Imagine you learn a friend is receiving treatment for a substance use disorder, what comes to mind? Many may picture your friend in a 28-day rehab facility or in a church basement attending a local 12-step meeting. Sure these are commonly available options, but would you ever picture your friend attending regular visits with a primary care physician, and receiving a medication that helps them reduce cravings? Were you aware the treatment could take the form of evening classes that helps them maintain motivation and skills for dealing with triggers and cravings? There's a spectrum of treatment settings providing increasing levels of care depending on the severity of the disorder. In this lesson, you will learn the distinction between five categories of treatment services along with the rationale for each. As an overview, let's review the five categories now in order from lowest to highest intensity. Peer support activities such as 12-step groups are considered ground level, because they are not evidence-based treatments provided by pro-trained professionals. The first step is outpatient services which can be provided in a general medical setting like a primary care or a psychiatry office. All patients may need a slightly higher step to intensive outpatient services, which can be provided at an addiction specialty treatment center or through partial hospitalization. The next step is to consider residential services where person lives and is monitored over weeks to ensure safety or initiate treatment. Recovery housing might also be considered in this level. The top step is intensive inpatient services where acute medical or psychiatric needs can be monitored. Each of these treatment settings can vary in frequency, treatment service, length of engagement, services provided and in the personnel involved in the delivery. Keep these factors in mind as we review the levels in more depth. Because peer support activities like alcoholics anonymous are ubiquitous and freely available, it is prudent to suggest them to all patients and assess interest and potential barriers to engagement. Generally because they fall outside of the medical system and have lower strength of evidence, we consider peer support groups to be complementary to other evidence-based treatments and not as stand-alone option. As for the frequency and length of engagement in a peer support setting, it is generally recommended people attend more frequently at first. Often people recommend 90 and 90, meaning 90 meetings in 90 days. Though the frequency of visits might lessen over time, people can stay engaged in peer support over the course of a lifetime. A 2014 study demonstrated that an increase in attendance correlates with increase in percent days abstinence from alcohol. In peer support settings, no billable services are provided and no licensed personnel are involved. Outpatient services can involve care at a primary care or general mental health clinic. Low-intensity outpatient services are appropriate for individuals who are medically stable, willing to engage in treatment recommendations and follow-up care, and for those who have good support system in place to help the recovery process. The key is to assess a person's severity of illness or what we often call acuity in medical terms. Outpatient services are generally appropriate for people with lower severity or less acuity, meaning they don't need consistent monitoring over a brief period of time but rather symptoms can be managed and goals achieved with less frequent monitoring over a long time. Like peer support services, frequency of outpatient visits might lessen over time, but can continue indefinitely. Just as someone with diabetes will require monitoring over the course of a lifetime, so should someone with a substance use disorder have checkups with some predetermined regularity. Outpatient services may involve treatment consistent with the management of any chronic relapsing remitting disease. For example, medications, drug or alcohol monitoring, counseling services and treatment of co-occurring medical and psychiatric disorders can all be provided on an outpatient basis. Family and couples therapy can also be useful in this setting. In an outpatient setting, personnel from various disciplines may be involved, but they may not all be housed in the same location. For instance, a person may receive buprenorphine from a primary care doctor, attend couples therapy with a licensed professional counselor, receive medication to control bipolar disorder from a psychiatric nurse practitioner and attend individual psychotherapy for past trauma from a psychologist all in different locations. Intensive outpatient services are slightly higher step or level of care. This type of setting is recommended for those who are initiating treatment, need extra support or who may not have sufficient support systems outside of the clinical setting. It is also appropriate for persons with co-occurring psychiatric and substance use disorders. These services are generally time-limited treatment approaches where a person who is struggling with substance use issues attends several days a week for up to several hours at a time, to help support the process of recovery. At some defined point, the illness becomes less severe or the acuity diminishes. This level of treatment ends. The services provided are similar to what can be available in an outpatient setting but they are frequently housed in the same location with deliberate coordination between disciplines: medications, psychotherapy, either individual or in a group, monitoring of substance use, treatment of co-occurring health conditions and employment planning might all be provided. In line with many services being provided, high-quality intensive outpatient services will employ multidisciplinary team. This team might include: physicians, psychologists, social workers, licensed professional counselors, marriage and family therapists and peer specialists among others. The next two levels in treatment setting feature a round-the-clock care of varying degrees. Residential services typically offer 24-hour care and patients are expected to remain on-site for treatment. Consider this level of care if someone needs a break from their current environment in order to initiate or re-initiate a long-term treatment plan. For example, someone who has been drinking daily for 20 years and has a difficulty achieving a period of abstinence in their usual environment, or a person who does not have strong social supports and is without an environment supportive of abstinence. For this individual, several weeks away from home might be necessary to receive the proper support and develop an aftercare plan that will effectively initiate a period of sustained recovery. Residential settings also include recovery housing for those whose current housing situation is too high risk to return to. Recovery housing provides long-term recovery support. Quality recovery houses follows set standards and require ongoing monitoring while encouraging treatment engagement. In residential settings, the person is provided intensive services and treatment monitoring 24/7 but only for a short period. For example, a few weeks to a few months. In recovery housing on the other hand, a person might be provided less oversight and provision but can stay for up to several years. Like other high-quality levels of care, a range of services may be offered in residential settings including: medically managed withdrawal, group and individual therapy, monitoring of substance use, medications to address cravings and ongoing use, management of co-occurring medical and psychiatric conditions and substance use education. A key service provided in residential settings is discharged planning to ensure a smooth step down from this high level of care. Without a solid ongoing post residential treatment plan, patients are at high risk for relapse. Similar to the personnel found in other treatment settings, high-quality residential services employ a multidisciplinary treatment team including: physicians, psychologists, social workers, licensed professional counselors, marriage and family therapists, peer specialists and chaplains among others. The top step is inpatient services which provide 24-hour nursing or medical care. You will consider this level of care for patients who require ongoing round-the-clock monitoring. Imagine a person with a cocaine use disorder who's suffered a stroke following cocaine use. This person would receive appropriate management for the stroke while also being monitored for continued cocaine use. Care coordination and motivational interviewing would be utilized to engage the person in ongoing substance use treatment. But ultimately, the substance use disorder would be treated on an ongoing basis following the intensive inpatient stay. Other examples include a person withdrawing from alcohol who's at risk of going into delirium tremens or someone who is acutely suicidal or psychotic. People generally have a short length of stay on inpatient services or as long as the acute issue remains unresolved. Services are often oriented to the acute medical or psychiatric issue along with treatment focused on engaging a patient in longer term addiction treatment. If you're getting the message that high-quality treatment involves in multidisciplinary team, then we are doing our job here. Inpatient settings are no different. Personnel in inpatient settings may include: physicians, physicians' assistants, nurses, pharmacists, social workers, chaplains and peer support specialists. So those are the five broad treatment settings or steps of care that you might consider for your patient: peer support activities, outpatient services, intensive outpatient services, residential and inpatient care. This variation reinforces our notion that treatment is not a one-size-fits-all approach and the care should be matched according to a patient's needs and goals.
