he treatment of addiction is sometimes called a science, but it is also an art. There is no “one size fits all” when it comes to addressing a chronic condition. In light of that fact, the American Society of Addiction Medicine created The ASAM Criteria, outlining a numerically ordered, description of levels of addiction treatment, also called the CONTINUUM. 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 ConditionIn 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.
Changes in ConditionLooking 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 Levels ThemselvesAll 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 AdolescentsThe 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 ServicesFor 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 ServicesLevel two is broken into two numerals, 2.1 and 2.5, and is the lowest level of care recommended for anyone with a co-occurring condition and addiction (also called a dual diagnosis). 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
Level 3 - Inpatient CareLevel 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.