The ASAM Criteria

ASAM Textbook Chapter 4-5

Levels of Care

The ASAM criteria conceptualize treatment as a continuum marked by five basic levels of care, which are numbered in Roman numerals from Levels 0.5 through Level IV. Thus, the ASAM criteria provides the addiction field with a nomenclature for describing the continuum of addiction services, as follows:

Level 0.5: Early Intervention
Level I: Outpatient Services
Level II: Intensive Outpatient/Partial Hospitalization Services
Level III: Residential/Inpatient Services
Level IV: Medically Managed Intensive Inpatient Services

Within each level, a decimal number (ranging from .1 to .9) expresses gradations of intensity within the existing levels of care. This structure allows improved precision of description and better "inter-rater" reliability by focusing on five broad levels of care. Thus the ASAM criteria describe gradations within each level of care. For example, a II.1 level of care provides a benchmark for intensity at the minimum description of Level II care (also see the Rapid Reference section of this text for a summary crosswalk of the levels of care).

Level 0.5: Early Intervention. Professional services for early intervention constitutes a service for specific individuals who, for a known reason, are at risk of developing substance-related problems or for those for whom there is not yet sufficient information to document a substance use disorder.

Level I: Outpatient Treatment. Level I encompasses organized, non-residential services, which may be delivered in a wide variety of settings. Addiction or mental health treatment personnel provide professionally directed evaluation, treatment and recovery service. Such services are provided in regularly scheduled sessions and follow a defined set of policies and procedures or medical protocols.

Level I outpatient services are designed to treat the individual's level of clinical severity and to help the individual achieve permanent changes in his or her alcohol- and drug-using behavior and mental functioning. To accomplish this, services must address major lifestyle, attitudinal, and behavioral issues that have the potential to undermine the goals of treatment or inhibit the individual's ability to cope with major life tasks without the non-medical use of alcohol or other drugs.

In the current edition (ASAM PPC-2R), Level I has been expanded to promote greater access to care for dual diagnosis patients, unmotivated patients who are mandated into treatment, and others who previously only had access to care if they agreed to intensive periods of primary treatment. The expansion reflects recent knowledge of and experience with cognitive behavioral therapies such as motivational interviewing, motivational enhancement, solution-focused therapy, and stages of change work, all of which may be appropriate for patients who previously would have been turned away as not ready for treatment, or in denial and thus in need of coerced intensive treatment. The expansion thus can enhance access to care and facilitate earlier engagement of patients in treatment, thereby allowing better utilization of resources and improving the effectiveness of recovery efforts.

Level II: Intensive Outpatient Treatment/Partial Hospitalization. Level II is an organized outpatient service that delivers treatment services during the day, before or after work or school, in the evening or on weekends. For appropriately selected patients, such programs provide essential education and treatment components while allowing patients to apply their newly acquired skills within "real world" environments. Programs have the capacity to arrange for medical and psychiatric consultation, psychopharmacological consultation, medication management, and 24-hour crisis services.

Level II programs can provide comprehensive biopsychosocial assessments and individualized treatment plans, including formulation of problem statements, treatment goals and measurable objectives—all developed in consultation with the patient. Such programs typically have active affiliations with other levels of care, and their staff can help patients access support services such as child care, vocational training and transportation.

Level III: Residential/Inpatient Treatment. Level III encompasses organized services staffed by designated addiction treatment and mental health personnel who provide a planned regimen of care in a 24‑hour live‑in setting. Such services adhere to defined sets of policies and procedures. They are housed in, or affiliated with, permanent facilities where patients can reside safely. They are staffed 24 hours a day. Mutual and self-help group meetings generally are available on-site.

Level III encompasses four types of programs: Level III.1: Clinically Managed Low-Intensity Residential Treatment; Level III.3: Clinically Managed Medium-Intensity Residential Treatment; Level III.5: Clinically Managed High-Intensity Residential Treatment; and Level III.7: Medically Monitored Inpatient Treatment.

The defining characteristic of all Level III programs is that they serve individuals who need safe and stable living environments in order to develop their recovery skills. Such living environments may be housed in the same facility where treatment services are provided or they may be in a separate facility affiliated with the treatment provider.

Level IV: Medically Managed Intensive Inpatient Treatment. Level IV programs provide a planned regimen of 24-hour medically directed evaluation, care and treatment of mental and substance-related disorders in an acute care inpatient setting. They are staffed by designated addiction-credentialed physicians, including psychiatrists, as well as other mental health- and addiction-creden­tialed clinicians. Such services are delivered under a defined set of policies and procedures and has permanent facilities that include inpatient beds.

Level IV programs provide care to patients whose mental and substance-related problems are so severe that they require primary biomedical, psychiatric and nursing care. Treatment is provided 24 hours a day, and the full resources of a general acute care hospital or psychiatric hospital are available. The treatment is specific to mental and substance-related disorders; however, the skills of the interdisciplinary team and the availability of support services allow the conjoint treatment of any co-occurring biomedical conditions that need to be addressed.

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