What are the ASAM levels of care and how are they determined?

The ASAM Criteria define a continuum of care from least intensive to most intensive: Level 0.5 (Early Intervention), Level 1 (Outpatient Services, less than 9 hours/week), Level 2.1 (Intensive Outpatient/IOP, 9-19 hours/week), Level 2.5 (Partial Hospitalization, 20+ hours/week), Level 3.1 (Clinically Managed Low-Intensity Residential), Level 3.3 (Clinically Managed Population-Specific High-Intensity Residential), Level 3.5 (Clinically Managed High-Intensity Residential), Level 3.7 (Medically Monitored Intensive Inpatient), and Level 4 (Medically Managed Intensive Inpatient). Placement is determined by assessing the patient across all six ASAM dimensions and matching the severity profile to the level of care that provides the appropriate intensity of services while being the least restrictive environment that is safe and effective.

What screening tools should I use for a substance abuse assessment?

Common validated screening tools include: the AUDIT (Alcohol Use Disorders Identification Test, 10 items) for alcohol use severity, the DAST-10 (Drug Abuse Screening Test, 10 items) for drug use severity, the CAGE questionnaire (4 items) as a brief alcohol screening, the NIDA Quick Screen (single question) as an initial screen for any substance use, the ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) for polysubstance screening, and the CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) or COWS (Clinical Opiate Withdrawal Scale) for withdrawal severity. For comprehensive diagnostic assessment, the ASI (Addiction Severity Index) provides a structured interview covering seven domains affected by substance use.

How is the ASAM assessment different from a standard biopsychosocial assessment?

The ASAM multidimensional assessment is specifically structured around six dimensions that determine substance use treatment placement: (1) Acute Intoxication and Withdrawal Potential, (2) Biomedical Conditions, (3) Emotional/Behavioral/Cognitive Conditions, (4) Readiness to Change, (5) Relapse/Continued Use/Continued Problem Potential, and (6) Recovery/Living Environment. While a biopsychosocial assessment covers biological, psychological, and social domains broadly, the ASAM assessment focuses specifically on how each dimension affects the appropriate level and type of substance use treatment. Many clinicians conduct a biopsychosocial assessment that incorporates ASAM dimensional analysis.

Can I recommend a level of care that the patient disagrees with?

Yes, and you should document both your clinical recommendation and the patient's preference. Level-of-care determination is a clinical judgment based on the six ASAM dimensions, not a patient preference. However, patient motivation (Dimension 4) is itself a factor in the assessment. If a patient needs residential treatment based on dimensions 1, 5, and 6 but is unwilling to attend residential, document this in your recommendation: note the clinically indicated level, the patient's stated preference, the clinical rationale for your recommendation, and any safety concerns associated with a lower level of care. Many insurance companies and managed care organizations use ASAM criteria as the standard for authorizing levels of care.

How do I assess for co-occurring mental health disorders during a substance abuse evaluation?

Dimension 3 of the ASAM Criteria specifically addresses emotional, behavioral, and cognitive conditions. Screen for depression (PHQ-9), anxiety (GAD-7), trauma/PTSD (PCL-5 or PC-PTSD-5), and psychosis. Determine whether psychiatric symptoms are substance-induced (occurring only during intoxication or withdrawal and expected to resolve with sustained abstinence) or independent (present during periods of sustained sobriety, or with onset predating substance use). This distinction affects treatment planning: independent co-occurring disorders require integrated dual-diagnosis treatment, while substance-induced symptoms may resolve with addiction treatment alone. When in doubt, treat both — co-occurring disorder treatment produces better outcomes than sequential treatment.

Substance Abuse Assessment: ASAM Criteria Documentation Guide

Assessment Reports|21 min read|Updated 2026-03-20|Clinically reviewed

What Is a Substance Abuse Assessment?

A substance abuse assessment is a comprehensive clinical evaluation designed to determine the nature and severity of an individual's substance use, identify co-occurring medical and psychiatric conditions, evaluate psychosocial factors affecting treatment, and recommend the appropriate level of care. The gold standard framework for substance use treatment placement in the United States is the ASAM Criteria (American Society of Addiction Medicine Criteria, currently in its fourth edition), which uses a multidimensional assessment across six clinical domains to match patients to the least restrictive, most effective level of treatment.

Unlike a brief substance use screening, which identifies whether a problem likely exists, the ASAM-based assessment characterizes the problem across multiple dimensions that directly determine treatment intensity, setting, and focus. The six ASAM dimensions are: (1) Acute Intoxication and/or Withdrawal Potential, (2) Biomedical Conditions and Complications, (3) Emotional, Behavioral, or Cognitive Conditions and Complications, (4) Readiness to Change, (5) Relapse, Continued Use, or Continued Problem Potential, and (6) Recovery/Living Environment. Each dimension is rated on a severity continuum, and the composite profile determines the recommended level of care — from outpatient services to medically managed inpatient treatment.

For psychologists and mental health professionals, the substance abuse assessment requires competency in diagnostic interviewing, familiarity with the pharmacology of commonly used substances, understanding of withdrawal syndromes and their medical management, knowledge of the ASAM continuum of care, skill in assessing motivation and readiness to change, and the ability to identify and address co-occurring psychiatric disorders within an integrated treatment framework.

When You Need It

When an individual presents for substance use treatment and level-of-care placement must be determined
When a referral source (court, employer, physician, family) requests a formal substance use evaluation to determine whether a substance use disorder is present and what treatment is indicated
When insurance or managed care requires an ASAM-based assessment to authorize a specific level of care
When a client in mental health treatment screens positive for substance use on a screening instrument and a comprehensive evaluation is needed
When a patient is being discharged from a higher level of care (detox, residential) and a step-down assessment is needed to determine the appropriate next level
When a DUI/DWI conviction or other legal involvement requires a substance use evaluation for the court
When an employee assistance program (EAP) referral requires formal evaluation of substance use concerns
When an individual is being assessed for medication-assisted treatment (MAT) for opioid or alcohol use disorder

Key Components / Required Sections

Identifying Information and Referral Context

Document the patient's demographics, the referral source, the reason for referral, and the context (self-referred, court-ordered, employer-mandated, physician-referred). Note whether the evaluation is voluntary or compelled, as this directly affects Dimension 4 (Readiness to Change).

Substance Use History

For each substance used (current and past), document:

Substance type, route of administration, and typical quantity per use occasion
Frequency of use (daily, weekly, episodic)
Age of first use and age of regular use onset
Duration of regular use
Periods of abstinence and circumstances of relapse
Progression of use (escalation, tolerance development)
Maximum use levels and most recent period of heavy use
Date and amount of last use for each substance
History of withdrawal symptoms (specify type and severity)
History of overdose or medical complications from use
Prior substance use treatment (type, setting, duration, outcome)

Screening Instrument Results

Administer and report scores from validated screening tools:

AUDIT (Alcohol Use Disorders Identification Test): 10-item WHO screening for hazardous drinking, harmful drinking, and alcohol dependence (scores 0-7 low risk; 8-15 hazardous; 16-19 harmful; 20-40 possible dependence)
DAST-10 (Drug Abuse Screening Test): 10-item screener for drug use problems (scores 0 no problems; 1-2 low; 3-5 moderate; 6-8 substantial; 9-10 severe)
CAGE (Cut down, Annoyed, Guilty, Eye-opener): 4-item brief screening (2+ positive responses suggest alcohol use disorder)
CIWA-Ar or COWS: Withdrawal severity assessment scales when acute withdrawal is present or recent

ASAM Dimension 1: Acute Intoxication and/or Withdrawal Potential

Assess the patient's current intoxication status, history and severity of withdrawal from each substance, and medical risk associated with withdrawal. Document the most recent use of each substance, current symptoms of intoxication or withdrawal, history of complicated withdrawal (seizures, delirium tremens), and whether medically managed detoxification is needed.

ASAM Dimension 2: Biomedical Conditions and Complications

Document current medical conditions, chronic health problems, medications, infectious disease status (HIV, Hepatitis B/C, TB), pregnancy status, nutritional status, and any medical conditions that could be complicated by substance use or withdrawal. Determine whether medical conditions require treatment that influences the level of care recommendation (e.g., a patient with unstable diabetes may need a medically monitored setting during early treatment).

ASAM Dimension 3: Emotional, Behavioral, or Cognitive Conditions

Assess current and historical psychiatric diagnoses, current psychiatric symptoms, suicidal and homicidal ideation, cognitive functioning, and the relationship between psychiatric symptoms and substance use. Distinguish substance-induced disorders from independent co-occurring disorders. Screen for depression (PHQ-9), anxiety (GAD-7), trauma (PCL-5), and psychosis. Assess cognitive functioning if impairment is suspected.

ASAM Dimension 4: Readiness to Change

Assess the patient's stage of change (precontemplation, contemplation, preparation, action, maintenance), awareness of the relationship between substance use and consequences, motivation for treatment, treatment preferences, and perceived barriers to change. This dimension does not determine whether someone gets treatment — it determines how treatment should be approached (e.g., motivational enhancement for precontemplative patients versus relapse prevention for patients in the action stage).

ASAM Dimension 5: Relapse, Continued Use, or Continued Problem Potential

Evaluate the patient's ability to manage their substance use without the structure of treatment. Consider: current cravings, history of relapse patterns and triggers, length of previous sobriety periods, awareness of relapse triggers, availability and use of recovery support, and response to prior treatment. This dimension helps determine how much external structure the patient needs.

ASAM Dimension 6: Recovery/Living Environment

Assess the patient's living situation, family and social support, peer group (using versus recovery-oriented), geographic access to treatment, financial resources, employment, legal status, and whether the home environment supports or undermines recovery. A patient who is otherwise appropriate for outpatient treatment but lives with an actively using partner may require a higher level of care or a change in living situation.

Diagnostic Impressions

Provide DSM-5-TR diagnoses for all substance use disorders identified, specifying severity (mild: 2-3 criteria; moderate: 4-5 criteria; severe: 6+ criteria) and specifiers (in early remission, in sustained remission, on maintenance therapy, in a controlled environment). Document co-occurring psychiatric diagnoses.

Level-of-Care Recommendation

Based on the composite assessment across all six dimensions, recommend the ASAM level of care. Document the clinical rationale linking dimensional findings to the recommended level.

Substance Abuse Assessment — Adult, Outpatient vs. IOP Determination

CONFIDENTIAL SUBSTANCE USE EVALUATION

Client: Michael S. Brennan Date of Birth: 03/28/1990 Age: 35 Date of Evaluation: 02/14/2026 Date of Report: 02/18/2026 Referral Source: Self-referred following DUI arrest on 01/30/2026; court-mandated evaluation per pretrial diversion program Evaluator: Dr. Karen Yoshida, Ph.D., Licensed Psychologist, CASAC

Referral Context

Mr. Brennan is a 35-year-old male who self-referred for a substance use evaluation as a condition of his pretrial diversion program following a DUI arrest (BAC 0.19). The court requires a comprehensive substance use assessment with a level-of-care recommendation. Mr. Brennan acknowledges that his drinking has become problematic and states he is "ready to get help," though he expresses preference for outpatient treatment due to work obligations.

Substance Use History

Alcohol:

First use: Age 14 (beer at a party)
Regular use onset: Age 18 (college; weekend binge drinking)
Current pattern: Daily consumption of 5-8 beers per evening on weekdays, 10-15 beers on weekend days. Occasionally substitutes vodka (4-6 oz per evening). This pattern has been consistent for approximately 3 years.
Prior pattern: Social weekend drinking in college and early 20s. Escalation to daily use began around age 30 following a divorce.
Tolerance: Reports needing significantly more alcohol to achieve the same effect. "Six beers barely buzz me now."
Withdrawal history: Reports mild-to-moderate withdrawal symptoms when he has attempted to stop or reduce: hand tremors, sweating, insomnia, anxiety, irritability. Has never experienced withdrawal seizures, hallucinations, or delirium tremens. Most recent withdrawal episode was 6 months ago when he attempted to quit on his own and lasted 2 days before resuming drinking.
Last use: 02/13/2026 (day before evaluation) — 6 beers between 6:00 PM and 11:00 PM
Blackouts: Reports 3-4 blackout episodes in the past year
Legal consequences: Current DUI (BAC 0.19); no prior DUI but received a disorderly conduct citation 2 years ago following an alcohol-related argument at a restaurant
Occupational consequences: Has called in sick to work approximately 8 times in the past 6 months due to hangovers. Received a written warning for attendance.
Interpersonal consequences: Divorce at age 30 (ex-wife cited his drinking as a primary factor). Current girlfriend of 18 months has expressed concern and threatened to leave if he doesn't get help.
Prior treatment: None. Has never attended AA or any formal substance use treatment.

Other Substances:

Cannabis: Used recreationally in college; occasional use (1-2 times/month) currently. DAST-10 score: 2 (low level of problems).
Cocaine: Used 5-6 times in his 20s; no use in past 5 years.
Opioids, benzodiazepines, stimulants: Denied any use.
Tobacco: Smokes 5-8 cigarettes per day, more when drinking. Has smoked since age 20.
Caffeine: 3-4 cups of coffee daily.

Screening Instrument Results

Instrument	Score	Interpretation
AUDIT	28	Probable alcohol dependence (score 20+)
DAST-10	2	Low-level drug problems
CAGE	4/4 positive	All four items endorsed — high probability of AUD
PHQ-9	14	Moderate depressive symptoms
GAD-7	10	Moderate anxiety symptoms
CIWA-Ar	8 (assessed at time of interview)	Mild withdrawal (scores under 10 = mild)
Columbia Suicide Severity Rating Scale	No current ideation	Denied ideation, plan, intent, and history of attempts

ASAM Dimensional Assessment

Dimension 1: Acute Intoxication and/or Withdrawal Potential

Mr. Brennan has a history of mild-to-moderate alcohol withdrawal symptoms (tremor, sweating, insomnia, anxiety) upon cessation. He has never experienced complicated withdrawal (seizures, DTs, hallucinations). His CIWA-Ar score at the time of assessment was 8 (mild withdrawal). He consumed 6 beers the evening before the evaluation and appears to require daily alcohol consumption to avoid withdrawal symptoms. He has never undergone medically supervised detoxification.

Clinical Severity: Moderate. Ambulatory detoxification with medical monitoring is likely sufficient if a medically supervised setting is available. He does not appear to require inpatient detoxification based on current CIWA-Ar score and absence of complicated withdrawal history, but medical consultation should precede any abrupt cessation of alcohol use.

Dimension 2: Biomedical Conditions and Complications

Mr. Brennan reports no chronic medical conditions. He has not seen a primary care physician in approximately 2 years. He takes no prescription medications. He reports occasional gastric reflux, which is worse on heavy drinking nights. He smokes 5-8 cigarettes per day. He has not been tested for liver function, hepatitis, or other alcohol-related medical complications recently. His BMI is approximately 28 (overweight).

Clinical Severity: Low-to-Moderate. No acute medical conditions requiring inpatient monitoring. However, given the duration and quantity of his alcohol use, comprehensive medical evaluation including liver function tests, CBC, and metabolic panel is recommended.

Dimension 3: Emotional, Behavioral, or Cognitive Conditions

Mr. Brennan reports symptoms consistent with moderate depression (PHQ-9 = 14): low mood, poor motivation, disrupted sleep, fatigue, difficulty concentrating, and feelings of guilt. He also endorses moderate anxiety symptoms (GAD-7 = 10): chronic worry about finances and work performance, restlessness, and muscle tension. These symptoms have been present for approximately 2 years, coinciding with the escalation of his drinking. He is uncertain whether the depression and anxiety cause his drinking or vice versa, stating, "I drink because I feel terrible, and I feel terrible because I drink."

He denied current suicidal ideation, self-harm history, and homicidal ideation. He denied psychotic symptoms. He has never been psychiatrically hospitalized. He has no prior psychiatric diagnoses or psychotropic medication trials.

Cognitive functioning appeared grossly intact during the interview. There were no signs of alcohol-related cognitive impairment. Attention, concentration, and memory appeared adequate.

Clinical Severity: Moderate. The depressive and anxiety symptoms require treatment but do not appear to require psychiatric hospitalization or intensive psychiatric stabilization. The temporal relationship between psychiatric symptoms and escalating alcohol use suggests a partially substance-induced presentation, but independent mood/anxiety disorder cannot be ruled out at this time. Re-evaluation of psychiatric symptoms after 2-4 weeks of sobriety will clarify the diagnostic picture.

Dimension 4: Readiness to Change

Mr. Brennan is in the contemplation-to-preparation stage of change. He acknowledges that his drinking is a significant problem ("I know it's out of control"), can identify multiple negative consequences (DUI, work problems, relationship strain, health concerns), and states he wants to change. However, he has ambivalence about what change looks like — he initially expressed a desire to "cut back to social drinking" rather than pursue abstinence, though he acknowledged that prior attempts to moderate have failed. He is externally motivated by the court requirement and the threat of his girlfriend leaving, but also demonstrates emerging internal motivation ("I don't want to end up like my dad — he died at 58 from cirrhosis").

He expressed preference for outpatient treatment rather than IOP, citing work obligations as a barrier to intensive programming.

Clinical Severity: Moderate. Mr. Brennan demonstrates awareness and willingness to engage in treatment but has ambivalence about abstinence versus moderation and may underestimate the intensity of treatment needed. Motivational enhancement should be integrated into early treatment.

Dimension 5: Relapse, Continued Use, or Continued Problem Potential

Risk factors for continued use are substantial:

Daily drinking pattern with physiological dependence
No prior treatment or recovery experience
No established recovery support network (no AA, no sober friends)
Poor coping skills for stress and negative emotions (uses alcohol as primary coping mechanism)
One failed self-directed quit attempt (lasted 2 days)
Ambivalence about abstinence
High-risk social environment (many friends are heavy drinkers; social life revolves around bars)

Protective factors:

Expressed motivation for change
Stable employment (though threatened)
Supportive romantic partner
No polysubstance dependence
No history of IV drug use

Clinical Severity: High. Without intensive structured support, Mr. Brennan is at high risk for continued daily alcohol use. His lack of any prior treatment experience, limited coping skills, high-risk social environment, and failed self-directed quit attempt suggest he needs more structure than standard weekly outpatient therapy can provide.

Dimension 6: Recovery/Living Environment

Mr. Brennan lives alone in a rented apartment. His girlfriend stays with him on weekends. His social network consists primarily of drinking friends — he estimates that 80% of his socializing involves alcohol. He has a strained relationship with his ex-wife (they co-parent a 6-year-old daughter, shared custody). His parents live in the area; his mother is supportive of treatment, his father is a "functional alcoholic" who minimizes Mr. Brennan's drinking. He is employed full-time as a project manager at a construction firm. He has health insurance through his employer. He has a valid driver's license (currently suspended following DUI).

Clinical Severity: Moderate-to-High. Mr. Brennan's living environment is not actively dangerous, but his social network is heavily alcohol-focused, he lives alone without daily recovery support, and his father models continued heavy drinking. These environmental factors increase relapse risk and support a higher level of care intensity.

Diagnostic Impressions

Alcohol Use Disorder, Severe (F10.20) — Mr. Brennan meets 8 of 11 DSM-5-TR criteria: tolerance, withdrawal, alcohol used in larger amounts/longer than intended, persistent desire to cut down with unsuccessful efforts, great deal of time spent in alcohol-related activities, important activities given up or reduced, continued use despite knowledge of physical or psychological problems caused by alcohol, and continued use despite recurrent social/interpersonal problems.
Major Depressive Disorder, single episode, moderate, rule out Alcohol-Induced Depressive Disorder (F32.1 vs. F10.24) — Moderate depressive symptoms present for approximately 2 years, temporally associated with escalation of alcohol use. Independent versus substance-induced etiology cannot be determined until a period of sustained sobriety allows re-evaluation. Treat symptomatically regardless of etiology.
Generalized Anxiety Disorder, rule out Alcohol-Induced Anxiety Disorder (F41.1 vs. F10.280) — Moderate anxiety symptoms with similar diagnostic uncertainty regarding primary versus substance-induced etiology.
Tobacco Use Disorder, Moderate (F17.210) — Daily cigarette use with continued use despite health awareness.

Level-of-Care Recommendation

Recommended: ASAM Level 2.1 — Intensive Outpatient Program (IOP)

Based on the composite assessment across all six ASAM dimensions, Mr. Brennan's clinical profile supports placement in an Intensive Outpatient Program (IOP, 9-12 hours per week, typically 3-4 evenings per week) rather than standard outpatient (Level 1) or residential treatment (Level 3).

Rationale for IOP over Standard Outpatient (Level 1):

Severe alcohol use disorder with physiological dependence (Dimension 1)
No prior treatment experience and no established recovery support (Dimension 5)
High relapse risk due to limited coping skills, alcohol-centric social environment, and failed self-directed quit attempt (Dimensions 5 and 6)
Co-occurring depressive and anxiety symptoms requiring concurrent monitoring (Dimension 3)
Standard weekly outpatient therapy (1 session/week) would not provide sufficient structure, peer support, or skill-building intensity for this severity level

Rationale for IOP over Residential (Level 3):

No history of complicated withdrawal, reducing medical risk of outpatient detox (Dimension 1)
No acute medical conditions requiring 24-hour monitoring (Dimension 2)
No acute psychiatric crisis (no suicidal ideation, no psychosis) (Dimension 3)
Stable housing and employment that would be disrupted by residential placement (Dimension 6)
Sufficient motivation and emerging readiness for change (Dimension 4)
Living environment, while high-risk, is not dangerous or actively destabilizing

Additional Recommendations:

Medical evaluation: Refer to primary care for comprehensive physical exam, liver function panel, CBC, metabolic panel, and medical clearance for ambulatory detoxification. Consider gabapentin or benzodiazepine taper protocol for withdrawal management under medical supervision.
Medication-Assisted Treatment (MAT): Referral to an addictions psychiatrist for evaluation of naltrexone (oral or injectable) to reduce alcohol cravings, which has strong evidence for moderate-to-severe alcohol use disorder.
Psychiatric evaluation: Referral for medication evaluation of depressive and anxiety symptoms. If symptoms persist after 4 weeks of sobriety, initiate antidepressant treatment (SSRIs are first-line for co-occurring AUD and depression).
IOP program components should include: group therapy (process and psychoeducational), individual counseling (motivational enhancement therapy transitioning to CBT/relapse prevention), substance use education, coping skills training, and introduction to 12-step or alternative mutual support groups (SMART Recovery).
Recovery support: Attend AA or SMART Recovery meetings minimum 3 times per week in addition to IOP. Obtain a sponsor or recovery coach within the first 30 days.
Relapse prevention planning: Develop a written relapse prevention plan identifying high-risk situations, early warning signs, and specific coping responses. Address the alcohol-centric social network by identifying at least 2 sober social activities per week.
Court-related: Provide monthly treatment compliance reports to the pretrial diversion program as required. Random urine drug screening and breathalyzer testing should be conditions of the treatment agreement.
Step-down plan: Following successful completion of IOP (typically 8-12 weeks), step down to standard outpatient (Level 1, 1-2 sessions per week) with continued MAT, psychiatric monitoring, and mutual support group attendance. Total treatment duration of 12 months minimum is recommended for severe AUD.
Re-evaluation: Reassess depressive and anxiety symptoms at 4 weeks of sobriety to determine independent versus substance-induced etiology and guide ongoing psychiatric treatment planning.

This is a sample for educational purposes only — not real patient data.

How to Write It Step by Step

Step 1: Establish the Referral Context and Legal Framework

Document whether the evaluation is self-referred, court-ordered, employer-mandated, or provider-referred. The referral context directly affects Dimension 4 (Readiness to Change) and the evaluator's obligations regarding reporting. For court-ordered evaluations, clarify the specific questions the court wants answered and the expected format.

Step 2: Conduct a Detailed Substance Use History

Go substance by substance: alcohol, cannabis, opioids (prescription and illicit), stimulants (cocaine, methamphetamine, prescription), benzodiazepines, hallucinogens, inhalants, and tobacco. For each substance, document the age of first use, age of regular use onset, current and past patterns, route of administration, tolerance and withdrawal, maximum use levels, periods of abstinence, and consequences. Many patients use multiple substances, and a single-substance history will miss the complexity.

Step 3: Administer Screening Instruments

Use validated screening tools to supplement the clinical interview. The AUDIT for alcohol and the DAST-10 for drugs are the minimum. Add the CIWA-Ar or COWS if the patient is in or at risk of withdrawal. Use the PHQ-9, GAD-7, and Columbia Suicide Severity Rating Scale to screen for co-occurring psychiatric conditions.

Step 4: Assess Each ASAM Dimension Systematically

Walk through all six dimensions in order. For each dimension, gather the relevant clinical data, rate the severity, and document your findings. Resist the temptation to skip dimensions — a patient with low severity on five dimensions but high severity on Dimension 6 (e.g., living in a drug house) may need a higher level of care than a patient with moderate severity across the board.

Step 5: Apply DSM-5-TR Diagnostic Criteria

Count the criteria met for each substance use disorder. The DSM-5-TR uses a severity spectrum: 2-3 criteria met = mild, 4-5 = moderate, 6+ = severe. Apply specifiers as appropriate (in early remission, in sustained remission, in a controlled environment, on maintenance therapy). Distinguish independent co-occurring disorders from substance-induced disorders when possible.

Step 6: Determine Level of Care Using ASAM Matching

The level-of-care recommendation should follow logically from the dimensional severity ratings. The guiding principle is to recommend the least restrictive level of care that safely and effectively addresses the patient's needs across all six dimensions. Document why you are recommending one level over the levels immediately above and below it.

Step 7: Write Specific, Actionable Recommendations

Beyond the level-of-care recommendation, provide specific treatment recommendations: type of therapy (MI, CBT, relapse prevention, 12-step facilitation), MAT considerations, psychiatric evaluation needs, medical follow-up, recovery support resources, and follow-up planning. For court-ordered evaluations, include compliance monitoring and reporting requirements.

Common Mistakes

Recommending a level of care based on a single dimension. A patient with severe withdrawal history (Dimension 1) but strong recovery support, high motivation, stable housing, and no co-occurring psychiatric conditions may still be appropriate for ambulatory detox and IOP rather than residential. Conversely, a patient with mild withdrawal risk but an actively dangerous living environment (Dimension 6) may need residential placement for safety. All six dimensions must be considered together.

Failing to distinguish substance-induced from independent psychiatric disorders. This distinction has major treatment implications. Substance-induced depression will likely improve with sustained sobriety, while independent major depression requires its own pharmacological and therapeutic treatment. When the distinction cannot be made at the time of assessment (which is common during active use or early recovery), document the diagnostic uncertainty and recommend reassessment after a period of sobriety.

Underestimating withdrawal risk. Alcohol and benzodiazepine withdrawal can be life-threatening. Any patient with a history of daily heavy alcohol use, prior complicated withdrawal, or co-occurring medical conditions should have withdrawal risk assessed by a medical provider before treatment planning assumes outpatient management is safe. Document your assessment of withdrawal risk and your recommendation for medical evaluation.

Treating the AUDIT or DAST score as diagnostic. Screening instruments identify probable problems and their severity — they do not diagnose substance use disorders. The AUDIT score supports your clinical assessment but does not replace the DSM-5-TR diagnostic interview. Report the screening score alongside, not instead of, the diagnostic formulation.

Ignoring the patient's recovery environment. A well-designed treatment plan will fail if the patient returns to a living situation that actively promotes substance use. Dimension 6 assessment should include specific questions about who lives in the household, whether substances are available in the home, whether the patient's social network is using-oriented or recovery-oriented, and what environmental changes are needed to support recovery.

Writing a single-substance assessment when polysubstance use is present. Many patients use multiple substances, and addressing only the primary substance while ignoring secondary substances is clinically insufficient. Each substance used should have its own history, and the interaction effects between substances (e.g., concurrent alcohol and benzodiazepine use dramatically increases withdrawal risk) should be addressed in the assessment.

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