The broad consensus, in both the drug treatment and treatment research communities, is that drug abuse treatment works, according to the Office of National Drug Control Policy in a study on treatment protocol effectiveness. And treatment is most effective for substance use disorders (SUDs) when there is a good fit between the level of care provided and an individual’s treatment needs. That is the conclusion of the American Society of Addiction Medicine (ASAM), joining similar findings from the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA).
The patient placement criteria that ASAM recommends are reportedly “the most widely used and comprehensive set of guidelines for placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions.” These lay out the following four core levels of care:
- Level 1 (traditional outpatient care)
- Level II (intensive outpatient care)
- Level III (residential inpatient treatment)
- Level IV (hospital-based)
For the great majority of those with a SUD, finding the right detoxification and treatment program comes down to choosing between inpatient treatment (Level III) and outpatient treatment (Level I or II), or a combination of both. This article will educate you on these three most commonly occurring levels of care, as well as important considerations when choosing a level of care that is right for you.
Residential Inpatient Treatment (Level III)
Residential inpatient treatment entails detoxification, or medically managed withdrawal from one or more substances, followed ideally by a minimum of 28 days of 24/7 care within a rehab facility (what’s also known as “short-term residential treatment”). This third level of care (at least 28 days of inpatient treatment) is the gold standard baseline for addiction treatment, on the basis of Treatment Outcome Studies (TOP’s) that show a direct correlation between the length and intensity of residential treatment and positive recovery outcomes. One TOP found, for example, that relapse rates dramatically decreased after 13 weeks of residential inpatient treatment (also known as “long-term residential treatment”).
Residential inpatient treatment is the best recovery entry point for individuals “with overwhelming substance use problems who lack sufficient motivation or social supports to stay abstinent on their own but do not meet clinical criteria for hospitalization,” according to a SAMHSA guide for clinicians. (This description characterizes a big proportion of those seeking drug or alcohol treatment.)
Intensive Outpatient Treatment (Level II)
According to treatment protocol from SAMHSA, intensive outpatient treatment (IOT) bundles a set of “core services” with other “enhanced services” in a setting that enjoys some of the same structures and supports as residential inpatient treatment, but with more opportunities to connect with a wider recovery community. SAMHSA’s “Quick Guide for Clinicians” lists these core services as what to expect in intensive outpatient treatment:
- Comprehensive biopsychosocial assessment
- Group, individual, and family counseling
- Psychoeducational programming
- Integration into support groups
- Relapse prevention training
- Substance use screening and monitoring
- Vocational and educational services
Other core services may include stress management techniques, family or couples groups, or interpersonal skills groups.
“Enhanced services” are those that may pertain to a specific group, such as a program serving working mothers of young children.
Outpatient Care (Level I)
Outpatient care comprises individual therapies and recovery services that, according to ASAM’s treatment guidelines, add up to roughly nine hours or less per week. This level of care is most effective as a step down from Level II (intensive outpatient) or III (residential inpatient) for those who have completed these more intensive levels of care and are in need of continuing care and/or maintenance therapies. There are some exceptions to this general rule. In some cases, outpatient care may help those who are resistant to entering residential treatment and/or those who have mild substance abuse problems that really can be treated via less intense intervention. What’s critically important to remember here, however, is that these “low-intensity programs may offer little more than drug education,” according to a guide to addiction treatment from NIDA. Those considering outpatient care as their only line of treatment for a SUD therefore benefit from doing thorough research when considering outpatient programs.
Inpatient vs. Outpatient Care: What to Consider
The single most important criterion to consider when choosing between inpatient versus outpatient treatment is which program will best help you recover from a drug or alcohol addiction. Along these lines, ASAM has found that the best possible recovery outcomes “must include” four basic elements: detoxification, rehabilitative counseling, continuing care and “Medication-Assisted Therapy” (MAT).
Generally, inpatient residential treatment is an effective way to ensure the presence of all four elements in a plan of care. Research also suggests that the delivery of these components tends to be more effective within an inpatient setting. For example, a study that compared inpatient detoxification from opiates to outpatient detoxification from opiates found the former (inpatient detox) was associated with significantly higher rates of treatment completion (and, in turn, much lower relapse rates). Similar results showed up in another overview of inpatient vs. outpatient detox for alcohol. There, too, the completion rate for inpatient detox was higher.
The same overview lays out other pros and cons of inpatient versus outpatient care. These are important to consider from an individual perspective, based on what you know about yourself. One advantage to inpatient care is that it cuts off access to alcohol or drugs for the duration of treatment and removes you from all your old environmental triggers. These two factors can be critical in helping individuals successfully move through that most vulnerable period of recovery (detox to early sobriety) without relapse.
On the other hand, if inpatient care is not possible because of finances, limited health insurance or other life circumstances—a brief phone consultation with an addiction professional can answer some of these concerns—intensive outpatient care (level III) may be an equally effective route, one study suggested. That study, published in the journal Psychiatric Services, compared treatment outcomes from residential inpatient and intensive outpatient programs, and found them generally equally effective. But an intensive outpatient program that includes the four components that ASAM identifies as essential to quality addiction treatment, (detoxification, rehabilitative counseling, continuing care and MAT), remains the best route.
Other considerations that should factor into a decision between inpatient and outpatient treatment include:
- Cost of program and extent of insurance coverage
- Length and structure of the program and whether it belongs to a full continuum of care (including aftercare and alumni resources, for example)
- Program location
- Reputation of treatment facility
- The evidence-based outcomes of group and individual therapies offered
- Accreditation and experience of clinical staff
These 12 Questions to Ask When Choosing a Treatment Center can provide further assistance.
Ultimately, a program that offers a full continuum of substance abuse care and includes inpatient and outpatient treatment and individualized options to match the level of care you need, should be the most important consideration. That will be the best predictor of a successful recovery outcome.