Professional treatment for addiction occurs in different settings that often get referred to as levels of care. The levels are really a continuum of options that fall into three large buckets:
- Residential (non-hospital)
- Hospital Inpatient
Within each of these broad options are a number of choices depending on your needs. Before heading off to treatment, I highly suggest reading up on the various levels of care and what they mean for you. Here is a brief summary of each:
Regular: This is the most common treatment setting defined as less than 9 hours of therapy per week. Usually you would receive 1 to 3 hours of treatment per week in some combination of individual, group, or medication check appointments (ASAM I).
Intensive: Defined as 9 or more hours of treatment per week. Usually you would attend treatment three times per week in three-hour session time blocks. Used when regular outpatient does not produce the desired outcomes (ASAM II.1).
Day Treatment/Partial Hospitalization: Defined as 20 or more hours per week. Treatment is often daily, but you get to sleep in your own bed! Used when intensive outpatient fails to produce the desired outcomes, but when residential care is either not available or not deemed necessary (ASAM II.5).
Detoxification: Utilizes regularly prescribed medication along with supportive counseling to assist in detoxification (ASAM I-D and II-D).
Methadone, Buprenorphine or Vivitrol Treatment: Treatment setting focuses on those who are addicted to opioids and utilizes one of a number of FDA approved medications. Treatment includes counseling, usually defined as regular or intensive outpatient. Some programs provide exclusive care to those struggling with opioids, while other programs treat a broad range of substance abuse disorders.
Private Practice Clinicians: Private practice clinicians work independently from any program and include: counselors, psychologists, social workers, nurse practitioners, psychiatrists, and certified addiction therapist. In smaller towns where no treatment programs exist, usually you can find a private practice clinician.
Short Term: Lasts 30 days or less. Residential means you are spending nights in treatment (24 hour care), where your entire stay in clinically-managed. This is a high-intensity experience (ASAM III.5).
Long Term: Typically treatment lasts longer than 30 days. Entire stay is clinically-managed with intensity varying from low to high. Used when 30 days does not produce outcomes where person can be stepped down to outpatient care (ASAM III.3).
Detoxification: Clinically managed detoxification or social detoxification where medical needs do not require hospital-level care (ASAM III.2-D).
Detoxification: Medically managed detoxification, often used when co-occurring medical problems requires monitoring, or when a local hospital is the only place to receive this kind of service (ASAM IV-D and III.7-D).
Treatment: Medically managed treatment, usually due to complicating physical health issues that requires a high level of medical intervention (ASAM IV and III.7).
What Level of Care Do You Need?
After reading the descriptions, or from past experience, you may have some idea as to the level of care you need. But if possible, it’s always a good idea to get an evaluation by an impartial licensed clinician that can assist you in making the best decision. By impartial, I mean someone who does not have a stake in where you go for treatment. Because treatment has become big business, often those who claim to do evaluations are really savvy intake coordinators who care more about what type of insurance you have and whether you can pay for treatment. Once you pass their money screening questions, the evaluation can turn into a sales pitch for why their particular program is perfect no matter what your needs.
Treatment is a significant investment in time and money, not to mention what is at stake in your life, so you want to be well informed before making any decisions. Ask your primary care physician for a referral, or investigate licensed clinicians in private practice with experience doing comprehensive evaluations.
Also, you may have noticed those letters and number after each description which refer to the American Society of Addiction Medicine (ASAM) levels of care. In the 1980s, ASAM developed outcomes-based criteria to provide guidance on what level of care a person should receive based on six factors: 1) need for detoxification, 2) medical issues requiring care, 3) emotional, behavioral or cognitive needs, 4) readiness to change, 5) potential for relapse, and 6) current living environment. Today, the criteria are used by clinicians in over 30 states to help make treatment decisions. That said, the criteria are not written in stone, but if you get an evaluation for treatment chances are good you will run across ASAM at some point.
Some Treatment Facts to Consider
Before finalizing your decision about treatment, you may want to consider a few facts that come from an annual survey done in the U.S. about the addiction treatment system (N-SSATS, most current data is 2013). While the survey does not capture every program, it covers most of them and provides a nice snap shot in time of who is in treatment, the settings being used, and types of treatments delivered.
Who is in Treatment?
On March 29, 2013 there were 1,249,629 people in treatment. Clients were in treatment for alcohol AND drug problems (47%), drug problems (39%), and alcohol problems (20%). The survey found that 45 percent of clients had co-occurring behavioral health problems, which tells me that many programs are doing a lousy job of thoroughly assessing trauma in all its forms. Personally, I believe depending on how you define trauma, most who struggle with addiction qualify for a co-occurring disorder.
Also, about a third of those in treatment receive methadone (26%), buprenorphine (4%) or Vivitrol (.3%) for opioid use disorders. The fact that one-third of all treatment admissions are specific to opioids is hardly surprising given the significant increase in overdose death from prescription drugs during the past decade.
One frustrating thing about these government surveys is that they focus exclusively on alcohol and drug problems, and ignore completely behavioral addictions. Check out the information on gambling, sex, food, and the internet for treatment details if that is your interest.
Where are People in Treatment?
Perhaps most revealing from the survey is that 90 percent of all treatment is outpatient care. Residential care accounts for only 9 percent of treatment admissions, while hospital inpatient accounts for only 1 percent. This means that most who are seeking treatment can do just fine with outpatient services, which come at a fraction of the cost of residential and hospital care.
Clients in Treatment, by Type of Care Received: 2003-2013 (N-SSTATS)
Taken from the 2014 N-SSATS report, the above figure graphically shows that outpatient care by far is the dominate setting for addiction treatment.
Another very interesting treatment fact is that the majority of treatment programs serve less than 100 clients at any given time. Most facilities have limited space, a few therapists, and often leverage limited resources by providing more group therapy than individual. There is nothing wrong with group therapy, but for most clients who have trauma histories, often groups become a way of hiding underlying issues. In most cases, you will be best served with a combination of group and individual therapy. The fact that many programs have so few clients also suggests that there may not be huge differences between seeking care from a small outpatient program versus someone in private practice.
Why are People in Treatment?
To answer this question I used 2013 data from the National Survey on Drug Use and Health (NSDUH) that collects lots of data on substance use and abuse yearly. Of course it says nothing about those in treatment for behavioral addictions.
Substances for Which Most Recent Treatment Was Received in the Past Year among Persons Aged 12 or Older: 2013
What Types of Treatment are Being Delivered?
As to therapeutic approaches, the N-SSATS provides additional evidence that many programs continue to provide a lot of general counseling and ignore important evidence-based interventions. I have written elsewhere about the overall effectiveness of addiction treatment, whether treatment is worth the cost, and how you can get the most from our present system. Suffice it to say that you should do your homework before writing any checks and heading off to treatment.
What Else Should I Know?
While face-to-face counseling has been the treatment norm for decades, online treatment interventions have been evolving for some time, and now provide you another alternative. You might notice that they are not included in the table on treatment settings, and that is because presently N-SSATS collects no data on these programs.
Because less than 10 percent of those who struggle with addiction at any given time are able to access and receive treatment, I believe strongly that online interventions will become the new norm in the future. Why do I believe this?
In a previous job I spent years researching abuse of alcohol and drugs in communities nationwide. I interviewed addiction treatment directors, government officials, pain physicians, school administrators, pharmacists, commanders of drug task forces, and many others, all in an attempt to learn as much as possible about the drivers of abuse and addiction in communities small and large. While I learned many lessons, the biggest take away was the lack of professional treatment availability in so many towns where it was badly needed.
In towns where treatment did exist, often I found long waiting lists, antiquated treatment not in line with current evidence-based practices, and those in need not wanting to attend programs due to the potential of being seen by others in their communities. There are many other reasons why so few receive treatment, but the main point is that research has now provided enough evidence that online interventions can be as effective as face-to-face counseling, and in some cases, actually produce better outcomes. At the same time, most folks now have access to high-speed internet. So I believe one answer to helping the 90 percent who receive no care for addictions are online solutions.
Will therapists become relics of the past? Absolutely not. We need face-to-face interactions to heal. But in the absence of human connection we need to do more than nothing for those struggling. And online interventions can get the ball rolling in the right direction.
One More Thing…
Explore the additional information on specific treatment settings on this site, and if possible, get a professional evaluator to help you make a decision about the appropriate level of care you need. Also know that your level of care will change over time, so read up on outcomes to know how to assess when changing levels makes sense.