Simon is a 16-year-old 10th grader with ADHD and cannabis use. Despite your motivational interviewing (MI) approach, his use has escalated, his grades have dropped, and he’s lost interest in sports and activities. Simon feels bored, hopeless, and disconnected, and sees no downside to cannabis. You discuss additional treatment options with him and his family. 

Navigating levels of care for youth with substance use disorders (SUDs) is challenging. Here, we’ll discuss how to choose levels of care based on the patient’s severity of substance use and readiness for change, with strategies for involving teens and parents in decision making.

Levels of care

First, let’s examine the typical levels of care that clinicians, patients, and families will consider, as well as when each level might be appropriate. 

Outpatient (OP) treatment

In OP treatment, patients participate in weekly individual or group therapy sessions, typically family-based therapy, motivational enhancement therapy, or cognitive behavioral therapy. Patients receive medication to reduce cravings and treatment for co-occurring conditions. This level of care is appropriate for mild substance use, especially with strong family support (Tanner-Smith EE et al, J Subst Abuse Treat 2013;44(2):145–158). For a refresher on severity of SUDs, visit: www.tinyurl.com/yuhrpx5f.

Inpatient (IP) treatment

IP treatment is 24-hour care that should be considered for acute and life-threatening substance use or risk of severe withdrawal (including from alcohol, benzodiazepines, and opioids). It is a step toward more definitive care in other settings. 

Support includes:

• Nursing
• Comprehensive assessment
• Social work
• Psychiatry and/or medical ­intervention
• Medically assisted withdrawal when necessary 

School-based (SB) services

SB prevention and treatment services vary widely and can include:

• Education and brief ­interventions (one to five sessions) (Carney T et al, ­Cochrane Database Syst Rev 2016;2016(1):CD008969).
• SB medical clinics (Benningfield MM et al, Child Adolesc Psychiatr Clin N Am 2015;24(2):291–303).

There are also specialized recovery high schools that can provide additional treatment and monitoring (Finch et al, Am J Drug Alcohol Abuse 2017;44(2):175–184; www.recoveryschools.org). 

Intensive outpatient programs (IOPs)

In IOPs, patients attend three to five therapy sessions weekly, including individual, group, and family therapy. This model provides structure while teens live at home and attend school. It also improves abstinence rates (Hogue A et al, J Subst Abuse Treat 2021;129:108402).

Partial hospitalization programs (PHPs)

PHP patients live at home but spend several hours daily, five to seven days a week, in treatment. This level of care resembles IP care with medical monitoring and intensive therapy. Consider this option to improve engagement and recovery outcomes in teens needing daily structure but not 24-hour care.

Residential treatment centers (RTCs)

RTCs provide out-of-home intensive treatment, education, and life skills training lasting weeks to months. Therapeutic boarding schools are similar but typically last one or more years, sometimes running year-round. These programs may:

• Follow IOP, PHP, or IP care
• Address specific psychosocial, personal, and family-centered needs with medically monitored, integrated services

RTCs may fail due to teens returning to substance-using friends, inadequate academic support, or unresolved family issues. Long-term studies show better abstinence success when families are actively involved (www.tinyurl.com/4yev6354).

Aftercare programs

Aftercare following IOP, PHP, or RTC can include therapy, group meetings, and SB programs that provide structure for teens reintegrating into daily life to reinforce skills and prevent relapse. 

Deciding on a level of care

Given the variety of treatment options for SUDs, the first step in choosing one for your patients is determining accessibility—what options are available in your community? Financial and logistical limitations also exist. Treatment centers may not accept certain insurance, including Medicaid, or restrict admissions based on mental or physical health diagnoses.

Depending on where you practice, OP treatment or higher levels of care may require an adolescent patient’s consent/assent, although in some states parental consent may suffice (Kerwin ME et al, J Child Adolesc Subst Abuse 2015;24(3):166–176). Adolescents may have different goals than parents, may not share their family’s concerns, and may have differing opinions on next steps. The American Society of Addiction Medicine (ASAM) criteria include several dimensions to determine the “least restrictive” level of care.

To help you make the best possible choice for your patients with the resources available, reference the following guide (adapted from ASAM and applied to Simon’s case):

1. Substance use severity and withdrawal risk: Teens with high withdrawal risk may need IP care or PHP. Simon’s increasing cannabis use might place him at withdrawal risk.
2. Co-occurring mental health conditions: IP treatment may be necessary for acute safety concerns like suicide or self-harm. PHP or RTC may be required when depression, anxiety, or ADHD doesn’t respond to OP or IOP. Simon may have depression but denies suicidal thoughts or self-harm.
3. Living environment: Stable living environments often support IOP or PHP, preserving pro-social aspects of a teen’s life. PHP or RTC longer than two weeks should incorporate schoolwork to keep the teen from falling behind. If the home environment contributes to substance use (eg, family conflict, substance use), RTC or therapeutic boarding school may help. With family and friends’ support, Simon could re-engage in healthy extracurricular activities.
4. Social-environmental stressors: Teens with stressors (eg, legal, academic) may need support beyond OP. Punishments like school suspensions may escalate substance use. Simon could benefit from focused academic support to catch up in his studies.
5. Engagement of patient, family, and support systems: Teen buy-in is vital for treatment success but may limit options unless external factors (eg, court orders) allow involuntary treatment. Family involvement improves outcomes. If family support is limited, RTC can provide consistency. Simon’s willingness to participate in care remains uncertain. 

See the proposed ASAM criteria here: www.tinyurl.com/2s3etsyp. 

Engaging teens and parents

Of course, treatment only works with buy-in from family members as well as patients themselves. A central part of MI is assessing and addressing the stages of change:

• Pre-contemplation: Not yet acknowledging that there is a problem behavior that needs to be changed.
• Contemplation: Acknowledging that there is a problem but not yet ready, not sure of wanting to change, or lacking the confidence to make the change.
• Preparation/determination: ­Getting ready to change.
• Action/willpower: Changing behavior. 
• Maintenance: Maintaining the behavior change.

(Source: www.tinyurl.com/25za844b)

To get a more in-depth discussion of this process, see: www.tinyurl.com/d7aery8h. 

In the meantime, to navigate these conversations, consider the following: 

• Explain treatment options in teen-friendly terms: “Simon, some programs will have you attend treatment several times a week but let you sleep at home.”
• Respect the teen’s goals: “Your input matters because you’re the one doing the work of recovery. Your parents are here to support you while we figure out what’s next.”
• Use motivational language supporting autonomy: “Help me understand your ideas about what might work with friends and schoolwork.”
• Address consent and assent: MI can help teens clarify their need for treatment and assent to care. But when a teen like Simon escalates to acute risk, IP care might be necessary even if he doesn’t agree. Explain risks to parents to empower them to act in their child’s best interest. This might include hiring professionals to escort the teen to a residential facility out of state, although evidence on the effectiveness of involuntary treatment is limited.
• Educate on aftercare: Teens like Simon need ongoing support. Set realistic expectations by helping patients and families understand that ­aftercare—such as IOP, support groups, or therapy—is part of an extended developmental process, not a quick fix.

Simon’s increasing use, plummeting grades, and loss of interest in activities indicate moderate to severe substance use, requiring more than OP. However, his family support favors IOP, allowing him to attend school and participate in activities while receiving care. After six weeks of IOP, Simon has stopped using cannabis, his grades and mood are improving, and he is enjoying and competing in debate club again.

Carlat Verdict 

Get to know local, regional, and national treatment resources for your patients. Use an organized approach and document your rationale about resources that make sense for the teen and the family at each stage of care. Your decisions will depend on your ability to support the teen’s motivation, as well as how the teen’s environment may help or hinder care.