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Addiction treatment can take place at any number of “levels of care.” A level of care represents a certain intensity of treatment. One such level is a residential program, where the patient resides at a facility and is immersed in a recovery-based environment through groups and individual clinical meetings. Another level is a partial hospitalization, where the patient lives at home but goes to a facility nearly every day. Yet another level is standard outpatient care, where the patient is seen regularly by a clinician or participates in groups up to a few times a week. A patient is admitted to a specific level of care based upon medical necessity. The necessity is a balance between risks and benefits, expense, and availability of services. 

Let’s take a look at a specific example: Crystal is a 35 year old woman with a history of 7 years of heroin use. She has been hospitalized twice over the years for overdoses, but never participated in any type of ongoing care for her addictive disease. Imagine a similar scenario for Rebecca, a 35 year old woman with diabetes, hospitalized twice over the years for diabetic ketoacidosis, but also never receiving any form of ongoing treatment. These two patients both present for treatment and are both interested in reduction of related symptoms. Neither has any medical or psychiatric acuity. Both are likely to respond well to outpatient treatment. Neither Crystal or Rebecca require a higher level of care. In fact, the higher level of care might be a misguided effort borne out of the thought that the more intensive the care, the more likely there would be a beneficial outcome, but that would result only in treatment failure due to a lack of long-term follow up for what, for both patients, involves a lifelong illness. 

What we are treating with Rebecca is diabetes, not momentary high blood sugar. With Crystal, what we are treating is addictive disease, not substance use, and not intermittent intoxication or withdrawal. Outpatient care is the centerpiece of treatment for lifelong chronic illness. It is, by itself, sufficient and beneficial for the vast majority of such patients. It shouldn’t always be the starting point; certainly there are some patients whose acuity and severity require a higher level of initial treatment. But these patients represent a minority of those with the illness. Recovery, not cure, is the goal of addictive disease treatment, and recovery generally takes a year or two to achieve. Even then, it requires constant attention through regular clinical treatment. And again, what we are treating is not substance use as that would imply that sobriety represents a solution. We are treating the discomfort that in everyone with addictive disease underlies the reason they continue to use substances despite themselves. We are treating the disease that manifests itself in the form of repeated utilization of a drug that has negative consequences. 

Dr. Stuart Gitlow
Chief Medical Officer
The Recovery Research Network