Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

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Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition DSM-5Substance Use
DisordersandAmerican Society of Addiction
Medicine (ASAM) Placement Criteria

• Presented by
• Julián Gonzales
• Division of Behavioral Health and Recovery
  Certification Section Supervisor

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• Purpose and Goals of todays presentation
• Highlight changes in DSM criteria from previous
  edition to current DSM-5.
• ASAM Placement Criteria Standards
• Discuss impact of changes for
• DBHR Certified Agencies
• Chemical Dependency Professionals
• Courts/Corrections/Department of Licensing

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• DSM-5 vs. DSM-IV- TRWhat changed?
• Names of the disorders and the symptoms needed to
  diagnose the conditions.
• Substance Dependence and Substance Abuse
  are no longer valid diagnostic categories.
• These two conditions are now combined into one
  called Substance Use Disorder.

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• DSM-5 vs. DSM-IV- TRWhat changed?
• The criteria for diagnosing Substance Use
  Disorder are now a combination of symptoms that
  were formerly used to diagnose Substance
  Dependence and Substance Abuse which are no
  longer diagnostic categories in DSM-5.

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• DSM-5 vs. DSM-IV- TRWhat changed?
• The number of criteria used to diagnose Substance
  Use Disorder has changed to a total of 11
  criteria.
• Previously
• Four Separate Substance Abuse Symptoms
• Seven Substance Dependence Symptoms

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• DSM-5 vs. DSM-IV- TRWhat changed?
• Now a minimum of two of the 11 symptoms have to
  be met to diagnose Substance Use Disorder.
• 2-3 symptoms Mild SUD
• 4-5 symptoms Moderate SUD
• 6 or more symptoms Severe SUD

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DSM-5 vs. DSM-IV- TRWhat changed? One Substance
Use Disorder symptom, cravings, has been added
to the combined Substance Abuse and Substance
Dependence symptoms. One former Substance Abuse
criteria, recurrent substance-related legal
problems has been eliminated.
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• DSM-5 vs. DSM-IV- TRWhat do these changes mean?
• Substance-related legal problems alone are no
  longer sufficient to diagnose a Substance Use
  Disorder.
• People who were being sent to an Outpatient
  treatment service based on a diagnosis of
  Substance Abuse could now be referred to
  Alcohol/Drug Information School, (education not
  tx) if they only met one criteria of SA.

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• DSM-5 vs. DSM-IV- TRWhat do these changes mean?
• Persons who have recurrent use in situations that
  are hazardous to themselves or others meet one of
  the minimum of two symptoms required to diagnose
  Substance Use Disorder, as opposed to only
  needing to meet one for Substance Abuse. Having
  only one symptom of Substance Use Disorder is
  insufficient to diagnose the condition.

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• DSM-5 vs. DSM-IV- TRWhat do these changes mean?
• People who were previously diagnosed with
  Substance Abuse will still be referred to
  participate in Outpatient treatment, not
  education, if they meet the diagnostic criteria
  for Mild (2-3 symptoms) Substance Use Disorder.
  Meeting one symptom is insufficient to refer the
  person to treatment.

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• DSM-5 vs. DSM-IV- TRWhat do these changes mean?
• People who were previously diagnosed with
  Substance Dependence will still be referred to
  participate in treatment, not education, if they
  meet the diagnostic criteria for Moderate (4-5
  symptoms) or Severe (6 or more) Substance Use
  Disorder.

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• DSM-5 vs. DSM-IV- TRWhat do these changes mean?
• The Washington State Department of Licensing has
  already adopted the use of these DSM-5 categories
  on the Assessment/Treatment reporting form.
• DBHR agencies were required to implement the use
  of DSM-5 as of September 1, 2013. (There is an
  exemption in effect for Medicaid billing using
  DSM-IV-TR)

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• DSM-5 vs. DSM-IV- TRWhat do these changes mean?
• Chemical Dependency Professionals in Division of
  Behavioral Health and Recovery certified programs
  are required to use American Society of Addiction
  Medicine Placement Criteria to make patient
  placement decisions and referrals. They cannot
  make referrals based on what a patient, attorney
  or any other person wants.

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American Society of Addiction Medicine (ASAM)
Criteria Treatment Criteria for Addictive,
Substance-Related and Co Occurring
Conditions The current edition was published and
became effective on October 31, 2013
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• ASAM Dimensions
• Dim 1 Acute Intoxication/WD
• Dim 2 Biomedical Conditions
• Dim 3 Emotional, Behavioral, Cognitive
  Conditions
• Dim 4 Readiness to Change
• Dim 5 Relapse, Continued Use/Continued
  Problem Potential
• Dim 6 Recovery/Living Environ

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• Multidimensional Risk Profiles
• Multidimensional / biopsychosocial
• Relates to the patients history
• Expressed as current risk status
• Involves a degree of change
• Assessment must integrate history, changing
  situation and current status
• Numerical Risk Rating - 0-4 Scale

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• Risk Domains Dimension 3
• Dangerousness/Lethality
• Interference with Recovery Efforts
• Social Functioning
• Ability for Self Care
• Course of Illness

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• Imminent Danger
• Probability that certain behaviors will occur
• Behaviors which pose risk to self or others
• Likelihood of those behaviors occurring in near
  future

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• Treatment Levels
• ASAM Levels of Care
• Level 0.5 Education/Early Intervention
• Level I Outpatient
• Level II.1 Intensive Outpatient
• Level III.1/3/5/7 Residential RH/LTC/IIP
• Level IV Medically Managed IIP

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• Diagnosis
• ASAM Criteria recommends the use of Diagnostic
  and Statistical Manual of Mental Disorders (DSM)
  in making diagnostic statements

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• Whats Next?
• DBHR Certification/Licensing survey staff will
  be reviewing certified programs for compliance
  with these diagnostic and placement criteria.

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• Whats Next?
• Agencies/Administrators/CDPs will be held
  accountable to make clinical decisions based on
  these criteria.
• Compliance with these criteria is mandatory, not
  optional. Failure to comply will result in
  deficiencies requiring corrective action.

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• Whats Next?
• Failure on the part of agencies or clinical staff
  to follow these rules can result in corrective
  action, fines, suspension or revocation of agency
  certification and the referral of noncomplying
  clinicians to the Department of Health for
  negligence, incompetence and unprofessional
  conduct.

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Conclusion When addressing the issue of persons
driving under the influence or engaging in other
illegal actions, certified agencies, CDPs, the
courts and DOL need to work together to make sure
patients are accurately diagnosed, referred and
treated in order to promote public health and
safety, and to ensure accountability for
behavior. We are the safety net.
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Contact Information

• Julián Gonzales, Supervisor
• Certification Section
• Division of Behavioral Health and Recovery
• julian.gonzales_at_dshs.wa.gov
• [phone]
• 1-877-301-4557