Patient Placement Criteria

It is popular to think that treatment for substance abuse and dependence consists of a 28-day inpatient stay that emphasizes the Twelve-Step model. This perception of substance use treatment is a product of the dominance of the Minnesota model that was developed by treatment providers to treat alcoholics. The model, which focuses on detoxification and rehabilitation, implies a bio-medical understanding of substance dependence. Consistently, research has demonstrated that substance dependence can and does occur without physiological changes. As a consequence, the World Health [Page 680]Organization and the American Psychiatric Association have made revisions to the diagnostic criteria for substance dependence to reflect these changes in scientific understanding. Currently, an individual may meet the criteria for substance dependence without exhibiting physiological changes such as tolerance or withdrawal symptoms. The net result of this change is that a variety of substance dependence treatment regimes are available that vary in treatment intensity and type of setting. The National Institutes of Health recognized that successful treatment requires the matching of treatment settings, interventions, and services to the particular problems and needs of the patient. In the early 1980s, substance dependence treatment providers were increasingly challenged not only to address which type of treatment was best for which kind of patient but also to define criteria that required movement from one level of treatment intensity to another. These questions arose from two different sources. First, funding sources for substance use disorder treatment services (e.g., managed health care organizations and publicly funded health care programs) were tasked with managing and containing health care costs through utilization review processes. During the 1980s, both the cost pressures of treatment and the development of managed care organizations resulted in multiple attempts by insurance organizations and managed care entities to establish treatment matching protocols. Second, substance use treatment providers were tasked with matching patient needs to clinically sound treatment plans and treatment settings. In 1985, at the request of the Minnesota legislature, the commissioner of human services established criteria for determining and placing patients on public assistance in an appropriate level of substance dependency treatment. This legislation marked the first formal effort to match placement to patient needs and spurred other attempts at developing patient placement criteria. The most widely recognized and, in many cases, adopted attempt at treatment matching is the patient placement criteria of the American Society of Addiction Medicine (ASAM).