ASAMOur company operates several programs in rural areas where people don’t have a lot of money. We’re being asked to use the ASAM patient placement criteria to determine the appropriate level of treatment. But we keep running into situations where they don’t seem to apply. You have any experience with this problem?”

Do I ever.

I worked with a program in a rural area where fewer than 40,000 residents were spread over an area of almost 10,000 square miles (no, I am not making that up). The community had a real problem with alcohol and drugs. Yet clinicians were continually coming up against barriers to the recommended level of treatment.

In the first place, the closest residential detox was 50 miles away, on the other side of a mountain. No outpatient detox. No halfway house, no long-term facility. There were a couple 30 day rehabs within an hour’s drive, but waitlists were more than a month. For practical purposes, outpatient and IOP were all they had.

Some patients were reduced to hopelessness at the thought of attending intensive outpatient sessions three nights a week. It had been hard enough to find transportation to the intake interview.

Counselors in such areas have to make real-world adjustments. Or else find someplace to refer the client (good luck with that).

There are appropriate grounds for making exceptions to ASAM-recommended levels of care. The obvious one is that the level isn’t available. You can also argue that the client has already demonstrated that he or she can’t hack it at that level. And of course, there are unusual circumstances or conditions that make a particular level of care unworkable. It’s a matter of justifying your decision.

Don’t forget that the client’s safety trumps all other considerations.

We need better rural healthcare. In the meantime, we do the best we can with the resources we have.

 


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