Episode #108

When therapists think about working with substance use, they may envision a meth addict or a heroin addict. They worry that someone will overdose and die. They are concerned that the person’s use will be more than they can handle. The great news is that the American Society of Addiction Medicine came up with guidelines to tell us exactly what constitutes needing a “higher level of care.” There are a ton of people that you can work with in your practice. The ASAM criteria can show you what is appropriate for outpatient therapy. 


You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use from a mental health perspective.  I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor.  It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice.   So join me each week as we talk about All Things Substance.

Welcome back to the All Things Substance Podcast. This is episode 108. Today we’re gonna be talking about levels of care. When I think of the phrase levels of care, I think about when I hear a therapist say This person needs a higher level of care than I can provide.

I know I have said those words. Sometimes I’m not even sure what a higher level of care would look like. I live in an area where resources aren’t as plentiful as they might be in a bigger city. Specifically, I live in a place where On one side of a state border, we don’t have many resources at all, and across the bridge into Minnesota, there’s a lot of resources comparatively anyway.

So when someone over here says that a person needs a higher level of care, we might not have that level of care available. There are probably a number of you in this place. I wanted to talk today about what levels of care means in terms of substance use. To do that. Let’s talk a little bit about levels of care in other disciplines, like in the medical world.

When I think of levels of care in the medical world, it starts with your primary care provider. There are a lot of folks who don’t have a primary care provider, and usually that’s because that is something that requires future planning and there’s a lot of folks who struggle because they’re in a survival mode. They struggle with housing security or food security, and having a primary care provider is just not an immediate concern. 

The way the system is built though primary care is where you start. After that you would go to urgent care, if it’s after hours or on a weekend, and in the years past in the United States, I’ve seen urgent care become something you do during the day if you can’t get into your primary care doctor. After that, of course, is the emergency room. After the emergency room, you could get admitted to the hospital, and once in the hospital you could go to the ICU, The intensive care unit.

That is what level of care means in the United States. There are also things like a swing bed, so that’s like a step down from being in the hospital after surgery. There are people who go to rehab facilities, which are another name for nursing homes where they can spend time there recovering before they’re discharged to home.

When it comes to the mental health world, we have levels of care too. There’s outpatient mental health, which tends to be the entry level. After that there’s intensive outpatient care which is usually a few hours a week. 

Then there’s partial hospitalization, which is day treatment, and that might be from say nine to 3:00 PM on a daily basis during the week. People go home in the late afternoon, evening. And then of course there’s the inpatient, which is the psych unit where someone stays for three to five days, depending after that, then we have more residential or what people might think of as institutionalized places.

State hospitals are sort of where those places are now, but they’re not the way they used to. State hospitals are where people go when they have a longer stay. So if somebody is what we call chaptered here in Wisconsin, it means that they’re on basically a six month agreement or a hold that happens from a judge and they’ve been committed and they have to do these things.

When it comes to levels of care for us as therapists, a lot of times we’re talking about risk and we’re talking about whether or not this person’s symptoms can be managed in an outpatient setting. When I was scrolling Facebook this morning, I saw someone say that they needed to refer someone to a higher level of care because  the therapist is telehealth only and the person is highly suicidal. 

It made me think about that. I’m a hundred percent telehealth since the pandemic, and I have a number of people who are suicidal, and I was thinking about what the risk might be. Clearly you’re not in the room with someone, and there have been a few times in my career that I’ve had to insist that someone stay until we get them transported to the hospital. That doesn’t always work, of course, and nobody’s gonna physically stop them from leaving, but I know that the comfort of your office when you’re through a screen, it can feel difficult to judge risk.

This is one reason I hear from therapists about their concerns in adding substance use to their scope of practice. They are concerned about risk. What I wanna talk about more in depth is levels of care and risk management when it comes to substance use. There are specific criteria that have been created by the American Society of Addiction Medicine.

The ASAM criteria as it’s called, is actually not new.  It was created in the 1980s to define one national set of criteria for providing outcome oriented and results-based care in the treatment of addiction. So I wanna talk about levels of care in substance use work, and then I wanna talk about what those levels are.

So just like we talked about the medical world and the mental health world, substance use also has levels of. So the first level of course, is outpatient. And outpatient is just like it sounds like. It is happening on an outpatient basis, and it is not multiple hours a week. It’s typically going to be probably three hours or less, depending on what the person needs. And depending on if we’re talking about a treatment center that specializes in substance use, or if we’re talking about someone who’s doing substance use individually.

After that would be intensive outpatient. Now, intensive outpatient care actually increases quite a bit in terms of the number of hours. In some circles, they’ll even call it dosage hours And so a person’s recommendation is done by the number of hours a week. Intensive outpatient in a number of places is 12 hours Anything over that  is qualifying for day treatment, which is the next level of care. 

Day treatment is just like it sounds, and it’s extremely similar to the mental health adult partial program. It is something that happens multiple days a week, usually four or five and is an all day thing, and the person goes home at night. After that it is residential. Residential is different from inpatient. 

In the mental health world, inpatient would be the next stop, but for substance use, it’s actually gonna be more residential. Residential when it comes to substance use is not necessarily medical. There are a few different categories of residential. We’ll get into that in a little. 

The last category is inpatient or detox. This is always medical. It is an acute medical need for somebody to get through detox and for medical stabilization before they could get transferred to a residential program. 

So when we think about mental health, if we take everyone who needs mental healthcare, let’s just imagine all of that. What we know is that the majority of people need outpatient mental healthcare. It’s the same with substance use. It is not the majority of people who need residential or inpatient care.  It’s not even the majority that needs day treatment. The majority of people who are using substances in a way that is problematic need outpatient. 

Let’s talk about what I mean when I say substances. I use substances to encompass all mood altering, well substances. What we are specifically dealing with almost always in outpatient is alcohol and weed. If it’s a treatment center, a substance use treatment center with specialists, then there are a lot more substances that fall into the outpatient category.

The majority of those people are doing outpatient work. Being as I live in an area where resources are scarce, there’s no such thing as residential care for people who have problems with addiction. It doesn’t exist and it’s not paid for by the state. 

Residential is something that everybody thinks of when they think of rehab. Someone needs to go to rehab, and what they mean is a place that’s a 28 day stay or something like that, and they think that that is the answer. 

Honestly, very few people end up in those places.  I’m not saying they couldn’t benefit from it, but they don’t get to go there. Up where I live and in the state of Wisconsin, we don’t have a residential treatment center, and at the same time, there’s no funding for it.

Medicaid decided to pay for it, under duress, a few years ago, but they’re only paying for the treatment, not for room and board. So for someone who needs residential, they have to come up with the money to pay for their room and board. 

People who need residential care typically don’t have insurance, let alone commercial insurance. If they have insurance, it’s gonna be Medicaid. In the state of Wisconsin, childless adults couldn’t get Medicaid until a number of years ago, and so they were just outta luck. So we ended up seeing a lot of people, an outpatient who didn’t belong there. When that happens, you get good at trying to manage.

So, for instance, I recall getting a phone call from the county about a juvenile who was involved in the juvenile justice system.  The student was in high school and had been taking opiates, pills specifically. Well, the danger we know about pills is that fentanyl is everywhere.

This student had overdosed and needed treatment. There’s no commercial insurance. There’s no place in the entire state of Wisconsin that takes Medicaid for adolescents, and certainly no place outside of Wisconsin would take them. Because Wisconsin Medicaid rates are notoriously low and crossing state lines is difficult.

So here we have a student who overdosed and needed treatment. Well, that’s me and that’s outpatient. That’s one hour a week. That is risky, and it’s either me or they wouldn’t have gotten seen. When you have a situation like that where you see someone that you think is outside the realm of one hour a week type therapy, If they won’t go see someone else or if there isn’t anything available or affordable, that’s about documentation.

I made it extremely clear to them and to their parents that they needed a higher level of care. I made it clear in the documentation that they needed a higher level of care and that in lieu of the availability of that care, I was going to provide the care that I could with the acknowledgement that there was more that was needed.

There are some therapists who are very risk averse who would not do that. They would see it as a disservice or a liability. The trouble is there’s no one else. The state isn’t going to fund this person’s care. Short of the family moving to another state, which believe me, I’ve recommended at times there isn’t more to do.

The ASAM criteria is what I use to look at what does this person need.  The ASAM criteria exists to help guide us into what a person needs rather than being of the opinion that everybody needs to go to rehab.  So the ASAM criteria to learn it, really learn it is like a six hour training and we aren’t going to do that and you don’t need to know all of it.

What I believe you need to understand is that the majority of people that come into your practice are going to fall in the outpatient or pre outpatient level. There are four levels, although it’s technically five and six dimensions. The dimensions are categories, they’re factors that we are looking at to make a determination about what level of care they need. 

So first I’ll tell you about the levels and then we’ll talk about the domains. Generally, people say there’s four levels of care. When I say there’s technically five, it’s because there’s a 0.5 level, and this is a prevention level.

This is where the person isn’t necessarily using at a level where they need outpatient treatment, but there is some room for some preventative activities like psychoeducation. Let me explain. If I interview someone and find out that they’re just starting to experience some negative consequences from drinking. Maybe they had their first blackout, maybe they ended up going home with someone they didn’t intend. Maybe they went to work and were super hungover. 

I’m looking at how many times has this happened? And so let’s say in this instance that it’s only happened maybe once or twice. Well, that’s not normal in terms of when we think of quote, normal drinking. It’s not normal to black out.  It’s not normal to not remember how you got places. It’s not normal to driving while you’re drinking, those kinds of things. But that person isn’t at a problematic level yet. It’s just starting. 

So they would be at a 0.5 prevention level or early intervention as it’s sometimes called. We don’t have to wait until someone is at their rock bottom to intervene in somebody’s use of alcohol and drugs. We can work on early intervention. Not everybody’s gotta hit a bottom. Sometimes they can realize they don’t like how something makes them feel and they can stop the progression. Prevention and early intervention is a level, but it’s considered 0.5.

So the first official level is level one, which is considered outpatient. What constitutes outpatient may differ in certain areas based on the number of hours recommended. Typically when I was running the treatment center, outpatient could be one hour a week, up to about six hours a week. Six hours would be something like a two and a half hour group twice a week, and one individual appointment. That is the spectrum of outpatient care. 

The next level is, of course, level 2. There are two subsections of level two. Level 2.1, which is intensive outpatient, which would be 12. Then there’s level 2.5, which is partial hospitalization, and that’s the kind of thing that’s going to be 12 hours and over, but they don’t stay there. How many hours are in a partial hospitalization can.

Level three has four different subsections. I’m gonna tell them to you and then I’m gonna tell you what you need to remember because you don’t technically need to know all of these things. So in these levels, 3.1 being the first level. Is clinically managed, low intensity residential services.

In this place There should be no withdrawal risk, so the person is not going to be going through any withdrawal, no significant medical problems that could detract from treatment. They’re in mild to moderate severity in their use, but still need stabilization, that they have a high likelihood of relapse, which is why they need residential rather than adult partial or outpatient care. And they don’t have a recovery environment that’s supportive for a 24 hour basis. With each level it’s really the level of withdrawal and the amount of relapses that the person has had that determines what level they end up in. 

Level 3.3 is a clinically managed population  with specific high intensity services with 3.1 and 3.3. You typically aren’t going to have medical staff. They may have somebody doing medication distribution, who has the training to do that, but there aren’t nurses or doctors on staff.  

When you get to 3.5 however, there are going to be medical staff at least during the day, but  in some places, 3.5 has to have medical staff around the clock. There are rules about this depending on how many patients, what kind of issues they’re gonna accept, and there is a higher risk of withdrawal.  It’s a minimal risk of severe withdrawal. That people would be in a moderate to mild withdrawal, that’s when they go to this level, But when we get to the more severe withdrawals, then we’re talking that the person needs, of course, a higher level of care.

The final level in the third level of care is 3.7. Which is medically monitored, intensive inpatient services. So this is where the person is at a high risk of withdrawal, but manageable at this level because they don’t need the full resources of a licensed hospital. They would, however, have medical staff 24 hours.

This is not detox though. Detox is level four. When somebody needs the full resources of the hospital, they go because of the risk of withdrawal. That’s when they’re at level four. There are a few instances where we’re dealing with that kind of withdrawal. The very first one and one of the most dangerous withdrawals is from alcohol. 

I’ve said this numerous times, and I’ll probably say it many more. That withdrawal can be terrible. It can be painful. It can be awful. You may want to die, but most of them aren’t going to kill you. There are a few that can, And then alcohol withdrawal being the most dangerous. There are people that die from alcohol withdrawal all the time. Interesting that most people don’t know that that happens.

My friend Jean McCarthy was drinking wine each day and was a high functioning alcoholic, although I don’t know that anyone really would’ve called her that. She didn’t know anything about withdrawal. Yet when she quit drinking, she found out extremely quickly how bad it can be. From hallucinations to the shakes, to just feeling like you got run over by a truck. The danger lies in the tremors that you get, and there’s a risk of seizures and cardiac events. 

The other withdrawal that is highly dangerous is from benzodiazepines. With those, there’s a high risk of having seizures. The other withdrawals are bad, and people who have used  would tell you that the worst withdrawal is from opiates or heroin. It is the most painful and the longest lasting, followed by meth. 

These withdrawals certainly could be dangerous if you had certain issues that would maybe cause a cardiac event or something like that.  People can survive them if they can stay sober enough to get through it. But the pain of those withdrawals is really intense. 

If someone is drinking on a daily basis or even semi daily, it should always be managed with a doctor. It doesn’t have to happen inpatient. It could happen on an outpatient basis. There are doctors who are willing to prescribe medications so that people can detox at home, but they are following them really, really closely.

Okay, so to recap, we have five levels of care. Point five is prevention, early intervention. Level one is outpatient. Level two is adult partial hospitalization and intensive outpatient. Level three is residential and inpatient. And level four is intensive inpatient. You will not treat people in outpatient that need level four care.

That is the kind of thing that is as risky as someone who is actively suicidal and they need to go to the hospital. They can refuse and there’s really nothing we can do about that. Even I would hesitate to be working with someone who needs level 4. I might stay in contact with them and try to get them to consider getting an assessment at a treatment center.

Because typically there are treatment providers in places like community mental health centers. When someone is at a level two, three, and four, those are not the kind of people who are using substances that I’m suggesting you work with. Those people do need to see a specialist. I am a firm believer, though, that you could stay working with them as their mental health therapist and coordinate with the person at the treatment center. 

So there are five levels; you would work with five or level one. And there are six dimensions. So think of this like our biopsychosocial, right? We have a number of dimensions that we’re looking at. We just don’t call them that in order to get the feel for somebody’s life. We’re looking at current symptoms, past symptoms, family history, medical history, trauma, history, those sorts of things. And then we’re making a determination. That’s what these dimensions are.

So with the six dimensions that are in the ASAM criteria, in order to find out where someone falls in the levels of care, you have to use each of these dimensions. There is a tool that you can get  that I think is maybe four or five pages that has the questions for each domain. It’s somewhat confusing and I find it easier to learn what the dimensions are and determine whether I think they can be treated in an outpatient or if they need more stability.

So there are a number of places online where there’s a crosswalk where it takes the ASAM criteria and breaks down the dimensions. I’ll put links in the show notes to these things so that you can take a look for yourself. Dimension one is always going to be about acute risk. This is about withdrawal.

The very first thing you have to establish is whether or not there’s a risk of withdrawal.  If there is a chance of withdrawal, how likely is it to happen and how risky is the withdrawal? So for instance, if someone is using alcohol, we need to know how much and how often, and for how long.

we need to know their longest period that they’ve gone without drinking and whether or not they had any symptoms. Like feeling sick the next day, feeling like they had the flu. The shakes aren’t necessarily the first thing that happens for everyone, but they do happen kind of middle of the road withdrawal from my experience with people. 

If there is alcohol withdrawal, they need a higher level of care. If they won’t get one, then you need to be talking with them about safety planning, just like we would with someone who has suicidal ideation. Talking with them about the risks of alcohol withdrawal and making sure that you’re documenting that. 

Typically, if someone is drinking daily, and I know people talk about a glass of wine a day, but  we are not talking about a four to five ounce glass of wine here. We’re talking about multiple glasses, a bottle, two bottles, whatever, and that is absolutely going to cause withdrawal unless they’ve only been drinking like that for a few weeks. That is the thing that we want them to, at the very least, have their doctor be on board with monitoring their symptoms. 

Typically, when there’s a severe risk of withdrawal, that’s an automatic level above level one. It doesn’t necessarily matter to you, whether it’s two or three or four. What you know is that they don’t belong in outpatient care and they need a specialist. So the goal, if it’s immediate withdrawal, and they do get the shakes, is to get them to go to the ER And barring that is to get them to go to a specialist.

It is helpful if you are able to have some kind of relationship with a local treatment center and you just call someday when you have a chance to ask about their intake process. It’s way easier for you to help your client make that call and set up an appointment doing that in session rather than trusting them to do it. It is difficult for people to follow through on their desire to change their drinking habit. 

My friend Jean would say that in the morning she had all the hope that she was gonna be able to quit drinking today. But she said that in the afternoon that would be gone. What she didn’t realize is that withdrawal was kicking in. It wasn’t until she quit cold turkey that she found out what withdrawal was like. 

So the first thing we’re assessing for is withdrawal potential and risk. If there’s no real significant withdrawal potential, like someone who’s smoking weed every day and they decide they wanna quit. Weed has a withdrawal. It’s addictive. You do get withdrawal from it. It’s just not that bad. It’s some vivid dreams, a headache, feeling irritable. Something you can deal with, and in general, not dangerous.

Dimension two is biomedical conditions and complications. And basically what this means is any kind of medical diagnoses or syndromes that could interfere with treatment and with withdrawal. So we’re talking about diabetes, high blood pressure or other types of medical issues that can get in the way. If it’s not severe, typically that’s gonna be a lower level.

Usually if it’s gonna be severe, you’re gonna have already hit a level three or four already because of the withdrawal syndrome.  Basically, these tend to go together if it’s gonna be high. 

Dimension three is emotional, behavioral, or cognitive conditions and complications. So this is exploring someone’s mental health history and current cognitive and mental health needs. So there are people who struggle with their mental health in a more significant capacity. 

Remember what we’re thinking about here is if they’re gonna make a change with their substance use, can they do it at home or not. If they can do it in the community, then they’re a level five, one or two. If they struggle significantly, they are probably going to need a residential program if it’s available.

Dimension four is readiness to change. Readiness to Change is a model that Prochaska developed to determine where someone is. The Readiness to change model it’s  pre-contemplation, contemplation, preparation, action, and maintenance. This is really important. Readiness to change. Is a huge factor in whether or not someone’s going to be making changes in their substance use. 

If you are exploring someone’s use of alcohol or weed, if they aren’t seeing it as a problem, then probably beating your head against that particular wall is not a great idea. We work on motivational strategies if we think there’s a problem to perhaps begin bringing that to their attention. Until they move from pre-contemplation into contemplation there’s not a ton we can do. 

Now, sometimes somebody is in pre-contemplation, but there’s still a level four because they’re really at risk for severe withdrawal and or death. So their readiness to change is sort of irrelevant. It is more about getting them the medical attention they need. 

Dimension five is relapse, continued use, or continued problem potential. So here we’re looking at risk for relapse and history of relapses. When somebody has chronically relapsed they typically are going to need a structured environment to be able to get any kind of sobriety days together.

They’ve tried it, and being out in the community is not working for them. For our people that we’re seeing an outpatient, they should be able to do this in the community. If they need a residential like stay overnight place, then they’re gonna be level three or four. That is not going to be someone that you’re working with. 

Dimension six is their recovery or their living environment. We wanna look at the people and places around them and see what they have for support. Is it a supportive recovery environment? Is that something that could keep them in the community instead of going into an overnight stay kind of situation?

It depends. Some people have a place they can go or someone sober that they can stay with. For a lot of folks that are using in a more severe way, they don’t have that because they’ve burned a lot of bridges or all of the people they’re around are also using. 

With the dimensions and with the levels of care here’s what I wanna come down to. You are not doing a full chemical dependency assessment. You’re just not. Nobody’s coming to you asking you to do that. When somebody is at a point where they need a chemical dependency assessment, which can be called any number of things in different places, that is going to be done by someone who has the specialty. They either have a substance use license or they have a substance use specialty. Those are the people that are making the determination about exactly, which dimensions are on which level of care. 

What I think is important for you is to know that there are levels that can and should be treated in an outpatient setting, and that mental health is a huge portion of that. For people who are in the early intervention prevention phase that’s a hundred percent stuff that we should be able to do. That is about evaluating whether something’s a problem, doing psychoeducation. This is stuff we do all the.

For level one, we’re looking at people who have some motivation to make a change or who are at least open to exploring if their use of whatever substance could be a problem for them. I’ve said this numerous times before, and I’ll say again, if someone is using it is going to impact your work. It just is. There is no way around it if they are using in a way that is not normal. And by normal I mean not recreational. Recreational is not to excess. It may be once in a while, but not on a regular basis. That is more problematic. 

So right now as you hear this,  you are invited to attend a webinar that I’m doing called Considering Cannabis. When we think about weed, we think about: is this a problem? Should I say anything? Does it matter? Is it gonna affect therapy? I don’t even know what to say about that. Or most of my clients are smoking weed or using it in some form. Why would I even bother with that? 

So I’m doing this webinar so that I can give fact-based information about the accuracy of certain claims,  about THC and how it’s used in the different forms and how those different forms affect people differently and how it impacts therapy.

The registration opens on Black Friday. You can sign up now to receive a reminder email, and the reminder email will have a coupon code for 50% off the Considering Cannabis webinar. You can check it out at betsy byler.com/cannabis.

The levels of care are important because I want you to be certain that no one is suggesting that you work with  people that are at high risk because of their substance. That is not something that I am suggesting, nor do I think you should do.

However, that leaves a large chunk of people that you could be helping, that would benefit from your intervention and from you being willing to address their substance use. I know it can feel kind of like a fish outta water sometimes, but I am here and want to help you navigate that. 

Next week on the podcast, we’re gonna be addressing a myth. The myth that says that you have to hit rock bottom  before someone can reach sobriety or get into recovery or make changes in their substance use. I hope you’ll join me for that podcast and until then, have a great week.

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.

Helpful Links

ASAM Criteria Intake Assessment Guide