Underlying Concepts Purpose of the ASAM PPC-2R - CASAT

Patient Placement Criteria 

Second Version, Revised 

ASAM PPC‐2R 

Teri Pichot, LCSW, MAC, LAC 

tpichot@denversolutions.com 

www.denversolutions.com 

Underlying Concepts 

• Biopsychosocial Perspective 

• Individualized Treatment 

• Treatment Follows Assessment 

• Least Restrictive Treatment Setting is Best 

Denver Center for SFBT 2011 

Purpose of the ASAM PPC‐2R 

• To Provide a Uniform Placement in Predefined Levels 

of Care (Based on the Client’s Evaluation) 

• To Provide a Thorough Assessment Across Six 

Dimensions 



www.denversolutions.com 1

DSM‐IV Diagnoses 

Substance‐Use Disorders 

1. Substance Dependence 

2. Substance Abuse 

Substance‐Induced Disorders 

1. Substance Intoxication 

2. Substance Withdrawal 

3. Substance‐Induced Mental Disorders 


Levels of Care 

I. Outpatient Care 

II. Intensive Outpatient/Partial Hospitalization 

Services 

III. Residential/Inpatient i i Services 

IV. Medically‐Managed Intensive Inpatient Services 


Levels of Care (ASAM PPC‐2R) 

0.5 Early Intervention 

I. Traditional Outpatient 

II.1 Intensive Outpatient 

II.5 Day Treatment 

III.1 Clinically‐Managed Low‐Intensity Residential 

Services 

III.3 Clinically‐Managed Medium‐Intensity Residential 

Services 

III.5 Clinically‐Managed High‐Intensity Residential 

Services 




Levels of Care (cont.) 

III.7 Medically‐Monitored Intensive Inpatient Services 

IV Medically‐Managed Intensive Inpatient Services 


Level I 

• Less than 9 hours per week of structured 

programming 

• Might be dual diagnosis treatment depending on skill 

of therapists and program designation 


Level II 

• II.1 Intensive Outpatient 

‐9 or more hours per week of structured programming 

‐Less capacity to address significant medical or 

psychiatric problems 

• II.5 Partial Hospitalization 

‐20 or more hours per week clinically intensive 

programming 

‐Access to psychiatric, medical, lab services 

‐Complications in dimensions 1, 2, or 3 requiring 

monitoring can be addressed 




Level III 

• III.1 Clinically‐Managed Low Intensity Residential 

Services 

‐Minimum of 5 hours per week of treatment services 

‐Dimension i 5 and 6 focused 

‐Application of recovery and interpersonal skills 

‐Staffed 24 hours a day 


Level III (cont.) 

• III.3 Clinically‐Managed Medium Intensity 

Residential Services 

‐Extended or long‐term care 

‐Habilitation Hbili i vs. Rehabilitation 

Rhbili i 

‐Elderly, developmentally delayed, cognitively impaired 

‐Slower‐paced, repetitive programming 



• III.5 Clinically‐Managed High Intensity Residential 

Services 

‐Therapeutic community 

‐Criminal Ci i l justice involvement, anti‐social 

il 

‐Focus on personal responsibility, social values 

‐Token economies, behavioral therapies 

‐Highly structured, prescribed activities 24 hours/day 

‐ASAM PPC‐2R broadened this category beyond 

therapeutic community model 





• III.7 Medically‐Monitored Intensive Inpatient 

Treatment 

‐More intensive medical services 

‐Usually U incorporates detoxification 

i 

‐Dual diagnosis, conjoint treatment 

‐More intensive staffing patterns, support services 


Level IV 

• Medically‐Managed Intensive Inpatient Services 

‐Medical needs are primary 

‐Hospital‐based services 

‐Life support measures available 

‐Substance abuse treatment is still given along side 

medical care 


Program Capabilities 

• Addiction‐Only Services (AOS) 

• Dual Diagnosis Capable (DDC) 

‐Staff must be able to provide mental health services 

‐Most non‐medication related mental health services 

provided or monitored 

• Dual Diagnosis Enhanced (DDE) 

‐Must have a psychiatrist on staff 

‐Staff must be able to provide mental health services 

‐All substance abuse/mental health services provided 




Detoxification Services 

(Dimension 1) 

• I‐D 

• II‐D 

• III.2‐D 

• III.7‐D 

• IV‐D 

Ambulatory Detoxification without On‐site 

Monitoring 

Ambulatory Detoxification with Extended 

On‐site Monitoring 

Clinically‐Managed Residential 

Detoxification Services (Social 

Detoxification) 

Medically‐Monitored Inpatient Detoxification 

Services 

Medically‐Managed Inpatient Detoxification 

Services 


Dimension 1: Alcohol Intoxication 

and/or Withdrawal Potential 

• Refers to current situation (not past or if the client 

uses again) 

• Are there current signs or withdrawal 

• Is there significant ifi risk ik of severe withdrawal ihd (seizures, 

DTs) 

• Medical Assessment 

• CIWA‐Ar Scale or other objective rating 


Dimension 2: Biomedical 

Conditions and Complications 

• Any current physical illnesses (not including 

withdrawal) that need to be addressed, or that may 

complicate treatment 

• Key: That may complicate treatment. Looking for 

degree of stability. 

• Are there chronic conditions that affect treatment 

• Axis III on DSM‐IV 

• HIV/AIDS Risk 

• Pregnancy 




Dimension 3: 

Emotional/Behavioral/Cognitive 

Conditions and Complications 

• Current psychiatric illnesses or psychological, 

behavioral, or emotional problems that need to be 

addressed or which complicate treatment 

• Any chronic conditions that affect treatment 

• These are Axis I and Axis II on the DSM‐IV 

• Major Depression, Dysthymia, Bipolar Disorder, 

Borderline Personality Disorder, etc. (i.e., “lying” 

would not usually be a dimension 3 issue) 

• Key: That may complicate treatment due to lack of 

current treatment and/or stability. 


Dimension 4: Treatment 

Acceptance/Resistance/Readiness 

to Change 

• Socrates 7A or 7D 

• How ready is the client to change 

• What is the client willing to do at this time 

• What does the client think he/she needs 

• External vs. Internal Motivation 

• High “Resistance” does not mean a higher level of care 


Dimension 5: Relapse/Continued 

Use/Continued Problem Potential 

• What is the client’s current skill level 

• Is it that the client won’t or can’t remain substance free 

• How long can the client remain substance free without 

structure 

• What worked before Has the client tried it recently 

• Unresolved grief 

• Poor impulsive control/uncontrolled anger (non‐diagnosis) 

• Cultural Issues such as mistrust (can also be Dimension 6) 

• Is there something that is putting client at increased risk 

(not taking psychiatric medication) 




Dimension 6: Recovery 

Environment 

• Who does the client have in his/her life who is 

supportive of the client 

• Who does the client associate with when he/she is able 

to remain substance free 

• Who does the client live with 

• What skills does the client have to cope with his/her 

living environment 

• Does the client have basic financial resources, 

employment, housing, that will increase likelihood of 

success 


Dimension 6: Recovery 

Environment (cont.) 

• Any legal involvement or external pressure (if so, how 

does the client interpret this) 

• Marital/Family Issues 


Important Points to Remember 

• The client must meet DSM‐IV criteria for abuse or 

dependency in order to be placed on any level higher 

than 0.5. 

• You can only cite each issue in one dimension. 

• The ASAM should be used any time level of care is 

changed (either up or down). 

• The ASAM PPC‐2R should be used to justify additional 

treatment in the same level of care. 




Level of Care Scenario 

• Jose Guillen attends two groups and one individual 

session a week. Each group is 1½ hours long and the 

individual session is 1 hour long. He also participates 

in couples counseling with his wife every two weeks for 

1 ½ hours each session. 

What level is this 



• Jason Kendall attends one individual session each 

week for 1 hour. He also receives monitored Antabuse 

and random urine screens. 

What level of Care is this 



• Chris Peters attends two educational groups a week 

and has one family therapy session a week for a total of 

4 ½ hours. His counselor is also working to get him a 

psychiatric evaluation for attention deficient disorder 

and to get him into a special vocational training 

program. The counselor also visits Chris at home once 

every two weeks. 

What level of care is this 





• Rhonda Jackson lives at the residential treatment 

program and attends one group a week and has one 

individual session each week with her case manager. 

She works 40 hours per week outside the facility and 

then turns over a portion of her wages as rent. She is 

also expected to clean her room and do other chores 

around the facility. She has to do breathalyzers when 

she returns from work as well as random urine screens. 




• At her residential program, Heather Graham 

participates in about 32 hours of therapeutic 

programming, which includes individual and group 

counseling as well as the family education program. 

Her vital signs are taken once daily and her 

medications are dispensed by a nurse. Her main 

treatment goals are to stabilize her psychiatric and 

medical problems and to reduce her risk of relapse. 

She plans on being in treatment about two weeks. 



How Concerned Are You 

• Low = Level I Can Address Issues on This Dimension 

• Moderate = Need Higher Level of Care Due to Issues 

on This Dimension 

• High = Stop Evaluation and Seek Urgent Services (i.e., 

Detox for Dimension 1, 911 or doctor for Dimension 2, 

Psych Hold for Dimension 3) 




Rate Your Concerns Based Upon: 

• History 

• Here and Now 

• How Worried 

(Avoid Fortune Telling) 


General Guidelines 

• All “Lows” = Level I 

• One “Moderate” = Level II 

• Two or More “Moderates” = Level III 


Partial ASAM Scenario 

• Janet Johnson reports she has several medical problems. 

She was diagnosed as diabetic about ten years ago. She 

takes oral insulin and watches her diet carefully. She says 

the diabetes does not cause her any current problems. She 

also was recently diagnosed with arthritis. This causes her 

some periodic stiffness in her hands. Her doctor has at this 

point only told her to take Advil and to apply heat. She 

denies any other medical problems and, on the ASI, said 

she needed no additional medical care. 

Based solely on this information, at which level would you 

place this client on the Biomedical Conditions and 

Complications dimension 





• Robert Rogers has spoken in a monotone throughout the 

assessment, appearing sad and lethargic. When asked, he 

denied any history of psychiatric treatment or any psychiatric 

problems. He did mention his sister thought he needed help. 

When this response was questioned, he spoke of his wife’s death 

a year ago and how difficult this had been. He says he has felt 

guilty, depressed, and “hopeless” since his wife’s death. He 

initially y denied any suicidal ideation or behavior, but then 

admitted to getting drunk about a month ago and walking in 

front of a car, because “I wanted to be with her.” He said he also 

tried to overdose on “sleeping pills” about two weeks ago. He 

says he bought a gun recently and won’t tell you what his plans 

are for the gun. 

Based solely on this information, at what level would you place this 

client on the Emotional/Behavioral Conditions and 

Complications dimension 



• Matt Matheson has had two DUIs in the last year and has 

been ordered into DUI Level II therapy. He clearly has 

developed tolerance to alcohol, has had occasional 

withdrawal symptoms, and drinking is consuming more 

and more of his time. However, he denies any significant 

physical or psychological problems due to drinking, has 

continued to hold a steady job, and has maintained his 

family relationships. When asked about the DUIs, Matt 

first says it was “just bad luck” and then starts to talk about 

the quotas that the police have. He will say he knows he 

needs to “cut down,” but will then talk about ways to avoid 

the attention of the police. 

Based solely on this information, at what level would you 

place this client on the Treatment Acceptance/Resistance 

dimension 



• Cathy Collins has been using various drugs for some 

time. She lives in a single room occupancy hotel and 

has no friends, only “acquaintances.” All of her 

acquaintances use drugs and usually use drugs with 

Cathy. She has only one sister living in the Denver area 

and rarely speaks with that sister. She receives 

disability payments and spends most of her time 

watching television. 

Based solely on this information, at what level would you 

place her on the Recovery Environment dimension 




Sample Client Issues List 

1 

2 

3 

4 

5 

Date 

ID 

Who 

ID 

Stage Dispo. 

Issue 


References: 

• Mee‐Lee, D. (2005). Overview of the ASAM Patient Placement 

Criteria (2 nd ed. rev.) (ASAM PPC‐2R). Washington, DC: 

SAMHSA’s Co‐occurring Center for Excellence (COCE). 

Retrieved November 15, 2007, from 

http://coce.samhsa.gov/cod_resources/PDF/ASAMPatientPlace 

h / /PDF/ASAMP ti tPl 

mentCriteriaOverview5‐05.pdf 

• Mee‐Lee, D. (Ed.). (2001). ASAM PPC‐2R: ASAM patient 

placement criteria for the treatment of substance‐related 

disorders (2 nd ed. rev.). Chevy Chase, MD: American Society of 

Addiction Medicine. 

• Pichot, T. (In Press). Animal‐assisted brief therapy: A solutionfocused 

approach (2 nd ed). New York, NY: Routledge. 


References (cont.): 

• Pichot, T., with Smock, S. A. (2009). Solution‐focused 

substance abuse treatment. New York, NY: Routledge. 

• Pichot, T., & Dolan, Y. (2003). Solution‐focused brief 

therapy: Its effective use in agency settings. 

Binghamton, NY: Haworth.

Underlying Concepts Purpose of the ASAM PPC-2R - CASAT

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