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“Failing Up” – and the ASAM Criteria

It has become common in the treatment of substance use disorders to accept the idea of treating an individual at a lower (and less expensive) level of care with the plan that if they fail (i.e. relapse) that then, and only then, is a higher level of care warranted. This concept of “failing up” is fraught with problems, especially in the treatment of licensed professionals in safety-sensitive positions. Let’s take a look at this phenomenon and the variables involved in deciding on treatment level assignment.

Levels of treatment have been divided generally into four levels: 1. outpatient, 2. intensive outpatient (IOP), 3. residential (in-patient) and 4. hospital. There are lots of hybrid levels, sometimes assigned decimal points, such as level 2.9, “full-time outpatient, sometimes referred to as “day treatment” or “PHP, i.e. partial hospitalization program,” which is almost “residential,” minus living onsite, thus level 2.9. In fact, levels of treatment and structure or intensity of treatment with all its varied components can be broken down into much more detail. Generally speaking, the higher the level of care, the more expensive the treatment.

The American Society of Addiction Medicine (ASAM) developed criteria that have evolved over the past 30 years now called, “The ASAM Criteria,” published in book form that has become widely adopted as the authoritative guide for deciding which level of care is appropriate for an individual. The guide suggests that six “dimensions” be considered in deciding on which treatment setting is appropriate, including: 1. acute intoxication and/or withdrawal, 2. biomedical conditions and complications, 3. emotional behavioral or cognitive conditions, 4. readiness to change, 5. relapse potential and 6. recovery/living environment. Without going into detail regarding these criteria, the overall gist is that the more severe the overall situation, the higher the level of care that is indicated. Additionally, in the current edition of the ASAM Criteria there is a chapter regarding “Persons in Safety Sensitive Occupations.” This chapter points out that additional factors must be considered for this population including: 1. risk to the public and 2. benefit of cohort specific treatment.

Unfortunately, each of the ASAM criteria are fairly subjective and insurance companies have frequently used The ASAM Criteria to deny care. Ironically, the framework of The ASAM Criteria has given insurance review the façade of legitimacy that has been used to undermine appropriate care. Insurance companies certainly prefer to ignore the chapter regarding safety sensitive occupations.

So how should we decide on appropriate level of care? When choosing a treatment modality for any illness, a physician must decide how aggressively to treat. Do you use the most effective therapy, or do you try a less aggressive therapy and save the “big guns” for later, if needed? For example, if someone presents with community acquired pneumonia, you have numerous choices to make. You could admit them to the hospital, even to the intensive care unit. You could start the strongest intravenous antibiotics, or you could use oral broad-spectrum antibiotics. Certainly, physicians vary in how aggressively they treat a given illness. Most treatable illnesses have a range of options for treatment from more casual to more aggressive. Often the more casual approach has higher risk but the aggressive approach is more costly and intrusive. The physician and the patient must decide how to proceed. So, what are some of the factors that are considered, sometimes explicitly or sometimes implicitly, in deciding?

Factors considered in trying to decide how aggressively to treat any illness:

  1. What are the facts regarding the success rates from more limited treatment vs more aggressive treatment?
  2. What are the risks if the limited treatment fails?
  3. What are the risks of the more aggressive treatment modality?
  4. Are there comorbidities in a particular patient that make the benefits vs risks different than normal?
  5. What is the availability of the various forms of treatment?
  6. Are the various forms of treatment covered by insurance? What are the costs of various forms of treatment?

So, let’s take a look at these variables as they relate to treatment of physicians with substance use disorders. The same analysis could be applied to other health professionals (e.g. dentists, pharmacists, etc.), pilots, legal professionals, police, etc. Here we will basically compare two levels of care:

  1. What are the success rates (in general) comparing inpatient vs outpatient treatment of substance use disorders? The answer is not totally clear. Finney, et al 1996,[i] found that not considering detox services inpatient treatment was superior. Other studies have found that treatment retention is the important issue and patients tend to be retained longer in inpatient programs. There are many anecdotal reports, from patients and programs, that taking time off and participating in inpatient treatment leads to better outcomes. Absolute proof, however, is still lacking.
  2. What are the risks if limited treatment fails? For licensed professionals, the risks of losing their career and/or potentially causing patient harm are significant. Most often with physicians, medical boards, hospitals, medical groups, etc., will be supportive for the first trial of addiction treatment but if there is a relapse, depending on if there is patient harm, the consequences are severe.
  3. What are the risks of the more aggressive treatment? Risks may include loss of income and possible risk of practice closure (which is rare). For most professionals it is inadvisable, or not allowed, to continue working while in addiction treatment anyway, so more intensive treatment while they are off work is advised. Similar to treating cancer, it is usually advisable to treat aggressively rather than risk recurrence.
  4. Are there comorbidities in a particular patient that make the benefits vs risks different than normal? This is where The ASAM Criteria may come into play. Are their co-occurring psychiatric disorders? Have there been previous relapses? What is the home situation?
  5. What is the availability of the various forms of treatment? There is no problem finding “full-time treatment” (i.e. either PHP or inpatient) for professionals. A number of centers around the country offer this type of program specifically for professionals.
  6. Are the various forms of treatment covered by insurance? What are the costs of various forms of treatment? Inpatient treatment is typically not covered as well by insurance and it is usually more expensive. However, less than compared to administrative legal costs associated with relapse, loss of career, etc., for a professional. Certainly, it can be argued that addiction is a devastating, life-threatening and career-threatening illness, not to even speak of the risk to patients and the damage to families. Most professionals are fortunate to have financial resources and support to obtain the best possible care.

Treatment of licensed professionals in safety-sensitive positions should be thorough and aggressive to preserve careers and lives. The ASAM Criteria chapter that addresses this issue is helpful but too often ignored by insurance companies. The concept of “failing up” should be avoided when working with licensed professionals as it is fraught with risk for their careers and patient safety.

 

[i] Finney JW, Hahn AC, Moos RH. The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on mediators and moderators of setting effects. Addiction Vol 91, Issue 12 Dec 1996, pg 1773-1796

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