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Assessment and Case Management of the Substance Abuse Patient

The assessment and treatment of addictions is a challenging area for both clinicians and case managers. Many addictions are chronic illnesses, with patients and their families pursuing multiple courses of treatment. A good understanding of appropriate assessment of the substance abuse patient is an integral part of the case management of this patient population.

The National Institute on Drug Abuse (NIDA) reports that, in 2006, 23.6 million Americans age 12 or older needed treatment for an illicit drug or alcohol abuse problem. Only 10.8 percent of this population received treatment at a specialty facility for the treatment of substance abuse disorders. Patients presenting with alcohol issues alone or in combination with another drug represented 39.7 percent of admissions to publicly funded facilities. Requests for treatment related to marijuana, heroin, crack cocaine, stimulants and other non-heroin opiates make up the majority of the remaining presenting symptoms, according to statistics from NIDA.

The initial assessment of a patient to determine the necessity of treatment and the appropriate level of care generally occurs on an ambulatory basis, often in the setting of an outpatient office, EAP assessment or admissions unit of a substance abuse treatment program. While some patients are self-referred, many patients are referred by concerned family or friends, an employer, a school or through the courts.

Step By Step

It is not uncommon for patients to present to an assessment setting or emergency department acutely intoxicated. In these situations, signs or symptoms of acute intoxication, acute withdrawal, or a history of complicated withdrawal may require urgent medical assessment. Evaluation for possible medical stabilization should be the initial consideration for all patients presenting with substance abuse disorders.

Certain drugs of abuse may lead to potentially lethal withdrawal syndromes. With regard to abusers of alcohol, benzodiazepines and barbiturates in particular deserve careful attention for possible withdrawal symptoms. A history of complicated withdrawal, including delirium tremens or seizures,
also indicates the need for possible admission to an inpatient detoxification program. Like other levels of substance abuse treatment, detoxification can occur in a 24-hour setting like an inpatient medically based program or in an ambulatory program. Detoxification does not constitute complete substance abuse treatment, and patients will require transition to an appropriate level of care following completion of any needed detoxification.

After any necessary detoxification program or the determination that no detoxification is needed, a request will generally be made for an appropriate level of care for substance abuse treatment. The initial screening interview and subsequent request for treatment should include the details of the patient’s substance use, related clinical information and other pertinent history.

Dates of first and last use for all substances, amounts and frequency of use should be assessed. The patient’s medical and psychiatric history and current symptoms should be documented. The patient may have medical issues such as a history of a myocardial infarction in the context of acute intoxication with cocaine that would affect the determination regarding appropriate level of care. Additionally, a patient who has significant problems with depression, anxiety or psychosis may also require psychiatric interventions in addition to substance abuse treatment.

Substance-induced mood, anxiety and thought disorders are commonly seen. The patient’s substance abuse treatment history, including past involvement with community supports such as AA and NA, motivation for treatment, and the level of sober support available to the patient in his or her current living environment should also be assessed. Presenting patients may report a failure of treatment at a lower level of care, a varying period of time since their last attempt at treatment, and a range of levels of involvement with 12-step programs such as AA and NA in the community.

Many treatment programs recommend that patients obtain an AA sponsor and attend meetings frequently to support their sobriety after completion of treatment. The patient’s level of compliance with these sorts of recommendations is an important factor in determining the appropriate level of care.

alternatives utilized by many patients strugglingOnce an appropriate assessment has been completed, decisions can be made regarding appropriate referrals for treatment by the assessing provider. Substance abuse treatment is available at many different intensities and settings. Community support groups including AA and NA are free support with addiction or working to maintain recovery. The 12-step approach utilized by these groups forms the basis for the majority of substance abuse treatment.

Outpatient treatment with a therapist skilled in addressing substance abuse treatment is often the initial formal substance abuse treatment. Many patients will also pursue treatment in an intensive outpatient treatment program. These programs generally meet three to five days a week for up to
three hours at a time. They generally include substance abuse education, the initiation of treatment, relapse prevention planning and in some cases, monitoring for sobriety with random urine drug screens.

Some patients require treatment in a more extended day program, which is the partialhospitalization level of care. If a restrictive 24-hour care setting is required, a residential substance abuse treatment program or inpatient rehabilitation program are options. Not all treatment facilities offer every level of care and this may impact the assessing facility’s recommendation regarding treatment.

Medical-necessity review and case management for substance abuse treatment has evolved as the medical literature and other factors have impacted our understanding of substance abuse treatment. Historically, many patients received all of their substance abuse treatment at 28-day residential care settings.

The majority of patient placement decisions and duration of treatment decisions are now made based on medical necessity criteria. Many health plans utilize their own criteria sets to make both admission and continued stay benefit decisions. Other plans rely on the American Society of Addiction Medicine (ASAM) Patient Placement Guidelines to make appropriate benefit decisions. The majority of criteria consider the multiple factors assessed at the time of admission to treatment in making these decisions. The ASAM criteria format these factors in a dimension format where each aspect of the patient’s health and environment is given consideration.

Sample Case and Discussion

The patient is a 30-year-old male who presented voluntarily at the urging of his wife, seeking treatment at the substance abuse residential level of care. The patient reported nine years of sobriety from heroin. The patient stated he had relapsed one month ago on cocaine, but his wife stated that he had been using crack cocaine for six months. The patient first used crack cocaine when he was 21 years of age and has been using three to four times a week since his relapse one to six months ago. The patient has not been using any other substances.

His last use of crack cocaine was three days prior to the request for admission. The patient had no signs or symptoms of withdrawal. The patient has no recent history of substance abuse treatment. He did have several episodes of treatment nine years ago in a prison program in Delaware. The patient has no acute comorbid mental health issues. He was not suicidal, self-injurious, homicidal, aggressive or psychotic. Medical history is remarkable for hypothyroidism. The patient is treated with appropriate medication for this condition. The patient is married. His wife is supportive but wants him to seek treatment. The patient is a carpenter and he is currently not working.

This history provided as part of a request for coverage for services provides the information needed to make a benefit determination regarding a request for services. Referral for detoxification is not required based on the patient’s lack of signs or symptoms of withdrawal. There is no reported history of complicated withdrawal. The documentation supports that the patient is medically stable and receiving treatment for his hypothyroidism. No acute psychiatric risk issues or symptoms are present. The patient has a history of maintaining sobriety for a long period of time. He has relapsed
for one to six months depending on how one regards the differing information provided by the patient and his wife. He has not had any recent substance abuse treatment. He is motivated for recovery and also has the support of his wife.

Based on the majority of medical necessity criteria sets, this patient could safely and appropriately be treated in a less intensive treatment setting than a 24-hour residential placement. A substance abuse intensive outpatient program would often be recommended based on this sample history.

Making benefit determinations regarding appropriate level of care and duration of treatment for substance abuse disorders requires a thorough and complete assessment. Interview with collateral resources, including family members, particularly when the presenting patient is a minor, is often an integral part of the initial assessment.

This information and progress in treatment can be used in tandem with medical necessity criteria to consider requests for all substance abuse treatment levels of care. Consultation with an appropriate clinician regarding medical necessity can aid in making determinations. Ideally, cases would be reviewed with a physician reviewer certified by the American Society of Addiction Medicine (now the American Board of Addiction Medicine) or board-certified in psychiatry with an additional psychiatry subspecialty. The field of addiction medicine is rapidly evolving as increasing amounts of evidence-based medical literature is available to inform providers, case managers and physician reviewers as they make recommendations for the assessment and treatment of the substance abuse patient.