What’s New in DSM-5 and The New ASAM Criteria?
Implications in an Era of Healthcare Reform
David Mee-Lee, M.D., Chief Editor, The ASAM Criteria
Senior Vice President, The Change Companies
A new edition of the Patient Placement Criteria for the Treatment of Substance-Related Disorders of the American Society of Addiction Medicine (ASAM) was unveiled October 24, 2013 in Arlington, Virginia. The new title is The ASAM Criteria – Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. As the most comprehensive set of guidelines for assessment, service planning, placement, continued stay and transfer/discharge of individuals with addiction and co-occurring conditions, ASAM’s criteria are required in over 30 states and in Department of Defense addiction programs around the world. Many payers also manage care using the criteria that are the most intensively researched set of addiction placement criteria in the USA and Europe.
The other significant publication in behavioral health care published in May, 2013 was the new fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association – DSM-5. Another significant publication just released in September, 2013 is the National Survey on Drug Use and Health (NSDUH) from SAMHSA, the Substance Abuse and Mental Health Services Administration. The results for 2012 reinforce what previous years’ data show – that millions of Americans needing addiction treatment are not identified; do not try to access services; and only about 10% actually get into specialty addiction services.
The new edition of The ASAM Criteria, DSM-5 and the NSDUH data are all significant given the current climate of healthcare reform. Consider the following data: The Affordable Care Act (ACA) is fully enacted in 2014, with potentially 30 million people now uninsured who could access health insurance. Not all will enroll and/or live in States that will not expand Medicaid to allow them to get health insurance. But there will still be millions more who have health insurance, even if it is just a fifth of those who eligible to be covered.
- Secondly, in the latest data from the 2012 National Survey on Drug Use and Health (NSDUH):
- 23.1 million people 12 years and older needed treatment for an illicit drug or alcohol use problem.
- But 20.6 million of those needing treatment did not receive treatment in a specialty addiction agency in the past year.
- 94.6% of those 20.6 million people did not perceive a need for treatment, so made no effort to seek treatment.
- 3.7% of those 20.6 million people felt they needed treatment but did not make an effort to seek treatment; and only 1.7% felt they needed treatment and made an effort to get treatment. A picture is worth a thousand words, so take a look:
So what to make of these data? Here is a challenge to ponder:
If there are millions more people who in 2014 can now be covered by health insurance with access to addiction treatment, how will addiction treatment agencies increase access to care when we already have waiting lists and can’t even meet treatment-on-demand now, for the 2.5 million people who did eventually receive specialty addiction treatment?
What’s New in The ASAM Criteria and DSM-5 and How They Can Help
Perhaps you noticed that in this new third edition of ASAM’s criteria, the title is The ASAM Criteria – no “patient placement” in the title. That does not diminish the importance that the new edition still places on defining levels of care and admission criteria for placement in the broad continuum of care. But this edition ties in with ASAM’s definition of addiction that sees addiction as “a primary, chronic disease of brain reward, motivation, memory and related circuitry.” Thus the new edition is as much about guidelines for chronic disease management as it is placing people in programs.
In the context of healthcare reform and the data from the NSDUH and other such data, the new edition of The ASAM Criteria with related notes on DSM-5:
- Expands on Level 0.5, Early Intervention services to include Screening, Brief Intervention, Referral and Treatment (SBIRT) to emphasize the importance of reaching out to the 20.6 million people who aren’t even thinking about addiction treatment. DSM-5’s new chapter on Substance-Related and Addictive Disorders defines 11 criteria in one new category Substance Use Disorder (SUD). If a person does not meet at least two of these 11 criteria, Level 0.5 is the service level needed. If two or more SUD criteria are met then the patient requires at least Level 1 services.
- Broadens perspectives that Level 1, Outpatient Treatment isn’t just a gateway into addiction treatment or “aftercare”, but should also be seen as ongoing disease management of addiction for maintenance chronic disease care from which some people will never “graduate” just as people don’t graduate or complete diabetes, hypertension and asthma treatment. Patients who are at least moderate (4-5 of the 11 SUD criteria) or severe SUD (6 or more criteria) will likely need ongoing chronic disease management.
- Preserves the importance of admission criteria for each level of care placement, but highlights that The ASAM Criteria are helpful beyond just defining specialty addiction treatment criteria. The multidimensional assessment of six dimensions provides a common language of assessment for general healthcare and mental health as well. Accountable Care Organizations will increasingly need to address those with addiction as these patients increase the ACO’s healthcare costs and hospital readmission rates. DSM-5 provides the diagnostic criteria to the Diagnostic Admission Criteria for each level of care; and The ASAM Criteria provides the guidelines on how to assess addiction and access a broad continuum of care.
- Expands on the importance of integrated co-occurring substance-related and mental health conditions to reach out to the many patients who revolve through acute psychiatric units with substance-induced psychosis and mood disorders. DSM-5 continues the criteria for Substance-Induced Disorders that is so important for clinicians to consider in the differential diagnosis. Too many people using “uppers” and “downers” are being diagnosed as Bipolar Disorder and prescribed a mood stabilizer medication when it is really a Substance Induced Bipolar Disorder needing addiction treatment.
- Builds on ASAM’s definition of addiction that reflects the “individual pathologically pursuing reward and/or relief by substance use and other behaviors.” Thus The ASAM Criteria has a new section on Gambling Disorder consistent with DSM-5’s new chapter on Substance-Related and Addictive Disorders and Internet Gaming Disorder in Section III, Conditions for Further Study.
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