In general, alcohol and other drug treatment can be understood as a spectrum of treatment options representing differences in setting, types and range of services, and intensity of service use and delivery.
The goal of treatment is to place the patient in the appropriate level of care; that is, to provide the specific services needed by each patient, at the appropriate level of intensity, within the appropriate setting.
Since the severity of the individual's illness is likely to fluctuate over time, the level of care should change accordingly.
The spectrum of treatment options required by patients concurrently dependent on opioids and stimulants represents similar requirements in regard to levels of care.
The best treatment setting for these patients is a comprehensive program that integrates effective interventions for narcotic treatment with specific treatment for stimulant abuse and a full array of social and community support services.
Ongoing assessment should ensure that the patient is receiving the appropriate services as often as needed and within the appropriate setting.
Many organizations, including managed care organizations, have developed guidelines regarding levels of care to be used in treating AOD abuse.
The ASAM guidelines are presented here as an example of such guidelines.
Although they have not been empirically evaluated, the guidelines were developed through extensive collaboration with providers, payers, and other addiction experts.
Listing them here should not be considered a recommendation or confirmation of their efficacy.
ASAM's four levels of care for AOD abuse treatment are described in Patient Placement Criteria for the Treatment of Psychoactive Substance Use Disorders (Hoffman et al. 1991). They are presented here, with brief descriptions of settings and services:
Level I: Outpatient treatment - An organized nonresidential treatment service or an office practice with designated addiction professionals and clinicians providing professionally directed AOD treatment.
This treatment occurs in regularly scheduled sessions usually totaling fewer than 9 contact hours per week. Examples include weekly or twice-weekly individual therapy, weekly group therapy, or a combination of the two in association with participation in self-help groups.
Level II: Intensive outpatient treatment (including partial hospitalization) -
A planned and organized service in which addiction professionals and clinicians provide several AOD treatment service components to clients. Treatment consists of regularly scheduled sessions within a structured program, with a minimum of 9 treatment hours per week. Examples include day or evening programs in which patients attend a full spectrum of treatment programming but live at home or in special residences.
Level III: Medically monitored intensive inpatient treatment - Can be described as an organized service conducted by addiction professionals and clinicians who provide a planned regimen of around-the-clock professionally directed evaluation, care, and treatment in an inpatient setting. This level of care includes 24-hour observaton, monitoring, and treatment. A multidisciplinary staff functions under medical supervison. An example is a program with 24-hour nursing care under the direction of physicians..
Level IV: Medically managed intensive inpatient treatment - An organized service in which addiction professionals and clinicians provide a planned regimen of 24-hour medically directed evaluation, care, and treatment in an acute care inpatient setting.
Patients generally have severe withdrawal or medical, emotional, or behavioral problems that require primary medical and nursing services.
Several AOD treatment service models do not fit precisely within these four levels of care. These service levels include halfway houses and extended residential programs such as therapeutic communities. These programs are designed for people who do not have housing, who experience housing instability, or who lack an organized support system. These programs are often used in conjunction with intensive outpatient treatment or inpatient treatment.
In addition to describing the levels of care, the ASAM patient placement criteria also provide specific guidelines for patient placement decisions. As the treatment needs of patients change, clinicians should make recommendations for their transition from one level of care to another.
Six dimensions of illness are described:
Acute intoxication and/or withdrawal potential
Biomedical conditions and complications
Emotional and behavioral conditions or complications
Within each dimension, specific assessment criteria help to determine the appropriate level of care for patients.
Table 1 on the following page provides an overview of the adult admission criteria described in the ASAM guidelines.
As noted in the CSAT TIP, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse:
The overall intent of patient placement guidelines is to place a person in the least intensive level of care that will achieve AOD treatment objectives without sacrificing safety or security.
The ultimate goals of the guidelines are to improve the effectiveness of care, to ensure access to affordable care, and to support the development of cost-effective treatment systems.
They are also an attempt to establish patient placement criteria that are acceptable to all treatment providers and payers.
They support efforts to establish a common language for AOD abuse treatment, to agree on consistent placement decisions, and to provide a focus for future research efforts.
These criteria should be considered dynamic, not fixed.
Future revisions are likely to be driven by research results and further review and application by the field (1994b).
The ASAM criteria continue to be reviewed and studied.
As indicated earlier, States and certain other regulatory bodies may have their own guidelines regarding levels of care.
For example, the Addiction Group of the American Psychiatric Association is establishing AOD abuse treatment guidelines that can be considered by intensive outpatient treatment programs when clarifying placement criteria.
In addition, CSAT, which has already developed a Model for Comprehensive Alcohol and Other Drug (AOD) Abuse Treatment (see table 2), is currently developing a TIP on levels of care and patient matching within MTPs.
During the course of its work, the Consensus Panel for this TIP suggested a spectrum of care for methadone-maintained patients who abuse cocaine.
While acknowledging the financial challenges that would result from any attempt to implement comprehensive services for these patients, the panel also suggested that the development of such services should be a high priority.
Programs are therefore encouraged to use their resources creatively to develop a spectrum of services that is as broad as possible, either individually or in collaboration with other programs in their area or region.
The levels of care envisioned by the Consensus Panel are similar to those developed by ASAM, except that they specifically include the provision of opioid substitution therapies as one component of treatment.
The levels are briefly described on page 83.
Examples of services offered within each level reflect the results of a modest survey of MTPs that offer cocaine-specific treatment components.
Level I - In this standard MTP, patients abusing stimulants are encouraged to participate in Cocaine Anonymous (CA) or other self-help groups, which may be hosted on site, and/or in special groups conducted by program staff for patients with urine toxicologies positive for stimulants.
When necessary, patients are referred for short-term inpatient detoxification.
Staff receive training on how to intervene with stimulant-abusing patients and may require the patients to attend additional counseling sessions.
Implementing this level of care does not require additional funding; it may require a slight revision in staff responsibilities.
Level II - In addition to the services provided at Level I, the MTP provides on-site group or individual counseling sessions one to three times per week specifically for stimulant abusers plus psychoeducational groups and self-help involvement.
Urine testing may be increased, often to once per week.
Some programs offer acupuncture or alternative medications as strategies for intervening with the stimulant abuse; others have developed rewards for stimulant-negative urines (e.g., theater tickets) or help patients set up accounts into which they deposit money that would have otherwise been spent on stimulants.
Increased costs are associated with urine testing (unless patient payment is required) and increased counselor or other staff time.
Level III - The MTP offers a cocaine-specific treatment track, which includes all of the services offered at Level II plus positive contingency management and intensive relapse prevention efforts.
Additional services may be offered as well.
One surveyed program provides intensive, highly structured cognitive-behavioral treatment for patients who meet diagnostic criteria for cocaine dependence.
Treatment, which is based on a model developed by Matrix Institute on Addictions, consists of two individual and two to three group sessions per week for 6 months.
During this treatment period, the cognitive, behavioral, emotional, and interpersonal aspects of cocaine use are addressed.
Session materials are drawn from the manual developed by Matrix Institute and use very concrete cognitive-behavioral and relapse prevention techniques.
The primary costs for this program are associated with staffing.
Patients in this program, which is being formally evaluated, have shown significant declines in cocaine and other drug use, as well as significant improvement in psychological status.
Level IV - Stimulant-dependent MTP patients participate in a structured day treatment or evening program that provides all the services offered at Level III plus education and social support services, 5 days per week.
One of the programs surveyed offers this level of care to narcotic addicts age 16-23 for whom opioid substitution therapies have been deemed appropriate.
Another operates within the framework of a modified therapeutic community concept.
Primary costs are associated with staffing, rent, utilities, insurance, and supplies and equipment.
Research data from both pro- grams document the success of this level of care.
Level V - Patients at this level participate in a therapeutic community (TC), while continuing to receive opioid substitution therapy.
The services provided at this level include group and individual counseling, family counseling, milieu therapy, social support services, education and vocational services, and so forth.
The costs associated with this level of care have been well documented.
In some areas, MTP and TC staffs have begun to explore the possibility of treating MTP patients in existing traditionally "drug-free" TCs.
Numerous complex problems must be resolved before this idea can become a reality; however, the concept represents an exciting new direction in AOD treatment.
Level VI - Patients at this level of care participate in inpatient substance abuse treatment.
The program may be medically monitored and offer the services provided at Level III of the ASAM spectrum or medically directed, comparable to Level IV in the ASAM structure.
The Maryland AOD agency now requires all AOD programs, including those providing inpatient substance abuse treatment (e.g., 28-day inpatient treatment and inpatient detoxification), to accept MTP patients who meet admission criteria and to maintain them on opioid substitution therapies.
Implementing this policy has presented numerous problems, but again, the concept promises to broaden the spectrum of available treatment opportunities for methadone-maintained patients who abuse cocaine.
The levels of treatment suggested by the Consensus Panel members represent an attempt to develop a spectrum of services for MTP patients dependent on stimulants.
At each additional level, more services are offered, at a greater level of intensity and increased cost.
Programs are encouraged to increase the levels of care available to their patients, using a variety of creative strategies, including those noted in the previous sections.
Ongoing assessment can then ensure that patients receive appropriate levels of care as they progress toward recovery.
1The information provided in this section is adapted from a draft version of Intensive Outpatient Treatment for Alcohol and Other Drug (AOD) Abuse: The Recommendations of a Consensus Panel(CSAT 1993a).
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