BAM: Brief Addiction Monitor

Currently available within the KipuEMR

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MEASUREMENT SCALE APPROVED BY THE JOINT COMMISSION

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The primary purpose of the Brief Addiction Monitor (BAM) is to support individualized, measurement-based care for substance use disorders (SUD). The BAM monitors a patient’s progress in and yields reliable data that is both easy to collect and readily integrated into SUD treatment planning. The BAM is a 17-item, multidimensional questionnaire administered electronically from KipuEMR to patients seeking or enrolled in SUD specialty care. It assesses three SUD-related aspects: Risk factors for substance use, protective factors that support sobriety and drug and alcohol use.

What is the BAM?

  • A 17-item measure of addiction problem severity that is designed to support measurement-based treatment in SUD specialty care settings.
  • May be administered as a clinical interview (in-person or telephonically) or via patient self-report; and, it typically takes about 5 minutes to complete.
  • Retrospectively examines the patient's behavior in the past 30- days, but has been adapted for repeated administrations as frequently as every 7 days (BAM for IOP).
  • Brief (17 items)
  • Multi-dimensional, with no single summary score validated so far
  • Items selected from valid/reliable measures
  • Initial item selection based on research on predictors of relapse and outcome
  • Data readily integrated into treatment planning
  • Categorical or continuous response options to items
  • Includes items that assess Risk factors for substance use, Protective factors that support sobriety, and drug and alcohol Use.
  • Produces composite scores for Risk and Protection as well as a Use score. A patient's clinical status may be assessed by examining individual BAM items and/or composite scores.

Items were selected for inclusion in the BAM based on their presence in existing SUD measures and/or on empirical support for their reliable and valid assessment of SUD relapse risk and treatment outcome. Each question yields an answer that ranges in value and is assigned a score that when tallied, yields a result that has been found to be a reliable predictor of treatment completion, progress monitoring, relapse risk and it also offers a guideline for further treatment planning. 

Two studies have been done on the psychometric properties of the BAM. One of the first studies made use of the continuous item version of the BAM. This study found support for the factor structure, internal consistency, test-retest reliability, and sensitivity to change of the BAM. In another study, BAM scores obtained weekly from a smartphone application over an 8-month period significantly predicted relapse status within the week following the assessment. End-users are strongly encouraged to pay attention to the item-level data because they have direct implications for treatment planning. The data identifies specific areas of need or resources that the patient brings to bear in his/her recovery.

Clinical Utility

  • Measurement based care emphasizes the use of standardized assessments, and other “tests” to help personalize care and guide treatment decisions.
  • Just as a primary care provider would routinely check glucose levels to better inform their treatment plan for a patient’s diabetes, routinely administering rating scales to monitor improvement or a change in mental health symptoms is considered best practice in providing optimal care.
  • Routinely using these tools to measure longitudinal changes and track treatment progress are associated with superior client outcomes when compared to usual care
  • Assessments alert clinicians to lack of progress, guides treatment decisions, identifies potential intervention targets, and assists in differential diagnosis
  • Assessments prompt changes in interventions if needed when things are not working or can prompt stepdown in care after a patient’s functioning has improved
  • The data can be used by the clinician to engage the client in therapeutic process, overall validating them as an active partner in their health care and mental wellness
  • It can improve communication between providers and facilitate collaboration among different services

Scoring and Interpretation 

Patients provide the numbers of days/nights on a Likert-scale ranging from 0-4 in the BAM-IOP and 0-30 in the BAM-R regarding their risk behaviors, protective behaviors, and substance use.

Other items require categorical responses each of which has a corresponding numerical score. For example on Item 1 of the BAM-R, Excellent=0, Very Good=8, Good=15, Fair=22, Poor=30, while on the BAM and BAM-IOP Excellent=0, Very Good=1, Good=2, Fair=3, Poor=4.

Examining scores from individual items is the most clinically relevant use of this measure. Clinicians are strongly encouraged to attend to the item-level data because they have direct implications for treatment planning. They identify specific areas of need or resources for the patient’s recovery. Each functional domain has an associated composite score which serves as cross-sectional marker of clinical status.

  • Use = sum of Items 4, 5, & 6 (Scores from 0 to 12 on the BAM-IOP and 0-90 on the BAMR; higher scores meaning more Use)
  • Item 7 (7A-7G) are not scored as part of the subscales but provide elaboration for item 6.
  • Risk = sum of Items 1, 2, 3, 8, 11, & 15 (Scores from 0 to 24 on the BAM-IOP and 0-180 on the BAM-R; higher scores meaning more Risk)
  • Protective = Sum of Items 9, 10, 12, 13, 14, & 16 (Scores from 0 to 24 on the BAM-IOP and 0-180 on the BAM-R; higher scores meaning more Protection)
  • Item 17 can be used as an overall assessment of treatment progress, but is not scored on any of the specific subscales

Note that the BAM does not generate a psychometrically refined total score. The developers caution that its three factor scores (Use, Risk, and Protective) need additional psychometric evaluation. However, patients and providers find it an appropriate set of items to inform initial treatment planning and for ongoing measurement based care.

Measuring Change

  • Measuring Change Good clinical care requires that clinicians monitor patient progress. It is important to compare most recent BAM scores with prior BAM scores to assess changes in functioning and risk status. Discussion with each patient about his/her data is strongly recommended for informing and promoting motivational enhancement and collaborative treatment planning. The goal is to see changes on each scale with each administration of the BAM; and, when changes are not evident, to consider adaptive, collaborative changes to the patient’s treatment plan. BAM
  • Because norms are not available for evaluating patients’ data, the BAM is best used in comparison to the individual’s previous scores and evaluations to assess clinical progress. Administration of the BAM at baseline and 3-months post baseline has been shown to reveal statistically significant reductions in problem frequency and severity, and improvements in protective factors or prosocial behaviors on all the items as well as on the three factor scores

 

BAM: An Accepted Measurement Scale
The Group for the Advancement of Psychiatry officially endorses the use of standardized symptom rating scales to supplement clinical interviews. The National Council for Behavioral Health endorses the use of research-backed outcomes measurement tools to help clinicians address functional deficits of individualized care plans.

The United States Army routinely uses a tablet-based symptom rating scale system in its specialty mental health clinics. Federally Qualified Health Centers in the state of Washington routinely use a web-based patient outcomes tracking system to assess symptom improvement among its integrated mental health primary care patients.

The National Commitee for Quality Assurance (NCQA) has proposed depression symptom monitoring and feedback as health plan performance measures for the 2016 Healthcare Effectiveness Data and Information Set (HEDIS). Likewise in 2015, Anthem Blue Cross Blue Shield,® UnitedHealthcare® and CMS (the Centers for Medicare and Medicaid Services) all announced value-based payment programs which incentivize measurement-based care.

Don’t forget, Kipu makes it super easy to create, test, and modify your own, or incorporate additional questions into the above tools for additional data points.

 

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BAM and the Veteran's Administration
Substance use disorders (SUDs) are of great concern for health care providers working with military veteran populations. Systematic evaluation of progress and outcomes within the Veterans Affairs (VA) is a critical component of care provided for the veteran population. The Brief Addiction Monitor (BAM) is a 17-item instrument used within VA to assess substance use and related constructs among veterans participating in SUD care. Initial evaluations, using a version containing continuous items, suggested that the items form three factors reflecting substance use, risk factors, and protective factors. Subsequent work, using the BAM version containing Likert-style items collected from a single VA Medical Center sample, did not support the proposed 3-factor solution. The current study used a nationwide sample of 4955 veterans to evaluate the factor structure of the BAM and its usefulness over time. Exploratory factor analyses conducted did not provide evidence of the originally proposed BAM factor structure but instead supported a 4-factor model (reflecting alcohol use, stress, risk, and stability) formed from 13 of the items. Further analyses conducted within a structural equation modeling framework showed that the four-factor model exhibited invariance across occasions of measurement, although internal consistency was found to be low for most subscales. Results provide caution against using BAM subscale scores to track treatment outcomes over time.