Assessing patients for optimal treatment by utilising and testing ASAM Criteria for substance use disorder and co-occurring psychiatric disorders Validity of ASAM Criteria
Doctoral thesis
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Date
2015Metadata
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- Institutt for psykologi [3109]
Abstract
The main purpose of this dissertation was to investigate ASAM Criteria software revised
version for predictive and convergent validity by assessing patients with a substance use
disorder to optimal level of care (LOC). The dissertation combines one unpublished pilot
study and three main papers. The pilot study is based on a satisfaction survey (n=8) and interrater
reliability testing of patient videos (n=5) and assessors’ agreement. The validation study
has a prospective naturalistic double-blind multi-site design and the three papers are based on
data from a structured baseline interview (n=261) and follow-up interview (n=153) three
months after treatment initiation. They were recruited from 10 different centres in the midregion
of Norway. The private and public treatment facilities included in this dissertation
cover the specialised treatment for substance use disorders in the region, with detoxification
services, outpatient, inpatient and residential treatment both short and long-term. Opioid
Maintenance treatment is also included, and can be given in either outpatient or inpatient
setting depending on patients’ needs. The public clinic follows a biopsychosocial approach for
understanding and treatment of substance use disorders which includes a variety of services.
Interventions include, for example, motivational interviewing, individual or group therapy
sessions, family therapy, cognitive therapy, milieu therapy, social skills training, vocational
training, physical training and many more. The various services provided in this region clearly
show the complexity in providing treatment for this disorder, and the need for thorough
assessment before placing patients at a specific LOC. The services are closely connected to or
in direct cooperation with the municipalities covering housing and occupational needs. The
theoretical framework for the dissertation is to apply a biopsychosocial approach to
understanding, assessment and treatment of patients with a substance use disorder. While this
is the consensus reached in the field, different approaches still exist. There is a necessity to
examine the history of the development of the concept of addiction to the substance use disorder definition we see and use today, to understand how the biopsychosocial approach
emerged as the consensus in the field. The shift from a moral model to medical approach is
vital to the understanding of the concept of the disorder and treatment of it. In addition, the
main diagnostic and classification systems that Norway and the ASAM criteria uses when
classifying substance use disorders will be discussed.
This study was initiated by the region itself in light of the need for harmonising the regions’
assessment practices and investigating the prevalence of service need in the region. Because
ASAM criteria software version is based on the DSM-IV criteria and follows a
biopsychosocial approach to substance use disorder, this approach was deemed appropriate. In
addition it is the only tool that can give automatic treatment recommendations on LOC
placement based on over 6000 calculations. In need of translation and because it was a revised
second edition, the criteria underwent validation testing on Norwegian substance use
disordered population even though validation testing from USA provides support for the use
of the criteria. ASAM criteria is a computer-assisted structured interview and clinical decision
support programme that implements validated tools including the Addiction Severity Index
and measures biopsychosocial conditions to match patients to an optimal LOC. Paper I
assessed patients seeking help for substance use disorders in order to determine the ASAM
Criteria’s predictive validity in terms of treatment outcomes among matched and mismatched
patients. At post-test, patients who had received matched treatment based on the ASAM
recommendation reported less use of alcohol and cannabis versus undermatched patients.
Overmatched patients had no better outcomes than matched patients; in some cases no change
occurred or a more intensive LOC was recommended at post-test. Consistent with prior
studies, the ASAM Criteria Software Norwegian version demonstrates elements of predictive
validity for determining intensity of LOC placement using all three prospectively planned
measures.
Paper II examined the discrepancies between ASAM Criteria LOC recommendations and
Treatment-as-Usual, along with the software’s ability to clinically distinguish between
patients with different LOC to determine convergent validity. The discrepancies found are in
line with previous research: the more intensive recommendation by ASAM yielded better
outcomes three months after for the matched group. The ability of the ASAM Criteria to
clinically distinguish between the different LOC lends support for the software’s convergent
validity. This ability to distinguish by severity was taken further in the third paper which also
examined the programme’s Dual Diagnosis taxonomy, incorporated in the second revised
version to assess patients’ need for more specialised programmes for co-occurring psychiatric
disorders. We aimed to study the prevalence of co-occurring disorders programme
recommendations and ASAM Criteria convergent validity in terms of locating patients with
co-occurring disorders and discriminating between severities among those who received more
intense recommendations. The results are in line with previous research with the use of these
criteria, and the different recommendations show differences in characteristics, severity and
outcomes. The higher the recommendation, the more psychiatric severity seen among the
patients recommended for them. Significant differences were seen in both characteristics and
severity. The results show a high prevalence of dual diagnosis programme recommendations
in this region and characteristically clinical meaningful differences between the different
recommendations. The new version of ASAM Criteria Software Dual Diagnosis taxonomy
convergent validity is supported by the results. The successful translation and software testing
in Norway should encourage larger studies – preferably across nations and treatment system –
seeking higher power with larger subsamples across primary drug of choice and
match/mismatched conditions.
Has parts
Paper 1: Stallvik, Marianne; Gastfriend, David R.; Nordahl, Hans Morten. Matching patients with substance use disorder to optimal level of care with the ASAM Criteria software. Published in Journal of Substance Use 2014 http://dx.doi.org/10.3109/14659891.2014.934305Paper 2: Stallvik, Marianne; Gastfriend, David R.. Predictive and convergent validity of the ASAM criteria software in Norway. Published in Addiction Research and Theory 2014 ;Volum 22.(6) s. 515-523 http://dx.doi.org/10.3109/16066359.2014.910512
Paper 3: Stallvik, Marianne; Nordahl, Hans Morten. Convergent Validity of the ASAM Criteria in Co-Occurring Disorders. Published in Journal of dual diagnosis 2014 ;Volum 10.(2) s. 68-78 http://dx.doi.org/ 10.1080/15504263.2014.906812