Crafting the Fourth Edition of The ASAM Criteria

Over the past three years, a team of editors, writing groups, councils, and committees has worked diligently to create the newly published Fourth Edition of The ASAM Criteria. This edition, says co-editor Navdeep S. Kang, PsyD, HSP, takes the Criteria to a new level.

In early 2020, work began on the Fourth Edition — a comprehensive set of standards that uses a holistic, person-centered approach to developing treatment plans for patients with addiction and co-occurring conditions. ASAM appointed R. Corey Waller, MD, MS, FACEP, DFASAM, as the project’s editor-in-chief and formed an editorial subcommittee to begin work on the edition.

Dr. Kang, Chief Quality Officer for Inpatient Services at Acadia Healthcare, served as one of the nine members of the editorial subcommittee. As a co-editor, Dr. Kang also chaired the writing group that created the chapter on co-occurring disorders.

One goal in creating the Fourth Edition, Dr. Kang said, was to make it more user-friendly than previous editions.

“We have attempted to make this piece of content as accessible and approachable as possible,” he said. “Whether we're talking to folks within the addiction space or folks who are outside of that specialty, my encouragement is to approach the content, to wrestle with it, and to see how it applies in your practice. I think people inside the field and out will find that the content is readily accessible and easy to apply. I’m hoping folks are as excited as we are to have it finally be available.”

The editorial subcommittee, Dr. Kang added, also wanted to make the Criteria accessible to a wider variety of specialties.

He said, “Wouldn’t it be great if we could equip primary care, family medicine, emergency medicine — places where people with addiction intersect — with clearer and easier-to-implement tools to help them play their part more effectively, identify someone with an addiction, determine where they needed to go for that specialty care, and get them moved there with some initial treatment planning in place?”

In terms of the creative process, Dr. Kang said everyone on the team worked together and had an “intense” amount of dialogue.

“The team met every week and exchanged quite a bit of communication asynchronously as well,” he said. “The scope of discussion around co-occurring disorders was both broad and ultimately quite detailed.”

The Fourth Edition employed a rigorous methodology for evidence and formal consensus development. Seventeen writing groups drafted standards for the Criteria, with as many structured literature reviews. Independent voting panels then rated the appropriateness of each standard and reconciled the feedback of the voting panels.

“Every single comment was reviewed, responded to, taken into account, deliberated upon,” Dr. Kang said. “To me, it was really important that we didn't just create this project in some kind of black box, but that it was an open and transparent process. It was very gratifying to not just be a part of the process or to chair a writing group or be on the editorial staff, but to ensure that we did it in a way that garnered broader engagement.”

The writing group that compiled the chapter on co-occurring disorders examined how to manage a person's substance use disorder and their co-occurring mental illness, Dr. Kang said. They also asked what the co-occurring capability should look like in this day and age, and what an addiction program that has enhanced capacity to address mental illness would look like.

“We really tried to take a 10-year look and say, ‘Where is the field today? Where can the field be in 10 years?’” he added. “How much can we push and be aspirational in regard to the clinical capability that we believe we should have as an industry to not just manage addictions, but to manage the oftentimes co-occurring mental illnesses that our patients experience?”

With the Criteria now available, Dr. Kang said he’s thrilled to have had the opportunity to help shape the field of addiction medicine through his involvement in the Criteria’s development. Like many addiction medicine specialists, he came to the field of addiction medicine from another specialty.

“Seven years ago, if you had told me I’d be leading the advancement of the addiction treatment industry in any way, I would've wondered how that's even possible because I was working exclusively in mental health, in hospital settings, and in an emergency room setting,” he said. “It’s very humbling.”

‘Why I Treat Addiction’

Dr. Kang was trained as a clinical psychologist with a concentration in the treatment of people with severe and persistent mental illness. While a substance use disorder treatment course was available to him during graduate school as an elective, he completed his doctorate without any specific training in addiction.

As he worked in his hospital’s inpatient and emergency room settings, Dr. Kang had an epiphany.

“I found that not only was I, as an individual clinician, ill-prepared to care for patients with substance use disorder, but that our whole ‘mainstream’ physical healthcare system was ill-equipped to do so,” he said. “We did not possess the proper terminology on how to talk about addiction. We didn’t know how to make patients feel safe to disclose or talk about their substance use. We didn’t clearly and robustly possess the clinical tools to take care of them. And we didn’t understand what the care continuum should look like and, therefore, how to get patients into long-term outpatient, chronic disease management.”

These realizations led Dr. Kang to participate in several ASAM workshops to become better educated on substance use disorder.

“The addiction medicine community has, for decades, had great ideas and research on how to effectively care for patients with substance use disorders, yet the mainstream health systems and community at large have failed to provide an effective platform, treatment pathways, or general acceptance for addiction specialists to propagate those ideas -- this is a huge injustice, particularly when juxtaposed with the scope and scale of addiction-related mortality we have seen as a nation over the past 25 years,” he said. “I wanted to do something about it and start by bringing addiction treatment programs closer to mainstream healthcare.”

The Fourth Edition of The ASAM Criteria is available in print and digital formats here.