Assessing patients for optimal treatment by utilising and testing ASAM Criteria for substance use disorder and co-occurring psychiatric disorders Validity of ASAM Criteria

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 The dissertation combines one unpublished pilot study and three main papers.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.