I write to address concerns raised by Dr. Richard Grant’s criticism of the American Society of Addiction Medicine (ASAM) criteria in the June 20 issue.
I agree, as does ASAM, with the need for "comprehensive use of criteria" and careful assessment of emotional/behavioral conditions that can precede and/or coexist with substance-related disorders. That is why "emotional/behavioral conditions and complications" was included in the six assessment dimensions of the ASAM criteria in the first place.
Dr. Grant’s concerns appear to relate more to "an article by Kessler and colleagues in the April Archives of General Psychiatry and his consultant experience than to the Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition (PPC-2), of ASAM (1996). However, the following may be helpful in addressing concerns raised:
- The criteria describe functional severities along each of the six assessment dimensions that might best be treated in a certain level within a continuum of care. In dimension 3, Emotional/Behavioral Conditions and Complications, there are clinical presentations caused by or related to a variety of psychiatric diagnoses. All of these clinical presentations include disorders that Dr. Grant felt important to consider.
- For example, in Level IV, Medically Managed Intensive Inpatient, the admission criteria include the following: "Concurrent emotional/behavioral illness that requires stabilization, daily medical management, and primary nursing interventions"; "Uncontrolled behavior that endangers self or others"; "A coexisting serious emotional/behavioral disorder that complicates the treatment of addiction and requires differential diagnosis and treatment." These criteria examples certainly apply to major Axis I diagnoses, including schizophrenic disorder, obsessive-compulsive disorder, and attention deficit/hyperactivity disorder.
- In Level II.1, Intensive Outpatient, the admission criteria states the following: "The patient has a diagnosed emotional/behavioral disorder, which requires monitoring and/or management due to a history indicating its high potential for distracting the patient from recovery or treatment."
- Monitoring or management of the emotional/behavioral disorder in no way suggests an "outmoded philosophy that such conditions should not be looked for or are ‘secondary’ to the substance use disorder." That philosophy is nowhere stated or implied in the ASAM criteria.
- Admission criteria of other levels of service also contain specific criteria in the emotional/behavioral dimension.
- There is a "Diagnosis" section in the ASAM criteria requiring certain diagnostic admission criteria be met for a specific level of service.
Those diagnostic criteria mention only substance-related disorders. The intent was to ensure that if patients receive addiction treatment, they should have an addiction disorder. ASAM criteria seek also to ensure that those with co-occurring mental disorders are identified and treated. Similarly, patients in mental health services must also be screened well for a preceding and/or coexisting substance-related disorder to ensure appropriate care.
I recognize that without orientation to the intent and implementation of the ASAM criteria, it is easy for one to misunderstand certain sections. I hope this is helpful.
David Mee-Lee, M.D.
Chair, ASAM Criteria Committee