The ASAM Criteria—the American Society of Addiction Medicine’s guidelines for addiction treatment—are not just a tool for program administrators and insurance bureaucrats. They provide a useful conceptual framework for thinking about your patients and what kind of care they need. In addition, insurance companies and government agencies often require you to document your patient’s clinical status in ASAM format before they will authorize payment for certain services.
In this article, we’ll provide you with the basics that you need to use the criteria. You might also want to get a copy of the entire book—a 460-page hardcover—as a desk reference for guidance on the finer points.
To illustrate how to use the criteria, consider a hypothetical patient who is seeing me for a routine office visit for medication management. The young man has a history of heroin and cocaine addiction, along with comorbid bipolar disorder. He is being managed with Suboxone and was doing well when I last saw him. In the interim, however, he relapsed on crack cocaine and has been unable to control his use. He is becoming depressed and is worried that he will start using heroin again in order to cope with his depression.
In the resulting progress note at the end of this article, you can see how I have incorporated the ASAM criteria. I did this to comprehensively document his condition and to ensure that I had information necessary to justify the more intensive (and therefore more costly) level of treatment that he needed.
Sample Outpatient Addiction Medicine Progress Note
There are essentially three steps in using these criteria. Step 1 is recording the diagnosis in ASAM’s six dimensions. Step 2 involves assigning a risk rating for each dimension. Finally, in Step 3, you bring all the data together to dial in the appropriate level of care.
Step 1: Diagnosis
You start by assessing the patient in six dimensions (Table 1). Dimension 1 is the core substance abuse issue—in this case opioid use disorder in remission, and active cocaine use disorder. Dimension 2 corresponds to past medical history (or Axis III in the old DSM), and Dimension 3 encompasses psychiatric disorders other than addiction—in this case, bipolar disorder. Dimension 4 reflects his motivation to seek treatment, which appears genuine; and Dimension 5 gauges the risk of continuing substance use, which I believe is significant. Finally, Dimension 6 assesses his current “recovery environment,” meaning whether his current psychosocial situation is likely to help or hinder his recovery efforts. For this patient, this is problematic since his peers are substance abusers and he has stopped attending 12-step meetings.
After populating the six dimensions with diagnoses and data, you then circle back to assign a risk rating for each dimension (Table 2). These range from zero (“non-issue or very low-risk issue”) to four (“issues of the utmost severity”). Higher risk ratings involve something ASAM calls “imminent danger,” which represents a high probability of “serious adverse consequences to the individual and/or others” in the next few hours to days. As you can see from the progress note, I assigned most of this patient’s issues a risk rating of 2, meaning “moderate difficulty in functioning.”
The final step involves matching the patient to an appropriate level of care (Table 3). As a general rule, patients with low risk ratings (0s and 1s) require minimal clinical supervision, those with moderate risk ratings (2s) need services several days per week, and those with high risk ratings (3s and 4s) require some sort of 24-hour care. While I felt that this patient required more intensive treatment than the basic outpatient care he was getting, I did not believe he needed either hospitalization or partial hospitalization. Therefore, I recommended intensive outpatient services, defined as nine or more hours of programming per week. My plan is to monitor his progress carefully in case his condition worsens, in which case he will likely need residential or inpatient care to stabilize.