The GuamBehavirol Health and Wellness Center (GBHWC) uses the American Society of Addiction Medicine Patient Placement Model-2R (ASAM PPC-2R) as the primary reference source for Guam’s substance treatment Continuum of Care. The Patient Placement Criteria (PPC) are guidelines developed by the American Society of Addiction Medicine (ASAM) that can be accurately used to assess the severity of patients' problems so that they can be admitted to the most appropriate level of care (admission criteria), remain in that level of care (continuing care criteria) and be discharged from that level of care (discharge criteria). These guidelines are divided into six assessment dimensions, as follows:
- Acute Intoxication and/Withdrawal Potential: What risk is associated with the patient’s level of acute intoxication? Is there serious risk of withdrawal symptoms based on the patient’s withdrawal history? Are there signs of withdrawal? Does patient need acute inpatient detoxification services or can he be served in an Outpatient detoxification setting?
- Biomedical Stabilization: Are there current physical illnesses other than withdrawal, that need to be addressed or which complicate treatment? Are there chronic conditions that affect treatment? e.g., chronic pain with narcotic analgesics.
- Behavioral Stabilization: Are there psychiatric illnesses or psychological, behavioral or emotional problems that need to be addressed or which complicate treatment? Are there chronic conditions that affect treatment? Do any emotional/behavioral problems appear to be an expected part of addiction illness or do they appear to be separate? Even if connected to addiction, are they severe enough to warrant specific mental health treatment?
- Readiness to Change: Does the patient feel coerced into treatment or actively object to receiving treatment? How ready is the patient to change? If willing to accept treatment, how strongly does the patient disagree with others’ perception that she/he has an addiction problem? GBHWC has opted to use the “Stages of Change” by Prochaska and Diclemente to determine patient’s readiness of change (See figure 1, Stages of Change). If patient is diagnosed with alcohol dependence but does not believe he has an alcohol problem, he would be placed in the Pre-contemplation Stage. Patient must then be placed in an ASAM Level 0.5 or I with the aim to raise awareness that a substance problem exists, with the use of motivational strategies. When patient moves to the Preparation Stage, then it will warrant a referral to a more intensive level of care for treatment.
- Relapse Potential: Is the patient in immediate danger of continued severe distress and drinking/drugging behavior? Does the patient have any recognition and understanding of, and skills for how to cope with his/her addiction problems and prevent relapse or continued use? How aware is the patient of relapse triggers, ways to cope with cravings to use and skills to control impulses to use?
- Recovery Environment: Are there any dangerous family, significant others, living or school/working situations threatening engagement and success? Does the patient have supportive friendship, financial or educational/vocational resources to improve likelihood of successful treatment? Are there legal, vocational, social service agency or criminal justice mandates that may enhance motivation for engagement into treatment?
PPCs also describe the level of care. It includes the distinct characteristics of each treatment modality, as indicated in the table below. GBHWC is aware that although many placement models exists in the Nation (US), the cry for standardization and the aim to have common language in the treatment field is essential in order to develop a broader continuum of care, has led many providers to use the ASAM PPC-2R model. In addition, the principle author and chief editor, Dr. Mee-Lee had visited Guam three times and provided extensive training on the model to GBHWC staff as well as community providers, with his last visit in September 2006. This ensured that treatment will have common knowledge of the different levels of care, develop skills to conduct thorough assessments and thus strengthen Guam’s referral system. Therefore, GBHWC defines Guam’s Continuum of Care Levels, as follows:
Chart 1. Guam’s Substance Treatment Levels of Care
Clinical Needs and Treatment Setting Examples
Level of Intensity By Number of Hours
|Level 0.5||Drug Education/Early Intervention||Risk Factors or problems, No DSM-IV diagnosis, Psycho-education, monitoring||Minimum of two hours weekly|
Levels of Care Continued
|Clinical Needs and Treatment Setting Examples||Level of Intensity By Number of Hours|
|Level I||Outpatient||DSM-IV diagnosis
Low severity of problems, Low-intensity outpatient
|Minimum of four hours and less than 9 hours weekly|
|Level I-D||Outpatient Detoxification
without Extended Onsite Monitoring
Medically Supervised, in Office or clinic setting or treatment facility
|One hour, two to three times weekly, or regularly scheduled sessions|
|Level II||Intensive Outpatient||DSM-IV diagnosis
Intensive Outpatient treatment, structured evening program
|Minimum of nine hours weekly|
|Level II.5||Day Treatment/Partial Hospitalization||Clinically-managed structured day program||Minimum of eight hours a day, five days a week|
|Level III.2-D||Social Detox./Clinically Managed||Social setting detoxification, may be residential||24 hours, 2 - 7 days|
|Level III.5||Residential<30 days||Residential treatment, structured therapeutic community||24 hours daily, up to 30 days|
|Level III.5||Residential>30 days||Significant problems with living skills, antisocial
|24 hours daily, more than 30 days to 6 mos.|
|Level III.7||Inpatient Semi-medically managed, or Medically-monitored, Severe problems with ASAM Dimension 3||Withdrawal symptoms or potential severe enough to require 24 hours inpatient monitoring||24 hours Inpatient, 2 - 5 days|
|Level IV||Full Medically-managed Intensive Inpatient Treatment, Hospital Setting||Withdrawal symptoms or potential severe enough to require inpatient care, physician management, Hospital||24 hours, Emergency Services, 1-5 days|
Drug Education and Early Intervention- ASAM Level 0.5:
Drug Education and Early Intervention is a crucial part of the continuum of care, but remains one of the most under-funded and under-developed part of the continuum. Drug Education is the least intensive outpatient service, totaling fewer than four (4) hours a week. It is designed for patients mainly with problems or risk factors related to substance use and needing drug and alcohol education. In addition, when an initial assessment is completed, an immediate Substance Related Disorder (DSM-IV substance abuse or dependence criteria) cannot be confirmed. Further assessment is warranted to rule in or out an addiction problem. Core service elements include, but not limited to, formal group drug education on the dynamics of addiction and the addiction process, medical aspects of addiction, drug-related legal aspects, and community resource awareness of available drug and alcohol service providers. Patients receive a minimum of twenty (20) drug education hours. The Superior Court of Guam’s Alcohol Treatment Program (ATP) and Drug Education Program (DEP) are equivalent to this level of care.
GBHWC has begun exploring new motivational strategies and engagement as part of the Early Intervention component of the continuum of care. Motivational Interviewing (MI-By Miller and Rollnick) is an effective evidence-based approach to overcoming the ambivalence that keeps people from making desired changes in their lives. Research supports evidence that early identification and intervention is cost-effective and yields positive results for the entire health system. As Alcohol and Other Drugs (AOD) early identification and intervention become a greater part of the continuum, prevention of the more serious complications of AOD problems can be minimized or avoided.
GBHWC defines indicated prevention, which concentrates on individuals who are at very high risk and may be using or experimenting with AOD, as early intervention. It goes on to define early intervention as targeting, in the early stages, individuals who have been assessed as having an AOD problem, as well as interventions at all levels of the continuum, which intervene at the earliest point, to produce the most effective results. Education and screening, which are components of each part of the continuum of care, are the first steps for assessing the need for early intervention and can occur in any environment - the doctor’s office or health clinic, school, mayor’s office, criminal justice system, or a number of community settings. Families, friends, and workplace colleagues are often the first to notice that a problem might exist, although they may not initially recognize it as an AOD problem. The easier the access to more formal screening and assessment (discussed in more detail later in this section), the easier it is to provide appropriate intervention services.
Because intervention may need to occur more than once, a continuum of education, outreach, case management, and drop-in facilities such as mayor’s offices are crucial. GBHWC recently funded Drug Education services as one of the means that can be used to educate individuals about AOD issues and engage pre-treatment ready individuals in intervention and treatment. Intervention success is often difficult to measure. It will work with its partners, using some of the same principles outlined in the drug education/early intervention section, to adopt and develop science-based models and best practices for the intervention component. GBHWC wants to emphasize that the prevention, intervention, treatment and recovery system is not a linear system, but a circular system. Individuals with AOD problems have a variety of needs that may reoccur at any point in the recovery process. This is an important concept in the early intervention models that GBHWC is considering. For instance, outreach and care/case management intervention is part of the continuum in the early, middle and aftercare/continued care components of the continuum, and links all aspects of the continuum. An individual may require outreach and case/care management to bring him/her into the system, but may also require these service elements to support
Screening and Assessment: Identifying individuals who may need assistance with an AOD problem is an important component of Early Intervention. The GBHWC will work with substance treatment providers to identify and to develop screening potential in the settings, which they already provide forms/levels of prevention or treatment services. Once an individual has been identified as having a possible AOD problem, the individual needs an appropriate assessment done to determine if the person 1) has an AOD problem, 2) the level of severity, 3) the required level of intervention or care, and 4) the appropriate intervention or treatment referral. Again, GBHWC requires and supports the use of the ASAM six assessment dimensions, when conducting appropriate screenings/assessments.
Screening and assessing individuals throughout the lifespan is an important function of developing a standardized process. The use of additional screening and assessment tools must be age and developmentally appropriate, as well as the range of responses to the screening/assessment outcomes. Children, youth, young adults and elders need screening instruments that take into consideration variables such as age, level of maturity, gender, culture, and family and peer environment. Standardized AOD screening and assessment tools used by all programs are part of the development of a Territory-wide treatment system intended to help patients move through the continuum of care seamlessly. Always adhering to federal and territory confidentiality regulations, programs can more readily exchange information as patients move from one level of treatment to another, without requiring patients to repeat the same process at every juncture.
Substance treatment providers will work with the GBHWC and its partners to identify essential elements, proven screening and assessment tools, and best practices, in order to ensure accurate and quality screening and assessment. The process will include age/developmentally, gender, race, ethnicity, and sexual orientation appropriate screening and assessment.
Outpatient Treatment – ASAM Level I:
The next level of care is Outpatient Treatment. These services function under a defined set of policies and procedures. This is a nonresidential organized group service or office visits, totaling fewer than nine (9) hours and a minimum of four hours a week, in which directed treatment and recovery services are provided by addiction-credentialed clinicians that help patients cope with life tasks without non-medical use of psychoactive substances. Clinicians provide directed evaluation, treatment and recovery services to patients with substance-related disorders. Core services elements include, but not limited to, referral for TB testing, treatment planning, drug education, minimal individual, group, or family counseling, drug testing, and ongoing bio-psychosocial assessment. Patients provisionally diagnosed with substance abuse (DSM-IV abuse criteria), or unmotivated patients diagnosed with substance dependence (DSM-IV dependence criteria) but are in early stages of change (Prochaska and DiClemente) and who are not yet ready to commit to full treatment and recovery are placed in this level of care. A primary objective with dependent patients is to engage resistant individuals in treatment and work towards securing a referral to the next appropriate level of care.
Outpatient Detoxification – ASAM Level I-D:
Level I-D is an organized outpatient service which may be delivered in an office setting, healthcare or addiction treatment facility, or in a patient’s home, by trained and licensed clinicians who provide medically supervised evaluation, detoxification and referral services according to a predetermined schedule. Such services are provided in regularly scheduled sessions. They should be delivered under a defined set of policies and procedures or medical protocols. Outpatient services should be designed to treat the patient’s level of clinical severity and to achieve safe and comfortable withdrawal from mood-altering drugs (including alcohol and tobacco) and to effectively facilitate the client’s transition into ongoing treatment and recovery, such as a referral to an Intensive Outpatient Program, as stated below.
A programmatic therapeutic milieu consisting of regularly scheduled sessions for a minimum of nine (9) hours a week in a structured program, which provides patients with the opportunity to remain in their own environment and/or retain their employment. It is designed for individuals needing multidimensional services that cannot be met at an Outpatient level of care and who do not need primary medical and nursing services at a partial hospitalization, or medically monitored intensive inpatient level of care. The patients need for psychiatric and medical services are addressed through consultation or referral arrangement. Patients diagnosed with substance dependence and not needing withdrawal monitoring are placed in this level of care. Core services elements include, but not limited to, referral for TB testing, ongoing bio-psychosocial assessment, treatment planning, drug testing, drug education, intensive individual/group/family psychosocial therapy, and intensive case management. Optimal elements include family support group, spirituality, AA/NA 12-step support groups, pre-employment skills training, nutrition education, and issuance of vouchers for childcare and transportation services.
The components of the partial hospitalization (Day Treatment) level of care include all cores, optimal, and enhancing multidimensional elements provided in an Intensive Outpatient level of care. GBHWC use to operate this level of care from Mondays through Fridays, from 7:30 am to 4:30 pm. Day treatment usually provides 20 or more hours of clinically intensive programming per week based on individual treatment plans. It is designed to provide patients who need a more structured care and environment, in comparison to Intensive Outpatient, but not severe enough to require 24 hours inpatient or residential services. Additional elements include easy access to psychiatric and medical services, recreational therapy, with basic nurse’s aide services available.
ASAM level III.2-D is sometimes referred to as “Social Setting Detoxification.” It is an organized service that may be delivered by appropriately trained and certified staff, who provides 24-hour supervision, observation and support for patients who are intoxicated or experiencing withdrawal, with the aim for them to achieve initial recovery from the effects of AOD. Prior to admission patients must provide a medical clearance document, to validate that there are no medical complications needing urgent attention. Social Detoxification is characterized by its emphasis on peer and social support. This level provides care for patients whose intoxication/withdrawal signs and symptoms are severe to require 24-hour structure and support, but the full resources of a medically monitored inpatient detoxification are not necessary. A social detoxification facility must have an agreement with local medical providers to ensure readily accessible emergency care when needed. Hospital affiliation providing 24-hour medical backup is a must. Staff members must be trained in admission, monitoring skills, including signs and symptoms of alcohol and other drug intoxication and withdrawal, as well as appropriate treatment
Residential treatment is a broad category that consists of many different treatment models. This is the most developed and supported part of the continuum. GBHWC defines this level as a 24-hour Inpatient program in a planned regimen of observation, monitoring, and treatment. It utilizes a multidisciplinary staff for patients whose biomedical, emotional, and/or behavior problems are severe enough to require inpatient services. It also includes all cores, optimal, and enhancing multidimensional elements provided in an Intensive Outpatient level of care. It serves patients who need a safe and stable living environment in order to develop their recovery skills. Mutual and self-help group meetings generally are available on-site. In order to assist its partners in understanding this part of the AOD system, GBHWC is using two categories to define AOD residential treatment: residential treatment less than 30 days and residential treatment more 30 days.
Residential treatment (sometimes referred as Rehabilitation) < 30 days includes several treatment modalities designed to assist individuals who need brief residential treatment interventions that address AOD problems. For most individuals who are physically addicted or otherwise determined dependent, this is the first part of entering the treatment process, but individuals may enter at any point on the continuum and/or may need to utilize this particular component more than once. Some of the residential treatment models that are considered part of this component are: detoxification, stabilization, observation, and transitional services, and short-term specialized treatment programs. The main goal of residential treatment < 30 days is to medically detoxify and/or stabilize individuals, to assess the exact nature of the AOD problem, to assist individuals with case management needs, and to access next-step treatment and support systems at the appropriate level of care. Furthermore, intense psychosocial therapy may be considered depending on the patient’s level of severity. Research supports that a significant number of patients have benefited from this level of care and were referred to less intense programs, such as Intensive Outpatient or Outpatient, and thus showed successful or favorable treatment outcomes.
Residential treatment >30 days: The residential treatment >30 days is the only part of the system that is supported by funding from the Substance Abuse Treatment Prevention (SAPT) Federal Block Grant, through GBHWC. GBHWC is working with its partners to broaden funding opportunities to increase the availability of beds and bed days to the system. This category consists of several different long-term treatment models. These models are designed to assist individuals and families in a safe, long-term, stabilized, therapeutic living situation to learn more about their AOD problems; strategies for relapse prevention; interpersonal, social, and life skills necessary to form productive personal relationships, career/work/educational opportunities, and community support systems. These models have individual treatment plans and/or case management plans that assist patients in maintaining sobriety and developing self-supportive, independent lives. Models included in the residential> 30 days include residential recovery homes, therapeutic communities, social rehabilitation models, youth residential programs, and family shelters. The Salvation Army’s Lighthouse Recovery Center for men and the Oasis Empowerment Center for women both fall under this level of care, as well as, any adult or adolescent clinically managed, 24-hour residential treatment program. Treatment capacity for both Centers is limited and needing expansion. Substance treatment providers are expected to have knowledge of the different elements of the residential system and linkages to each component
Level III.7-D is sometimes referred to as “Semi-Medically-Managed” service. It is an organized service delivered by medical and nursing professionals, which provides 24-hour medically supervised evaluation and withdrawal management in a permanent facility with inpatient beds. Services are delivered under a defined set of physician-approved policies and physician-monitored procedures or clinical protocols. This level provides care for patients whose withdrawal signs and symptoms are sufficiently severe to require 24-hour inpatient care. GBHWC further defines this service, as indicated treatment, which concentrates on patients who are experiencing high-risk ASAM dimension 3 problems.
This level of care has primary medical and nursing services and the full resources of a general hospital available on a 24-hour basis with multidisciplinary staff to provide support services for both alcohol other drug treatment and coexisting acute biomedical, emotional, and behavioral conditions that need to be addressed. It is staffed by designated addiction-credentialed physicians, psychiatrists, as well as other mental health and addiction-credentialed clinicians. Such services are delivered under a defined set of policies and procedures and have permanent facilities that include inpatient beds. The treatment is specific to mental and substance-related disorders; however, the skills of the interdisciplinary team and the availability of support services allow the conjoint treatment of any co-occurring biomedical conditions that needs to be addressed.
Ambulatory Treatment: Ambulatory AOD treatment refers to the available outpatient services for the Guam continuum of care, such as Drug Education, Outpatient, or Intensive Outpatient. Individuals can utilize these services at any point in the continuum. Some individuals may need only the support and guidance of outpatient counseling, others may need outpatient counseling after a short-term or long-term residential stay for support and maintenance of recovery. Some individuals need to begin treatment at the least intensive level to find that they need a more intensive program or environment to maintain sobriety. Ambulatory services have the flexibility of providing individual and group counseling one to two times a week, day treatment, acupuncture services, psycho-educational groups, youth services, case/care management, and opiate maintenance. Ambulatory services are paired with residential services in the family shelters. Ambulatory settings can provide and support many of the service needs of the AOD continuum, including outreach, early intervention, central intake, case/care management, and aftercare and recovery support.
Substance treatment providers are expected to have knowledge of the different elements of ambulatory services and have linkages to each service
Aftercare/Continued Care and Recovery:
The aftercare and recovery AOD service, as a distinct component, is another under funded and underdeveloped part of the continuum. AOD is a chronic condition, similar to other chronic health conditions that require constant support and attention to prevent relapse. Relapse can occur at any point in the recovery process. Individuals and families who have completed a treatment regimen will have been exposed to relapse prevention strategies. However, even with this knowledge, relapse can occur due to a myriad of biological, physiological, psychological, emotional, life circumstance, societal or peer pressure, including thinking that time has cured the AOD problem. Because of the stigma attached to AOD problems, it is difficult at any point for individuals and families to seek assistance, but after any length of recovery, it may be even harder. This component needs to be especially sensitive to the way in which shame and embarrassment can be attached to relapse, and must have services that are non-judgmental, welcoming, flexible, supportive, and easily accessible and available. These services can take the form of case/care management, outreach, drop-in centers, or informal and formal support networks. The treatment system currently utilizes self-help programs to provide recovery support. However, the aftercare and recovery AOD component is a newer part of the formal system of care. This component can provide a much-needed support mechanism for sobriety and provide cost savings as well preventing the serious human complications of relapse, including death. Continued Care programs can operate one to two sessions, for one to two hours, on a weekly basis. Primary focus is for providers to facilitate recovery plans, to further stability in patient lives. Treatment providers are expected to work with the GBHWC in the planning, design, implementation, and evaluation of aftercare and recovery models. The GBHWC and its partners will utilize science-based models and best practices in designing and evaluating this component. Providers are expected to have strong linkages with this system.
Reference Sources: 1) American Society of Addiction Medicine (ASAM) Patient Placement Criteria 2nd Revision. 2) The Massachusetts Department of Public Health Bureau of Substance Abuse Services Fiscal Year 2006, Terms and Conditions and Standards of Care, For the Alcohol and Other Drugs Service System
The Drug & Alcohol Branch (D & A) is a branch under the Clinical Services Division of the Guam Behavioral Health and Wellness Center. It’s mandated by Guam Public Law 17-21 to provide comprehensive inpatient/residential and community-based outpatient substance abuse treatment programs and services for the people of Guam. D & A’s mission is to continually strive to improve, enhance, and promote the physical and mental well-being of individuals suffering from the effects of alcohol and drug abuse or dependence.
D & A remains committed for continued development and strengthening of Guam’s referral system for substance abuse treatment services. It uses the American Society of Addiction Medicine Patient Placement Criteria 2nd Revision (ASAM PPC-2R) to define levels of care for Guam’s substance abuse treatment services. For detailed understanding of these levels you may click on “Substance Abuse Standards of Care”
D & A provides three levels of care including Drug Education/Brief Intervention ASAM 0.5, Level I Outpatient, and Level II Intensive Outpatient. These programs are known as “New Beginnings.” D & A has existing contracts with non-profit organizations to provide Level III.5 Residential, Level III.2-D Social Detoxification services, and lower levels as stated above.
The philosophy of New Beginnings is that individuals who suffered from any substance abuse or addiction deserve to have a second chance to achieve sobriety and gain quality of life. This is initial stage of sobriety is their New Beginning. The philosophy emphasizes a holistic approach where the physical, mental, spiritual, emotional, and behavioral aspects need to be addressed simultaneously in order to increase favorable treatment outcome. To ensure New Beginnings keeps its mandate and treatment philosophy it uses evidence based models. This is highly recommended by the Substance Abuse Mental Health Services Administration (SAMHSA) of the US Department of Health & Human Services.
The Matrix Model is one of two models used by D & A. It is a comprehensive, evidence-based, individualized program with more than twenty years of research and development by the Matrix Institute on Addictions, an affiliate of the University of California at Los Angeles Integrated Substance Abuse Programs. It is a structured treatment experience designed to give substance abusers the knowledge, structure, and support to allow them to achieve abstinence from alcohol and drugs and initiate a long-term program of recovery. Its approach is non-confrontational, non-judgmental, and empowering while moving patients from the withdrawal stage onto maintenance or continued care. And finally gain quality of life.
The second model is called “Dual-Diagnosed Recovery Counseling (DDRC)” by Dr. Dennis C. Daley, one of the leading US researchers for dual-diagnosed treatment. This evidence-based model is used to treat patients with dual disorders. This means patients have one distinctive psychiatric disorder and one distinctive substance-related disorder. DDRC integrates a variety of educational, motivational, cognitive, and behavioral changes. It promotes the patients involvement in the stages of recovery and ongoing change. The following are some of the goals of the model:
- Helps patients to accept both disorders
- Helps patients become educated about the dual disorders, treatment, recovery, and relapse
- Achieve and maintain abstinence from alcohol and other drugs
- Stabilize from acute psychiatric symptoms or reduction of the severity of symptoms
- Improve cognitive, behavioral, and interpersonal coping skills
- Help patients make positive lifestyle changes
- Intervene in the process of relapse to either the substance use or psychiatric disorder.
The DDRC model is being implemented under the Mentally Ill Chemically Addicted (MICA) program. MICA is as ASAM Level 0.5 education program designed to assist individuals, between the ages of 18 and over, in the beginning stages of their recovery. Group sessions are two hours a day, once weekly. Higher levels of care having more treatment hours a week are currently being develop for dual-diagnosed patients with higher risk for relapse.
The Drug & Alcohol Branch known as “New Beginnings” is open from Mondays through Fridays from 8:00 a.m. to 5:00 p.m. Closed on Saturdays, Sundays, and government holidays.
Suite 102 to 105, J & G Commercial Center, Hagatna, Guam. It’s behind Nissan Auto City near Bank of Guam’s main branch and Paradise Fitness Center in Hagatna.
Access to Services
Interested individuals make walk-in and request for an ASAM Assessment. Results of the assessment will determine eligibility and the most appropriate placement into a level of care.
The Guam Behavioral Health and Wellness Center currently does not charge for any of its Drug & Alcohol Services. Walk-in individuals may avail of the ASAM Assessment. However, those with health insurance coverage will be referred to their primary physician for further care.
For more information, interested individuals may contact the Branch Supervisor at (671) 475-5438 or by fax at (671) 477-7782.