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Deciding to attend treatment is a powerful and courageous decision. It takes introspection, reflection, and honesty to decide that help is needed and to take the next step and reach out for help. After deciding on going into a treatment program, the next question that may come to mind is, “what kind of treatment do I need?” This question is very understandable and essential in ensuring that the next treatment steps will set up one for success in recovery. Substance use disorder (SUD) treatment consists of several general categories: detoxification, inpatient rehabilitation, and outpatient rehabilitation. Many treatment programs may offer all levels of care in one location, which can be convenient when searching for a reputable program. While these categories are accurate as an overview, they can be broken down into even more specific services, often referred to as levels of care.
The American Society of Addiction Medicine (ASAM) is an organization that was created in the 1950s to define the disease of addiction and research efficacious treatment approaches. ASAM has become the go-to organization for research-backed medical treatment for substance use disorders and an establishing guideline for treatment. Most psychiatrists and addiction specialists are trained within the ASAM framework, including certifications that ASAM specifically provides. This framework also provides a structured setting for providing treatment, including the current levels of care.
ASAM developed the levels of care to ensure that individuals were receiving the proper services. For example, someone who has been drinking excessive amounts of alcohol to the point of experiencing physical dependence and withdrawal effects (e.g., tremors, nausea, seizures, etc.) would likely require level 4 Intensive Inpatient/Detoxification to reduce the severe risk of medical danger associated with those symptoms.
On the other hand, someone who is having difficulty stopping cannabis usage but has not experienced any adverse medical effects would most likely require a lower level of care as the risks present are less severe. It is important to note that the levels of care are meant to progress downward. If an individual started at level 4, the next step would be to go down to level 3 as a continuation of treatment, referred to as the continuum of care. This care path continues to level 1, with a conclusion of primary treatment once the condition has become safely managed.
The most important rule that treatment professionals follow is to provide care options to individuals seeking services that are supportive of their needs and the least restrictive to their everyday lives. This process can be a difficult balancing act, but we know from many years of research that when someone is overly restricted with little risk to justify it, it leads to negative feelings about seeking treatment – which can derail the entire treatment procedure.
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ASAM has created different domains that incorporate many different elements of one’s life that a behavioral health or medical professional can assess. This multidimensional assessment, also called a biopsychosocial assessment, is the tool that helps medical professionals decide which level of care is the most appropriate.
This assessment reviews a person’s biological, psychological, and social conditions. The dimensions are then assigned a risk level from 0-4, with 0 representing very low risk and 4 representing imminent harm probable without intervention.
This assessment includes the following:
This dimension focuses on active substance use, which includes the frequency, duration, intensity, and severity of current substance use. This dimension also determines the risk of current or potential withdrawal symptoms that may be life-threatening without proper medical intervention. Depending on the answers provided, a medical professional may recommend medical detoxification if their risk rating is significant. If the risk level identified is level 4, the risk of medical complications is considered high. At this point, a hospital may be required to perform the detox process. Medical treatment for substance use is often derived from the identified risk level associated with this dimension.
This dimension examines the medical conditions that often occur with substance use disorders. It reviews current or potential medical conditions that can impact how medical professionals provide treatment and any history of medical treatment. Chronic pain and pregnancy are examples of common conditions that require specific planning for effective care to be provided, especially when medical detoxification is involved. Specialists will review any current medical needs to ensure that the patient can be treated safely within inpatient programs that are not hospital-based.
Reviewing for potential co-occurring behavioral health disorders such as depression, anxiety, or bipolar disorder is an essential element in the evaluation. This dimension identifies potential mental health disorders, emotional challenges, traumatic experiences, and potentially harmful behaviors (risk to self or others) that may disrupt the treatment process. Specialists will consider the history of treatment approaches (medications, therapies, strategies) used in the past. Medication management and specific therapeutic interventions are often derived from this domain.
Motivation matters in all change processes, and the reasons for motivation are extremely important in substance use and behavioral health services. This domain reviews current levels of motivation for recovery by the “Stages of Change” model, also referred to as the trans-theoretical model of change. This model uses 6 “stages” that identify where someone may be in terms of motivation in recovery. The stages are:
Specialists frequently use this model throughout treatment as a way of gauging progress.
The risk of relapse is understandably a major concern during an assessment. This dimension focuses on the current risk of relapse by exploring any history of relapse experiences and present risk factors. Risk factors can include triggers, craving severity, use of healthy coping strategies, ability to obtain substances easily, and level of accountability. Specialists will also review medication adherence, as many addiction treatments utilize anti-craving medications that require daily use for maximum effectiveness. A history of impulse control and lack of following medical guidance often indicate a need for higher levels of care.
This dimension attempts to assess current stressors from social relationships, such as family conflict, as well as employment, legal, or environmental consequences experienced because of substance use. The assessment also reviews how safe the home environment may be for someone in early recovery, which may encourage recommendations for family therapy. Alternatives such as sober living environments may be recommended.
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While it is important to understand how addiction professionals come to the treatment recommendations they provide, it is even more critical for an individual to be willing to partake in these recommendations. Sometimes after an assessment, the addiction professional and the individual disagree over what level of care is necessary. It is encouraged to have multiple opinions from behavioral health professionals, just as with any other medical condition, so all the identified options are on the table. If the medical professionals present similar recommendations, all participating individuals will hopefully agree on the next steps.
One of the most important steps of treatment is moving forward with the plan to enter treatment so the recovery process can truly begin. Contact a treatment provider today to learn more about levels of care.
Travis Pantiel, LMHC, MCAP
Travis Pantiel is a Licensed Mental Health Counselor and a National Board-Certified Counselor with specialized expertise in the co-occurring disorder treatment field.
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