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Prior to the 1980’s, addiction treatment consisted predominantly of three core forms:
- 12-step recovery programs
- Minnesota-Model style rehab centers
- Outpatient clinics including methadone programs or therapists’ offices
Most people would be referred to treatment either through their family doctor or friends who had experience with addiction recovery. Those doctors would also struggle with making the referrals, as there were no good guidelines for addiction treatment levels of care. The whole process was heavily based on anecdotal experience.
In the mid-1980’s, the American Society of Addiction Medicine (ASAM) started developing such guidelines to build more structure to the treatment matching process. In 1991, they released a formal set of guidelines called the Patient Placement Criteria which used a set of six dimensions to match people to a ladder of four different levels of care. The underlying theory was that more severely addicted people with more intense problems would get referred to higher levels of care, whereas more stable people with less disease burden could succeed in less intense outpatient settings.
The six dimensions, rated from 1-4 in terms of severity, according to the ASAM criteria are as follows:
If the person were to immediately stop using substances, would there be a medically significant withdrawal phenomenon which may warrant acute medical care? Of note, opioid withdrawal is not life-threatening but can be miserable enough that people may have a difficult time completing a detox process without slipping back into relapse.
2. Medical Stability
Active medical conditions can disrupt treatment, hence a person with severe medical comorbidity may require a higher level of treatment to address such issues. Examples include chronic health problems such as diabetes or new infections connected to drug use such as Hepatitis C, HIV, or sexually transmitted diseases. Only specific, qualified facilities can actively manage complex medical conditions.
3. Psychiatric Issues
This dimension is where we would place Dual Diagnosis issues. Dual diagnosis means concurrent mental health conditions such as depression or anxiety disorders in addition to an addictive disorder. More severe and unstable psychiatric issues will highly disrupt treatment and may require more structured care, all the way up to and including locked psychiatric units for urgent safety needs.
4. Motivation Level
This dimension is scored on an inverse scale. The more motivated the person is to change and quit drug use, the less intense the level of treatment. People who are precontemplative and severely impaired by drug use may need full residential care. Those people would drop out or poorly engage in standard outpatient counseling. The assumption with this dimension is that for a person to succeed in lower levels of care, motivation to change needs to get progressively stronger.
5. Relapse Potential
This dimension addresses things like coping skills, basic interpersonal skills, awareness and understanding of the disease of addiction, and risks for relapse when presented with drugs or highly triggering situations. People who are in need of these things are often better served by higher-level treatments to provide them the appropriate clinical education.
6. Recovery Environment
A person’s environment includes both issues of stability/homelessness as well as social networks which may be either supportive of recovery or enabling of continued drug use. The more dysfunctional the recovery environment, the greater the need for daily structure and guidance for the person. One of the traits inherent in residential treatment is intense structure. In contrast, outpatient care can be highly unstructured and will require an overall healthier mentality.
After reviewing the dimensions for each patient, we would provide guidance and education about the different addiction treatment levels of care. As there are four levels of treatment, this corresponds to the ASAM score of 1-4 for each of the six dimensions. Some clinicians will average the numbers to determine a bulk score. Others will emphasize certain variables, such as detoxification when advising people about what treatment path to take.
This zone is the most common area of addiction treatment. It can involve a primary care doctor, therapist, psychiatrist, or recovery coach. There are different levels of intensity for outpatient care, ranging from two therapy sessions per week to monthly follow-up visits. It is common that a person in early addiction recovery may see their therapist weekly and that this will become less intense with good progress.
Intensive Outpatient Services (IOP) / Day Treatment
IOP is usually a 3-month program that is often run through a hospital or clinic. It involves mostly group therapy but may include some individual therapy appointments. Groups usually meet three times per week for around 2-3 hours per session. This program increases the structure of your life and may be beneficial if you continue to have relapses while in standard outpatient treatment. Day Treatment is more intense than IOP and may last between 2-8 weeks. It is often hosted as a 9-5 group Monday through Friday. This path is analogous to working a full-time job as recovery. Many insurance programs use the term Partial Hospitalization interchangeably with Day Treatment. People enrolled in a typical Day Treatment program are still living at home during the process.
Sober Living / Extended Care
Extended Treatment is a step down from the most intense residential care. It involves a blend of day treatment services combined with a structured living environment. Through the CeDAR continuum of care, the Residential Extended Care (REC) program functions at this level of treatment.Sober Living environments are the least intense forms of this level of care. They provide an accountable living situation but often require the patient to add a form of dedicated treatment on top. For instance, a patient may reside in a Sober Living home while attending an IOP.
This is typical addiction rehab. The length of time in residential treatment may range from 5 to 90 days depending on the nature of the program. It is a 24/7 program in which you will be living in a safe environment while getting clean and sober. This is the highest level of addiction treatment and is sometimes necessary to completely break out of the addiction cycle. People who require medically-supervised detox are appropriate for this level of care.
A sensible way of separating each of these four levels of treatment is to list the average number of hours per week with each program:
- Outpatient – 1-2 hours/wk
- IOP – 9 hours/wk
- Extended Care – 20-30 hours/wk
- Residential – 40-60 hours/wk
More clinical time may be needed for a more severe addiction. A person with a less severe disease can succeed with less intense treatment. Navigating this schematic for treatment matching is what a skilled, high-level treatment center will do. There is a logical, stepwise approach to linking people with the appropriate treatment and aftercare. Through being sensible and realistic about care needs, you can achieve a good recovery outcome. The continuum of care model is key.