Health Services for Addiction Treatment and Levels of Care

Abstract

Health services for substance use disorders include the multidisciplinary factors that affect the content, access, economics, and treatment outcomes of patients. Among these is the influential concept that addictive disorders are chronic illnesses best addressed through a continuum of care wherein the clinical characteristics of patients are matched to therapeutic services. The patient placement criteria of the American Society of Addiction Medicine (ASAM) exemplify this approach. These criteria are now accepted by government agencies and commercial insurers in authorizing and paying for treatment. Providers, patients, and payers are increasingly emphasizing the measurement of value and performance in the delivery of health services. The treatment of substance use disorders is the focus of substantial quality and performance scrutiny, and the development of suitable measures of quality performance is underway.

Review Questions

JB is a 39-year-old male businessman with a history of heavy drinking that began in high school when his girlfriend broke up with him. After a recent divorce, his drinking increased to daily binge drinking that he seems to have no control over. Laboratory tests from a recent annual physical exam revealed marked elevations in both AST and ALT which prompted his primary care doctor to screen for an alcohol use disorder using the MAST (Michigan Alcoholism Screening Test). JB screened positive, and his physician discussed his drinking behavior with him and recommended that he cut down on his use of alcohol. When JB attempted to do so, he became severely anxious, tremulous, and sweaty. He went to the local emergency department, but he was so uncomfortable and shaky in the waiting room that he decided to go home. His only relief came after he impulsively consumed three shots of his usual alcoholic beverage. He called his primary care physician back and explained what had transpired. He was skeptical that anything could help him but accepted a referral to a local substance use treatment program for an intake evaluation.

• 1. What is the purpose of the intake evaluation?

  • A. To reduce the primary care physician’s clinical burden

  • B. To evaluate whether JB could pay for treatment out-of-pocket

  • C. To determine the appropriate level of care for JB’s initial treatment

  • D. To ensure that JB had no legal issues pending

  • E. To introduce JB to the program staff

  Best Answer: C. To determine the appropriate level of care for JB’s initial treatment

  Explanation: A multidimensional assessment is fundamental to determining the level of care that best matches the patient’s clinical presentation.

• 2. Which of the following was most influential in determining JB’s initial level of care?

  • A. His history of failed relationships

  • B. His history of alcohol withdrawal symptoms

  • C. His elevated liver enzymes

  • D. His preferred alcoholic beverage

  • E. His skepticism about treatment helping him

  Best Answer: B. His history of alcohol withdrawal symptoms

  Explanation: According the ASAM/Medicaid criteria, risk for a withdrawal syndrome is a criterion to determine the need for heightened medical monitoring or inpatient status for a patient.

  JB was admitted to a medically monitored residential treatment program. He experienced moderate alcohol withdrawal symptoms which were managed by the physician and treatment team over the next 5 days. After a week in the program, JB begins to talk in groups and engage in therapy. However, his mood remained low despite his abstinence from alcohol. The program physician began a trial of antidepressant medications. The treatment team continued to assess JB for other relevant clinical issues. In parallel with this clinical assessment, the treatment team began discharge planning. They recommended that upon discharge, JB continue treatment in an Intensive Outpatient Program that is a component of this community addiction treatment program.

• 3. ASAM Standards of good clinical practice in addiction treatment suggest that patients should be evaluated for which if of the following?

  • A. Work and financial status

  • B. Transportation and housing needs

  • C. Tobacco use disorders

  • D. Need for marital or couple’s therapy

  • E. Pharmacogenetic metabolic status

  Best Answer C. Tobacco use disorders

  Explanation: According to the ASAM’s Standards of Care for the Addiction Specialist Physician screening for tobacco use disorders is one of the quality performance measures for the addiction professional.

• 4. What does JB’s transition from a residential treatment program to an Intensive Outpatient Program reflect?

  • A. His poor response to initial treatment

  • B. Concerns that he cannot afford the residential program

  • C. His potential to have a conflict with other patients

  • D. The availability of a continuum of care

  • E. His unresolved depressive symptoms

  Best Answer: D. The availability of a continuum of care

  Explanation: In addiction treatment the “continuum of care” is interpreted as a fluid treatment system in which patients initially enter treatment at a level appropriate to their clinical needs, and then step up to more intensive treatment or down to less intense treatment as clinically indicated. JB’s transition to an Intensive Outpatient Program is a less intensive treatment.