The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related and Co-Occurring Conditions, as its full title suggests, offers guidelines for care based on several important factors, used in assessment for appropriate care for addiction or substance abuse (and, when appropriate, co-occurring conditions–more on that later).
The levels of care guide facilities with describing care services available, help practitioners and families with placement in an appropriate facility to assist with recovery, and assist insurance companies with billing codes for level of treatment. Levels of care are called a continuum because those receiving treatment can move fluidly up and down the treatment levels, as appropriate and as conditions improve or worsen.
More importantly, though, levels of care improve outcome: treating addiction with the appropriate level of intensity for that individual makes recovery more likely and more sustainable.
Here’s what you need to know.
Assessing a Complex Condition
In order for an assessment of an appropriate level of care to be determined, two things are required: a thorough understanding of treatment levels and an honest assessment of the individual.
As simple as that sounds, many complexities may get entangled in that process. For example, insurance companies or court orders from judges may choose a lower level of care (such as outpatient treatment) for financial reasons, because it is a first attempt at treatment, or seemingly more accessible. Those factors may have nothing to do with the two criteria named above. The problem, then, is that treatment can look like it “doesn’t work,” when, in fact, it was never the appropriate treatment program for that particular individual’s condition.
So first, a more thorough definition of addiction:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”
Given that addiction affects the biology, psychology, social function and even the spiritual state of the individual involved by its very definition, it’s easy to see why a oone-size-fits-allapproach would have little chance of success–it would need to address those complex and individual factors in a way that cuts to the root of the problem for that person.
Fortunately, the assessment guidelines by the ASAM look at several criteria to determine the condition of these aspects of an individual’s life, factors such as:
- What the individual has been using, and for how long,
- Health history and level of physical change/diminished health as a result of substance abuse,
- Emotional and behavioral state, including readiness/willingness to change,
- Previous experience with attempts to change, and history of relapse,
- Current living conditions, employment, state of familial relationships, etc, which may impact the success of treatment.
As you can see from this list, differences in appropriate care naturally emerge as you have an understanding of the individual being assessed. For example, someone with a job, a great deal of familial support, and a genuine interest in changing would not need the same level of care as an individual with a diminished physical condition from substance abuse, insecure living conditions, a history of relapse, or no desire to change.
Changes in Condition
Looking at an assessment, such as determining appropriate care, can begin to seem like something that would be decided by an outsider–family members, a physician, a court order, etc might all want to dictate how change should go. In some cases, intervention is indeed necessary, and the physical or emotional condition of the addict is not in good enough shape to determine to make a change on their own.
However, the guidelines for level of care were written with the addict in mind–as much as possible, the individual with a substance use disorder should have a say in how treatment goes.
The National Institutes of Health maintains a library of medicine, The National Center for Biotechnology Information (NCBI), which makes research into health sciences broadly available for the public. For those old enough to remember going to a library and getting out little boxes of microfiche or rolls of film with medical research journals on it, the internet has changed all of that. Now, many publications and the raw research behind them are available for anyone with a desire to read them.
Thanks to this database, anyone can understand the two primary settings for addiction treatment: inpatient and outpatient care. The levels of care guidelines are subdivisions within these two primary possibilities.
Additionally, the NCBI has published what has become known as “Least Restrictive Care”–a patient’s basic, human and civil rights and right of choice for care, which state:
- Patients should be treated in those settings that least interfere with their civil rights and freedom to participate in society.
- Patients should be able to disagree with clinician recommendation for care. While this includes the right to refuse any care at all, it also includes the right to obtain care in a setting of their choice (as long as considerations of dangerousness and mental competency are satisfied). It implies a patient’s right to seek a higher or different level of care than that which the clinician has planned.
- Patients should be informed participants in defining their care plan. Such planning should be done in collaboration with their healthcare providers.”
The guidelines do go on to acknowledge the complexity of situations and state laws, which vary. If an individual is a serious threat to himself or others, of course, a higher level of intervention and care would be warranted. Yet, all substance abuse has an inherent element of self-harm.
All of this means that great care must be taken to provide appropriate care, while maintaining an addict’s self-determined involvement and civil rights.
Ideally, even more intense levels of intervention and care, will work toward improving the addict’s ability to freely and cooperatively improve his or her condition. All treatment facilities have this data, and therefore choosing the right treatment program for a friend or loved one should be done with an eye toward long-term improved decision-making power.
The Levels Themselves
All of the above data pertains to a better assessment of the addict, as an individual, but what about the other criteria for effective assessment–an understanding of the levels themselves?
But first, a note about recovery rates. If you or a loved one have struggled with substance abuse, it’s easy to feel hopeless, as if addiction is unmanageable. People give up, turn to substitute addictions, or otherwise come to believe that the situation is irreparable. In actuality, treatment for addiction has comparable success rates to other chronic conditions, such as Type I Diabetes and hypertension.
The comparison to other chronic diseases is more useful than just those success rates, though. Take diabetes, for example. No one questions the diabetic about not eating cake and cookies, but when someone with a substance use disorder chooses to abstain even from alcohol, friends and family don’t always understand. Or when someone with a substance use disorder has a long-term treatment program, with follow-up for many years, insurance companies want to stop paying for it.
But a chronic disease doesn’t evaporate. One can manage a condition and even completely change–just as addiction changes the mind, body and spirit, freedom from addiction can make lasting changes–but the appropriate long-term management for a chronic condition is an individual decision and process.
Overall, addiction treatment has a success rate of 40-60% across all treatment options. Obtaining the best outcome, then, has a great deal to do with choosing the appropriate level of care.
There are five overall levels–0 to 4, with decimals to delineate the sub-levels along what is intended to be a continuous line of care. The freedom to move up and down that line, as a condition changes, is built into the decimal system.
Level 0.5 – Early Intervention for Adults and Adolescents
The smallest level of care might not even be recognizable as treatment, because it is instead an educational level, a preventative treatment.
When adults or adolescents identified as at-risk for substance use disorders receive preventative education, they are getting Level 0.5 care. This level can vary greatly, but may include:
- Information about the potential for addiction of a prescription drug, such as a painkiller after an operation.
- Drug education in at-risk communities or facilities, such as schools or even detention facilities.
- Assessment of unconfirmed substance use disorder, the assessment process itself not yet being a placed level of care above 0.5.
Level 1.0 – Outpatient Services
For those tackling a substance abuse problem, or in the maintenance stages of a substance use disorder, receiving less than 9 hours per week of care (6 hours/week for adolescents), the care level is considered Level 1.0.
Outpatient services are often the first request of insurance companies or court orders, due to the lower cost of these reduced services. Those undergoing outpatient services can still maintain full-time employment or school, live at home and otherwise continue day-to-day living.
However, outpatient services may not be the appropriate level of care. When detoxification is needed or the stress of everyday life triggers substance abuse, removal from the scene to a live-in, inpatient facility, or a change of environment, may be a necessary part of recovery.
Even after a higher level of care on the CONTINUUM, most people in recovery will at least receive outpatient treatment to maintain stability.
Level 2 – Intensive Outpatient or Partial Hospitalization Services
Co-occurring disorders refer to a complex list of conditions that may be present, in conjunction with, in advance of, or in result of addiction. That list includes:
- Personality disorders, such as bipolar disorder
For those individuals with a dual diagnosis, people whose treatment should include a detoxification component, or adults or adolescents with an extensive history of alcohol or drug abuse, Level 2 care should be considered the minimum level of care.
Level 2.1 is called Intensive Outpatient Services. It includes 9 or more hours of treatment per week for adults, and 6 or more hours per week for adolescents. The individual attends treatment services during the day, but can still go to school or work in the evenings and/or weekends, while undergoing active care.
Level 2.5 is called Partial Hospitalization Services for adults and adolescents. It typically includes 20 or more hours of services per week, but for those stable enough to not require 24-hour care (such as able to be housed in a nearby facility).
Level 3 – Inpatient Care
Level three has four further subcategories, but they all involve residential or hospitalization care. At least for the initial stages of care, in many cases, detoxification in a supervised setting may be the safest approach to treatment.
Withdrawal can be dangerous, or even deadly (in the case of benzodiazepines (benzos), opiates or alcohol). Alcohol withdrawal syndrome may include hallucinations, fever and seizures, known as delirium tremens (DT). Drug withdrawal can induce vomiting, which potentially leads to serious dehydration.
The length of time of substance abuse, and the complete list of substances involved, are a crucial component of assessment to determine appropriate level of care, within all levels, including the sublevels of Level 3.
- Level 3.1 – Clinically Managed Low-Intensity Residential Services includes 24-hour structure and support, with at least 5 hours of clinical treatment services per week.
- Level 3.3 – Clinically Managed Population-Specific High-Intensity Services is the designation for 24-hour specialized care, for those individuals with cognitive impairments or in danger (of self-harm or in a dangerous living environment). This level of care provides the structure and assistance needed under those circumstances, for adults only.
- Level 3.5 – Clinically Managed Medium-Intensity Residential Services (for adolescents) and Clinically Managed High-Intensity Residential Services (for adults) is a transitional level, of more intense care, to stabilize care until outpatient services would be appropriate. As discussed in Level 1.0, a more intense level of care may be required for initial treatment stages (such as detoxification), until an individual in recovery can safely participate in outpatient-only care.
- Level 3.7 – Medically Monitored High-Intensity Inpatient Services (for adolescents) and Medically Monitored Intensive Inpatient Services Withdrawal Management (for adults) – this designation level includes 24-hour medical supervision, such as round-the-clock nursing staff, and those who require medication, or have medical conditions such as dementia. Level 3.7 would not normally be a first line of approach, but only after demonstrated inability to complete withdrawal through other levels of care.
Level 4 – Clinically Managed Intensive Inpatient Services
The highest level of intensity of treatment is for those who require 24-hour medical care, with daily physician supervision, due to severe and unstable medical conditions, is Level 4. The goal of Level 4 care, like other higher designations, is to provide the intense care needed for patients to safely participate in a lower level of care, with greater personal mobility and freedom, after an initial period of restrictive and medically-monitored treatment.
Any inpatient treatment is at least Level 2, but residential facilities provide Level 3 care, and may include a focus on life skills such as communication skills or job training. Level 3 care includes daily structure and treatment, such as detoxification services, but may also include activities such as hikes, sports, art therapy or music therapy, to name a few.
The goal of inpatient care is to assist with the initial detoxification process, but in an environment that is also safe for personal assessment and growth. Through individual or group therapy sessions, life-skills building activities and seminars, and the guided attainment of personal goals, an individual receiving inpatient care become better prepared to return to daily life and handle its stressors without substance abuse.
Start with an Assessment
To determine the appropriate level of care for yourself or a loved one, speak with one of our highly trained staff. We start with a thorough assessment which will assist with both placement and appropriate treatment objectives to start the road to recovery. In those cases where previous treatment was left incomplete, we can help you determine the appropriate level of care for a more successful treatment process.
Get started with an assessment today.
Detoxification is a process in which people addicted to drugs or alcohol are medically cleansed of the toxins created by those substances. Detoxification, or detox for short, is almost always the first step in the rehabilitation process for addicts and alcoholics. Before addicted individuals can be admitted to treatment, they must first complete the detox process. There are many different forms of detoxification depending on the substance of dependence and the severity of the addiction.
There are also some drugs of abuse that do not necessarily create a particularly significant physiological dependence and therefore do not specifically require medical detoxification, such as methamphetamines, cocaine, and marijuana. The abuse of these drugs can result in a serious psychological dependence which often requires intense therapy and residential treatment, but not necessarily medically assisted detox. Nevertheless, detox protocols do exist for these substances. Other drugs such as heroin, alcohol, and prescription medications like opiates, barbiturates, and benzodiazepines create not only a psychological but also a serious physical dependence, requiring medical detoxification in most if not all cases of long-term use.
The Detox Process
There are mainly three steps involved in drug and alcohol detoxification:
- Evaluation – The patient is first tested and evaluated for detox. Mental health issues and psychological evaluation will also be conducted to help evaluate the patient’s underlying issues.
- Medical Stabilization – This can be done with or without medication, but in most cases, medication is necessary to help stabilize the patient and treat withdrawal symptoms.
- Guiding patient to treatment – The final step is the recovery process itself, usually involving continuing on in a drug rehabilitation program.
Alcohol is one of the most dangerous drugs of abuse, not only because of its availability and social acceptance but also because of its damaging effects and dangerous detox. Many alcoholics who try to stop drinking on their own experience uncomfortable and even dangerous withdrawal symptoms, and in the worst cases, these symptoms can be fatal. Alcohol withdrawal symptoms are dependent on the severity of the alcoholism and length of time the alcohol abuse has be going on. During alcohol detoxification, the patient is medically monitored during the withdrawal of the alcohol from their system. During this process, alcoholics may experience anywhere from mild to severe withdrawal symptoms such as sweating, headaches, anxiety, increased heart rate, insomnia, agitation, and delirium tremens (DT’s) leading to seizures and sometimes even death . At a medical detoxification program, medical staff will use various medications to ease the most severe symptoms of alcohol withdrawal. Most often drugs in the class of benzodiazepines such as Librium and Diazepam are used to assist with anxiety and act as anticonvulsants to prevent seizures from alcohol withdrawal. Despite the medical assistance, alcohol detoxification always runs risks and for very severe cases of alcoholism where the patient has experienced cirrhosis of the liver or other organic diseases caused by drinking, the detox process can last several weeks to months for medical care. Most cases of alcohol detoxification, however, take anywhere from 3 to 10 days.
Heroin and opiate-based painkillers like Vicodin, Percoset, Darvon, Morphine, Fentanyl, OxyContin, and Methadone not only cause a psychological addiction, but also a physical addiction that makes the detoxification process especially difficult. With stimulant drugs, the addiction is mostly psychological and the physical symptoms are kept to a relatively low grade of discomfort.
Detofication of opiates from the body is a process that often involves other drugs being administered to make the process more tolerable. Some of the symptoms of opiate withdrawal are nausea, vomiting, diarrhea, high fever, cold sweats, shaking, muscles spasms, insomia, extreme fatigue, and muscle aches. Because the pain and discomfort is so severe in many cases of opiate withdrawal, addicts are often given benzodiazepines like Klonopin or Valium to “take the edge off” and help an individual to relax and hopefully sleep through the detoxification process. Alternatively, other opiates are used to gradually taper the addict, most often buprenorphine (Subutex® or Suboxone®) or methadone. These drugs have very long half-lives, so when the effects of them wear off, the user experiences less severe withdrawal symptoms than from their drug of choice.
Detoxification of opiates from the body, like with stimulants, can range in length and severity, depending on the individual and his or her drug and health history. In general, a traditional opiate detox takes anywhere from 3-10 days, and thereafter a period of time when the recovered user may experience mild depression, lethargy, and fatigue, and other protracted withdrawal symptoms, known by the acronym PAWS (Post Acute Withdrawal Syndrome).
Another form of opiate detoxification is rapid opiate detox, in which doctors anesthetize the patient, administer a combination of opiate antagonist medications (usually narcan and/or naltrexone) that send the patient into immediate acute withdrawal for several hours while under anesthesia until the opiates are out of the system. Patients are usually monitored in the hospital overnight and then sent home within 1 day of the procedure.
Benzodiazepines are drugs classified as mild tranquilizers, which act as Central Nervous System (CNS) depressants, slowing brain function and relaxing muscles. Although benzodiazepines have beneficial uses, such as their uses as muscle relaxants and sleep aids, the prolonged use of these drugs can lead to extreme physical dependence, which makes the detox process very dangerous. Generally, when people addicted to benzodiazepines such as Xanax, Ativan, Valium and Klonopin undergo the withdrawal process, they can experience sleep disturbances and insomnia, irritability, headaches, fatigue, sweating, anxiety, and most importantly, seizures. The withdrawal process generally creates the very symptoms that benzodiazepines are indicated to treat. The way medical staff ensure safety during the withdrawal process for individuals addicted to benzodiazepines is to administer limited amounts of phenobarbital, as it is less addictive and less powerful than the benzodiazepines it is used to treat, but works well as a mild sedative and anti-epileptic (anti-seizure) medication. Until the toxins from benzodiazepine abuse have been completely removed from the body, it is important for the addict to remain under medical care. The cessation of benzodiazepine use can cause dangerous and sometimes deadly seizures until the drug is out of the body. For some of the drugs in this class with longer half-lives, the toxins can remain in the body for as long as 4-6 weeks depending on the severity and length of the abuse.
Detoxification from Cocaine, Methamphetamines, and Other Stimulants
Detoxification from stimulants like cocaine, crack crack cocaine and meth, like with any other substance, can be psychologically grueling. Detoxifying the body of these kinds of drugs can cause significant psychological withdrawal symptoms including anxiety, irritability, insomnia, severe cravings, and fatigue. Detoxification from methamphetamine specifically can cause psychotic reactions, severe depression, and confusion.
The most common detox medications used to treat stimulant withdrawal are antidepressants and mood stabilizers. The detox process can last anywhere from 3 to 10 days, but in most cases tends towards the shorter end of this scale.
The Importance of Detox for Drug and Alcohol Recovery
The process of detoxification is only the beginning of drug or alcohol rehabilitation, but it is one of the most important parts of this process. Detox is imperative because the psychological, social and behavioral rehabilitation process cannot begin if there is still a physical dependence on drugs and alcohol. This physical dependence is one of the main motivations for alcoholics and drug addicts to continue using, as it is responsible for the painful and sometimes dangerous physical withdrawal symptoms that occur upon cessation.
Detoxification seems imposing because of the horrible stigma it has for being painful and uncomfortable, but rest assured that it is necessary for the recovery process to begin, and pales in comparison to the pain and dangers associated with continuing addictive behaviors. The medical staff required for the detox process is dedicated to ensuring the safety and comfort of this procedure, and are assisted by a myriad of medicines available to aid.
As it is with finding the appropriate treatment center, it is important to find the right detox facility to assist with withdrawal from addictive substances. Some treatment centers do not offer detox, while others do, but this service can be found at most hospitals.
If you are having trouble determining the best detox facility for an individual’s needs, give us a call. We offer comprehensive, no-cost assessment and referral services to drug and alcohol detoxification programs and addiction treatment centers. If you are in need of help, please explore our site, fill our our confidential online drug and alcohol assessment, and by all means, CALL US – we’re here to help.