THE ASAM CRITERIA ASSESSMENT INTERVIEW GUIDE

THE ASAM CRITERIA ASSESSMENT INTERVIEW GUIDE

If emergent physical or mental health needs are identified, consider immediate referral to ED or call 911.

If the patient is intoxicated or in withdrawal, it may be more appropriate to complete a full ASAM Criteria Assessment once their conditionhas been stabilized. Consider immediate referral for medical evaluation or withdrawal management services.

Before we get started, can you tell me about why you have come to meet with me today?
DIMENSION 1 - ACUTE INTOXICATION OR WITHDRAWAL POTENTIAL
I am going to read you a list of substances.Could you tell me which ones you have used, how long, how recently, and how you used them?
ALCOHOL
Date of last use:
Avg. drinks per drinking day:
In the last 30 days, how often have you had:[For females] 4 or more drinks on one occasion?
[For males] 5 or more drinks on one occasion?
[For males] 5 or more drinks on one occasion?
DIMENSION 1 - ACUTE INTOXICATION OR WITHDRAWAL POTENTIAL
1. I am going to read you a list of substances.
Could you tell me which ones you have
used, how long, how recently, and how you
used them?
 NEVER USED DURATION
of continuous use		 FREQUENCY
in last 30 days		 ROUTE
Select all that apply
Estimate Years and/or Months of use
4-7 days/week 1-3 days/week 3 or less days/month Not Used
Oral Nasal/snort Smoke Inject Other (rectal,patches,etc.)
ALCOHOL
Date of last use: Avg. drinks per drinking day: In the last 30 days, how often have you had: [For females] 4 or more drinks on one occasion? [For males] 5 or more drinks on one occasion? 		Year,
Month,
HEROIN, FENTANYL, OR OTHER NON-PRESCRIPTION OPIOIDS
Date of last use: 		Year,
Month,
PRESCRIPTION OPIOID MEDICATION MISUSE
Specify type: Were these medications from a valid prescription? Yes No
Date of last use: 		Year,
Month,
BENZODIAZEPINES/OTHER SEDATIVES/HYPNOTICS/SLEEPING MEDICATION MISUSE
Were these medications from a valid prescription? Yes No
Date of last use: 		Year,
Month,
COCAINE/CRACK
Date of last use: 		Year,
Month,
METHAMPHETAMINE/OTHER STIMULANTS:
Date of last use: 		Year,
Month,
PRESCRIPTION STIMULANT MISUSE
Specify type: Were these medications from a valid prescription? Yes No
Date of last use: 		Year,
Month,
MISUSE OF OTHER PRESCRIPTION DRUGS:
Specify type:
Date of last use: 		Year,
Month,
CANNABIS OR MARIJUANA:
Date of last use: 		Year,
Month,
NICOTINE OR TOBACCO:
Date of last use: 		Year,
Month,
OTHER DRUG:
Date of last use: 		Year,
Month,
Substance Use History
I am going to ask you a few more questions about your substance use, and any withdrawal risks you may have. The response options are either "Yes/No" or "Not at all," "A Little," "Somewhat," "Very," or "Extremely." Use motivational interviewing skills to develop discrepancy between any problems mentioned and the patient's assessment of whether addiction is a problem.
Not at all A Little Somewhat Very Extremely
How much are you bothered by any physical or emotional symptoms when you stop or reduce using alcohol or other drugs? (For example, body aches, nausea or anxiety that interfere with your everyday life when you stop or reduce your use.) Please describe:
Are you currently experiencing withdrawal symptoms, such as tremors, excessive sweating, rapid heart rate, anxiety, vomiting, etc.? (Please describe specific symptoms and consider immediate referral for medical evaluation):
Are you currently experiencing withdrawal symptoms, such as tremors, excessive sweating, rapid heart rate, anxiety, vomiting, etc.? (Please describe specific symptoms and consider immediate referral for medical evaluation):

Note: If the patient is intoxicated or in active withdrawal it may not be appropriate to complete a full ASAM Criteria Assessment. Consider immediate referral for medical evaluation or withdrawal management services.

Do you find yourself using more alcohol and/or other drugs in order to get the same effect? (Are there any patterns that indicate higher tolerance?) Please describe:
Do you have a history of serious withdrawal, seizures, or life-threatening symptoms during withdrawal? Please describe and specify substance(s):
Do you have a history of serious withdrawal, seizures, or life-threatening symptoms during withdrawal? Please describe and specify substance(s):

Date of last severe withdrawal episode 		Yes No
Do you have a history of overdose (e.g., loss of consciousness, needing medical intervention)? Please describe and specify substance(s):

How recent was your last overdose?

Interviewer note: Inquire whether the patient has received training/been equipped with naloxone. Provide naloxone resources.

Yes No

If opioids - Do you have access to naloxone?

Yes No
Have you used substances in the last 48 hours? If yes, what?
List:

Short-acting opioids (e.g., heroin): Onset of withdrawal symptoms is 8-24 hours after last use Long-acting opioids (e.g., methadone): Onset of withdrawal symptoms is 12-48 hours after last use

Yes No
Interviewer observation: Does the patient seem to have current signs of with- drawal or intoxication? Please describe: (refer to list in item 2 for withdrawal signs) Intoxication Withdrawal None
Problem Statements and Goals (Optional, for treatment planning purposes)
Interviewer instructions: get quotes in the patient's own words. Remember to create goals that are concrete, measurable, and achievable
What concerns do you have about your risk for overdose?
What concerns do you have about your risk for withdrawal?
What concerns do you have about getting medication or other treatment for withdrawal symptoms, if any?
What goals do you have for your management of withdrawal or overdose risk?
SEVERITY RATING - DIMENSION 1 (Acute Intoxication and/or Withdrawal Potential)
For guidance assessing risk, please see Risk Rating Matrices in The ASAM Criteria, 3rd ed.:
  • For alcohol, see pages 147-154
  • For sedatives/hypnotics, see pages 155-161
  • For opioids, see "Risk Assessment Matrix" on page 162
Note: Stimulant withdrawal from cathinones (bath salts) or high dose prescription amphetamines can be associated with intense psychotic events needing higher level of care
0 None 1 Mild 2 Moderate 3 Severe 4 Very Severe
  • No signs of withdrawal/ intoxication present
  • Mild/moderate intoxication
  • Interferes with daily functioning
  • Minimal risk of severe withdrawal
  • No danger to self/others
  • May have severe intoxication but responds to support
  • Moderate risk of severe withdrawal
  • Moderate risk of severe withdrawal
  • No danger to self/others
  • Severe intoxication with imminent risk of danger to
  • Severe intoxication with imminent risk of danger to self/others
  • Difficulty coping
  • Significant risk of severe withdrawal
  • Incapacitated
  • Severe signs and symptoms
  • Presents danger, i.e.,seizures
  • Continued substance use poses an imminent threat to life
Withdrawal management (WM) follow up for controlled or mild symptoms Prioritize the link to medical WM services Urgent, high risk or severe WM needs, high need of support 24-hours/day Emergency Departmentimminent danger
Alcohol Opioids Benzodiazepines Stimulants other
DIMENSION 2 – BIOMEDICAL CONDITIONS AND COMPLICATIONS
1. Do you have a primary care clinician who manages your medical concerns? Yes No
Provider name:
Provider contact:
2. Are you currently taking any medications? List all known medications for medical/physical health condition(s), including over the counter medications (Mental health medications will be discussed in the next section)
MEDICATION(S) DOSE (if known) FREQUENCY e.g., 1, 2, 3, 4 x/day PURPOSE (to treat what symptom/illness) NOTES
Do you use marijuana or marijuana-related products (including CBD [cannabidiol] or other extracts) as medicine? Yes No
Specify type:
Frequency:
Purpose (physical health symptom/illness):
Are you currently using contraception? Yes No
Specify type:
Note to interviewer:
  • For patients who report use of marijuana or marijuana-related products, refer to patient's screening results, such as the NIDA Quick Screen V1.0.0F1ASSIST. Is patient at risk for Cannabis Use Disorder?
  • Refer to substance use history in Dimension 1 for possible drug interactions or increased potential for disordered use, i.e., opioids prescribed for chronic pain in a patient with opioid use disorder.
  • Use motivational interviewing (MI) skills to explore impact of any substance use that may be risky.
3. Do you have any concerns about a medical/physical health problem or disability at this time? Yes No
Please describe:
4. Approximately, when is the last time you saw a doctor or other healthcare clinician? (Month and year if known): What did you see them for (if known)?
Please describe:
5. I am going to read you a list of physical health issues. Do you currently have, or have you been diagnosed with, any of the following?
Heart problems
High Blood Pressure
High Cholesterol
Blood Disorder
HIV
Stomach/Intestinal Problems
Cancer (specify type(s)):

Allergies:
Seizure/Neurological Problems
Thyroid Problems
Kidney Problems
Liver Problems
Viral Hepatitis (A, B, or C)
Asthma/Lung Problems
Muscle/Joint problems
Vision Problems
Hearing Problems
Dental Problems
Tuberculosis (TB)
Sexually Transmitted Disease(s):

Infection(s):

Other:
Diabetes
Sleep Problems
Chronic Pain
Chronic
Note:
6. Interviewer observation: are any of these medical/physical health issues potentially infectious to other staff or patients? (Seek medical or nursing consultation if unsure) Please describe:
Yes No
Please describe:
7. (Confirm, ask if not known) Are all of these medical/physical health problems in good control or stable with current treatment? Please describe:
Not sure Unstable/uncontrolled Stable w/ treatment Stable w/out treatment NA
Please describe:
8. Do you need additional treatment for new, worsening or more severe symptoms/problems? Please describe:
Yes No Don't know
Please describe:
9. Are these medical/physical health issues (listed in the table above) either caused or made worse by alcohol or other drug use? (e.g., cause you to neglect treatment, make medical/physical health problem worse, cause injection injuries?) Please describe:
Yes No Don't know
Please describe:
10. Are you up to date on your vaccines? (COVID, Tdap, Flu, HepA, HepB, MMR, Tetanus, VAR, other) :
Yes No Don't know
Please describe:
11. If female sex at birth, are you, or do you think you could be, pregnant?:
Yes No / N/A No Sure 1st, weeks 0-13 2nd, weeks 14-27 3rd, weeks 28 +
a. If yes, how many weeks/which trimester? 1st, weeks 0-13 2nd, weeks 14-27 3rd, weeks 28 +
b. If yes, have you seen a clinician for pregnancy care? yes No / N/A
Please describe:
12. Additional comments on medical/physical health conditions, prior hospitalizations (include dates and reasons):
Self-Report Scales
For the next questions, the response options are Not at all,A Little,Somewhat,Very, or Extremely.
Not at all A Little Somewhat Very Extremely
13. How much do any of these health issues (above) make it harder for you to take care of yourself? (e.g., hygiene, grooming, dressing, eating, housework, living independently, etc.) Please describe:
14. How much do any of these health issues make it harder for you to go to school, work, socialize or engage in hobbies or other interests? Please describe:
15. How much do these health issues make it harder for you to go to SUD treatment or stay in SUD treatment? Please describe:

Not applicable

Do you have someone who can support you with these health issues? (Probe, even if they "don't need help" do they have a support person?) Please describe: Yes Maybe No
Note: If a patient has a physical health problem that prevents them from reliably attending treatment, do they have supports to help manage their condition and ensure that they attend treatment?
Problem Statements and Goals (Optional, for treatment planning purposes)
17. What concerns do you have about your physical health and/or medical conditions?
18. What goals do you have for your physical health and/or medical conditions?
18. What goals do you have for your physical health and/or medical conditions?
19. Question to be answered by interviewer: Does the patient re- port medical/physical health symptoms that would be considered life threatening or require immediate medical attention?
Yes No
Please describe:
Severity Rating - Dimension 2 (Biomedical Conditions and Complications)
0 None 1 Mild 2 Moderate 3 Severe 4 Very Severe
  • Fully functional/no significant pain or discomfort
  • Mild symptoms interfering minimally with daily functioning
  • Able to cope with physical discomfort
  • Acute or chronic biomedical problems are non-life threatening but are neglected and need new or different treatment
  • Health issues moderately impacting *ADLs and independent living
  • Sufficient support to manage medical problems at home with medical intervention
  • Poorly controlled medical problems requiring evaluation
  • Poor ability to cope with medical problems
  • Insufficient support to manage medical problems independently
  • Difficulty with ADLs and/or independent living
  • Unstable condition with severe medical prob- lems,** including but not limited to:
  • Emergent chest pain
  • Delirium tremens (DTs)***
  • Unstable pregnancy
  • Vomiting bright red blood
  • Withdrawal seizure in the past 24 hours
  • Recurrent seizures
Regular follow up, low intensity services for controlled conditions Priority follow up and evaluation for new/ uncontrolled conditions Need for evaluation and treatment, including medical monitoring in conjunction with 24-hour nursing to ensure stabilization Need for evaluation and treatment, including medical monitoring in conjunction with 24-hour nursing to ensure stabilization
Interviewer Instructions:
For guidance assessing Dimension 2, see ASAM Criteria, 3rd ed. "Assessment Considerations" text box at the bottom of page 45.
For guidance assessing risk ratings and modalities for Dimension 2, see text box "Dimension 2: Biomedical Conditions and Complications" on page 76 of The ASAM Criteria, 3rd edition.
DIMENSION 3 - EMOTIONAL, BEHAVIORAL, OR COGNITIVE CONDITIONS AND COMPLICATIONS
1. Interviewer observation: Is the patient disoriented? Does the patient endorse, or do you suspect cognitive or memory issues?
Yes No
Please describe:
2. Have you ever been told by a physical or mental health clinician that you have a mental health problem or brain injury? Please describe: (e.g., diagnosis, date, and type of injury, if known)
Yes No
Please describe:
3. Are you currently in treatment, or have you previously received treatment, for mental health or emotional problems? Please describe: (e.g., treatment setting, hospitalizations, duration of treatment)
Yes No
Please describe:
4. If yes*: Have your mental health symptoms been stable (check all that apply)?
N/A Stable with treatment/meds Stable without treatment/meds Unstable Not sure
Please describe:
5. This next question can be sensitive, and you can choose to skip the question or respond with just a yes or no if you prefer. Have you ever experienced any abuse (this can include physical, emotional, or sexual abuse) or any other traumatic events?
Yes No Skipped Unstable Not sure
Please describe:
List all current medication(s) for psychiatric condition(s): N/A
Yes No Skipped Unstable Not sure
MEDICATION(S) DOSE (if known) FREQUENCY e.g., 1, 2, 3, 4 x/day PURPOSE (to treat what symptom/illness) NOTES
Notes :
*Do you use marijuana or marijuana-related products (including CBD [cannabidiol] or other extracts) as medicine for any psychiatric condition(s):
Yes No
Specify type:
Frequency:
Purpose:
7. Do you have a mental health care provider? [Mental health care providers should be identified for collaboration and releases of information obtained]
Yes No N/A
Provider name:
Provider contact:
8. I am going to read you a list of mental health symptoms and behaviors that might be concerning to some people. Can you tell me if any of these have been bothering you in the last 30 days? Also, if you have these symptoms, please let me know if they happen
MOOD PAST 30 DAYS Only when using or withdrawing from alcohol or other drugs
Depression/Sadness
Loss of pleasure/interest
Hopelessness
Irritability/Anger
Impulsivity
Interviewer observation: Pressured speech
Feeling unusually important/Grandiosity
Racing thoughts
Anxiety
Anxiety/Excessive worry
Thoughts that you cannot stop if you want to/Obsessive thoughts (Not including thoughts about using substances)
Behaviors that you cannot stop if you want to/Compulsive behaviors (Not including usingsubstances)
Flashbacks
Psychosis- Include interviewer observation
Paranoia (e.g., feeling
Delusions, feeling you were especially important in some way, or that you were receiving special messages, or that people were out to harm you (false beliefs inconsistent with culture)
OTHER
Sleep problems
Memory/Concentration
Gambling
Risky sex behaviors
Physical aggression towards people or property,describe: (e.g., what happened?)
Other
Note :
9. Are these issues (listed in the table above) either caused or made worse by alcohol and/or other drug use? Please describe:
Yes No Not sure
Please describe:
10. Do you ever see or hear things that other people say they do not see or hear (e.g., hearing voices. Probe, does this occur only while using or withdrawing from alcohol or other drugs)? Please describe:
Yes No
Please describe:
11. Have you had thoughts of hurting yourself? Yes No
Have you had thoughts that you would be better off dead? Yes No
Please describe:
a. *If yes: Are you having these thoughts today? Yes No
Note to interviewer: Seek immediate clinical consultation and/or contact emergency services for imminent danger of harm to self or others. Assess acute suicidality, homicidality, and risk (e.g., plans, firearm access, etc.).
b. Have you ever acted on these feelings to hurt yourself? Yes No
12. Have you had thoughts of harming others? Please describe: Yes No
a. If yes: Are you having these thoughts today? Yes No
b. Have you ever acted on these feelings to harm others? Yes No
Interviewer instructions: Follow all local laws and procedures for disclosing any reportable events regarding harm to self, others, elders or children.
Note :
Self-Report Scales
For the next questions, the response options are Not at all,A Little,Somewhat,Very, or Extremely.
Not at all A Little Somewhat Very Extremely
13. How much do any of these emotional health symptoms from the list we discussed above make it harder for you to take care of yourself? (e.g., hygiene, grooming, dressing, eating, housework, living independently, etc.) Please describe:
14. How much do any of these emotional health symptoms make it harder for you to go to school, work, socialize or engage in hobbies or other interests? Please describe:
15. How much do these health issues make it harder for you to go to SUD treatment or stay in SUD treatment? Please describe:

Not applicable

15. How much do these emotional health symptoms make it harder for you to go to SUD treatment or stay in SUD treatment? Please describe:

Not applicable

Problem Statements and Goals (Optional, for treatment planning purposes)
16. What major problems (if any) have been caused by these mental health or emotional symptoms? Problem: is there one issue or symptom that is the worst for you?
Please describe:
17. What concerns or worries do you have about getting treatment for your mental health or emotional symptoms or issues?
Please describe:
18. What goals do you have for your mental and emotional health?
Please describe:
19. Interviewer observation: Is further assessment of mental health needed? Yes No
Please describe:
Severity Rating - Dimension 2 (Biomedical Conditions and Complications)
0 None 1 Mild 2 Moderate 3 Severe 4 Very Severe
  • No dangerous symptoms
  • Good social functioning
  • Good self-care
  • No symptoms interfering with recovery
  • Possible diagnosis of emotional, behavioral,cognitive condition
  • Requires monitoring for stable mental health condition
  • Symptoms do not interfere with recovery
  • Some relationship impairments
  • Symptoms distract from recovery
  • Requires treatment and management of mental health condition
  • No immediate threat to self/others
  • Symptoms do not prevent independent functioning
  • Inability to care for self at home
  • May include dangerous impulse to harm self/others
  • Does require 24-hr support
  • At risk of becoming a 4/Very Severe without treatment
  • Life-threatening symptoms including active suicidal ideation
  • Psychosis
  • Imminent danger to self/others
Further assessment and referral or follow-up with existing mental health (MH) provider Prioritize follow up or new evaluation with MH provider for new/uncontrolled conditions Urgent assessment and treatment for unstable signs and symptoms Emergency Departmentimmediate assessment
Interviewer Instructions:
Take into account cognitive impairments.
Choose the score that is closest to your overall impression. Patients may not exhibit every symptom within a severity rating. The patient's historical functioning does NOT override the status. Current level of functioning DOES override historical functioning (see ASAM Criteria, 3rd Ed. page 56).
Interviewer Instructions:
For guidance assessing Dimension 3, see ASAM Criteria, 3rd Ed. p. 46-48 and p. 77-81.
For guidance assessing cognitive impact on placement, see ASAM Criteria, 3rd Ed. p. 234.
DIMENSION 4 - READINESS TO CHANGE
1. I am going to read you a list of items that are sometimes impacted by alcohol or other drug use. Please indicate how much your alcohol or other drug use affects these aspects of your life. The response options are, "Not at all," "A Little," "Somewhat," "Very," or "Extremely."
For guidance assessing cognitive impact on placement, see ASAM Criteria, 3rd Ed. p. 234.
Interviewer instruction: As co-occurring disorders are common, also explore the patient's readiness to address any mental health diagnoses or issues.
Not at all A Little Somewhat Very Extremely
Work
School
Mental health/Emotions
Hobbies/Recreation
Legal matters (e.g., DUI)
Finances
Family relationships
Friendships
Romantic partners
Self-esteem
Physical health
Enjoyment of activities
Sexual function
Hygiene/Self-care
Other
Notes: Include interviewer observations. Does patient have curiosity, interest, or insight? Does the patient show curiosity and interest in learning about the impact of substance use on themselves and people close to them? Do they show insight into problems, for example, the consequences of their use (such as DUIs, sexually transmitted infections, etc.?)
Interviewer instructions: When possible and appropriate, mirror the patient's language. When asking questions, use the same words or phrases they use to describe their experiences. Engage patient where they are most ready for change. Remember, the patient is at Action for at least one issue, or they would not attend the assessment. People may be at different stages for different priorities (MH vs. SUD vs. a physical or social prob- lem). Use MI skills to develop discrepancy between any problems they have mentioned and their assessment of addiction as a problem. For more information on readiness to change, see pgs. 49 and 50 of The ASAM Criteria, 3rd Ed.
2. Do you believe changing your use of substances could improve any of these aspects of your life (listed in the table above)? Please describe:
Yes No I don't know
Please describe:
3. Do you think you need treatment to change your use of substances?
Yes No, it is not a problem No, I can stop anytime without help No, I can stop anytime without help I don't know
Please describe:
4. Interviewer observations: What stage(s) of change is the patient exhibiting? (circle one) Is stage of change different for different issues?
Issue:
Precontemplation Contemplation Preparation Action Maintenance
Note :
Not at all A Little Somewhat Very Extremely
5. Based on the issues we have discussed, how much is substance use a problem for you? (The response options are,Not at all,A Little,Somewhat,Very,or Extremely.)
Please describe:
6. Have you done anything in the past to change your alcohol or other drug use (e.g., attending mutual help groups, changing substances used or friends)? Yes No
Please describe:
a. If you have had treatment, how helpful was it? Please describe:
7. Do you have concerns or fears that make it hard for you to go to or stay in treatment (e.g., stigma; I won't have friends anymore; I don't want to be away from my family; I don't have time, housing, safe childcare; domestic partners would not be supportive of my recovery; other)?
Yes No
Please describe:
8. Do you want to quit or cut back your alcohol or other drug use?
Yes, quit Yes, cut back Not sure No, neither
Please describe:
Self-Report Scales
9. Who else in your life cares about whether you quit or cut back (e.g., probation, courts, family, Child Protective Services, employer, etc.)?
List:
For the next questions, the response options are Not at all,A Little,Somewhat,Very,or Extremely
Not at all A Little Somewhat Very Extremely
10. How much do you feel they care about whether you quit or cut back?
11. How important is it for you to make changes in your life at this time (changes related to SUD, mental health or other issues)?
Please describe:
12. How important is it for you to stop your alcohol or other drug use?
Please describe:
13. How ready are you to stop or reduce your alcohol or other drug use?
Please describe:
14. Putting aside any others' opinions about your use, how important is it to you to get treatment for your alcohol or other drug use?
Please describe:
Problem Statements and Goals (Optional, for treatment planning purposes)
Interviewer instructions: If the patient is not ready to change alcohol or other use, are they ready for changes in other areas? Probe to get more information regarding other areas that patient may want to change.
Are there other things in your life that you would like to be different from how they are now?
If things were better than they are now, what would that look like?
What concerns do you have about changing your alcohol or other drug use or other aspects of your life (in order to achieve your goals)?
Note :
Severity Rating - Dimension 4 (Readiness to Change)
0 None 1 Mild 2 Moderate 3 Severe 4 Very Severe
  • Proactive responsible participant in treatment
  • Committed to changing alcohol or other drug (AOD) use
  • Willing to enter treatment
  • Ambivalent to the need to change
  • Reluctant to agree to treatment
  • Low commitment to change AOD use
  • Variable adherence to treatment
  • Unaware of and not interested in the need to change
  • Unwilling/only partially able to follow through with treatment
  • Passively compliant, goes through the motions in treatment
  • Rejecting need to change
  • Engaging in potentially dangerous behavior
  • Unwilling/unable to follow through with treatment recommendations
Requires moderate intensity services for motivational enhancement Requires moderate intensity services for motivational enhancement Requires high intensi- ty engagement and/or motivational enhancement services to prevent decline in functioning/safety Secure placement for acute or imminently dangerous situations and/or close observation required
Additional Comment(s):
DIMENSION 5 - Relapse, Continued Use, or Continued Problem Potential
1. What is the longest period of time that you have gone without using alcohol and/or other drugs?
Days Months Weeks Years N/A, never
a. How long ago did that end? Days Months Weeks Years N/A, never
Interviewer instruction: it is not a relapse if patient is not in/has never been in recovery.
2. What helped you go that long without using alcohol and/or other drugs? (Probe for personal strengths, peer support, medication, treatment, etc.)
N/A, never
3. If you relapsed in the past, what kinds of things do you think led to your relapse?
N/A, never
4. If you plan to quit or cut back, how will you manage this goal? (e.g., stop on my own; go to treatment; take medications as prescribed; attend self-help groups; change relationships, job, habits, or circumstances; etc.)? :
N/A, never
Please describe :
5. What problems could happen or get worse if you do not get help for alcohol or other drug use and/or mental health issues? (Probe how soon could these things happen, short-term risk? Long-term risks?)
N/A, never
Please describe :
6. Interviewer observations: How severe/dangerous/ IMMINENT* are consequences of the current situation? Please describe:
Few/Mild/No consequences/Not imminent Some/Not severe consequences/in weeks or month Many/Severe consequences/Imminent within hours or days
Please describe :
Interviewer instruction:To help identify possible emer- gencies, consider the likelihood that behaviors presenting a significant risk of serious adverse consequences to the individual and/or others (as in reckless driving while intoxicated, suicide, or neglect of a child) will occur in the very near future, within hours and days, rather than weeks or months. (See ASAM Criteria, 3rd ed. p. 65 and graphic on p. 67).
Self-Report Scales
I am going to read you a list of questions about ongoing pressures that you might be facing right now. These might be the kinds of stressors that make you use or want to use alcohol or other drugs. The response options are,Not at all,A Little,Somewhat,Very,or Extremely.
How much have you been bothered or triggered by the following?
Not at all A Little Somewhat Very Extremely
7. Cravings, withdrawal symptoms, and/or negative effects of alcohol or other drug use
8. Social pressure (friends, at work, at school, at home)
9. Difficulty dealing with feelings/emotions (Probe for anxiety, depression,boredom, anger, etc.)
10. Financial stressors (e.g., paying bills, worry about losing work)
11. Physical health problems including issues such as chronic pain
12. How likely is it that you will either relapse or continue to use alcohol or other drugs without treatment or additional support?
13. Which trigger(s) or problem(s) have been the worst for you in the past month or so?
Please describe :
14. Generally, how do you handle these issues or triggers (e.g., how do you cope)?
Please describe :
15. Do you feel like you have a good plan and ability to deal with these issues or triggers (probe items listed above)? Why or why not?
Please describe :
16. Interviewer observations: Does the patient show good insight into their triggers, MH symptoms, coping mechanisms,and other risks?
Yes, good insight Some insight Very limited insight Dangerously low insight
Please describe :
Problem Statements and Goals (Optional, for treatment planning purposes)
17. What are the current, most pressing issues that might cause you problems or cause you to use alcohol or other drugs or use more than you planned to?
Problem(s):
18. What would it look like if those issues were resolved? What would it take to resolve them?
Problem(s):
Severity Rating - Dimension 5 (Relapse, Continued Use, or Continued Problem Potential)
0 None 1 Mild 2 Moderate 3 Severe 4 Very Severe
  • Low/no potential for relapse
  • Some minimal risk for use
  • Fair coping and relapse prevention skills
  • Some or inconsistent use of coping skills
  • Able to self-manage with prompting
  • Little recognition of risk for use
  • Poor skills to cope with relapse
  • No coping skills for relapse/addiction problems
  • Substance use/behavior places self/others in imminent danger
Low-intensity relapse prevention services are needed or self-help/peer support group Relapse prevention services and education are needed.
Possible need for:
  • intensive case management
  • medication management
  • assertive community treatment
 Relapse prevention services including:
  • structured coping skills training
  • motivational strategies
  • assertive case management and assertive community treatment
  • possible need for structured living environment
 Likely needs all services listed in "Severe"
  • For acute cases, need for 24-hour clinically managed living environment. OR
  • For chronic cases, not imminently dangerous situations, need 24-hour supportive living environment
Additional Comment(s):
DIMENSION 6 - RECOVERY/LIVING ENVIRONMENT
1. In the past two months, have you been living in stable housing that you own, rent, or stay in as part of a household? (Negative response indicates homelessness.)
Yes No
Please describe :
2. Are you worried or concerned that in the next two months you may NOT have stable housing that you own, rent, or stay in as part of a household? (Positive response indicates risk of homelessness.)
Please describe :
3. Do you need different housing than what you currently have?
Yes No
Please describe :
4. Who do you live with? (friends, family, partner, roommates)
Please describe :
5. Are you working/going to school/retired/disabled/unemployed?
School Work Retire Disability Other
Please describe :
6. What are the sources of your financial support?
Paid work Benefits (SSI, SSDI) Family/Friends Illegal/Under the table Other
a. Which of these is the biggest source of your income? (Circle one)
7. How do you spend your free time (e.g., when not working? Probe for free time when not using alcohol or other drugs)?
Please describe :
8. Do you have any reading or learning challenges that need support (e.g., in school did you require supports, do you require support for disabilities at work? Are you able to use workbooks, computers and email)?
Yes no
Please describe :
9. Do you have needs in any of the following areas to help support you as you cut back on alcohol or other drug use?
Transportation Education Childcare Legal Housing Financial Employment Other
Interviewer instruction: Use MI skills to develop discrepancy between any problems they have previously mentioned and whether they might need support in the areas listed.
10. Are you engaged with any of the following social service agencies?
Child Protective Services Tribal Service Agency Health and Human Services Other
11.Have you had criminal justice issues related to alcohol or other drug use? Note if patient engages in criminal behavior related to their drug use (e.g., for money for alcohol or other drugs, or because they are under the influence) Are you currently engaged with probation, parole, or diversion courts?
Yes no
Please describe :
12. Are you required to go to SUD treatment? (e.g., by Child Protective Services, employer, professional groups, probation, parole).
Yes no
Please describe :
13. Are you a veteran? (Veterans may have access to special benefits such as housing)
Yes no
Please describe :
14. Have you ever participated in peer support groups such as NA/AA, SMART recovery, Dual Recovery Anonymous, Women for Recovery, SOS or others?
Yes no
Please describe :
15. Do you currently live in an environment where others are regularly using drugs or alcohol?
Yes no
a. If yes, Do you have an alternative place to live where others are not regularly using drugs or alcohol? Yes no
16. Do any of your current relationships pose a threat to your safety?
Yes no

a. If yes:
i. Has this person used a weapon against you or threatened you with a weapon? Yes no
ii. Has this person threatened to kill you or your children? Yes no
iii. Do you think this person might try to kill you? Yes no
17. Do any other current situations pose a threat to your safety?
Yes no
18. Does your alcohol or other drug use ever create situations that are dangerous for you or threatening to others?
Yes no
Please describe :
Interviewer instruction: *If yes, follow emergency protocols for your agency and
county in situations involving imminent danger and reportable events.
Immediate (TODAY) Urgent (WITHIN DAYS) Timely placement is required as part of regular treatment
Self-Report Scales
I am going to read you a list of questions about things in your environment that may affect you. The response options are Not at all. A Little,Somewhat,Very or Extremely.
19. Are there people, places, or things that are supportive of your quitting or cutting back your AOD use?
a. How supportive are they?
Supportive people: (List) Not at all A Little Somewhat Very Extremely
Supportive places: Not at all A Little Somewhat Very Extremely
Supportive things: Not at all A Little Somewhat Very Extremely
20. Are there people, places or things that make quitting or cutting back more difficult?
People: Not at all A Little Somewhat Very Extremely
Places: Not at all A Little Somewhat Very Extremely
Things: Not at all A Little Somewhat Very Extremely
Problem Statements and Goals (Optional, for treatment planning purposes)
21. What concerns or problems do you have with your current living situation or environment?
Problem(s):
22. What changes in your work/home/community are you able or willing to make to support cutting back or stopping your alcohol or other drug use? (e.g., get peer support, move, change jobs, change friends)
Nothing Not sure
Goal(s):
23. What changes in your work/home/community are you unable or unwilling to make to support cutting back or stopping your alcohol or other drug use? (e.g., get peer support, move, change jobs, change friends)
Nothing Not sure
Please describe :
24. If things improved in your environment, what would that look like? What are your goals for your environ- ment? This might include getting a job, going back to school, getting social services, etc.
Nothing Not sure
Goal(s):
Severity Rating – Dimension 6 (Recovery/Living Environment))
0 None 1 Mild 2 Moderate 3 Severe 4 Very Severe
  • Able to cope in environment/supportive
  • Passive/disinterested social support, but still able to cope
  • No serious environmental risks
  • Unsupportive environment, but able to cope in the community with clinical structure most of the time
  • Unsupportive environment,difficulty coping even with clinical structure
  • Environment toxic/hostile to recovery
  • Unable to cope and the environment may pose a threat to safety
May need assistance in:
  • finding a supportive environment
  • developing supportsre: skills training
  • childcare
  • transportation
 Needs assistance listed in "Mild," as well as:
  • assertive care management
 Needs more intensive assistance in
  • finding supportive living environment
  • skills training (depending on coping skills and impulse control)
  • assertive care management
  • Patient needs immediate separation from a toxic environment
  • Assertive care management
  • Environmental risks require a change in housing/environment
  • For acute cases with imminent danger: patient needs immediate secure placement
Additional Comment(s):
ASAM Summary of Multidimensional Assessment:
Transfer information gathered from medical records and brief assessments to the table below:
SEVERITY
Mild Moderate Severe
SUD Diagnosis Provisional Confirmed
Diagnostic Tool Used:
SUD Diagnosis Provisional Confirmed
Diagnostic Tool Used:
Co-occurring Diagnosis Provisional Confirmed
Diagnostic Tool Used:
Co-occurring Diagnosis Other:
A higher severity rating indicates a need for higher intensity and dosage of services as well as a lower level of patient functioning.
SEVERITY RATING
DIMENSION Not at all A Little Somewhat Very Extremely
DIMENSION 1 Acute Intoxication and/or Withdrawal Potential 1 2 3 4 5
DIMENSION 2 Biomedical Conditions and Complications 1 2 3 4 5
DIMENSION 3 Emotional, Behavioral, or Cognitive Conditions and Complications 1 2 3 4 5
DIMENSION 4 Readiness to Change 1 2 3 4 5
DIMENSION 5 Relapse, Continued Use, or Continued Problem Potential 1 2 3 4 5
DIMENSION 6 Recovery/Living Environment 1 2 3 4 5
Withdrawal Management:
Substances for which WM is indicated:
Nicotine/tobacco Alcohol
Opioid
Sedatives/Hypnotics/Benzodiazepines
Stimulants (e.g., cocaine, methamphetamine, MDMA)
wm_indicated not indicated
Other
Note: Forced or non-medically directed withdrawal can be dangerous, is unethical, and is counterproductive. Safe and comfortable withdrawal enhances engagement in treatment.
There is a continuum of withdrawal management. For example, if withdrawal is not stabilized at Level 2, then patient should be raised to Level 3.
**Level 3.2WM can be considered for patients who need 24-hour support to complete withdrawal management/increase likelihood of continuing treatment, and who can self-administer medications with supervision.
1-WM 2-WM 3.7-WM 4-WM
  • Outpatient
  • Secure home environment
  • High general functioning
  • Needs daily or less than daily supervision
  • Likely to complete WM and continue treatment or recovery
  • Intensive outpatient
  • Need for support all day
  • At night has supportive family or living situation such as, supportive housing/ shelter **
  • Likely to complete WM
  • Has ability to access medical care in person or telemedicine (not ER)
  • Residential
  • Severe withdrawal
  • Needs 24-hour nursing support and daily access to physician
  • Unlikely to complete WM without medical monitoring
  • Hospital
  • Severe, unstable withdrawal
  • Needs 24-hour nursing and daily physician visits to manage medical instability
  • Setting must include addiction services
Medications for Addiction Treatment
Medications are available for treatment of acute withdrawal from opioids, alcohol, sedatives, and nicotine and for ongoing treatment of opioid, alcohol and nicotine use disorder.
These should be offered to patients entering treatment.
Completed by:
Date:
Signature:
Clinical Supervisor (as required):
Date:
Signature:
ASAM CRITERIA LEVEL OF CARE: CONCURRENT TREATMENT AND RECOVERY SERVICES
Opioid Treatment Program NTP, methadone program
Office Based Opioid Treatment Buprenorphine, naltrexone
Other MAT, (for SUD other than OUD) E.g., Primary care, psychiatrist, nurse practitioner. Pharmacotherapy, i.e., medications for alcohol and nicotine use disorder
COC E.g., Primary care, psychiatrist, nurse practitioner. Pharmacotherapy, i.e., medications for alcohol and nicotine use disorder
COE Co-Occurring Enhanced treatment, integration of services and equal attention for unstable mental health conditions and SUD
Biomedical Enhanced Biomedical Enhanced treatment, integration of services and equal attention for serious physical health conditions and SUD
*Housing Biomedical Enhanced treatment, integration of services and equal attention for serious physical health conditions and SUD
Recovery Support Services Patient needs
Transportation
Childcare
Legal Services
Vocational
School Counseling
Financial Assistance
12 Step
Peer Support
Other
For guidance see The ASAM Criteria, 3rd ed. p. 124 "Decisional flow to Match Assessment and Treatment/Placement Assignment"
Referred to (treatment provider name):
INDICATED LOC ACTUAL LOC
Level 4 - Medically Managed Intensive Inpatient Services COE BIO OTS Level 4 COE BIO OTS
Level 3.7 - Medically Monitored Intensive Inpatient COE BIO OTS Level 3.7 COE BIO OTS
Level 3.5 - Clinically Managed COE BIO OTS Level 3.5 COE BIO OTS
Level 3.3 - Clinically Managed Population-Specific High-Intensity Residential COE BIO OTS Level 3.3 COE BIO OTS
Level 3.1 - Clinically Managed Low-Intensity Residential COE BIO OTS Level 3.1 COE BIO OTS
Level 2.5 - Partial Hospitalization COE BIO OTS Level 2.5 COE BIO OTS
Level 2.1 - Intensive Outpatient COE BIO OTS Level 2.1 COE BIO OTS
Level 1 - Outpatient Services COE BIO OTS Level 1 COE BIO OTS
Reasons for Discrepancy between Indicated and Actual Placement
Circle all that apply
Not applicable - no difference
Patient preference.
Recommended program is unavailable in geographic region.
Lack of physical access (e.g., transportation, mobility).
Conflict with job/family responsibilities.
Patient lacks insurance.
Patient has insurance, but insurance will not approve recommended treatment.
Program available but lacks opening or wait list too long.
Program available but declines to accept patient due to patient characteristic(s), e.g., history, clinical status.
Inappropriate court or other mandated treatment contradicts ASAM Criteria recommendation
Patient left/eloped.
Clinician disagrees with ASAM Criteria recommendation (please explain):

Final Disposition is not known.
Other (please explain):

Appendix
Distinguishing Differences Between The ASAM Levels of Care
Start at the top. If the description in the row does not match current needs of the patient, then proceed to the next row to reach appropriate LOC. ASAM LOC Additional services available at these ASAM Levels of Careo
Medication for OUD Biomedical enhanced Co-Occurring Enhanced (COE)
Any D1, D2, or D3 are rated Very Severe, and/or need to address acute problems requiring primary medical and nursing care managed by a physician in a hospital or psychiatric hospital 4 On-site On-site On-site
Patient needs 24-hour nursing care with medical monitoring:
  • Severe problems in D1 or D2 or D3
  • Moderate severity in at least 2 of the 6 dimensions, at least one of which is D1, D2, or D3
 3.7 On-site or OTS On-site On-site
Patient needs 24-hour supportive addiction treatment
  • Patient environment is provocative to relapse
  • There is considerable likelihood of continued use or relapse with imminent serious/dangerous consequences
  • No need for 24-hour medical monitoring
  • No significant cognitive impairments
  • Needs 24-hour SUD addiction specialty, addiction supports to prevent acute emergency
  • Cannot go unsupervised, not appropriate for waiting list
 3.3 On-site or OTS On-site, Primary, or Specialty care On-site
Patient's temporary or permanent limitations, e.g., due to cognitive impairment, make outpatient treatment strategies not feasible or not effective
  • Needs 24-hour structure with addiction specialty support
  • There is considerable likelihood of continued use or relapse with imminent serious/dangerous consequences
3.3 On-site or OTS On-site, Primary, or Specialty care On-site or link to specialty care
Patient likely to immediately relapse or continue use, or may not be able to function (engage in recovery), or is unsafe in the "real world" unless receiving 24-hour supportive structure
  • No need for 24-hour medical monitoring
  • No significant cognitive impairments
  • Needs 24-hour structure with addiction specialty support
  • Safely able to access the community and outpatient services unsupervised
 3.1 On-site or OTS On-site, Primary, or Specialty care On-site and specialty consultation
Patient is safe in outpatient treatment, but not able to engage in or progress in treatment without daily moni- toring or management
  • Not ready for full immersion in the "real world"
  • For patients with OUD, can go to OTP
  • Moderate or low severity in D2, as well as moderate severity in D4 or D5 or D6
  • Physical health problems don't interfere with addiction treatment but can be distracting and need medical monitoring e.g., unstable hypertension or asthma; chronic back pain
2.5 or OTP OTP or OBOT On-site, Primary, or Specialty care On-site and specialty consultation
Patient can progress in treatment with supports while practicing new recovery skills and tools in the "real world"
  • For patients with OUD, can go to OTP
  • No to low severity in D1, D2, and D3; as well as moderate severity in D4 or D5 or D6
 2.1 or OTP OTP or OBOT Primary, or Specialty care On-site and specialty consultation
Patient has Opioid Use Disorder, current/recent depen- dence according to federal requirements. (See ASAM Criteria, 3rd Ed. text box on p. 290. See p. 296 for diagnostic admission criteria)
  • Patient can receive OTP services as stand-alone services or concurrently with another LOC.
 OTP OTP Primary, or Specialty care On-site and specialty consultation
Patient needs less than 9 hours per week of treatment.
  • Patient is committed to recovery, high level of readi- ness to change; problems are stable but need profes- sional monitoring. Patient is able to engage in collabo- rative treatment.
  • Patient is in early stages of change and not ready to commit to full recovery. A more intensive Level of Care may lead to increased conflict, passive compliance or even leaving treatment.
  • Patient has achieved stability in recovery but needs ongoing monitoring and disease management.
 1 or OBOT OTP or OBOT Primary, or Specialty care On-site and specialty consultation
*Medication should also be made available for Alcohol Use Disorder and Nicotine Use Disorder.
Notes:
Interviewer Instruction: Start at the top (Level 4) of the table above to find the least intensive, most effective Level of Care. to get to least intensive, most effective Level of Care. (See The ASAM Criteria, 3rd Ed. p. 124)
  • Decide the realistic/acceptable Level of Care, factoring in motivation/acceptability, and patient preference (e.g., sole breadwinner, sole childcare/ eldercare provider, employment constraints, and patient goals).
  • Place patient in Level of Care that meets the most of the patient's needs, if that Level of Care is not available, care management should be used to piece together services that safely meet the patient's needs as completely as possible.
  • Also, consider the patient's mental health conditions.
  • Co-occurring Capable (COC): All Levels of Care should be co-occurring capable.
  • Co-occurring Enhanced (COE): is indicated for higher intensity mental health care. This includes on-site, cross-trained mental health professionals, medication management, and psychiatric consultation.
  • Opioid Treatment Services (OTS):
  • Opioid Treatment Programs (OTP) a.k.a. Narcotic Treatment Programs (NTP) - have high patient oversight, direct administration of medications (usually methadone) on a daily basis.
  • Office-Based Opioid Treatment-has lower patient oversight than OTPs, physician in private practice or public clinics, prescribes outpatient supplies of medications (usually buprenorphine or extended-release naltrexone).
HIGH PRIORITY - IMMEDIATE NEED PROFILE
HIGH PRIORITY - IMMEDIATE NEED PROFILE
Dimension If Then
Life threatening Level 4, or emergency department evaluation
1 D1-CURRENT Severe life-threatening withdrawal symptoms Perform immediate evaluation of need for acute
2 D2-CURRENT Severe life-threatening physical health problems Perform immediate evaluation of need for acute
2 D2 is severe/very severe Consider intensive physical health services or hospital care
3a D3a-Imminent danger to self or others Perform immediate evaluation of need for acute
3b D3b-Unable to function in activities of daily living or care for self with imminent dangerous consequences Perform immediate evaluation of need for acute
3 D3 is severe/very severe Consider intensive mental health services or inpatient MH care
4a/b4b D4a-Patient needs SUD or MH treatment but is ambivalent or feels it is unnecessary (e.g., severe addiction but patient feels controlled use is still ok; psychotic, but blames a conspiracy) D4b-Patient has been coerced or mandated to assessment/ treatment Patient to be seen within 48 hours for motivational strategies, unless patient is imminently likely to walk out and needs more structured intervention
Ensure linkage to necessary services
5a D5a-Patient is under the influence and acutely psychotic, manic, suicidal Assess further need for immediate intervention (e.g., take car keys away, support person pick patient up, evaluate need for immediate psychiatric intervention)
5b/c D5b-Patient likely to continue to use and or have active acute symptoms in imminently dangerous manner, without immediate secure placement
D5c-Patient's most troubling problem(s) dangerous to self or others 		Patient to be referred to a safe or supervised environment
6 D6- Any dangerous situations threatening the patient's safety, im- mediate well-being, and/or recovery (e.g., living with drug dealer; physically abused by partner; homeless in freezing temperatures) Patient to be referred to a safe or supervised environment
IF - THEN CONSIDERATIONS BY DIMENSION
Dimension If Then
1 If patient is withdrawing from alcohol, opioids,benzodiazepines (etc.) Medications to assist with withdrawal and Medications for Opioid Use Disorder (MOUD) as indicated
Ask client preference (use MI style)
1 If patient has immediate access to (MOUD) induction (e.g.,buprenorphine, methadone): It reduces severity in D1
1 & 2 If D1 is addressed Consider whether addressing risk in D1 reduces risk in D2
1 If patient has history of opioid use Consider take-home naloxone
2 If patient has severe medical problems, but has immediate access to appropriate medical care Risk rating for D2 may be lower
3 If Residential is indicated PLUS cognitive impairment, 3.3 is indicated
3 If there is a rating of severe or very severe in D3 May indicate need for inpatient mental health services
4 If D4 is severe/very severe Can be addressed with Motivational Enhancement Therapy in outpatient if otherwise appropriate for outpatient care
4 & 5 For OUD, if severe/very severe risk in D4 and D5 For outpatient withdrawal management and medication management: might be more appropriate to NTP/OTP- daily dosing, monitored, evaluated more frequently
4 & 5 For OUD, if mild risk on D4 and D5 For medication management: Consider OBOT (lower over-sight at OBOT than NTP/OTP)
5 For OUD, if mild risk on D4 and D5 May indicate need for supportive living environment either in Level 3.1 (or higher) or sober living/recovery residence and more intensive LOC
6 If lacking a safe recovery environment Consider recovery residence or shelter if not precluded by severity in other dimensions
Overall WM is indicated and there is high severity in all dimensions Consider higher intensity placement for WM
Overall A dimension is currently rated 0- no risk There is no need for services in that dimension at this time. (See The ASAM Criteria, 3rd ed., p. 73)
OBOT/buprenorphine - A qualified practice setting is a practice setting that: (a) Provides professional coverage for patient medical emergencies during hours when the practitioner's practice is closed.(b) Provides access to case-management services for patients including referral and follow-up services for programs that provide, or financially support, the provision of services such as medical, behavioral, social, housing, employment, educa- tional, or other related services.(c) Uses health information technology (health IT) systems such as electronic health records, if otherwise required to use these systems in the practice setting. Health IT means the electronic systems that health care professionals and patients use to store, share, and analyze health information.(d) Is registered for their State prescription drug monitoring program (PDMP) where operational and in accordance with Federal and State law. PDMP means a statewide electronic database that collects designated data on substances dispensed in the State. For prac- titioners providing care in their capacity as employees or contractors of a federal government agency, participation in a PDMP is required only when such participation is not restricted based on their State of licensure and is in accordance with Federal statutes and regulations.(e) Accepts third-party payment for costs in providing health services, including written billing, credit, and collection policies and procedures, or Federal health benefits.