What Does Stepping Down, or Up, in Addiction Treatment Mean?

If you or your loved one are experiencing a substance use disorder and are looking into treatment options, you may be confused about the terms “stepping up” and “stepping down.” Addiction treatment occurs on a continuum, so stepping down in addiction treatment means going from a more intense treatment setting or program to a less intense one.

When and Why Would I Step Up or Step Down?

It is important to note that a person can go up and down through different levels of treatment. Treatment options range from low-intensity outpatient treatment, which meets a few hours per week, to intensive 24/7 inpatient treatment. At any point, a person getting any level of treatment can go from less intensive services and “step up” to a higher level of treatment.

For example, a person may be in an outpatient program but is unable to maintain sobriety after going home in the evening. They may go to outpatient treatment for a few hours a day but then relapse at night after seeing friends who encourage him or her to drink or use drugs. A person in this situation may then need to step up to an inpatient program that can provide them with 24/7 support for a while, to help make sure that the person can use coping skills to resist relapse.

Another person may start treatment in an inpatient program. After being there for a few weeks or months, they may then be ready to “step down” to intensive outpatient treatment and attend treatment 20 hours a week or so, then go home at night. They may progressively step down then into less intensive outpatient, eventually just going to individual counseling sessions and/or support groups. This would typically happen after the person has gone through a certain amount of treatment programming and has a strong handle on their recovery.

What are my Treatment Options?

According to the American Society of Addiction Medicine (ASAM), a continuum of treatment options is available because one size does not fit all. For example, a person with a mild substance use disorder who is primarily using marijuana would not need the same level of treatment as a person with a severe substance use disorder who is using heroin and alcohol.

Someone with a mild substance use disorder might only need outpatient treatment for 9 hours a week or less, which is a Level 1 treatment option. If a person has a substance use disorder along with a co-occurring mental health disorder, they might need Level 2 intensive outpatient treatment, which is usually 9 or more hours of treatment each week.

The next level of treatment is partial hospitalization, which ASAM calls Level 2.5. In a partial hospitalization treatment program, a person will usually go to treatment for around 20 hours per week. The next step is residential treatment, offering 24/7 support and oversight. The amount of treatment and oversight is on a continuum, ranging from low-intensity residential treatment to highly structured residential services. The highest level of treatment according to ASAM is Level 4, which is a 24/7 structured, intensive medically managed level of treatment that involves at least 16 hours of counseling each week.

So, throughout these levels of treatment, a person may step up if he or she needs more support and intervention to maintain sobriety, and when a person is doing well, he or she can step down to a lower level form of treatment with less support.

How do I Know if I Need Help?

If you are questioning if you or your loved one has a problem with drugs or alcohol, it can be helpful to know how a substance use disorder is diagnosed. According to the Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-V), which addiction treatment professionals use as the standard for diagnosing substance use disorders, you may have a substance use disorder if you experienced at least 2 of the following symptoms in the past 12 months:

• Using more of a substance than you originally meant to.
• Having arguments with loved ones about your use of a substance.
• Using the substance prevents you from performing your tasks at work, or in school, or in caring for your children.
• You use a substance in high-risk situations, such as driving.
• You keep on using a substance, despite knowing it makes your physical or emotional issues worse.
• Making unsuccessful attempts to stop using, or to cut back on your use of a substance.
• Spending a significant amount of time looking for a substance, using it, and recovering from using it.
• Giving up things you used to enjoy, such as friendships or hobbies, in order to use the substance.
• Cravings or urges to use a substance.
• Experiencing withdrawal when you stop using the substance.
• Developing tolerance to a substance, which means you need to take more and more of it to feel the effects of it.

You may have a mild substance use disorder if you have 2-3 of these signs. If you have 4-5, you may have a moderate substance use disorder. If you have 6 or more, you may be diagnosed with a severe substance use disorder.

Only a substance use treatment professional can diagnose you with a substance use disorder. If you are assessed and found to have a substance use disorder, numerous treatment options are available.

Where Can I Get Help?

At American Addiction Centers, we offer several levels of treatment, where you can step up or step down according to your needs. Our caring and compassionate staff will assess your needs and situation and help you find the right place to start your treatment. As you go through treatment, our providers will reassess your treatment needs regularly to determine when you may need to step down or step up to the appropriate treatment level.