Seeking treatment for a Substance Use Disorder can create many challenges. So, where do you start? The number of acronyms and terms alone can make you scratch your head. Fortunately, there is a system to determine appropriate level of care and even better, you do not have to make that decision alone. The American Society of Addiction Medicine (ASAM) developed a set of placement criteria, beginning in the 1980’s, to provide guidelines to assess appropriate level of care. This multi-dimensional approach utilized by clinicians and care managers allows for objective decision making, individualized care, and improved client outcomes. Overall, the ASAM criteria helps those struggling with substance use disorders to be matched with tools and services to promote long-term recovery.
First, let’s start with clearing up the differences in levels of care and what each entails. Treatment occurs on a continuum, with a range of the level of structure, intensity, and monitoring.
Medically monitored/managed residential (“detox”) programs are on the most intensive continuum of treatment. They offer 24-hour support, with a focus on medically managing symptoms of substance use and co-occurring disorders. This includes acute biomedical, emotional, behavioral, and cognitive problems that require primary medical and nursing care for stabilization. Examples include severe withdrawal management and stabilization of severe co-occurring needs such as acute suicidality.
Clinically managed residential (“rehab”) programs offer daily clinical programming to develop recovery skills and allow for a drug and alcohol free environment to promote physical and psychological wellness. This level of care is designed to serve those who have functional limitations and need a safe and stable living environment in order to develop recovery skills to minimize the risk of immediate relapse when transferred to a lower level of care.
Partial Hospitalization Programs (PHP) provide frequent and structured programming without the need for 24-hour support. These programs typically have direct access to psychiatric care to monitor and manage co-occurring and post-acute withdrawal symptoms.
Intensive Outpatient Programs (IOP) treatment consists of structured clinical programming in an outpatient setting, with group and individual sessions, offered several times throughout the week. An IOP program typically involves continued monitoring and support with direct application of skills into various life areas (I.e. work, interpersonal relationships).
Outpatient Programs (OP) treatment varies in terms of services and settings. OP typically occurs in regularly scheduled sessions tailored to help the client achieve goals related to addictive behaviors, behavior/emotional issues, and coping with stressors without the use of substances. The goal is to achieve stability in recovery and develop outside supports for sustained recovery.
Secondly, let’s look at the 6 dimensions of ASAM criteria and questions to consider in determining appropriate level of care:
1. Acute Intoxication and Withdrawal – this criteria takes into consideration the individual’s substance use patterns and risk for withdrawal symptoms (how often the person uses, last use of a substance, any current withdrawal, any history of severe withdrawal symptoms such as seizures).
2. Biomedical Conditions and Complications – identifies chronic health conditions and current physical illnesses. Additionally, this dimension focuses on the level of ability for client to manage these conditions on their own or if additional support is needed.
3. Emotional, Behavioral, or Cognitive Conditions and Complications – focuses on the psychiatric and mental health presentation of the individual. Considerations include identifying if the person has a psychiatric diagnosis(es), the severity of presenting symptoms and if these are expected as part of the addictive disorder of if they are autonomous. (Can the person manage tasks of daily living? Do the psychiatric needs complicate treatment or create a risk?)
4. Readiness to Change – assesses the degree to which the individual is ready to make a change. The assessor will look for factors, both internal and external, that have motivated the individual to seek treatment. The Stages of Change model aids in determining the level of readiness. (How aware is the person of the relationship between addictive behaviors and negative life consequences?)
5. Relapse/Continued Use, Continued Problem Potential – identifies level of risk of continued relapse. Considerations include the level of impulse control client exhibits, history/patterns of substance use, and coping skills.
6. Recovery and Living Environment – overview of where the person is living, considering if they are living with other people who are using substances. Who are the individual’s supports? Are they involved in community support programs? (I.e. Alcoholics Anonymous, Refuge Recovery). Dimension 6 is also where to note any barriers/complications, such as limited access to transportation.
Level of care is determined based on the barriers, risks, strengths, and supports identified in each criterion to decipher the intensity, medical management, and residential supports needed.
A few things should be noted regarding levels of care. First, ASAM criteria is not a one-time fixed assessment, and should be utilized to assess and reassess the client throughout the course of care. It not only is used to help individuals enter the appropriate level of care, but also to be able to step-up or step-down depending on their presentation. Additionally, Medication Assisted Treatment (MAT) such as Suboxone and Vivitrol can be utilized across all levels of care.
To determine appropriate level of care, it is imperative to engage in an assessment with a professional trained in utilizing the ASAM to make a level of care recommendation. Because each person comes with their unique journey and experience, treatment is not “one size fits all.” Using multi-dimensional criteria allows for assessment of the whole person in order to match them with the most effective interventions and support. Quality treatment is available, and recovery is possible.
Author: Brigid Spollen, MA, LPC – Footprints to Recovery – Counselor
Text used: The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. American Society of Addiction Medicine, Third Edition (2013)