
• “Conditions” refers to co-occurring mental disorders (dual diagnosis)
• “Complications” refers to addiction-related, mental health problems that can distract the client’s
attention from primary addiction recovery treatment
(b) Terminology Used
The addiction and mental health fields have not yet reached consensus on terminology to describe
individuals who are experiencing simultaneous addictive and mental health disorders. Clearly, this
issue requires further discussion and consensus building. In the interim, the ASAM PPC 2R has
adopted the term “Co-occurring Mental and Substance Related Disorders” in formal titles so as to
remain consistent with the Diagnostic and Statistical Manual of Mental Disorders of the American
Psychiatric Association. Throughout the text, however, the term “dual diagnosis” is used for the sake
of simplicity and because it appears to have the widest acceptance nationally. (The authors recognize
that “dual diagnosis” is an inexact term and that it fails to accommodate populations other than those
with mental and substance related disorders – such as persons with coexisting addictive and biomedical
or developmental disorders – but the advantages of simplicity and wide acceptance were judged to
outweigh these deficits. We expect to revisit this decision in future editions of the Patient Placement
Criteria.)
(c) Adult versus Adolescent Criteria Differences
• Dimension 3 Subdomains
• Assumptions about Adolescent Criteria – developmental issues; co-occurring emotional, behavioral
and cognitive issues and the need for a more clinically-sophisticated staff
• More focus on mental health issues for adolescents who often have co-occurring emotional/
behavioral issues. No AOS, DDC or DDE descriptions in adolescent criteria
(d) Dual Diagnosis Program Descriptions – AOS, MHOS, DDC, DDE
When the first edition of the ASAM Patient Placement Criteria (ASAM PPC 1) was published in
1991, the criteria generally were designed for programs that offered only addiction treatment services.
However, the PPC 1 also acknowledged that some patients had co-occurring mental and substance use
problems and thus included Dimension 3, Emotional/Behavioral Conditions and Complications. Such
patients are not adequately treated in programs that offer only addiction treatment services.
The ASAM PPC 2R describes three types of services: those that offer Addiction-Only Services (AOS),
those that are Dual Diagnosis Capable (DDC), and those that are Dual Diagnosis Enhanced (DDE).
AOS has been modified to describe Mental Health-Only Services (MHOS). Programs capabilities are
defined as follows:
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Understanding and Using ASAM PPC-2R
Description of Services
1. Programs that offer Addiction-Only Services (AOS)/Mental Health-Only Services (MHOS)
• Cannot accommodate patients with psychiatric illnesses that require ongoing treatment,
however stable the illness and however well functioning the individual. Such programs are said
to provide Addiction-Only Services (AOS). Cannot accommodate those with addiction illness
are Mental Health-Only Services.
• The policies and procedures typically do not accommodate co-occurring disorders: for
example, individuals on certain psychotropic medications generally are not accepted in AOS,
coordination or collaboration between chemical and mental health services is not routinely
present, and mental health issues are not usually addressed in treatment planning or content in
AOS and vice versa in MHOS.
2. Dual Diagnosis Capable (DDC) Programs
• Dual Diagnosis Capable (DDC) programs routinely accept individuals who have co-occurring
mental and substance related disorders.
• DDC programs can meet such patients’ needs so long as their psychiatric disorders are
sufficiently stabilized and the individuals are capable of independent functioning to such a
degree that their mental disorders do not interfere with participation in addiction treatment in
AOS; and vice versa.
• DDC programs address dual diagnoses in their policies and procedures, assessment, treatment
planning, program content, and discharge planning.
• They have arrangements in place for coordination and collaboration between chemical and
mental health services.
• They also can provide addiction consultation, psychopharmacologic monitoring and
psychological assessment and consultation on site; or by well-coordinated consultation off-site.
3. Dual Diagnosis Enhanced (DDE) Programs
• DDE programs can accommodate individuals with dual diagnoses who may be unstable or
disabled to such an extent that specific psychiatric and mental health support, monitoring and
accommodation are necessary in order for the individual to participate in addiction treatment.
• DDE programs are staffed by psychiatric and mental health clinicians as well as addiction
treatment professionals. Cross training is provided to all staff. Such programs tend to have
relatively high ratios of staff to patients and provide close monitoring of patients who
demonstrate psychiatric instability and disability.
• DDE programs typically have policies, procedures, assessment, treatment planning and
discharge planning that accommodate patients with dual diagnoses.
• Dual diagnosis-specific and mental health symptom management groups are incorporated
into addiction treatment. Motivational enhancement therapies are more likely to be available
(particularly in outpatient settings)
• Ideally, there is close collaboration or integration with a mental health program that provides
crisis back-up services and access to mental health case management and continuing care.
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Understanding and Using ASAM PPC-2R
4. Experimental Matrix and Co-occurring Disorders (ASAM PPC-2R, pp. 281-312; pp
313-339)
Matrix for Matching Services to Needs
Risk Rating
and Description
Types of Services
and Modalities Needed
Intensity of Service/
Level of Care/Setting
Assess severity and level of
function to identify needs
for services in all six ASAM
assessment dimensions
Identify what variety of
services are required to address
priority needs based on the risk
assessment in each dimension
Determine what type of service
setting and level of care can
efficiently, safely provide the
needed intensities of service
Risk ratings are benchmarked
on a scale of 0 to 4 with 0
indicating full function and
no risk in this assessment
dimension
If 0, no specific services are
needed in this assessment
dimension
Intensity of services are
benchmarked on a scale of 0
to 4 with 0, indicating that
no specific level of care or
treatment setting is needed in
this assessment dimension
If risk rating is 1-4, the severity
and risk level rises with the
higher number in whatever
assessment dimension is being
assessed
Specific services in an
individualized treatment
plan are designed to match
the severity, level of function
and risk in this assessment
dimension
The intensity of services will
rise with the higher risk rating
in Dimensions 1 -3, but will
be variable for Dimensions
4-6 depending on the mix of
services in the middle column
Risk Description. The risk descriptions and ratings within each assessment dimension help staff
determine the immediacy and scope of the service plan by guiding what types and modalities of service
are needed. They also indicate the intensity or level of service at which the patient can be treated with
safety and efficacy.
Risk Domains. A Risk Domain is an assessment subcategory within Dimension 3, as described below:
(ASAM PPC-2R, p. 182)
• Dangerousness/Lethality. This Risk Domain describes how impulsive an individual may be with
regard to homicide, suicide, or other forms of harm to self or others and/or to property. The
seriousness and immediacy of the individual’s ideation, plans and behavior—as well as his or her
ability to act on such impulses—determine patient’s risk rating and type/intensity of services needed.
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Understanding and Using ASAM PPC-2R
• Interference with Addiction Recovery Efforts. This Risk Domain describes the degree to which
a patient is distracted from addiction recovery efforts by emotional, behavioral and/or cognitive
problems and, conversely, the degree to which a patient is able to focus on addiction recovery. (High
risk and severe impairment in this domain do not, alone, require services in a Level IV program.)
• Social Functioning. This Risk Domain describes the degree to which an individual’s relationships
(e.g., coping with friends, significant others or family; vocational or educational demands; and
ability to meet personal responsibilities) are affected by his or her substance use and/or other
emotional, behavioral and cognitive problems. (Note that high risk and severe impairment in this
domain do not, in themselves, require services in a Level IV program.)
• Ability for Self Care. This Risk Domain describes the degree to which an individual’s ability to
perform activities of daily living (such as grooming, food and shelter) are affected by his or her
substance use and/or other emotional, behavioral and cognitive problems. (Note that high risk and
severe impairment in this domain do not, in themselves, require services in a Level IV program.)
• Course of Illness. This Risk Domain employs the history of the patient’s illness and response to
treatment to interpret the patient’s current signs, symptoms and presentation and predict the
patient’s likely response to treatment. Thus, the domain assesses the interaction between the
chronicity and acuity of the patient’s current deficits. A high risk rating is warranted when the
individual is assessed at significant risk and vulnerability for dangerous consequences either because
of severe, acute life threatening symptoms, or because a history of such instability suggests that high
intensity services are needed to prevent dangerous consequences.
For example, a patient may present with medication adherence problems, having discontinued
antipsychotic medication two days ago. If a patient is known to rapidly decompensate when medication
is stopped, his or her rating is high. However, if it the patient slowly isolates without any rapid
deterioration when medication is stopped, the risk rating would be less. Another example is the patient
who has been depressed and socially withdrawn. If this has been a problem for six weeks, the risk rating
is much higher than for a patient who has been chronically withdrawn and isolated for six years with a
severe and persistent schizophrenic disorder.
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Understanding and Using ASAM PPC-2R
5. Revised Constructs for Dimension 5: Relapse/Continued Use Potential (ASAM PPC2R, pp 341-353)
A. Historical Pattern of Use
1. Chronicity of Problem Use
• Since when and how long has the individual had problem use or dependence and at what level
of severity?
2 2. Treatment or Change Response
• Has he/she managed brief or extended abstinence or reduction in the past?
B. Pharmacologic Responsivity
3. Positive Reinforcement (pleasure, euphoria)
4. Negative Reinforcement (withdrawal discomfort, fear)
C. External Stimuli Responsivity
5. Reactivity to Acute Cues (trigger objects and situations)
6. Reactivity to Chronic Stress (positive and negative stressors)
D. Cognitive and behavioral measures of strengths and weaknesses
7. Locus of Control and Self-efficacy
• Is there an internal sense of self-determination and confidence that the individual can direct
his/her own behavioral change?
8. Coping Skills (including stimulus control, other cognitive strategies)
9. Impulsivity (risk-taking, thrill-seeking)
10. Passive and passive/aggressive behavior
• Does the individual demonstrate active efforts to anticipate and cope with internal and external
stressors, or is there a tendency to leave or assign responsibility to others?
6. The Adolescent Criteria
• Dimension 3 subdomains added
• The traditional format of levels of service maintained for PPC-2R
• Level I is less than six hours/week not less than nine hours as in the adult criteria
• Level II.1 is six hours per week not nine hours /week as in adult criteria
• Levels of Service similar to those of Adult PPC-2 Criteria with one less Level III service – no III.3
• No separate detoxification levels of service
• A proposed new format of criteria (modeled on the Co-occurring Disorders criteria Matrix) in a
section of ASAM PPC-2R that will indicate new directions for the Adolescent Criteria
• More focus on mental health issues for adolescents who often have co-occurring emotional/
behavioral issues. No AOS, DDC or DDE descriptions in adolescent criteria
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Understanding and Using ASAM PPC-2R
G. How to Organize Assessment Data to Focus Treatment
Immediate Need Profile
Assessor considers each dimension and with just sufficient data to assess immediate needs, checks “yes”
or “no” for the following questions:
1. Acute Intoxication and/or Withdrawal
Potential
(a) Past history of serious withdrawal,
life-threatening symptoms or seizures
during withdrawal? e.g., need for IV
therapy; hospitalization for seizure
control; psychosis with DT’s; medication
management with close nurse monitoring
and medical management? No Yes
(b)Currently having similar withdrawal
symptoms? No Yes
4. Readiness to Change
(a) Does client appear to need alcohol or
other drug treatment/recovery and/or
mental health treatment, but ambivalent
or feels it unnecessary? e.g., severe
addiction, but client feels controlled
use still OK; psychotic, but blames a
conspiracy.
No Yes
(b)Client has been coerced, mandated
or required to have assessment and/or
treatment by the criminal justice system,
health or social services, work/school, or
family/significant other?
No Yes
2. Biomedical Conditions/Complications
Any current severe physical health
problems? e.g., bleeding from mouth or
rectum in past 24 hours; recent, unstable
hypertension; recent, severe pain in chest,
abdomen, head; significant problems in
balance, gait, sensory or motor abilities
not related to intoxication.
No Yes
5. Relapse/Continued Use/Continued Problem
Potential
(a) Is client currently under the influence? No Yes
(b)Is client likely to continue to use or
relapse in an imminently dangerous
manner, without immediate care? No Yes
(c) Is client’s most troubling, presenting
problem(s) that brings the client for
assessment, dangerous to self or others?
(See examples above in dimensions 1, 2
and 3)
No Yes
3. Emotional/Behavioral/Cognitive Conditions/
Complications
(a) Imminent danger of harming self or
someone else? e.g., suicidal ideation
with intent, plan and means to succeed;
homicidal or violent ideation, impulses
and uncertainty about ability to control
impulses, with means to act on.
No Yes
(b)Unable to function in activities of daily
living, self with imminent, dangerous
consequences ? e.g., unable to bath, feed,
groom and care for self due to psychosis,
organicity or uncontrolled intoxication
with threat of imminent safety to self,
others as regards death or severe injury No Yes
6. Recovery Environment
Are there any dangerous family,
significant others, living/work/school
situations threatening client’s safety,
immediate well-being, and/or sobriety?
e.g., living with a drug dealer; physically
abused by partner or significant other;
homeless in freezing temperatures No Yes
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Understanding and Using ASAM PPC-2R
H. How to Target and Focus Service Priorities
Decision Tree to Match Assessment and Treatment/Placement Assignment
What Does the Client Want? Why Now?
Does client have immediate needs due to imminent
risk in any of the six assessment dimensions?
Conduct multidimensional assessment
What are the multiaxial DSM IV diagnoses?
Multidimensional Severity /LOF Profile
Identify which assessment dimensions are currently most
important to determine Tx priorities
Choose a specific focus and target for each priority dimension
What specific services are needed for each dimension?
What “dose” or intensity of these services is needed
for each dimension?
Where can these services be provided, in the least
intensive, but safe level of care or site of care?
What is the progress of the treatment plan and placement
decision; outcomes measurement?
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Understanding and Using ASAM PPC-2R
Case Presentation Format
Before presenting the case, please state why you chose the case and what you want to get from
the discussion
I. Identifying Client Background Data
Name
Age
Ethnicity and Gender
Marital Status
Employment Status
Referral Source
Date Entered Treatment
Level of Service Client Entered Treatment (if this case presentation is a treatment plan review)
Current Level of Service (if this case presentation is a treatment plan review)
DSM Diagnoses
Stated or Identified Motivation for Treatment (What is the most important thing the clients
wants you to help them with?)
First state how severe you think each assessment dimension is and why (focus on brief history
information and relevant here and now information):
II. Current Placement Dimension Rating (See Dimensions below 1 - 6) 1.
2.
3.
4.
5.
6.
(Give a brief explanation for each rating, note whether it has changed since the client entered
treatment and why or why not)
This last section we will talk about together:
III.What problem(s) with High and Medium severity rating are of greatest concern at this time?
Specificity of the problem
Specificity of the strategies/interventions
Efficiency of the intervention (Least intensive, but safe, level of service)
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Understanding and Using ASAM PPC-2R
I. Engaging the Client as a Participant in Treatment
1. Stages of Change and How People Change
12-Step model - surrender versus comply; accept versus admit; identify versus compare
Transtheoretical Model of Change (Prochaska and DiClemente):
• Pre-contemplation: not yet considering the possibility of change although others are aware of a
problem; active resistance to change; seldom appear for treatment without coercion; could benefit
from non-threatening information to raise awareness of a possible “problem” and possibilities for
change.
• Contemplation: ambivalent, undecided, vacillating between whether he/she really has a “problem”
or needs to change; wants to change, but this desire exists simultaneously with resistance to it; may
seek professional advice to get an objective assessment; motivational strategies useful at this stage,
but aggressive or premature confrontation provokes strong resistance and defensive behaviors; many
Contemplators have indefinite plans to take action in the next six months or so.
• Preparation: takes person from decisions made in Contemplation stage to the specific steps to be
taken to solve the problem in the Action stage; increasing confidence in the decision to change;
certain tasks that make up the first steps on the road to Action; most people planning to take action
within the very next month; making final adjustments before they begin to change their behavior.
• Action: specific actions intended to bring about change; overt modification of behavior and
surroundings; most busy stage of change requiring the greatest commitment of time and energy; care
not to equate action with actual change; support and encouragement still very important to prevent
drop out and regression in readiness to change.
• Maintenance: sustain the changes accomplished by previous action and prevent relapse; requires
different set of skills than were needed to initiate change; consolidation of gains attained; not a static
stage and lasts as little as six months or up to a lifetime; learn alternative coping and problem-solving
strategies; replace problem behaviors with new, healthy life-style; work through emotional triggers of
relapse.
• Relapse and Recycling: expectable, but not inevitable setbacks; avoid becoming stuck, discouraged,
or demoralized; learn from relapse before committing to a new cycle of action; comprehensive,
multidimensional assessment to explore all reasons for relapse.
• Termination: this stage is the ultimate goal for all changers; person exits the cycle of change, without
fear of relapse; debate over whether certain problems can be terminated or merely kept in remission
through maintenance strategies.
Readiness to Change - not ready, unsure, ready, trying: Motivational interviewing (Miller and
Rollnick)
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Understanding and Using ASAM PPC-2R
The Transtheoretical Model of Behavior Change
The Stages of Change
Termination
Maintenance
Action
Contemplation
Preparation
Precontemplation
The Processes of Change
Precontemplation Contemplation
Preparation
Action
Maintenance
Consciousness Raising
Social Liberation
Helping Relationships
Emotional Arousal
Self-Reevaluation
Environmental Reevaluation
Commitment
Reward
Countering
Environment Control
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Understanding and Using ASAM PPC-2R
2. Developing the Treatment Contract – What Does the Client Want?
Client
Clinical Assessment
Treatment Plan
What?
What does client want?
What does client need?
What is the Tx contract?
Why?
Why now?
What’s the level of
commitment?
Why? What reasons are revealed
by the assessment data?
Is it linked to what client
wants?
How?
How will s/he get
there?
How will you get him/her to
accept the plan?
Does client buy into the
link?
Where?
Where will s/he do
this?
Where is the appropriate setting
for treatment? What is indicated
by the placement criteria?
Referral to level of care
When?
When will this
happen?
How quickly?
How badly does s/he
want it?
When? How soon?
What are realistic expectations?
What are milestones in the
process?
What is the degree of
urgency?
What is the process?
What are the expectations
of the referral?
J. Improving the Range and Use of Treatment Services
1. Dimension 4, Readiness to Change Assessment and Matching
Stage of Change
Service Track
Treatment Processes Used
PPC-2R Level
Precontemplation
Discovery Track
Consciousness-Raising, Social
Liberation
Level 0.5 or I
Contemplation
Discovery Track
As above, plus Emotional
Arousal, Self-Evaluation
Level I
Preparation
Mix of Discovery &
Recovery Tracks
Emotional Arousal, SelfEvaluation, Commitment
Levels I - II.5
Action
Recovery Tracks
Commitment, Reward,
Countering, Environment
Control, Helping
Relationships
Levels I - II.5
Relapse, Recycling
Relapse Track
Based on assessed Stage of
Change to which client has
regressed or recycled
Levels I - IV
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Understanding and Using ASAM PPC-2R
2. Example Policy and Procedure to Deal with Recovery and Psychosocial Crises
Recovery and Psychosocial Crises cover a variety of situations that can arise while a patient is in
treatment. Examples include, but are not limited to, as follows:
1. Slip/ using alcohol or other drugs while in treatment.
2. Suicidal, and the individual is feeling impulsive or wanting to use alcohol or other drugs.
3. Loss or death, disrupting the person’s recovery and precipitating cravings to use or other impulsive
behavior.
4. Disagreements, anger, frustration with fellow patients or therapist.
The following procedures provide steps to assist in implementing the principle of re-assessment and
modification of the treatment plan:
1. Set up a face to face appointment as soon as possible. If not possible in a timely fashion, follow the
next steps via telephone.
2. Convey an attitude of acceptance; listen and seek to understand the patient’s point of view rather
than lecture, enforce “program rules”, or dismiss the patient’s perspective.
3. Assess the patient’s safety for intoxication/withdrawal and imminent risk of impulsive behavior and
harm to self, others, or property. Use the six ASAM assessment dimensions to screen for severe
problems and identify new issues in all biopsychosocial areas.
• Acute intoxication and/or withdrawal potential
• Biomedical conditions and complications • Emotional/behavioral/cognitive conditions and complications
• Readiness to Change
• Relapse/Continued Use/Continued Problem potential
• Recovery environment
4. Discuss the circumstances surrounding the crisis, developing a sequence of events and precipitants
leading up to the crisis. If the crisis is a slip, use the 6 dimensions as a guide to assess causes. If the
crisis appears to be willful, defiant, non-compliance with the treatment plan, explore the patient’s
understanding of the treatment plan; level of agreement on the strategies in the treatment plan; and
reasons s/he did not follow through.
5. Modify the treatment plan with patient input, to address any new or updated problems that arose
from your multidimensional assessment in steps 3 and 4 above.
6. Reassess the treatment contract and what the patient wants, if there appears to be resistance to
developing a modified treatment plan in step 5 above.
7. Determine if the modified strategies can be accomplished in the current level of care; or need a more
or less intensive level of care in the continuum of services.
8. If, on completion of step 6, the patient recognizes the problem/s; understands the need to change
the treatment plan to learn and apply new strategies to deal with the newly-identified issues; but still
chooses not to accept treatment, then discharge is appropriate.
9. Document the crisis and modified treatment plan or discharge in the medical record.
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Understanding and Using ASAM PPC-2R
3. The Coerced Client and Working with Referral Sources
The mandated client can often present as hostile and resistant because they are at “action” for staying
out of jail; keeping their driver’s license; saving their job or marriage; or getting their children back. In
working with referral agencies whether that be a judge, probation officer, child protective services, a
spouse, employer or employee assistance professional, the goal is to use the leverage of the referral source
to hold the client accountable to an assessment and follow through with the treatment plan.
Criminal justice professionals such as judges, probation and parole officers untrained in addiction and
mental health run the risk of thinking that mental health and addiction issues can be addressed from a
criminal justice model. They can see mandated treatment for addiction and mental health problems as a
criminal justice intervention e.g., mandate the client to a particular level of care of addiction treatment
for a fixed length of stay as if ordering an offender to jail for a jail term of three months.
Unfortunately, clinicians and programs often enable such criminal justice thinking by blurring the
boundaries between “doing time” and “doing treatment”. Clinicians say that they cannot provide
individualized treatment since they have to comply with court orders for a particular program and level
of care and length of stay. For everyone involved with mandated clients and think this way, the 3 C’s are
important:
3 C’s
• Consequences – It is within criminal justice’s mission to ensure that offenders take the
consequences of their illegal behavior. If the court agrees that the behavior was largely caused
by addiction and/or mental illness, and that the offender and the public is best served by
providing treatment rather than punishment, then clinicians provide treatment not custody
and incarceration. The obligation of clinicians is to ensure a person adheres to treatment; not
to enforce consequences and compliance with court orders.
• Compliance – The offender is required to act in accordance with the court’s orders; rules and
regulations. Criminal justice personnel should expect compliance. But clinicians are providing
treatment where the focus is not on compliance to court orders. The focus is on whether there
is a disorder needing treatment; and if there is, the expectation is for adherence to treatment,
not compliance with “doing time” in a treatment place.
• Control –The criminal justice system aims to control, if not eliminate, illegal acts that
threaten the public. While control is appropriate for the courts, clinicians and treatment
programs are focused on collaborative treatment and attracting people into recovery. The only
time clinicians are required to control a client is if they are in imminent danger of harm to
self or others. Otherwise, as soon as that imminent danger is stabilized, treatment resumes
collaboration and client empowerment, not consequences, compliance and control.
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Understanding and Using ASAM PPC-2R
The clinician should be the one to decide on what is clinically indicated rather than feeling
disempowered to determine the level of service, type of service and length of service based on the
assessment of the client and his/her stage of readiness to change. Clinicians are just that, not right
arms of the law or the workplace to carry out mandates determined for reasons other than clinical.
Thus, working with referral sources and engaging the identified client into treatment involves all of
the principles and concepts above to meet both the referral source and the client wherever they are
at; to join them in a common purpose relevant to their particular needs and reason for presenting for
care now at this point in time. The issues span the following:
1. Common purpose and mission – public safety; safety for children; similar outcome goals
2. Common language of assessment of stage of change – models of stages of change
3. Consensus philosophy of addressing readiness to change – meeting clients where they are at;
solution-focused; motivational enhancement
4. Consensus on how to combine resources and leverage to effect change, responsibility and
accountability – coordinated efforts to create incentives for change and provide supports to allow
change
5. Communication and conflict resolution - committed to common goals of public safety;
responsibility, accountability, decreased legal recidivism and lasting change ; keep our collective
eyes on the prize “No one succeeds unless we all succeed!”
K. Gathering Data on Policy and Payment Barriers
• Policy, payment and systems issues cannot change quickly. However, as a first step towards reframing
frustrating situations into systems change, each incident of inefficient or in adequate meeting of a
client’s needs can be a data point that sets the foundation for strategic planning and change
• Finding efficient ways to gather data as it happens in daily care of clients can help provide hope and
direction for change:
25
Understanding and Using ASAM PPC-2R
Clinical Assessment and Placement Summary
Name:
1 of 4
Date:
Immediate Need Profile: Consider each dimension to assess immediate needs. Check “yes” or “no” for
the following questions:
Dimension
1.Acute
Intoxication
and/or
Withdrawal
Potential
Questions
Yes No
1(a) Past history of serious withdrawal, life-threatening symptoms or seizures
during withdrawal? e.g., need for IV therapy; hospitalization for seizure
control; psychosis with DT’s; medication management with close nurse
monitoring and medical management?
1(b) Currently having severe, life-threatening and/or similar withdrawal
symptoms?
2
Any current severe physical health problems? e.g., bleeding from mouth or
2.Biomedical
rectum in past 24 hours; recent, unstable hypertension; recent, severe pain in
Conditions/
chest, abdomen, head; significant problems in balance, gait, sensory or motor
Complications
abilities not related to intoxication.
3(a) Imminent danger of harming self or someone else? e.g., suicidal ideation with
3.Emotional/
intent, plan and means to succeed; homicidal or violent ideation, impulses
Behavioral/
and uncertainty about ability to control impulses, with means to act on.
Cognitive
Conditions/
3(b) Unable to function in activities of daily living, care for self with imminent,
Complications
dangerous consequences? e.g., unable to bathe, feed, groom and care for
self due to psychosis, organicity or uncontrolled intoxication with threat of
imminent safety to self, others resulting in death or severe injury.
“Yes” to questions 1a and 1b; or 1b alone; 2 and/or 3 requires that the caller/client immediately receive medical
or psychiatric care for evaluation of need for acute, inpatient care.
4.Readiness to
Change
4(a) Does client appear to need alcohol or other drug treatment/recovery and/or
mental health treatment, but ambivalent or feels it is unnecessary? e.g., severe
addiction, but client feels controlled use still OK; psychotic, but blames a
conspiracy.
4(b) Client has been coerced, mandated or required to have assessment and/
or treatment by the criminal justice system, health or social services, work/
school, or family/significant other?
“Yes” to questions 4a and/or 4b alone, requires caller/client to be seen for assessment within 48 hrs, and preferably
earlier, for motivational strategies, unless patient is imminently likely to walk out and needs containment.
5(a) Is client currently under the influence?
5. Relapse/
Continued Use/ 5(b) Is client likely to continue to use or relapse in an imminently dangerous
Prob. Potential
manner, without immediate care?
5(c) Is client’s most troubling, presenting problem(s) that brings he or she for
assessment, dangerous to self or others? (See examples above in dimensions 1,
2 and 3)
“Yes” to question 5a alone, assess for further need for immediate intervention e.g., taking keys of car away;
having a relative/friend pick client up if severely intoxicated and unsafe.
6. Recovery
Environment
6
Are there any dangerous family, sig. others, living/work/school situations
threatening client’s safety, immediate well-being, and/or sobriety? e.g., living
with a drug dealer; physically abused by partner or significant other; homeless
in freezing temperatures.
“No” to questions 1, 2 and 3 and “Yes” to questions 5b, 5c and/or 6, requires that the caller/client be referred
to a safe or supervised environment e.g., shelter, alternative safe living environment, or residential treatment
depending on level of severity and impulsivity.
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Understanding and Using ASAM PPC-2R
Clinical Assessment and Placement Summary
2 of 4
Rating of Severity/Function: Using assessment protocols that address all six dimensions, assign a
severity rating of 0 to 4 for each dimension that best reflects the client’s functioning and severity. Place a
check mark in the appropriate box for each dimension.
Risk Ratings
Intensity of Service Need
1.
(0) No Risk or Stable – Current risk
absent. Any acute or chronic problem
mostly stabilized.
No immediate services needed.
(1) Mild - Minimal, current difficulty
or impairment. Minimal or mild
signs and symptoms. Any acute or
chronic problems soon able to be
stabilized and functioning restored
with minimal difficulty.
Low intensity of services needed for
this Dimension. Treatment strategies
usually able to be delivered in
outpatient settings
(2) Moderate - Moderate difficulty
or impairment. Moderate signs and
symptoms. Some difficulty coping or
understanding, but able to function
with clinical and other support
services and assistance.
Moderate intensity of services, skills
training, or supports needed for this
level of risk. Treatment strategies may
require intensive levels of outpatient
care.
(3) Significant – Serious difficulties
or impairment. Substantial difficulty
coping or understanding and being
able to function even with clinical
support.
Moderately high intensity of services,
skills training, or supports needed.
May be in, or near imminent danger.
(4) Severe - Severe difficulty or
impairment. Serious, gross or
persistent signs and symptoms. Very
poor ability to tolerate and cope with
problems. Is in imminent danger.
High intensity of services, skills
training, or supports needed. More
immediate, urgent services may
require inpatient or residential
settings; or closely monitored case
management services at a frequency
greater than daily.
27
Dimensions
2. 3. 4. 5.
6.
Understanding and Using ASAM PPC-2R
Clinical Assessment and Placement Summary
3 of 4
Placement Decisions: Indicate for each dimension, the least intensive level consistent with sound
clinical judgment, based on the client’s functioning/severity and service needs.
ASAM PPC-2R Level of
Detoxification Service
Level Dimen. 1
Intoxic/
Withdr.
I-D
Ambul. Detox without
Extended On-Site
Monitor.
Ambul. Detox with
II-D
Extended On-Site
Monitoring
Clinically-Managed
III.2-D
Residential Detoxification
Medically-Monitored CD III.7-D
Inpatient Detoxification
Medically-Managed
IV-D
Intensive Inpatient Detox.
ASAM PPC-2R Level
Level
of Care for Other
*
Treatment and Recovery
Services*
Early Intervention /
Prevention
Outpatient Services /
Individual
Intensive Outpatient
Treatment (IOP)
Partial Hospitalization
(Partial)
Apartments /ClinicallyManaged Low-Int. Res.
Svcs.
Clinically-Managed MedIntens. Residential Svcs.
Clinically-Managed HighIntens. Residential Svcs
Medically-Monitored
Intens. Inpatient
Treatment
Medically-Managed
Intensive Inpatient
Services
Opioid Maintenance
Therapy
Dimen. 2
Biomed
Dimen.
Dimen. 4
3 Emot./ Readiness
Behav/
to Change
Cognitive
Dimen. 5 Dimen. 6
Relapse,
Recovery
Continued Environ.
Use/
Problem
0.5
I
II.1
II.5
III.1
III.3
III.5
III.7
IV
OMT
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Understanding and Using ASAM PPC-2R
Clinical Assessment and Placement Summary
4 of 4
Placement Summary
Level of Care/Service Indicated - Insert the ASAM Level number that offers the most
appropriate level of care/service that can provide the service intensity needed to address
the client’s current functioning/severity; and/or the service needed e.g., shelter, housing,
vocational training, transportation, language interpreter
Level of Care/Service Received - ASAM Level number -- If the most appropriate level
or service is not utilized, insert the most appropriate placement or service available and
circle the Reason for Difference between Indicated and Received Level or Service
Reason for Difference - Check only one number -
1. Service not available
2. Provider judgment
3. Client preference
4. Client is on waiting list for appropriate level
5. Service available, but no payment source
6. Geographic accessibility
7. Family responsibility
8. Language
9. Not applicable
10.Not listed (Specify):
Anticipated Outcome If Service Cannot Be Provided – Check only one number 1. Admitted to acute care setting;
2. Discharged to street;
3. Continued stay in acute care facility;
4. Incarcerated;
5. Client will dropout until next crisis;
6. Not listed (Specify):
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Understanding and Using ASAM PPC-2R
Tracy
A 16-year-old young woman is brought into the emergency room of an acute care hospital. She had
gotten into an argument with her parents and ended up throwing a chair. There was some indication
that she was intoxicated at the time and her parents have been concerned about her coming home late
and mixing with the wrong crowd. There has been a lot of family discord and there is mutual anger and
frustration between the teen and especially her father. No previous psychiatric or addiction treatment.
The parents are both present at the ER, but the police who had been called by her mother brought
her. The ER physician and nurse from the psychiatric unit who came from the unit to evaluate the
teen, both feel she needs to be in hospital given the animosity at home, the violent behavior and the
question of intoxication. Using the six ASAM assessment dimensions, the biopsychosocial clinical data
is organized as follows:
Dimension 1, Intoxication/Withdrawal: though intoxicated at home not long before the chairthrowing 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 a reoccurrence of the 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.
Severity Profile: Dimension:
Severity:
1 2 3 4 5 6
Services Needed:
Site of Care:
30
Understanding and Using ASAM PPC-2R
Ann
DSM IV Diagnosis: Alcohol Dependence and Marijuana Abuse; Major Depression
Ann, a 32-year-old white, divorced female, came in for assessment for the first time ever. She has been
abstinent for 48 hours from alcohol and reports that she has remained so far up to 72 hours during the
past three months. When she has done this she states she has experienced sweats, internal tremors and
nausea, but has never hallucinated, experienced D.T.’s or seizures.
She states she is in good health except for alcoholic hepatitis for which she was just released from the
hospital one week ago. Her doctor referred her for assessment. She smokes up to 3 or 4 joints a day, but
stopped yesterday. In addition to the above, Ann describes two past suicide attempts using sleeping pills,
but the most recent attempt was three years ago and she sees a psychiatrist once a month for review of
her medication. She takes Prozac for the depression and doesn’t report abuse of her medication.
Ann reported that she lives in a rented apartment and has very few friends since moving away after her
divorce a year ago. She is currently unemployed after being laid off when the supermarket she worked
at closed. She has worked as a waitress, check-out person and sales person before and says she has never
lost a job due to addiction.
Ann appears slightly anxious, but is not flushed. She speaks calmly and is cooperative. Ann shows
awareness of her consequences from chemical use, but tends to minimize it and blame others including
her ex-husband who left her without warning. She doesn’t know much about alcoholism/chemical
dependency, but wants to learn more. She has one son, age 11, who doesn’t see any problems with her
drinking and doesn’t know about her marijuana use.
31
Understanding and Using ASAM PPC-2R
Carl
Carl is a 15-year-old young man who you suspect meets DSM criteria for Alcohol Abuse and Marijuana
Abuse, with occasional cocaine (crack) use on weekends. He reports no withdrawal symptoms, but then
he really doesn’t think he has a problem and you are basing your tentative diagnosis on reports from the
school, probation officer, and older sister.
Carl has been arrested three times in the past eighteen months for petty theft/shoplifting offenses. Each
time he has been acting intoxicated but denies use. The school reports acting up behavior, declining
grades and erratic attendance, but no evidence of alcohol/drug use directly. They know he is part of a
crowd that uses drugs frequently.
Yolanda, Carl’s 24-year-old sister, has custody of Carl following his mother’s death from a car accident
eighteen months ago. She is single, employed by the telephone company as a secretary, and has a threeyear-old daughter she cares for. She reports that Carl stays out all night on weekends and refuses to obey
her or follow her rules. On two occasions she has observed Carl drunk. On both occasions he has been
verbally aggressive and has broken furniture. A search of his room produced evidence of marijuana and
crack which Carl claims he is holding for a friend.
32
Understanding and Using ASAM PPC-2R
Kim
Kim is a 29-year-old, Caucasian, single mother, unemployed woman who was referred because of
depression with suicidal and homicidal ideation, but no specific plan or means to follow through. The
client appeared depressed and had made verbal threats towards the Child Protective Services office as
well as suicidal threats and feelings, if she did not get her children back.
Two months earlier, her two sons, who are two and a half and eight were put in a foster home because
she supposedly left them unattended. She says that her boyfriend of fourteen years actually pushed
her down some steps and she fell and was unconscious for four days. She had taken two hits of crystal
methamphetamine and says that as a result of the “dirty” urine test, her children were taken away from
her and she is very angry and depressed about this. Her boyfriend who is now in jail for parole violation
is apparently being charged with attempted murder because of the incident.
Kim has been depressed over wanting to get her children back and angry at “the system” because she
feels she has been wronged. She says that she has not used any drugs other than one day two month’s
ago, for nearly three years and was very active in Alcoholics Anonymous having a sponsor and being
involved up until eight months ago. Kim has drifted away from Alcoholics Anonymous and feels that
this may have caused her relapse in two months earlier. She wants to get her life together but also has
been feeling angry about the difficulty of getting public assistance and has been making verbal threats of
wanting to “blow people’s brains out” and also feelings of wanting to give up and “that she is cracking
up”.
Kim denies any current use of alcohol or other drugs although admits in the past to having significant
problems with cocaine and marijuana. She has had a previous psychiatric hospitalization four years ago,
when she had cut her wrists and needed a couple of sutures after an argument with her boyfriend.
Kim has been having no trouble with sleep and has had an increased appetite with a slight increase in
weight but her energy and libido have been decreased and she has had suicidal feelings. She has been
having some trouble with constipation, poor hearing in her left ear and occasional headaches perhaps
related to the fall two months ago. Her menstrual periods have been normal and she smokes a pack of
cigarettes every two days. She does want help, however, mainly though to get her children back.
33
Understanding and Using ASAM PPC-2R
Stephen
Stephen is 51 years old and is accompanied by his wife. He wants help, but is depressed. During his
intake interview for this, his second DUI arrest, he looks disconsolate and he speaks in a monotone as
he wonders if his wife will leave him. His alcohol use has resulted in alienation from his children, guilt
feelings and his job may now be threatened, as he has been warned by his supervisor about his poor
attendance and performance. Most of his friends drink, but none of them think he is an alcoholic.
He has not had any previous addiction treatment other than DUI classes after his first DUI four years
ago. He attended AA for six months on and off and did have a sponsor, but felt more and more that he
wasn’t as bad as others at AA and gradually stopped going.
Stephen has been alcohol-free for three weeks. He has used cocaine (snorting) about three times per
month over the past four years, but stopped two months ago. He has had no legal or financial problems
related to cocaine. Stephen has continued on diazepam (Valium) 5 mg. qid which he has taken for five
years to relax him because of mild hypertension. He has no other chronic physical problems but has lost
10 pounds weight over the past month and has been sleeping poorly. He wishes he could sleep and get
away from all his problems but denies any organized suicidal plans and says he wants help.
34
Understanding and Using ASAM PPC-2R
Literature References
“Addiction Treatment Matching – Research Foundations of the American Society of Addiction Medicine (ASAM) Criteria”
Ed. David R. Gastfriend has released 2004 by The Haworth Medical Press. David Gastfriend edited this special edition that
represents a significant body of work presented in eight papers. The papers address questions about nosology, methodology,
and population differences and raise important issues to continually refine further work on the ASAM PPC. (To order:
1-800-HAWORTH; or www.haworthpress.com)
International Center for Clinical Excellence – www.centerforclinicalexcellence.com
Post Office Box 180147 Chicago, IL 60618-0573
Tel: (773) 404-5130; Fax: (847) 841-4874; Mobile (773) 454-8511
Mee-Lee, D & Gastfriend, D.R. (2008): “Patient Placement Criteria”, Chapter 6, pp79-91in Marc Galanter & Herbert D.
Kleber (eds) Textbook of Substance Abuse Treatment 4th Edition. American Psychiatric Publishing, Inc. Washington, DC.
Mee-Lee, David (2009): “Moving Beyond Compliance to Lasting Change” Impaired Driving Update Vol XIII, No. 1.
Winter 2009. Pages 7-10, 22
Mee-Lee D, Shulman GD (2009): “The ASAM Placement Criteria and Matching Patients to Treatment”, Chapter 27 in
Section 4, Overview of Addiction Treatment in “Principles of Addiction Medicine” Eds Richard K. Ries, Shannon Miller,
David A Fiellin, Richard Saitz. Fourth Edition. Lippincott Williams & Wilkins, Philadelphia, PA.,USA. pp 387-399.
Mee-Lee D, McLellan AT, Miller SD (2010): “What Works in Substance Abuse and Dependence Treatment”, Chapter 13 in
Section III, Special Populations in “The Heart & Soul of Change” Eds Barry L. Duncan, Scott D.Miller, Bruce E. Wampold,
Mark A. Hubble. Second Edition. American Psychological Association, Washington, DC. pp 393-417.
The ASAM Patient Placement Criteria: PPC Supplement on Pharmacotherapies for Alcohol Use Disorders. Eds Marc J.
Fishman, M.D., David Mee-Lee, M.D., Gerald D. Shulman, M.A., MAC, FACATA, George Kolodner, M.D., and Bonnie
B. Wilford, M.S. Published by Lippincott Williams & Wilkins 2010.
Mee-Lee, David (2001): “Treatment Planning for Dual Disorders”. Psychiatric Rehabilitation Skills Vol.5. No.1, 52-79.
Mee-Lee D, Shulman GD, Fishman M, Gastfriend DR, and Griffith JH, eds. (2001). ASAM Patient Placement Criteria for
the Treatment of Substance-Related Disorders, Second Edition-Revised (ASAM PPC-2R). Chevy Chase, MD: American
Society of Addiction Medicine, Inc. American Society of Addiction Medicine - 4601 Nth. Park Ave., Arcade Suite 101,
Chevy Chase, MD 20815. (301) 656-3920; Fax: (301) 656-3815; www.asam.org; To order ASAM PPC-2R: (800)
844-8948.
Miller, William R; Rollnick, Stephen (2002): “Motivational Interviewing - Preparing People for Change” Second Edition,
New York, NY. Guilford Press.
Prochaska, JO; Norcross, JC; DiClemente, CC (1994): “Changing For Good” Avon Books, New York.
Assessment Instrument Resources
Level of Care Index (LOCI-2R): Checklist tool listing ASAM PPC-2R Criteria to aid in decision-making and
documentation of placement.
Dimensional Assessment for Patient Placement Engagement and Recovery (DAPPER): Severity ratings within each of the
six ASAM PPC-2R dimensions.
To order: The Change Companies at 888-889-8866; www.changecompanies.net
For clinical questions or statistical information about the instruments, contact Norman Hoffmann, Ph.D. at 828-454-9960
in Waynesville, North Carolina; or by e-mail at [email protected]
35
Understanding and Using ASAM PPC-2R
Crosswalk of the ASAM PPC-2R Adult Placement Criteria:
Levels of Service 0.5 through IV (ASAM PPC-2R Pages 27-33)
Criteria
Dimensions
LEVEL 0.5
Early Intervention
DIMENSION 1:
No withdrawal risk
Acute
Intoxication &/
or Withdrawal
Potential
DIMENSION 2:
None or very stable
Biomedical
Conditions &
Complications
DIMENSION 3:
None or very stable
Emotional,
Behavioral
or Cognitive
Conditions &
Complications
DIMENSION 4: Willing to explore how
current alcohol or drug
Readiness to
use may affect personal
Change
goals
OMT
LEVEL I
LEVEL II.1
Opioid Maintenance Outpatient Treatment Intensive Outpatient
Therapy
Physiologically
Not experiencing
Minimal risk of severe
dependent on opiates significant withdrawal,
withdrawal
and requires OMT to
or at minimal risk of
prevent withdrawal
severe withdrawal
None or manageable
with outpatient
medical monitoring
None or very stable, or
is receiving concurrent
medical monitoring
None or manageable None or very stable, or
in an outpatient
is receiving concurrent
structured environment
mental health
monitoring
None or not a
distraction from
treatment. Such
problems are
manageable at Level
II.1.
Mild severity, w/
potential to distract
from recovery; needs
monitoring
Ready to change
the negative effects
of opiate use, but is
not ready for total
abstinence
Ready for recovery but
Has variable
needs motivating and
engagement in tx,
monitoring strategies
ambivalence, or lack
to strengthen readiness.
of awareness of the
Or high severity
substance use or mental
in this dimension
health problem, and
but not in other
requires a structured
dimensions. Needs a
program several times
Level I motivational
a week to promote
enhancement program
progress through the
stages of change
Needs an
At high risk of relapse
Able to maintain
Intensification of
DIMENSION 5:
understanding of, or
or continued use
abstinence or control
addiction or mental
Relapse, Cont. skills to change, current
without OMT and
use and pursue recovery
health symptoms
Use or Cont.
alcohol and drug use
structured therapy to
or motivational goals
indicate a high
Problem
patterns
promote treatment
with minimal support
likelihood of relapse
Potential
progress
or continued use or
continued problems
w/o close monitoring
& support several times
a week
DIMENSION 6: Social support system Recovery environment Recovery environment Recovery environment
or significant others
is supportive and/or
is supportive and/or
is not supportive
Recovery
increase the risk of
the client has skills to
the client has skills to
but, w/ structure &
Environment
personal conflict about
cope
cope
support, the client can
alcohol or drug use
cope
36
Understanding and Using ASAM PPC-2R
Crosswalk of the ASAM PPC-2R Adult Placement Criteria:
Levels of Service 0.5 through IV (ASAM PPC-2R Pages 27-33)
Criteria
Dimensions
LEVEL II.5
Partial Hospitalization
DIMENSION 1:
Moderate risk of severe
withdrawal
Acute
Intoxication &/
or Withdrawal
Potential
DIMENSION 2:
Biomedical
Conditions &
Complications
DIMENSION 3:
None or not sufficient to
distract from treatment. Such
problems are manageable at
Level II.5.
LEVEL III.1
Clinically-managed Low
Intensity Residential Services
No withdrawal risk, or
minimal or stable withdrawal.
Concurrently receiving Level
I-D (minimal) or Level II-D
(moderate) services
LEVEL III.3
Clinically-managed Medium
Intensity Residential Services
Not at risk of severe withdrawal,
or moderate withdrawal is
manageable at Level III.2-D
None or stable, or receiving
concurrent medical monitoring
None or stable, or receiving
concurrent medical monitoring
Mild to moderate severity,
w/ potential to distract from
recovery; needs stabilization
None or minimal; not distracting Mild to moderate severity; needs
to recovery. If stable, a Dual
structure to focus on recovery. If
Emotional,
Diagnosis Capable program
stable, a Dual Diagnosis Capable
Behavioral
is appropriate. If not, a Dual
program is appropriate. If not,
or Cognitive
Diagnosis Enhanced program is
a Dual Diagnosis Enhanced
Conditions &
required.
program is required. Tx should
Complications
be designed to respond to the
client’s cognitive deficits
Open to recovery, but needs
Has little awareness & needs
Has poor engagement in
DIMENSION 4:
a structured environment to
interventions available only at
tx, significant ambivalence,
Readiness to
maintain therapeutic gains
Level III.3 to engage and stay
or lack of awareness of the
Change
in tx; or there is high severity in
substance use or mental health
this dimension but not in others.
problem, requiring a near-daily
The client therefore needs a Level
structured program or intensive
I motivational enhancement
engagement services to promote
program.
progress through stages of
change
Understands relapse but needs
Has little awareness and needs
Intensification of addiction
DIMENSION 5:
structure to maintain therapeutic
intervention available only at
or mental health symptoms,
Relapse, Cont.
gains
Level III.3 to prevent continued
despite active participation
Use or Cont.
use, with imminent dangerous
in a Level I or II.1 program,
Problem
consequences, because of
indicates a high likelihood of
Potential
cognitive deficits or comparable
relapse or continued use or
dysfunction
continued problems w/o neardaily monitoring and support
Environment is dangerous,
Environment is dangerous and
DIMENSION 6: Recovery environment is not
but recovery is achievable if
client needs 24-hour structure to
supportive but, w/ structure &
Recovery
learn to cope
support & relief from the home Level III.1 24-hour structure is
Environment
available
environment, the client can
cope
37
Understanding and Using ASAM PPC-2R
Crosswalk of the ASAM PPC-2R Adult Placement Criteria:
Levels of Service 0.5 through IV (ASAM PPC-2R Pages 27-33)
Criteria
Dimensions
LEVEL III.5
LEVEL III.7
LEVEL IV
Clinically-managed Medium Medically-monitored Intensive Medically-managed Intensive
/ High Intensity Residential
Inpatient Services
Inpatient Services
Services
At minimal risk of severe
At high risk of withdrawal, but
At high risk of withdrawal and
DIMENSION 1:
withdrawal at Levels III.3 or
manageable at Level III.7-D
requires the full resources of a
Acute
III.5. If withdrawal is present, it
and does not require the full
licensed hospital
Intoxication &/
meets Level III.2-D criteria
resources of a licensed hospital
or Withdrawal
Potential
None or stable, or receiving
Requires 24-hour medical
Requires 24-hour medical
DIMENSION 2:
concurrent medical monitoring
monitoring but not intensive
and nursing care and the full
Biomedical
treatment
resources of a licensed hospital
Conditions &
Complications
Moderate severity; needs a 24Because of severe and unstable
DIMENSION 3: Demonstrates repeated inability
to control impulses, or a
hour structured setting. If the
problems, requires 24Emotional,
personality disorder requires
client has a co-occurring mental
hour psychiatric care with
Behavioral
structure to shape behavior.
disorder, requires concurrent
concomitant addiction treatment
or Cognitive
Other functional deficits require
mental health services in a
(Dual Diagnosis Enhanced)
Conditions &
a 24-hour setting to teach
medically monitored setting.
Complications
coping skills. A Dual Diagnosis
Enhanced setting is required for
SPMI - Severely and Persistently
Mentally Ill
Has
marked
difficulty with,
Resistance is high and impulse
Problems in this dimension do
DIMENSION 4:
or opposition to tx, with
control poor, despite negative
not quality the client for Level
Readiness to
dangerous consequences; or
consequences; needs motivating
IV services
Change
there is high severity in this
strategies available only in a
dimension but not in others. The 24-hour structured setting. Or,
client therefore needs a Level
if 24-hr setting is not required,
I motivational enhancement
the client needs a Level I
program.
motivational enhancement
program.
Unable to control use, with
Problems in this dimension do
DIMENSION 5: Has no recognition of the skills
needed to prevent continued
imminently dangerous
not qualify the client for Level
Relapse, Cont. use, with imminently dangerous
consequences, despite active
IV services
Use or Cont.
consequences
participation at less intensive
Problem
levels of care
Potential
Environment is dangerous and
Problems in this dimension do
DIMENSION 6: Environment is dangerous and
the client lacks skills to cope
the client lacks skills to cope
not qualify the client for Level
Recovery
outside of a highly structured
outside of a highly structured
IV services
Environment
24-hour setting
24-hour setting
Note: This overview of the Adult Admission Criteria is an approximate summary to illustrate
the principal concepts and structure of the criteria.
38
Understanding and Using ASAM PPC-2R
DAPPER – Dimensional Assessment for Patient Placement Engagement and Recovery
DAPPER
linked to
on may be
istrations
ases, this
ext of all
no tool or
6
fmann, Ph.D.
in any manner
Date of Birth:
Male
/
Female
/
Age:
Evaluation Dates
Date for A-1:
/
/
Date for A-2:
/
Date for B-1:
/
/
Date for B-2:
/
Date for C-1:
/
month
/
day
Date for C-2:
year
With which ethnic grouping does patient identify:
___ (1) Hispanic/Latino – white
___ (2) Hispanic/Latino – non-white
___ (3) African-American
___ (4) Native American
___ (5) Native Hawaiian/Pacific Islander
___ (6) Asian
___ (7) Middle Eastern
___ (8) Caucasian/White
___ (9) Multiracial/Biracial/Other
Current marital status at entry into treatment:
___ (1) Never married
___ (2) Divorced
___ (3) Separated
___ (4) Widowed
___ (5) Living as married
___ (6) Married
Highest degree earned:
___ (1) No high school diploma earned
___ (2) High school diploma or GED
___ (3) Vocational/technical/business school grad.
___ (4) Associate degree
___ (5) Bachelor’s degree
___ (6) Master’s, doctoral, or other postgrad. degree
Employment status upon entry into treatment:
___ (1) Working full time for pay (35 hr./wk. or more)
___ (2) Working part time for pay (< 35 hr./wk.)
___ (3) Unemployed
___ (4) Not working for pay by choice
___ (5) Disabled
___ (6) Retired
/
/
/
month
/
day
year
Primary job type when working for pay:
___ (1) Professional
___ (2) Upper-level management/business owner
___ (3) Mid-level management
___ (4) Sales/marketing
___ (5) Supervisory
___ (6) Craft/skilled trades/technical
___ (7) Office/white collar/clerical
___ (8) Transportation/equipment operator
___ (9) Laborer/unskilled worker
___ (10) Service worker (waiter/waitress)
___ (11) Domestic worker (housekeeper, etc.)
___ (12) Military service
___ (13) Other (specify)
Diagnostic Impressions
Substance
Not
Determined
eing rated.
tal score
be critical.
e needing to
ed for
Gender:
Dependence
does the first
rating a
e with the
me rating is
trainee or
the booklet
ining option
Name:
ID:
Abuse
ents on a
corded using
s circled
ns labeled
X” is used
-2,” B-2,”
s ease of
ws for an
Dimensional Assessment for Patient Placement Engagement and Recovery
Norman G. Hoffmann, Ph.D., David Mee-Lee, M.D., & Gerald D. Shulman, M.A., M.A.C., FACATA
No
Diagnosis
ring allows
columns:
DAPPER.
TM
Alcohol
Marijuana
Cocaine (powder or crack)
Stimulants of any type
Sedative/hypnotics/tranquilizers
Heroin
Inhalants
PCP
DAPPER PLACEMENT INDICATIONS
TM
Dimensional Assessment for Patient Placement Engagement and Recovery
Name:
Items 1.1 - 1.4
ID #:
Items 1.5 - 1.7
Dimensional Specifications for Admission
Level 0.5
Hallucinogens
Other/unknown/mixedLevel I
Items 1.8 - 1.1
All six dimensions meet Level 0.5 criteria or present no problem.
Items 1.11 - 1.
All six dimensions meet Level I criteria or present no problem.
Level II.1
One of Dimensions 4-6 meets Level II.1, and Dimensions 1-3 are no higher than Level II.1.
Level II.5
One of Dimensions 4-6 meets Level II.5, and Dimensions 1-3 are no higher than Level II.5.
Comments:
Level III.5
Dimension 4-6 all meet Level III.5 criteria, and Dimensions 1 - 3 are no higher than Level III.5.
©©Norman
2000, 2004,
Norman G. Hoffmann,
G. Hoffmann—Copyright,
2000,Ph.D.
2004 All
Allrights
Rightsreserved.
Reserved.
Evince Clinical Assessments
offered
byAssessments,
The ChangePO
Companies®,
5221 Sigstrom
Drive,
Carson City, NV
89706
Evince
Clinical
Box 17305, Smithfield,
RI 02917
USAIII.7
Level
At least
two of the six dimensions meet III.7, and at least one must be Dimension 1, 2, or 3.
Tel: 401-231-2993
or toll free in theFax:
USA:
800-755-6299, www.changecompanies.net
Fax: 401-231-2055
Telephone: 888-889-8866;
775-885-2610;
775-885-0643;
Reproduction
or adaptation
in materials
any form, in may
wholebe
or in
part, by any
means, is a violation
of copyrightinand
constitutes
unethical
and unprofessional
No part
of these
adapted,
photocopied
or reproduced
any
form. Such
duplication
is a conduct.
PLACEMENT PROFILE
conduct.
It is
illegal to duplicate this page in any manner
© 2000, 2004, Norman G. Hoffmann,violation
Ph.D. of copyright and constitutes unprofessional
Indicate the level of care recommended on each dimension for each assessment.
1. Intoxication/Withdrawal
1st
Asmt.
2nd
Asmt.
3rd
Asmt.
4th
Asmt.
5th
Asmt.
6th
Asmt.
______
______
______
______
______
______
2. Biomedical Conditions/Complications ______
______
______
______
______
______
3. Emotional/Behavioral/Cognitive
______
______
______
______
______
______
4. Readiness to Change
______
______
______
______
______
______
5. Relapse/Cont. Use/Problem Potential
______
______
______
______
______
______
6. Recovery Environment
______
______
______
______
______
______
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
Level of Care Indicated:
______
______
______
______
______
______
Level of Care Received:
______
______
______
______
______
______
Reason for Placement Difference, if any
______
______
______
______
______
______
Date of Assessment:
Reasons for Differences: Blank if no difference; 1. Service not available; 2. Provider judgment; 3. Patient preference; 4. On waiting list for appropriate level;
5. No payment resource; 6. Geographic accessibility; 7. Family responsibility; 8. Language; 9. Other – not listed.
Reference pages of the ASAM PPC-2R document, which can be obtained from the American Society of Addiction Medicine:
All levels of care for Dimension 1: pp. 163-175 (Note
Level III.7: Dimension 2 on pp. 102-103; Dimension 3 on pp.
specifications for individual substances in this section).
103-112; Dimension 4 on pp. 112-115; Dimension 5 on pp.
Level 0.5: Dimensions 2-4 on p. 43;
Dimensions 5 & 6 on p. 44.
39
Items 2.7 - 2.1
Comments:
Items 3.1 - 3.5
Items 3.6 - 3.1
Items 3.11 - 3.
Items 3.15 – 3
Item 3.17: Gui
Comments:
Level IV: Dimension 2 on p. 133; Dimension 3 on pp. 133134.
(Note: Dimensions 4-6 do not qualify patients for
admission to this level.)
Levels II.1 & II.5: Dimension 2 on p. 64; Dimension 3 on pp.
64-65; Dimension 4 on pp. 66-67; Dimension 5 on pp. 67-68;
Dimension 6 on p. 68.
Mee-Lee, Shulman, & Hoffmann
Items 2.4 - 2.6
116-122; Dimension 6 on pp. 122-126.
Level I: Dimension 2 on p. 50; Dimension 3 on p. 51;
Dimensions 4 & 5 on p. 52; Dimension 6 on p. 53.
© 2000, 2004, Norman G. Hoffmann, Ph.D.
Items 2.1 – 2.3
DAPPER
2
It is illegal to duplicate this page in any manner
© 2000, 2004, Norman G. Hoffmann, Ph.D.
Understanding and Using ASAM PPC-2R
Shulm
© Mee-Lee,
2000, 2004,
No
DAPPER – Dimensional Assessment for Patient Placement Engagement and Recovery
DAPPER Dimension 1: Acute Intoxication / Withdrawal Potential
........A
se..... 0
........ 1
........ 2
........ 3
e...... 4
B
0
1
2
3
4
C
0
1
2
3
4
........ 0
........ 1
........ 2
........ 3
........ 4
0
1
2
3
4
0
1
2
3
4
nt
........ 0
........ 1
........ 2
........ 3
........ 4
0
1
2
3
4
0
1
2
3
4
........ 0
........ 1
........ 2
........ 3
........ 4
0
1
2
3
4
0
1
2
3
4
B-1 C-1
_ ____ ____
........ 0
........ 1
........ 2
........ 3
........ 4
0
1
2
3
4
0
1
2
3
4
B-1 C-1
_ ____ ____
USE SCALE
A-1 B-1 C-1
____ ____ ____
1.1. Last Use
A
No use in past month ...................................................... 0
No use in past 3 days ...................................................... 1
Use in past 3 days ........................................................... 2
Use within past day......................................................... 3
Use within past 12 hours ................................................ 4
B
0
1
2
3
4
C
0
1
2
3
4
1.2. Quantity of Recent Use
No use or far below intoxication e.g. 1-2 drinks .......... 0
Increased use with well-controlled social behavior...... 1
Use of substance results in obvious intoxication .......... 2
Use of substance results in uncontrolled behavior ....... 3
Heavy quantities result in ongoing dysfunction ........... 4
0
1
2
3
4
0
1
2
3
4
1.3. Frequency of Recent Use
No use or used once or twice ......................................... 0
Sporadic or less than weekly.......................................... 1
At least weekly use ......................................................... 2
Daily use.......................................................................... 3
Multiple substances used on a daily basis..................... 4
0
1
2
3
4
0
1
2
3
4
1.4. Potentiating Substances – Additive Effects
No use of multiple potentiating substances................... 0
Possible potentiating combinations ingested ................ 1
Ingested small amount of potentiating substances........ 2
Ingested substantial quantity of substances................... 3
Potentially lethal combination of substances ................ 4
INTOXICATION SCALE
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
1.6. Physical Signs and Symptoms of Intoxication
Vital signs, gait, speech, coordination normal.............. 0
Mildly unstable vital signs, speech, gait, coordination 1
Mod. unstable vital signs, speech, gait, coordination... 2
Severely unstable vital signs, gait, coordination........... 3
Life-threatening changes in vital signs.......................... 4
0
1
2
3
4
0
1
2
3
4
y
........ 0
........ 1
........ 2
........ 3
........ 4
0
1
2
3
4
0
1
2
3
4
1.7. Mental Signs & Symptoms of Intoxication
Oriented, alert, normal mental function ........................ 0
Mild disturbance of mood, cognition, function ............ 1
Mod. disturbance of mood, cognition, function............ 2
Fluctuating orientation, severe disturb. in function ...... 3
Disoriented, clouded consciousness, or psychotic........ 4
0
1
2
3
4
0
1
2
3
4
© 2000, 2004, Norman G. Hoffmann, Ph.D.
B
0
1
2
3
4
C
0
1
2
3
4
1.9. Mental Status Signs & Symptoms of Withdrawal
Oriented, alert, full mental function .............................. 0
Mild anxiety, agitation, depression, dysfunction.......... 1
Mod. Depression, anxiety, agitation, dysfunction ........ 2
Severe depression, agitation, anxiety, dysfunction....... 3
Suicidal, psychotic, disoriented, hallucinating ............. 4
0
1
2
3
4
0
1
2
3
4
1.10. History of Withdrawal Problems
No prior history of withdrawal problems...................... 0
Minor problems noted in prior withdrawal ................... 1
History of moderate withdrawal problems.................... 2
History of severe withdrawal problems......................... 3
History of life-threatening withdrawal problems ......... 4
0
1
2
3
4
0
1
2
3
4
A-1 B-1 C-1
____ ____ ____
1.11. Client’s Coping Skills with Intoxication/Withdrawal
Symptoms
Fully able to cope with intoxication/withdrawal .......... 0 0 0
Mild difficulty tolerating symptoms/functioning ......... 1 1 1
Moderate difficulty tolerating symptoms/coping ......... 2 2 2
Severe difficulty tolerating symptoms/functioning ...... 3 3 3
Unable to tolerate or cope with symptoms.................... 4 4 4
1.12. Living Arrangement Regarding Detoxification
Persons fully able to assist in detoxification ................. 0 0
Someone available to offer partial assistance ............... 1 1
Unreliable persons available .......................................... 2 2
No one available to assist in detoxification...................
3 3
DAPPER Dimension
Living in environment that encourages use .................. 4 4
0
1
2
3
4
nt
........ 0
........ 1
........ 2
........ 3
........ 4
fmann,
in anyPh.D.
manner
1.8. Physical Signs and Symptoms of Withdrawal A
No problems: vital signs, tremor, sweats, GI ................ 0
Mildly abnormal vital signs, tremor, sweats, etc .......... 1
Mod. unstable vital signs, CNS or GI problems ........... 2
Severe unstable vital signs, CNS or GI problems......... 3
Life-threatening vital signs, seizures ............................. 4
MODIFICATION FACTORS SCALE
A-1 B-1 C-1
____ ____ ____
1.5. Level of Current Intoxication
None – not indicated....................................................... 0
Sub intoxication level ..................................................... 1
Mildly intoxicated........................................................... 2
Very intoxicated.............................................................. 3
Stuporous......................................................................... 4
A-1 B-1 C-1
____ ____ ____
WITHDRAWAL SCALE
Comments:
3
0
1
2
3
5:
4
ENGAGEMENT SCALE
Relapse / Continued Use / Continued Problem Potential
VIOLENCE P
C
0
1
2
3
4
3.1. Violence P
No history or i
Mild tendency
History of occa
History of occa
Chronic violen
A-1 B-1 C-1
____ ____ ____
3.2. Emotiona
Not volatile....
Volatile only w
Volatile with m
Prone to volati
Very volatile a
5.1. Engagement in Ongoing Recovery
A
Highly willing to do whatever is necessary .................. 0
Moderate willingness to do whatever is necessary....... 1
Ambivalent about taking necessary steps...................... 2
Unwilling to engage in recovery efforts........................ 3
Actively opposed to recovery activities ........................ 4
B
0
1
2
3
4
C
0
1
2
3
4
5.8. Mental Health Related Risk Factors
A
No co-occurring mental health problems ...................... 0
Acute MH problems pose minimal risks....................... 1
Moderately stable MH problems pose moderate risk... 2
Serious/chronic MH problems pose ongoing risk ........ 3
Unstable MH problems pose high risk .......................... 4
5.2. Self Help Recovery Involvement
High level of willingness to participate......................... 0
Moderate willingness to participate............................... 1
Ambivalent about participation ..................................... 2
Generally unwilling to participate ................................. 3
Actively
opposed to
participation
..................................
4
It is illegal
to duplicate
this
page in any
manner
0
1
2
3
4
0
1
2
3
4
REACTIVITY SCALE
5.3. Engagement in Recovery Maintenance Services
High level of willingness to participate......................... 0
Moderate willingness to participate............................... 1
Ambivalent about participation ..................................... 2
Generally unwilling to participate ................................. 3
Actively opposed to participation .................................. 4
0
1
2
3
4
0
1
2
3
4
5.4. Expectancies about Treatment
Realistic and positive expectancies ............................... 0
Positive but somewhat unrealistic expectancies ........... 1
Mixed expectancies about change ................................. 2
No expectancies for positive change ............................. 3
Negative/grossly unrealistic expectancies..................... 4
0
1
2
3
4
0
1
2
3
4
RISK FACTORS SCALE
5.10. Reactivity to Chronic Stress
Non-reactive.................................................................... 0
Mildly reactive ................................................................ 1
Moderately reactive ........................................................ 2
Strongly reactive ............................................................. 3
Intensely reactive ............................................................ 4
0
1
2
3
4
0
1
2
3
4
5.11. Reactivity to Acute Cues (trigger objects / situations)
Non-reactive.................................................................... 0 0 0
Mildly reactive ................................................................ 1 1 1
Moderately reactive ........................................................ 2 2 2
Strongly reactive ............................................................. 3 3 3
Intensely reactive ............................................................ 4 4 4
A-1 B-1 C-1
____ ____ ____
CRAVING SCALE
5.6. Alcohol Related Risk Factors
No use.............................................................................. 0
Episodic use (less than weekly) ..................................... 1
Regular use (once or twice a week)............................... 2
Frequent use (3 or more times a week) ......................... 3
Daily intoxication ........................................................... 4
0
1
2
3
4
0
1
2
3
4
5.7. Drug Related Risk Factors
No use of illicit drugs ..................................................... 0
Sporadic use of drugs (<1X/week) not injected .......... 1
Moderate use of drugs (1-3X/week), not injected ........ 2
Frequent use (>3X/week) and/or smoking drugs.......... 3
Daily use of illicit drugs and/or IV drug use................. 4
0
1
2
3
4
0
1
2
3
4
Mee-Lee, Shulman, & Hoffmann
DAPPER
40
B
0
1
2
3
4
5.9. Pharmacological Responsivity (positive reinforcement
from use and/or negative withdrawal reinforcement)
Negligible reinforcement................................................ 0 0 0
Mild reinforcement ......................................................... 1 1 1
Moderate reinforcement ................................................. 2 2 2
Strong reinforcement ...................................................... 3 3 3
Very strong reinforcement ............................................. 4 4 4
5.5. Demographic Risk Factors (under 25; never married,
unemployed; no H.S. diploma or GED)
No demographic risk factors .......................................... 0 0 0
One or two changeable demographic risk factors......... 1 1 1
One or two durable demographic risk factors............... 2 2 2
Three demographic risk factors ..................................... 3 3 3
Four or more significant demographic risks ................. 4 4 4
© 2000, 2004, Norman G. Hoffmann, Ph.D.
DAPPER
A-1 B-1 C-1
____ ____ ____
8
A-1 B-1 C-1
____ ____ ____
5.12. Level of Craving Experience
No cravings ..................................................................... 0
Infrequent cravings ......................................................... 1
Intermittent cravings....................................................... 2
Frequent cravings............................................................ 3
Constant cravings............................................................ 4
0
1
2
3
4
0
1
2
3
4
5.13. Ability to Resist Cravings Impulses
Able to resist cravings/impulses .................................... 0
Able to resist cravings/impulses for long periods......... 1
Able to resist cravings/impulses for brief periods ......... 2
Able to resist cravings briefly only with support........... 3
Unable to resist cravings ................................................. 4
0
1
2
3
4
0
1
2
3
4
© 2000, 2004, Norman G. Hoffmann, Ph.D.
It is illegal to duplicate this page in any manner
Understanding and Using ASAM PPC-2R
3.3. Dangerou
No indication o
Occasional tho
Frequent suicid
Currently suici
Currently suici
3.4. Dangerou
No thoughts ab
General though
Specific target
Current desire
Has target and
3.5. Dangerou
No indication o
Slight risk to s
Moderate risk
Significant risk
Mental conditi
FUNCTIONIN
3.6. Cognitive
Normal cognit
Slight deficit(s
Moderate defic
Severe deficit(
Profound defic
3.7. Attention
No difficulty f
Some distracti
Moderately dis
Short attention
Unable to stay
© 2000, 2004, No
™
l
O
c
I
–
2r
Adult Level of Care Index – 2R
Norman G. Hoffmann, Ph.D., David Mee-Lee, M.D., & Gerald D. Shulman, M.A., M.A.C., FACATA
Name:
Interviewer:
ID #:
Age:
Date of Birth:
___ ___ / ___ ___ / ___ ___ ___ ___
month
Current Marital Status (check one):
herapy, and
c craving or
Employment Status (check one):
system, but has
support or an
s manifested the
nitive problems in
ble on an outpatient
s OMT medically
ATA
NV 89706.
tion of copyright
6
7
8
9
10
11
(3) Unemployed
(4) Not working by choice
12
13
14
15
16+
Alcohol
Marijuana
Cocaine
Opioids
Amphetamines/Stimulants
Sedative/Hypnotic/Anxiolytic
Hallucinogens
PCP
Inhalants
Poly/Unspecified
Club Drugs
Steroids
Tobacco
Other (specify)
D5
D6
D7
A1
Social
Problems
D4
Legal
Problems
D3
Hazardous
Use
D2
Role
Obligations
Time Spent
Using
D1
Abuse
Sacrificing
Activities to Use
Physical/Psych.
Consequences
Desire/Attempts
to Stop
Dependence
Excessive
Use
Substance
Withdrawal
Diagnostic
Impressions
Abuse
rs are supportive
mprove likelihood of
4 5
(3) Separated
(6) Living as married
Diagnosis Related Information (check all that apply):
ENt
make OMT feasible;
3
year
(3) Hispanic/Latino
(6) Biracial/Other
(2) Divorced
(5) Married
(1) Working full-time (35 hr./wk or more)
(2) Working part-time (less than 35 hr./wk)
2
(2) Female
day
(2) African-American
(5) White/Caucasian
(1) Never married
(4) Widowed
Highest Grade Completed (circle): 1
(1) Male
month
(1) Asian
(4) Native American
Dependence
ntensification of
s, or deteriorating
nt plan; or
to lack of awareness
ing gratification, or
ment.
year
day
Ethnic Background (check one):
uSE, Or
pOtENtIAl
Sex:
Current Date: ___ ___ / ___ ___ / ___ ___ ___ ___
Tolerance
E
herapy, and
ss and recovery; or
nal events, but
nt may be effective
ated structured
LOCI-2R – Adult Level of Care Index - 2R
A2
A3
A4
l O c I – 2r™
Adult Level of Care Index – 2R
SUMMARY OF FINDINGS
Name:
ID #:
Dimensional Specifications for Admission
Level 0.5
All six dimensions meet Level 0.5 criteria.
Level I
All six dimensions meet Level I criteria or present no problem
Level II.1
One of Dimensions 4-6 meets Level II.1, and Dimensions 1-3 are no higher than Level II.1.
Level II.5
One of Dimensions 4-6 meets Level II.5, and Dimensions 1-3 are no higher than Level II.5.
© 2001, Norman G. Hoffmann, Ph.D. All rights reserved.
Evince Clinical Assessments offered by The Change Companies®, 5221 SigstromLevel
Drive,
Carson City,All
NV
III.1
six89706.
dimensions meet at least Level III.1 criteria.
Telephone: 888-889-8866; 775-885-2610; Fax 775-885-0643; www.changecompanies.net
Level III.3
All six dimensions meet at least Level III.3 criteria.
No part of these materials may be adapted, photocopied or reproduced in any form. Such duplication is a violation of
All six dimensions meet at least Level III.5 criteria.
copyright and constitutes unprofessional conduct.Level III.5
Level III.7
At least two of the six dimensions meet Level III.7 criteria, and at least one must be Dimension 1, 2, or 3.
Level IV
At least one of Dimensions 1, 2, or 3 meets Level IV criteria.
Level OMT
Meets Opioid Maintenance Therapy specifications for all six dimensions.
Adult Admission Profile
Indicate the highest level of care indicated on each dimension for each assessment.
1st
Asmt.
2nd
Asmt.
3rd
Asmt.
4th.
Asmt.
5th
Asmt.
6th
Asmt.
______
______
______
______
______
_______
2. Biomedical Conditions/Complications ______
______
______
______
______
_______
3. Emotional/Behavioral/Cognitive
______
______
______
______
______
_______
4. Readiness to Change
______
______
______
______
______
_______
5. Relapse/Cont. Use/Problem Potential
______
______
______
______
______
_______
6. Recovery Environment
______
______
______
______
______
_______
1. Intoxication/Withdrawal
Date of Assessment:
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
Level of Care Indicated:
______
______
______
______
______
______
Level of Care Received:
______
______
______
______
______
______
Reason for Placement Difference, if any: ______
______
______
______
______
______
Reasons for Differences: 0. Not applicable – no difference; 1. Service not available; 2. Provider judgment; 3. Patient preference; 4. On waiting list for appropriate level;
5. No payment resource; 6. Geographic accessibility; 7. Family responsibility; 8. Language; 9. Other – not listed.
Reference pages of the ASAM PPC-2R document, which can be obtained from the American Society of Addiction Medicine:
All levels of care for Dimension 1: pp. 163-175 (Note
specifications for individual substances in this section).
Levels III.1, III.3, III.5, and III.7: Dimension 2 on pp. 102-103;
Dimension 3 on pp. 103-112; Dimension 4 on pp. 112-115;
Dimension 5 on pp. 116-122; Dimension 6 on pp. 122-126.
Level 0.5: Dimensions 2-4 on p. 43;
Dimensions 5 & 6 on p. 44.
Level I: Dimension 2 on p. 50; Dimension 3 on p. 51; Dimensions
4 & 5 on p. 52; Dimension 6 on p. 53.
Levels II.1 & II.5: Dimension 2 on p. 64; Dimension 3 on pp.
64-65; Dimension 4 on pp. 66-67; Dimension 5 on pp. 67-68;
Dimension 6 on p. 68.
Level IV: Dimension 2 on p. 133; Dimension 3 on pp. 133-134.
(Note: Dimensions 4-6 do not qualify patients for admission to
this level).
Level OMT: Dimensions 1 & 2 on p. 142; Dimensions 3-5 on p.
142; Dimension 6 on p. 143.
LEvEl III.3 – cl
INtENSI
Status characterize
___ a. Unable to co
structured 2
___ b. Assessed as
environmen
or substanc
___ c. Significant d
or
___ d. Social netw
drugs such
less intense
___ e. Living arran
___ 1. Lives
dealer
___ 2. Living
recove
or
___ f. Vulnerabilit
victimizatio
lEvEl III.3 – Du
Meets criteria for L
___ a. Severe and
___ b. Mental cond
training in t
___ c. Insufficient
that is not s
assertive co
or other sup
___ d. Requires su
achieve stab
lEvEl III.5 – cl
rESIDEN
Status is character
___ a. Unable to co
structured 2
___ b. Assessed as
risk of phys
at a lower l
___ c. Social netw
goals are ju
___ d. Significant d
or
___ e. Living arran
___ 1. Lives
dealer
___ 2. Living
recove
Note: for transfer and discharge guidelines, see pp. 35-40.
© 2001, Norman G. Hoffmann, Ph.D.
41
It is illegal to duplicate this page in any manner.
Understanding and Using ASAM PPC-2R
© 2001, Norman G
LOCI-2R – Adult Level of Care Index - 2R
DIMENSION 5: RELAPSE, CONTINUED USE, OR CONTINUED PROBLEM P
DIMENSION 1: ACUTE INTOXICATION / WITHDRAWAL
lEvEl III.7-D – MEDIcAlly MONItOrED INpAtIENt
DEtOxIFIcAtION
___ c. Intensification of symptoms and deteriorating functioning at
lEvEl III.5 – Dual Diagnosis Enhance
Status characterized by either (a) or (b):
a lower level of care despite amendments to the treatment
Meets criteria for Level III.5 plus any of t
___ a. Severe withdrawal risk that is manageable at this level of
plan; or
___ a. Psychiatric symptoms pose a mode
service as evidenced by any of the following:
___ d. Despite active participation at a less intensive level of care,
relapse to substance dependence or
___ 1. CIWA-Ar score = 10 or greater by the end of the
continued use or psychiatric deterioration poses imminent
imminent serious consequences; o
period of outpatient monitoring available in Level
dangerous consequences without close 24-hour monitoring
___ b. Behaviors pose a relapse risk as ind
II-D; or
and structured treatment.
___ 1. Criminal/antisocial behaviors
___ 2. Daily use of sedative-hypnotics at more than
___ 2. Association with antisocial in
therapeutic levels for more than 4 weeks and is
lEvEl III.3 – Dual Diagnosis Enhanced
___ 3. Inability to understand relaps
unresponsive to appropriate efforts to maintain dose
Meets criteria for Level III.3 plus any of the following:
behaviors.
at therapeutic levels; or
___ a. Psychiatric symptoms pose a moderate risk of relapse to
___ c. Case management and collaboratio
___ 3. Daily use of sedatives above a therapeutic level
substance dependence or mental/psychiatric decompensation
may be necessary to manage anti-c
for more than four weeks, plus daily alcohol use
with imminent serious consequences; or
opioid maintenance medications; o
or regular use of another drug known to pose a
___ b. Cognitive deficits result in medication noncompliance or
___ d. Preparation of the resident for trans
severe risk of withdrawal. Signs and symptoms of
risk-taking behaviors requiring 24-hour structured services;
level of care, a different type of ser
withdrawal are of moderate severity, and cannot
or
lEvEl III.2-D – clINIcAlly MANAgED rESIDENtIAl
and/or reentry into the community
be stabilized by the end of the period of outpatient
___ c. Case management and collaboration across levels of care
DEtOxIFIcAtION
management and transition arrange
monitoring available at Level II-D; or
may be necessary to manage anti-craving, psychotropic, or
Status characterized by both (a) and (b):
emotional, behavioral, or cognitive
___ 4. Marked lethargy or hypersomnolence due to
opioid maintenance medications; or
___ a. Not at risk for severe withdrawal, and moderate withdrawal
intoxication with alcohol or other drugs, and a
___
d.
Cognitive
deficits
or
emotional
issues
(in
preparation
lEvEl
III.7 – MEDIcAlly MONItO
is safely manageable at this level of service as evidenced by
history of severe withdrawal, or the altered level of
for transfer to a less intensive level of care, a different
INpAtIENt
any of the following:
consciousness has not stabilized at the end of the
type of service in the community, and/or reentry into the
Status
characterized
by any of the followi
___ 1. Intoxicated or is withdrawing from alcohol and
period of outpatient monitoring available at Level
community) require case management and staff exploration
___
a.
Acute
psychiatric or substance use
CIWA-Ar less than 8 at admission, and monitoring
II-D; or
of supportive living environments.
danger of harm to self or others in
is available to assure that it remains below this level;
___ 5. Daily use of injectable opiates for more than
monitoring and structured support;
or
two weeks and a history of inability to complete
lEvEl III.5 – clINIcAlly MANAgED hIgh-INtENSIty
___ b. An escalation of relapse behaviors
___ 2. Opiate withdrawal signs and symptoms are
withdrawal as an outpatient or without medication
rESIDENtIAl trEAtMENt
acute symptoms pose an imminent
distressing but do not require medication for
at Level III.2-D; or
Status characterized by any of the following:
others in the absence of monitoring
reasonable withdrawal discomfort, and patient
___ 6. Antagonist medication is to be used in withdrawal in
___ a. Failure to recognize relapse triggers and lack of commitment
found in a medically monitored set
is impulsive and lacks skills needed to prevent
a brief but intensive detoxification (as in multi-day
to continuing care despite the fact that continued use poses
immediate continued drug use; or
___
c.
The
modality of treatment or protoc
pharmacological induction onto naltrexone); or
an imminent danger of harm to self or others requires 24(e.g., aversion therapy) require a m
___ 3. Stimulant withdrawal – marked lethargy,
___ 7. Marked lethargy, hypersomnolence, agitation,
hour monitoring and structured support; or
program.
hypersomnolence, paranoia or mild psychotic
paranoia, depression or mild psychotic symptoms
___ b. Despite best efforts, the inability to control use and/or other
symptoms, and these are still present beyond period
due to stimulant withdrawal, and has poor impulse
behaviors with attendant probability of harm to self or
lEvEl III.7 – Dual Diagnosis Enhance
of outpatient monitoring available in Level II-D.
control and/or coping skills to prevent immediate
others requires 24-hour monitoring and structured support;
Meets criteria for Level III.7 plus any of t
AND
continued drug use.
or
___ a. Psychiatric symptoms that pose a m
or
___ b. Assessed as not requiring medication, but does require
___ c. Psychiatric or addiction symptoms, such as drug craving,
relapse to a substance dependence
this level of service to complete detoxification and enter
___ b. This level of care is required to complete detoxification and
difficulty postponing immediate gratification, and other drug
___ b. Follow through with treatment is p
into continued treatment or self-help recovery because
enter into treatment or self-help recovery as evidenced by
seeking behaviors, poses an imminent danger of harm to self
his or her relapse problems are esc
of inadequate home supervision or support structure as
any of the following:
or others in the absence
of
DIMENSION 4: READINESS
TO CHANGE
D
behavioral, or cognitive problems
evidenced by meeting (1) or (2) or (3):
___ 1. Requires medication and has a recent history of
24-hour monitoring and structured support; or
mental health and substance abuse
___ 1. Lacks coping skills to deal with a recovery
detoxification at a less intensive level of care,
___ d. A crisis situation poses imminent danger of relapse,
___ c. Suicidal ideation with a plan, but a
environment that is not supportive of detoxification
marked by inability to complete detoxification.
with dangerous emotional, behavioral, or cognitive
and can be maintained at this level
and entry into treatment; or
lEvEl
lEvEl
0.5 – EArly
INtErvENtION
and enter
into continuing
addiction
treatment, and
consequences;
orII.5 – pArtIAl hOSpItAlIzAtION
prOcEED tO N
Status characterized by (a) and either (b) or (c):
Status
characterized
by:skills or supports to
continues
to have
insufficient
___ 2. Has a recent history of detoxification at less
___ e. Despite active participation at a less intensive level of care,
___ a.MANAgED
No indicati
lEvEl
Iv – MEDIcAlly
___detoxification;
Willing to gain
complete
or understanding of how current use may be continued
intensive levels of service marked by inability to
___
Willingness
to participate
in treatment
usea.and/or
psychiatric
decompensation
poseand sufficient
or
trEAtMENt
harmful.
complete detoxification or to enter into continuing
readiness
to change in
suggest
that treatment
___ 2. Has a recent history
of detox at a less intensive level
imminent dangerous
consequences
the absence
of close of sufficient
___
b.
Emotional
Problems
on
Dimension
5
do
not
qualify f
addiction treatment, and patient continues to have
intensity
can be effective;
AND
of care, marked by inability to complete detox.
24-hour monitoring
and structured
treatment.
very mild
lEvEl
I – OutpAtIENt
SErvIcES
insufficient skills to complete detoxification; or
and enter
into continuing
addiction treatment,
and
___ b. Structured therapy and services involving at least 20 hours
monitoring
Status
is characterized
by (a)orand
any of to
(b) or (c) or (d):
continues
to have
insufficient skills
supports
___ 3. Recently has demonstrated an inability to complete
per week are required because motivational interventions at
___detox.;
a. Willing
complete
or to participate in treatment planning and to attend all
detoxification at less intensive levels of service.
a lower level of care have failed; or
scheduled
activities
mutuallyoragreed upon in the treatment
___ 3. Comorbid physical,
emotional,
behavioral
___ c. Perspective and lack of impulse control inhibit ability to
lEvEl 0.5 – EA
plan; AND
cognitive condition
that increases clinical severity
make behavioral changes without repeated, structured,
Status characteriz
___ b. Acknowledges
a substance-related
and/or mental health
of the withdrawal
and complicates
detox. is
clinically directed motivational interventions.
___ Emotional
wants
help to change; or
manageable inproblem
a Level and
III.7-D
setting.
complicati
lEvEl II.5 – Dual Diagnosis Enhanced
___ c. Ambivalence about a substance-related and/or mental health
appropriatt
11 or (c):
© 2001,
G. Hoffmann,
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© 2001, Norman G. Hoffmann, Ph.D.
It is illegal toproblem
duplicate
this page
in any and
manner.
2
Meets
criteria for Ph.D.
admission to Level II.5 plus (a) or (b)
requires
monitoring
motivating strategies
but Norman
with thera
not a structured milieu; or
___ a. Manifests little awareness of co-occurring mental disorder;
___ d. Does not recognize the substance-related and/or mental
or
lEvEl
I – Out
health problem(s), but is invested in avoiding further
___ b. Follow-through in treatment is so poor or inconsistent due
Status characteriz
consequences.
to emotional, cognitive, or behavioral problems that less
___ a. No sympto
intensive services are not succeeding or feasible; or
___ b. Psychiatric
lEvEl II.1 – INtENSIvE OutpAtIENt trEAtMENt
___ c. Requires more intensive engagement, community
Status characterized by (a) and either (b) or (c):
AND
involvement, or case management services due to
___ c. Mental stat
___ a. Willingness to participate in treatment and to explore
emotional, cognitive, or behavioral problems than are
___ 1. Un
awareness and readiness to change suggest that sufficiently
available at a lower level program.
___ 2. Par
intensive treatment can be effective; AND
pro
___ b. Structured therapy and programmatic milieu to promote
lEvEl III.1 – clINIcAlly MANAgED lOW-INtENSIty
AND
treatment progress and recovery are required because
rESIDENtIAl trEAtMENt
___
d.
Poses
no
ri
motivational interventions at a lower level of care have
Status characterized by one of the following:
victimizati
failed; or
___ a. Acknowledges the existence of a psychiatric condition
___ c. Perspective inhibits ability to make behavioral changes
and/or substance use problem and is sufficiently ready and
lEvEl I – Dual
without repeated, structured, clinically directed motivational
cooperative enough to respond to low-intensity residential
Status characteriz
interventions.
treatment; or
___ a. The patien
___ b. Due to early stage of readiness to change, needed
other emo
lEvEl II.1 – Dual Diagnosis Enhanced
engagement and motivational strategies can be provided via
substanceMeets criteria for admission to Level II.1 plus (a) or (b) or (c):
Level III.1 plus augmentation by additional Level I or II
___ b. Although r
services; or
___ a. Reluctance regarding treatment and ambivalence about
persistent
commitment to change a co-occurring mental health
___ c. A 24-hour structured milieu is required to promote treatment
with ment
problem; or
progress and recovery, because motivating interventions
Level I ser
have failed in the past and are assessed as not likely to
___ b. Follow-through in treatment is poor or inconsistent due to
AND
succeed in the future in an outpatient setting; or
the behavioral health problems so that treatment at a lower
___ c. Mental fun
level is neither succeeding nor feasible; or
___ d. Impaired ability to make behavior changes without repeated,
___ 1. Un
structured motivational interventions in a
___ c. Awareness or commitment to change is so limited that an
___ 2. Par
24-hour milieu.
adequate level of functioning cannot be maintained without
pro
intensive outpatient services that integrate mental health and
AND
lEvEl III.1 – Dual Diagnosis Enhanced
addiction treatment services.
___ d. Assessed a
Meets criteria for Level III.1 plus any of the following:
vulnerabil
___ a. Ambivalent regarding commitment to address a
co-occurring mental health problem; or
___ b. Lack of consistent follow-through with treatment due to
emotional behavioral, or cognitive problem; or
___ c. Minimal awareness of a problem, or being unaware of the
need to change requiring active interventions with family,
significant others, and other external systems to create
incentives and align incentives so as to promote engagement
in treatment.
___ c. Patient is likely to complete detoxification and enter
continued treatment or self-help recovery as evidenced by
meeting (1) and either(2) or (3) or (4):
___ 1. Patient or support persons clearly understand
instructions for care and are able to follow
instructions; AND
___ 2. Has an adequate understanding of ambulatory
detoxification and has expressed commitment to
enter such a program; or
___ 3. Has adequate support services to ensure
commitment to completion of detoxification and
ongoing treatment or recovery; or
___ 4. Willing to accept a recommendation (e.g., attend
outpatient sessions or self-help groups) for
treatment once withdrawal has been managed.
© 2001, Norman G. Hoffmann, Ph.D.
42
8
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Understanding and Using ASAM PPC-2R
© 2001, Norman G