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ASAM Patient Placement Criteria: Supplement on Pharmacotherapies for Alcohol Use Disorders

Richard Balon, MD

Wayne State University, Detroit, MI, USA

Edited by Marc J. Fishman, Gerald D. Shulman, David Mee-Lee, George Kolodner, and Bonnie B. Wilford. Philadelphia, PA: Wolters Kluwer/Lippincott Williams and Wilkins; 2010; ISBN 978-0-7817-9122-9; pp 204; $54.95 (paperback).

Many psychiatrists and other physicians treat alcohol use disorders using various pharmacotherapies. Most physicians probably treat these disorders based on what they learned during their training or hopefully the latest literature. However, most of us probably do not consider and understand the many variables involved, “including a complete assessment of the patient’s individual medical, psychiatric, environmental, and social issues, as well as knowledge of the uses of a variety of pharmacological and nonpharmacological interventions” (p 1). In other words, what, when, to whom, and under what circumstances, because each treatment should be individualized to reflect patients’ needs and to reflect his/her response to treatment. Specific guidance in a structured form has not always been available. The American Society of Addiction Medicine (ASAM) put together Patient placement criteria (now in their second, revised edition) to “assist clinical staff in using the variables to provide timely, appropriate, and effective care” (p 1). This volume specifically addresses pharmacotherapy, although at the end it briefly reviews selected nonpharmacologic therapies as well. The volume has been put together by a group of editors, but expert advisors, field reviewers, and the Steering Committee of Coalition for National Clinical Criteria are listed as contributors.

The book consists of 7 chapters and 4 appendices. Chapter 1, “Introduction,” briefly overviews alcoholism and its treatment and presents some staggering numbers. “About 3 in 10 US adults drink at a level that increases their risk for medical, psychiatric, and social problems. Of these heavy drinkers, about 1 in 4 meet the criteria for alcohol abuse or dependence” (p 1). The chapter further explains treatment planning using the ASAM criteria and the purpose of this supplement. Chapter 2, “Role of the ASAM criteria in the treatment of alcohol use disorders,” summarizes the principles embodied in the ASAM criteria, the need for individualized treatment planning, and then explains how to use the ASAM criteria to match patients to treatment. The authors point out that there are 4 models of care—complications-driven treatment; diagnosis, program-driven treatment; individualized, assessment-driven treatment; and outcomes-driven treatment—and that the ASAM criteria play “an integral role in the latter two approaches by providing a multidimensional assessment structure for treatment planning that meets the patient’s assessed needs and improves the prospect for a positive outcome” (p 12). The ASAM assessment dimensions are: 1: Acute intoxication and/or withdrawal potential; 2: Biomedical conditions and complications; 3: Emotional, behavioral, or cognitive conditions and complications; 4: Readiness to change; 5: Relapse/continued use/continued problem potential; and 6: Recovery environment. Unfortunately, most treating professionals probably do not consider all of these dimensions. The large part of this chapter also includes a risk assessment matrix with a large table demonstrating dimensional interactions that can increase or reduce severity and risk. The authors state that the primary goal of the matrix is “to promote improved assessment, treatment planning, and placement of patients with substance use disorders (with or without co-occurring disorders) by adopting a more holistic, multidimensional approach that matches patient’s needs” (p 23). The authors emphasize that the patient’s diagnosis is a necessary but insufficient determinant of service needs and that risk:

  • is multidimensional and bio-psychosocial

  • relates to the patient’s history

  • is expressed in current status

  • involves a degree of change from baseline or premorbid functioning

  • its assessment must integrate the patient’s history, changing situation, and current status.

The final part of this chapter reviews issues such as compliance vs adherence (the term compliance is falling into disuse), caring for patients with co-occurring disorders and inability to access services, and assessment of imminent danger.

The next chapter, “Strategies for managing alcohol withdrawal” finally gets into specific pharmacotherapy issues. It discusses assessing the risk of withdrawal first, including definitions of degrees of intoxication and withdrawal presentation and assessment using the Clinical Institute Withdrawal Assessment for Alcohol, Revised Scale (CIWA-Ar). The mainstay medications for withdrawal—benzodiazepines— and their use are reviewed first. It is a useful discussion of mechanism of action, safety, evidence of effectiveness, selection of a specific benzodiazepine, precautions, contradictions, use in pregnancy, dose, and duration of treatment. I was a bit surprised by the statement that benzodiazepines are classified by the FDA in pregnancy category C (p 37), because I believe they mostly are in category D and should be avoided during pregnancy, especially the first trimester. This chapter also includes a discussion of adjunctive medications for alcohol withdrawal (eg, carbamazepine), alternate medications for detoxification (pentobarbital, beta-adrenergic blocking agents, anticonvulsants), and nonpharmacologic therapies for alcohol withdrawal. Chapter 4, “Placement criteria for managing alcohol withdrawal,” provides step-by-step treatment guidance within the abovementioned dimension 1, listing 4 levels of care (ambulatory detoxification without extended on-site monitoring, ambulatory detoxification with extended on-site monitoring, residential/inpatient detoxification, and medically managed intensive in-patient detoxification). Most of this chapter consists of a large, detailed risk assessment matrix for dimension 1 in the form of a large, detailed table. Chapter 5, “Strategies for preventing and managing relapse,” emphasizes that “relapse rarely is caused by any single factor and often is the result of an interaction of individual situational, physiologic, and sociocultural factors” (p 55). The chapter starts with nonpharmacological approaches to relapse prevention (eg, identifying environmental cues, identifying environmental stressors, establishing a more balanced lifestyle, helping the patient understand and manage craving, improving interpersonal relationships, and others) and then moves to pharmacological approaches. The chapter reviews FDA-approved medications—acamprosate, disulfiram, and naltrexone (both oral and injectable forms)—and off-label and experimental uses (eg, topiramate, baclofen, serotonergic antidepressants, ondansetron). The review of each approach is detailed, discussing all the aspects as I mentioned in the case of benzodiazepines for withdrawal. The chapter also includes a discussion of developing a treatment plan, such as selection of a pharmacologic agent, contraindications and cautions, combining pharmacotherapies, integrating pharmacologic with psychosocial therapies, duration of treatment, and treatment of co-occurring disorders, including contraindications and cautions of certain medications in some diseases. The chapter includes summarizing tables.

Chapter 6, “Placement criteria for preventing and managing relapse,” builds on the previous chapter and discusses treatment levels within dimension 5 (relapse and its possible risk) using different levels of care (early intervention, outpatient treatment, intensive outpatient treatment/partial hospitalization, residential/inpatient treatment, and medically managed intensive inpatient treatment). It also reviews domains for assessing risks in dimension 5 (1: history and pattern of substance abuse, 2: response to substance effects, 3: response to external stimuli) and provides a matrix to develop a risk profile including a comprehensive inventory of relapse stressors and environmental problems. This chapter also includes comprehensive tables summarizing the matrix and other material reviewed in the chapter.

Finally, chapter 7, “Case example of risk assessment,” contains 7 detailed cases with their initial presentation, dimensional assessment, placement, discussion, follow-up, reassessment, and other aspects. Included are tables summarizing issues such as patient’s dimensional severity profile, etc. This chapter allows the reader to fully understand how to apply the placement criteria to clinical reality.

The book includes 4 appendices, A: Assessment process and instruments (eg, Addiction Severity Index, Alcohol Dependence Scale, Drinker Inventory of Consequences, AIWAAr, and the National Institute on Alcohol Abuse and Alcoholism’s steps for assessment for alcohol use disorders); B: Selected nonpharmacologic therapies for alcohol use disorders (eg, motivational enhancement therapy, cognitive-behavioral therapy, individual counseling, group therapies, 12-step programs, community reinforcement approach, assertive community treatment, and case management); C: Glossary of terms; and D: Contributors.

This is a useful volume that would be appreciated by all who specialize in alcohol use disorders. Other clinicians treating alcohol use disorders—especially those treating comorbid mental disorders—also will find this book useful because the volume is comprehensive, structured, informative, authoritative, and well referenced. One can learn a lot and realize the complexity of the field and need for a structured approach to treating alcohol use disorders just by skimming through this book. I believe this book could be useful as a teaching text in residency training and especially in addiction fellowship programs.