When to Refer Clients Using Substances: A Best Practice Guide

Overview

At Rula, we believe that most therapists possess the core clinical skills such as motivational interviewing, cognitive-behavioral techniques, and a strong therapeutic alliance to effectively support clients with mild-to-moderate Substance Use Disorders (SUD).

We recognize that, depending on your specific training and clinical experience, you may feel that a referral is necessary to remain within your professional scope of practice. However, we encourage providers to pause before making this transition, as unnecessary referrals can disrupt the continuum of care and discourage clients from continuing to seek help. This article provides a framework for deciding when to continue outpatient treatment with specialized support versus when a client requires a Higher Level of Care (HLOC) referral. 

A Generalist Framework 

Research consistently shows that the quality of the therapeutic relationship is a primary predictor of success in substance use disorders treatment. Most SUDs are co-occurring with the same conditions you likely treat every day (anxiety, depression, trauma).

Before considering a referral, remember:

• SUD is a Chronic Condition: Like diabetes or asthma, it often requires ongoing management beyond a time-limited stay in a facility. 

• The Power of Stability: Transitioning a client to a new provider is disruptive and can be a barrier to successful care. If the client is engaged and safe, the best place for them may be in treatment with you. 

• Harm Reduction: You can provide immediate value by utilizing harm reduction strategies and psychoeducation.
  • Overdose Prevention: Educating the client on Naloxone (Narcan) access and/or the use of fentanyl test strips to test for the presence of fentanyl in the client’s local supply.
  • Managed Use: Collaboratively setting goals to delay the "first use" of the day, establishing "dry days," or ensuring the client eats and hydrates before using.
  • Safer Use Practices: Discuss safer use practices (such as never sharing equipment, starting with a small dose, avoiding mixing with medications, alcohol, or other substances) to reduce the risk of infection or overdose.

For more information on supporting clients, refer to the SAMHSA Overdose Prevention and Response Toolkit. 

Clinical Tip: If you’re unsure whether to refer due to scope, ask yourself: "Is this referral based on a lack of clinical evidence for progress, or my own discomfort with the diagnosis?"  You can also join one of our many Clinical Consult Groups, including our Substance Use Disorders Consult Group. 

Mutual Support Groups

Patients with substance use disorders are often encouraged to participate in mutual support groups that focus on recovery. These groups are community-led and provide opportunities to connect with others who share similar experiences and build support networks focused on recovery. These groups can be a wonderful compliment to ongoing therapy support.  Some examples include:

• Alcoholics Anonymous (AA)
• Narcotics Anonymous (NA)
• SMART Recovery
• National Alliance on Mental Illness (NAMI)
• Al-Anon Family Groups 

When to Consider a Specialized Outpatient Provider

A specialized provider is a therapist who has specific certifications (e.g., CADC, LADC) or extensive experience in addiction-specific modalities (Seeking Safety for Co-Occurring Trauma). Although most licensed therapists can support substance use disorders, please be aware of the requirements in your state to determine when to refer to specialized providers. 

Consider a referral to a specialized outpatient Rula provider when:

1. Clinical Complexity: The client’s substance use is the primary driver of their distress, and you feel your current interventions (CBT, DBT, MI) are not gaining traction after 4-6 sessions.

2. Specific Modality Needs: The client requires a specific addiction-focused protocol that falls outside your scope of practice.

3. Therapist Competency: You have reached the limit of your training regarding specific substances or behavioral addictions, and consultation has not resolved the gap.

When to Refer to a Higher Level of Care (HLOC)

A Higher Level of Care (HLOC) includes Intensive Outpatient (IOP), Partial Hospitalization (PHP), Residential Treatment, or Medically Monitored Detox. These referrals are based on acuity and safety, not just the presence of a diagnosis. 

Tip: Rula’s Care Coordination team can support with referrals to SUD-specific Outpatient, Intensive Outpatient (IOP), and Partial-Hospitalization Programs. 

Level of care recommendations and treatment plans are developed based on multidimensional patient assessments that consider the patient’s biomedical, psychological, and social needs. Using the ASAM (American Society of Addiction Medicine) Criteria as a guide, refer to HLOC if the client meets one or more of the following:

1. Intoxication, Withdrawal, and Addiction Medications

• Using substances with a high risk of complications from withdrawal, including alcohol, benzodiazepines, and opioids, especially if the patient has an increased tolerance for the substance or experiences withdrawal symptoms when they attempt to cut back or stop using.

2. Medical Conditions

• Medical issues (liver disease, pregnancy, severe pain) that make outpatient treatment unsafe without medical monitoring.

3. Psychiatric and Cognitive Conditions

• Severe trauma symptoms, cognitive impairment, or co-occurring psychosis that prevents participation in standard 1-to-1 therapy.

4. Substance Use-Related Risks

• High likelihood of imminent risky behavior or overdose that cannot be managed with a safety plan in a weekly setting.

5. Recovery Environment Interactions

• A living situation that is physically dangerous or entirely lacks support.
• Note: Consider recommending a Recovery Residence (RR) in conjunction with outpatient care as an alternative to a referral to a higher clinical level, if appropriate. 

6. Person-Centered Considerations 

• Significant barriers to care (transportation, childcare, social determinants of health) or a specific need for motivational enhancement that requires the structure of an IOP. 

Important Note: if your client is at immediate risk for withdrawal or other safety concerns, it is important to support them in connecting with medical services by contacting emergency services or helping them get to their nearest hospital emergency room. 

Best Practices for Transitioning Care

If you determine that a referral is clinically necessary, follow these steps to ensure patient safety and engagement:

Transparency: Discuss the clinical rationale for the referral with the client. Frame it as "adding the right layer of support” rather than not being the right fit for your client. 

Safety Planning: While the client waits for a HLOC intake, update their safety plan and increase the frequency of check-ins, if needed. Best practice is to continue seeing your client until you’ve confirmed they’re actively being treated by another provider and are engaged in the appropriate level of care. Failure to do so can lead to risk for both you and the client.

Continuing Care (When Appropriate): Rula leaves the decision of whether or not to resume care with your client after a higher level of care (HLOC) referral up to you as their clinician. In some cases, this means you'll temporarily suspend seeing the client while they engage in a higher level of care support, such as PHP and IOP. In other cases, you may continue treating the client while they engage in an adjunct service, such as medication management or group therapy. Refer to this Help Center resource: How to Schedule/Resume Care For An Inactive Client. 

Quick Reference Summary

For additional resources on supporting clients who use substances, please refer to our Rula Help Center articles:

• Clinical Care Guideline: Substance Use Disorders (SUD)
• Supporting Clients Who Use Substances: A Collaborative Guide for Outpatient Therapists

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75(6), 842–852. https://doi.org/10.1037/0022-006X.75.6.842

Logan, D. E., & Marlatt, G. A. (2010). Harm reduction therapy: A practice-friendly review of research. Journal of Clinical Psychology, 66(2), 201–214. https://doi.org/10.1002/jclp.20669 

Meier, P. S., Barrowclough, C., & Donmall, M. C. (2005). The role of the therapeutic alliance in the treatment of substance misuse: A critical review of the literature. Addiction, 100(3), 304–316. https://doi.org/10.1111/j.1360-0443.2004.00935.x

Miller, W. R., & Rollnick, S. (2023). Motivational interviewing: Helping people change and grow (4th ed.). Guilford Press.

Substance Abuse and Mental Health Services Administration. (2020). Substance use disorder treatment for people with co-occurring disorders. Treatment Improvement Protocol (TIP) Series, No. 42. SAMHSA Publication No. PEP20-02-01-004.

Waller, R. C., Boyle, M. P., & Daviss, S. R. (Eds.). (2023). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring conditions (Vol. 1: Adults) (4th ed.). Hazelden Publishing.

Updated May 20, 2026 18:05