When considering treatment for drug or alcohol addiction, there are many options to choose from. However, there are only four main categories of addiction treatment programs. Known as levels of care, these categories include outpatient programs, more intensive outpatient treatment, residential rehab, and inpatient treatment.
The level of care required will vary based on the severity of the person’s substance use disorder (SUD) and other important factors related to their recovery needs, such as their physical and mental health status, personal and family history with substance use, and more.
Professionals at addiction treatment centers perform careful assessments and evaluations to determine the appropriate program and services for people seeking help. These professionals consider many factors when determining an individualized care plan for each client. If a treatment center does not offer the treatment necessary for a client’s recovery needs, a referral may be provided for another facility.
If you or a loved one feels overwhelmed at the prospect of seeking and receiving care, remember that the first step is the most crucial, no matter how small it seems. According to research from Mental Health America, 17.82% of adults in the U.S., or more than 45 million people, met the criteria for a substance use disorder (SUD) in 2023. However, studies also show that most people who need treatment never seek it. In fact, in 2021, 94% of Americans ages 12 and older with an SUD never received treatment, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), and in that same year, nearly 107,000 people in the U.S. died from overdoses, a record number at that time.
Learn more about levels of care for addiction treatment, important factors considered when developing a treatment plan, and more.
Why Are There Levels Of Care For Addiction Treatment?
Substance abuse treatment is an individualized experience and may vary widely from person to person. Different care levels are designed to meet a variety of treatment needs to support stabilization and long-term recovery.
Drug and alcohol treatment plans are determined, in part, based on the substance(s) used, the frequency of use, the amount(s) used, and how long the person has been using the substance(s). Aside from the person’s substance use, several other factors are also considered.
Other variables of importance when determining an addiction treatment plan include:
- co-occurring medical, emotional, behavioral, or cognitive issues
- family history of addiction
- home environment, e.g., children, divorce or other conflicts, or other stressors
- legal issues
- trauma
- readiness and willingness for change
Because so many areas of a person’s life intersect to determine the appropriate means of treatment, different levels of care for addiction treatment are necessary. Higher levels of care may be held in a hospital-like environment where 24-hour supervision is provided, while lower levels of care may occur in an outpatient setting. A continuum of care also makes it possible for people to enter treatment and gradually “step down” to programs of lesser intensity based on their ongoing progress and needs.
The ASAM Criteria
Levels of care are determined according to the severity of a person’s SUD following the criteria outlined by the American Society of Addiction Medicine (ASAM). Founded in 1954, ASAM is a professional medical organization representing more than 7,500 physicians, clinicians, specialists, and other professionals in the field of addiction medicine. The ASAM Criteria is the most extensive and widely recognized set of objective standards concerning the treatment of people with addiction and dual diagnosis in regard to their placement, continued service, and transfer. A multidimensional approach is used so that each client is understood as a whole person, not seen as a diagnosis.
According to ASAM Criteria, there are four main levels of care for addiction treatment:
- level 1: outpatient services
- level 2: intensive outpatient programs (IOP) and high-intensity outpatient programs (HIOP)
- level 3: residential
- level 4: inpatient
When a person is evaluated for SUD, they undergo an assessment process. The ASAM Criteria is the most extensive assessment process used in addiction medicine today. Clients are assessed across six dimensions so that professionals can understand their unique needs, strengths, and challenges.
ASAM’s six dimensions of substance use disorder include:
- dimension 1: intoxication, withdrawal, and addiction medication needs
- intoxication and associated risks
- withdrawal and associated risks
- addiction medication needs
- dimension 2: biomedical conditions
- physical health concerns
- pregnancy-related concerns
- sleep problems
- dimension 3: psychiatric and cognitive conditions
- active psychiatric concerns
- persistent disability
- cognitive functioning
- trauma exposure and related needs
- psychiatric and cognitive history
- dimension 4: substance use-related risks
- likelihood of risky substance use
- likelihood of risky substance use disorder-related behaviors
- dimension 5: recovery environment interactions
- ability to function in current environment
- safety in current environment
- support in current environment
- cultural perceptions of SUD
- dimension 6: person-centered considerations
- patient preferences
- barriers to care
- need for motivational enhancement
To perform the assessment, medical professionals use the ASAM Criteria Assessment Interview Guide to ask clients a series of questions about their current condition and history with SUD.
Answers to these questions help determine the client’s needs and the appropriate level of care for addiction treatment.
The Levels Of Care In Addiction Treatment
Within the four broad levels of care as determined by ASAM are decimal numbers representing further gradations in care, again with higher numbers representing more intensive care. Below, we’ll take a closer look at each individual level of care.
Level 1: Outpatient Services
Outpatient services are designed for people with less severe SUDs, or as a step down from more intensive treatment, such as an intensive outpatient program (IOP). Outpatient services allow clients to receive treatment while still living at home or residing in a sober living facility. Clients participate in treatment for up to nine hours per week, which may include one or two sessions. While in outpatient treatment, clients have the flexibility to continue living their daily lives.
Outpatient services may include:
- ambulatory detoxification
- drug testing
- group therapy
- family programs
- medication-assisted treatment (MAT)
Outpatient services may be appropriate for people who have completed residential rehab and require and/or wish to participate in regular addiction treatment as they gradually reintegrate into their communities and day-to-day lives.
The following criteria describe Level 1 clients:
- minimal risk of severe withdrawal
- stable physical health
- stable and predictable mental health
- readiness to change
- ability to abstain from or control use with minimal support
- supportive home environment
- fair and appropriate coping skills
There are three different tiers of Level 1 support, according to the ASAM Criteria: long-term remission monitoring, outpatient therapy, and medically managed outpatient.
Level 1.0: Long-Term Remission Monitoring
Long-term remission monitoring is recommended for people who have been stable in their recovery for more than a year. People are typically referred to long-term remission monitoring after having completed months of more intensive treatment. Regular recovery management check-ups are provided every three months at a minimum. If additional care is needed, it is swiftly provided.
Level 1.5: Outpatient Therapy
Outpatient therapy may be suitable for clients who are beginning treatment or as a step-down model following more intensive care. Regular outpatient therapy sessions are held throughout the week at non-residential treatment centers, in a practitioner’s office, or in a doctor’s office that employs therapists. Clients learn how to use healthy coping mechanisms to manage their emotions, how to better understand their addiction and its underlying cause, and ways to prevent relapse.
There are several types of outpatient therapies. A combination of therapies may be used based on the client’s needs.
Types of outpatient therapy include:
- one-on-one (individual) therapy
- group therapy
- marriage and family therapy
- couples’ therapy
Level 1.7: Medically Managed Outpatient (MMO)
Medically managed outpatient (MMO) treatment provides medical and psychiatric support for people with SUDs who are prescribed medications for detoxification, and/or who have concerning mental health symptoms. MMO services are administered in addiction treatment centers, practitioner’s offices, healthcare facilities, opioid treatment programs, and more. Clients return home after receiving treatment.
MMO includes:
- counseling and behavioral therapies
- medical observation
- medication management
Level 2: Intensive Outpatient Programs (IOP) and High-Intensity Outpatient Programs (HIOP)
The second tier of outpatient services are more intensive than the first tier, offering clients added support and structure. Some clients at this level may be considered low risk in regards to SUD, while others pose a moderate risk; however, clients still return home or to a sober living environment after receiving treatment. The complexity of care increases between Level 1 and Level 2, and such programs typically offer 24-hour crisis services.
The following criteria describe Level 2 clients:
- minimal to moderate risk of severe withdrawal
- stable physical health
- mental health issues of mild to moderate severity
- variable to poor engagement in treatment
- requires a structured program or a near-daily structured program
- high likelihood of relapse without close monitoring and support
- unsupportive home environment
- fair and appropriate coping skills, or able to cope with structure and support
There are three different tiers of Level 2 support, according to the ASAM Criteria: intensive outpatient program (IOP), high-intensity outpatient program (HIOP), and medically managed outpatient.
Level 2.1: Intensive Outpatient Program (IOP)
An IOP is structured similarly to a standard outpatient program, but with a greater time commitment. Clients in IOPs for substance abuse and co-occurring mental health disorders meet with clinicians and support groups for at least 10 hours each week, or typically three to four hours each day.
An IOP is ideal for people who still need a high level of support but do not meet the requirements for inpatient care. It’s also ideal as a step down after completing inpatient care.
Some of the services provided in IOPs include:
- one-on-one counseling
- group therapy
- life skills training
- support groups
Clients in IOPs may also participate in education on addiction and its contributing factors.
Topics of these classes may include:
- emotional regulation
- relapse prevention
- vocational skills
- self-understanding
- support networks
- trauma education
Level 2.5: High-Intensity Outpatient Program (HIOP)
An HIOP, also known as a partial hospitalization program (PHP), is the most intensive outpatient therapy program available for people with SUDs and co-occurring mental health conditions. Medical supervision and/or detox treatment may also be provided in an HIOP.
Clients are typically expected to participate in their HIOP for six to eight hours a day, or 30 to 40 hours per week. Unlike standard outpatient programs, HIOPs don’t allow clients to work or attend school full time while in the program. This level of care can serve as an alternative to inpatient rehab for those who qualify, and a middle ground between inpatient and standard outpatient programs.
Some of the services provided in HIOPs include:
- one-on-one therapy
- group therapy
- medical supervision
- mental health care
- medication-assisted treatment (MAT)
- physical therapy
- family support programs
Level 2.7: Medically Managed Intensive Outpatient
Medically managed intensive outpatient is an SUD program where symptoms of withdrawal are managed in a hospital setting. This level of care is appropriate for people with severe SUDs that require a combination of medication, behavioral therapy, and round-the-clock medical support and/or mental health care. Clients may need support for managing symptoms of withdrawal or beginning or changing addiction medicine.
Level 3: Residential Treatment
In residential treatment, people with SUDs receive intensive therapeutic care in a dedicated rehab facility. Residential treatment is typically voluntary and may be long-term. Clients receive services while living at a non-hospital-setting rehab center or in treatment communities, halfway houses, or sober living facilities. Services may entail a variety of therapies, depending on the client’s needs, to help them develop the skills to maintain a sober lifestyle after completing treatment.
Residential treatment services may include:
- addiction education
- family support programs
- family visitation
- one-on-one therapy
- group therapy
- marriage and family therapy
- medication management
- medication-assisted treatment (MAT)
- skills-building workshops
- transportation assistance
- vocational support
- aftercare programs
The type of rehab center chosen and the length of stay may vary based on the client’s health insurance. The typical length of stay is 30, 60, or 90 days, though some programs are longer.
The following criteria describe Level 3 clients:
- minimal or manageable risk of severe withdrawal
- stable to poor physical health
- poor mental health, with mild to moderate symptoms
- little or no desire to change
- moderate to high risk of relapse
- poor coping skills
- unsupportive, high-stress home environment
There are three different tiers of Level 3 support, according to the ASAM Criteria: clinically managed low-intensity residential, clinically managed high-intensity residential, and medically managed residential.
Level 3.1: Clinically Managed Low-Intensity Residential
Clinically managed low-intensity residential treatment is the least intensive residential treatment available for people with SUDs. Clients receive treatment in a safe, structured, and supportive environment, typically a freestanding facility, with 24-hour supervision. The goal is for clients to eventually transition to a lower level of care, such as an outpatient program, after completing treatment.
A variety of services are available to support clients at different stages of recovery. Level 3.1 programs may arrange for clients to receive medical treatment, such as dental care or lab testing, and arrange for their transportation to and from these facilities. Therapies and skill-building experiences are designed to foster a sense of responsibility, self-confidence, and community, to help clients live a fulfilling, independent life outside of treatment. Services are designed to promote community reintegration.
Level 3.5: Clinically Managed High-Intensity Residential
Clinically managed high-intensity residential programs are similar to Level 3.1 services, but are more intensive and provide more structure. Level 3.5 services are suitable for clients with more severe SUDs, ongoing withdrawal symptoms, and/or co-occurring mental health disorders with moderate to severe symptoms. Clients at a Level 3.5 facility require constant support from a multidisciplinary team of staff with the possibility for intervention if necessary.
Level 3.7: Medically Managed Residential
Medically managed residential treatment services provide medical care in addition to clinical services. Level 3.7 treatment is suitable for clients with a medical and/or psychiatric condition that requires 24-hour monitoring to ensure safety and stabilization.
Medically managed residential treatment entails:
- 24-hour nursing care
- 24-hour access to specialized and intensive care
- 24-hour access to physician care
- 24-hour supervision, monitoring, and treatment
- access to the same comprehensive resources as a general or psychiatric hospital
Level 4: Inpatient Treatment
Inpatient treatment is the most intensive level of care available to people with SUDs and co-occurring mental health disorders. Inpatient treatment is often recommended to people who have not found success in outpatient programs and other forms of treatment.
Clients in inpatient rehab receive intervention treatments, including medical detoxification, in a hospital-like setting with the goal of stabilization. At this stage, medical intervention is required as a result of severe SUD and/or long-term substance abuse.
Inpatient treatment is generally not long-term and is only intended to continue for as long as stabilization is required. After stabilization, clients can step down to other forms of treatment, such as residential care.
The following criteria describe Level 4 clients:
- severe withdrawal symptoms
- have a severe or life-threatening medical condition and/or overall poor physical and mental health
- no desire to change, rejecting the idea of treatment
- active substance abuse
- unable to function
- pose a health and/or safety risk to others
- live in an unsupportive, risky, and/or dangerous environment, are unemployed, and/or are displaced or unsheltered
Determining The Right Course Of Addiction Treatment
Every person who receives treatment for a SUD will undergo an evaluation and assessment process. Medical, clinical, and/or treatment staff will present a treatment plan that aligns with the client’s needs.
Using the ASAM Criteria, important factors considered for determining an SUD treatment plan include:
- the substance(s) used, the frequency of use, the quantity used in a typical 24-hour period, the length of time a person has used substance(s), personal history of substance abuse, family history of substance abuse, and history of relapse
- current withdrawal symptoms
- co-occurring medical and/or mental health disorders
- readiness to change
- the presence of a healthy support system, i.e., family, friends, community, and others
- previous experiences in treatment and associated outcomes
- personal preferences regarding treatment programs and plans
The course of a treatment plan may change as a client progresses and is reevaluated accordingly. Treatment may also vary depending on the availability or lack of health insurance, the availability of beds in local facilities, and more.
Resources
There is a lot of information to take into account when considering levels of care for addiction treatment. The following resources can provide you and your loved ones with important details about substance abuse and available treatment options.
National Institute of Mental Health (NIMH): One of 27 institutes and centers that make up the National Institutes of Health (NIH), NIMH conducts and raises awareness about research concerning the treatment and prevention of mental health disorders, which includes SUD.
National Institute on Drug Abuse (NIDA): One of 27 institutes and centers that make up the National Institutes of Health, NIDA performs research on SUD, including addiction recovery.
National Institute on Alcohol Abuse and Alcoholism (NIAAA): Also part of the NIH, NIAAA is responsible for funding 90% of all research on the causes, consequences, treatment, and prevention of alcohol addiction and other alcohol-related issues nationwide.
Substance Abuse and Mental Health Services Administration’s (SAMHSA) Treatment Locator: SAMHSA is a branch of the U.S. Department of Health and Human Services that strives to raise awareness and improve outcomes for people affected by, and/or at risk of, substance use and mental health disorders. Its treatment locator provides information about local treatment facilities in the U.S. and is searchable by the types of treatment available, the forms of payment accepted, and more.
