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DLRS Home > Office of Substance Abuse > Chapter 2 Driver Education and Evaluation Programs Procedure Manual > Section L

Community Services Programs

Office of Substance Abuse - Chapter 2 Driver Education and Evaluation Programs Procedure Manual - Section L - Completion of treatment guidelines

Statement of purpose

This document sets forth a common framework within which community-based service providers of DEEP approved substance abuse services can evaluate, treat and recommend completion of treatment of persons suspended for operating under the influence. It presents criteria for classifying individuals according to their degree of progression in the disease of alcohol and/or other drug addiction and recommends appropriate treatment requirements. Consistent use of this framework should result in a uniform approach to the DEEP evaluation, referral and treatment process.

Although addicted persons share the characteristics of loss of control, they nevertheless differ in the degree to which they have progressed in their disease. This progression is a gradual worsening of the person's condition and an increasing dependence on, and involvement with substances. This continuum of change has often been conceptualized as a series of stages reflected in the physical, psychological, social, economic and other conditions of the person. The Guidelines follow this common practice by distinguishing four stages of dependence.....the early stage, the middle stage, the late and final stages, and the non-addicted stage of the problem user.

The number of negative consequences and the frequency and severity of occurrence of each consequence characterize each stage. The number, severity and frequency of negative consequences increase as the individual progresses from problem user to final stage.

The client's needs and thus the appropriate treatment response differ according to the client's stage in the progression. That is, a treatment approach that might be effective with a problem user may be completely ineffective with a person in the middle stage. Conversely what might be appropriate for a middle stage person might be entirely too intensive and restrictive for a problem user.

Clinical experience and knowledge of published studies generated the series of stages mentioned above. Client's needs are defined and matched to those general types of treatment most suited to meeting those needs. This establishes a guideline for the practitioner's use during the initial client clinical substance abuse evaluation. It also provides DEEP with a reference point for assessing evaluations.

Obviously, electing sufficient information about multiple areas of an individual's life is not always easy, especially when the individual may be consciously or unconsciously denying or minimizing the extent of his involvement with substances. It is critical to supplement information obtained from the substance abuser with information obtained from significant others. Thus the true pattern of the person's involvement with substances may only emerge after a somewhat lengthy series of interviews. This information may then be used to clarify the individual's degree of chemical addiction.

This is not a magic formula for classifying every individual unambiguously into one particular category. Rather, this system describes general patterns of behavior that usually are associated with a given degree of progression into alcoholism/other drug addiction. It provides a set of reference points for gauging an individual's degree of harmful involvement with substances. Based on these reference points, a suitable intensity and modality of treatment may be recommended.

The guidelines represent the appropriate number of contact hours necessary within a minimum time period for significant client improvement in each stage. However, chemical addiction is an illness that affects each individual differently. Each individual because of his/her own particular circumstances responds differently to required treatment.

Some problem users and chemically addicted clients may respond readily to recommended treatment. In these cases, the guidelines may require more treatment than necessary. However, if the client is completed prior to the recommended threshold the reason for recommending early completion must be justified in the status report or discharge summary. Other clients may not respond to treatment for a significant period of time resulting in the continued need for treatment beyond the recommended number of sessions and minimum time lines. When the counselor decides there is a need for continued treatment that may go beyond thresholds established by the Completion of Treatment Guidelines, the counselor is required by regulation to justify the extension of treatment.

The rest of this document is given over to delineating the typical problems and behaviors experienced by individuals in each of the identified stages. Associate with each stage is the treatment approach recommended by the Driver Education and Evaluation Programs (DEEP) as having the highest probability of successful outcome, without being overly restrictive. In an effort to reduce ambiguity, terms requiring precise definition are defined in the appendix of the document.

Salient Characteristics/Symptoms

1. PROBLEM USER

The most important distinguishing characteristic of this group is that they have not yet lost control over their use of drugs. Although there is always some risk of adverse consequences from drug use, most individuals do not experience such consequences, or experience them only infrequently and to a mild degree. Persons in this stage are focused on the short term and artificial benefits substance use appears to bring them. Typically, use is fostered by social pressure or by internal needs. The person may have turned to substance use to dull feelings of pain and insecurity. They may use chemicals as substitutes for other forms of satisfaction.

Interventions in this stage typically do not require intensive treatment approaches. Generally, individuals may require a bolstering of their self-esteem in order to better withstand peer pressure, and to inject more intrinsic satisfaction into their lives. These persons should also receive objective information on the effects of substance abuse and the long-term risks of continuing their pattern of use. Some individuals may have deep rooted underlying problems that may require intensive treatment, possibly including referral to specialized programs.

These less intensive treatment interventions can usually be accomplished in 6 outpatient contact hours spread over a 45-day period.

  1. PHYSICAL
    (1) Abuse of substance(s) four times or less per year
    (2) Risk of physical injury as a result of abuse
    (3) May be experiencing physical difficulties as a result of abuse
    (4) No physical addiction
    (5) Impairment four times or less per year as a result of substance abuse
  2. PSYCHOLOGICAL
    (1) Use of substance may eliminate ability to perceive harmful consequences
    (2) Abuse of substance has enabled the individual to learn that the substance may be used to relieve stress/problems
    (3) Harmful consequences may have resulted from abuse of substance
    (4) Individual justifies abusing substance four times or less per year
  3. SOCIAL
    (1) Possible financial, legal, housing, employment and/or educational difficulties as a result of substance abuse (less than several occasions)
    (2) Beginning difficulties with family and significant others as a result of abuse
    (3) Association with those who will accept and encourage use

2. Treatment Modality Recommended Duration and Frequency of Treatment

  1. Outpatient 6 contact hours over a 45-day period
  2. Elective aftercare


3. EARLY STAGE

The individual in this stage has become dependent upon the use of substances. It is likely that he/she has experienced loss of control over consumption of one or more substances. The person has begun to make psychological adjustments to minimize the appearance of substance use, and to ensure continued access to substances.

Many physical, economic and social problems experienced by the problem user have begun to worsen and new problems have arisen.

Generally the person is still employed, and still within an intact family. The involvement of significant others is an important component of the treatment process.

Treatment needs to overcome the person's denial, rationalization and minimization of his/her substance use. Education and awareness of the nature of substance abuse are also required. Once the denial has been overcome, the person must be given the tools required to live a life free from substance use. It is often necessary to provide counseling for the resolution of ancillary problems that have arisen due to the person's substance abuse.

In order to accomplish these tasks, a minimum of 12 contact hours over a 90-day period is recommended. Usually, successful treatment can be accomplished in an outpatient setting. Severe situational problems may justify residential services. As in all subsequent stages of the illness, the treatment agent should forge a link between the person and appropriate self-help group. An aftercare program is usually necessary to ensure continued maintenance of sobriety.

  1. PHYSICAL
    (1) Abuse of substance(s) more than four times per year
    (2) May experience physical injury as a result of abuse
    (3) Physical difficulties as a result of abuse
    (4) Physical addiction not readily evident
    (5) Possible unpleasant and/or fearful experiences with substance(s)
    (6) Loss of memory as a result of substance abuse
    (7) Tolerance increase (appropriate substances)
  2. PSYCHOLOGICAL
    (1) Dependence on substance to relieve stress/difficulties
    (2) Stress/difficulties as a result of substance use
    (3) Minimizes use/abuse of substance(s)
    (4) Attempts to control use/abuse of substance(s)
    (5) Frequent (more than four times per year) loss of control of quantity and frequency results in impaired judgment and reasoning ability
    (6) Increasing impatience, reliance and/or preoccupation with the use of substance(s)
    (7) Cause and effect of use, feelings and/or consequences projected onto other people, places and/or things
  3. SOCIAL
    (1) Has experienced difficulties in the area of financial, legal, housing, employment and/or education several times as a result of substance(s) abuse
    (2) Difficulties with family and significant others as a result of substance abuse
    (3) Seeks out those who will accept and encourage substance abuse
    (4) Seeks out social activities to include substance abuse situations

4. Treatment Modality Recommended Duration and Frequency of Treatment

  1. Outpatient 12 contact hours over a 90-day period
  2. Aftercare

5. MIDDLE STAGE

Individuals in this stage are still maintaining some elements of a "normal" affiliation with society. However, their substance abuse has become a primary component of their life and affects every area of it. Substance abuse has become almost a prerequisite for feeling "normal." Problems in all areas of living are more numerous and more severe than in earlier stages.

It is possible that individuals in this stage may require detoxification to rid their bodies of toxic effects of substance abuse prior to participating in counseling. Given the severity of their problems, a longer and more intensive period of treatment is required. Some persons with a relatively intact and supportive home environment may only require outpatient services. These should consist of at least 18 contact hours over a 120-day period. Persons living in a deteriorated environment, or with physical problems requiring some supervision, or with more severe psychological or social problems, may require residential treatment.

Aftercare programs geared to the person's needs are strongly recommended and may be required for as much as two years following initial treatment.

  1. PHYSICAL
    (1) Established pattern of abuse of substance(s) more than four times per year
    (2) May be experiencing physical injury/disorders as a result of repeated abuse
    (3) Experiencing unpleasant/fearful experiences with substance(s)
    (4) Tolerance change (appropriate substances)
    (5) Physical addiction may be evident
    (6) Frequent (more than four times per year) loss of memory
    (7) Frequent (more than four times per year) incapacitation as a result of an established pattern of abuse.
  2. PSYCHOLOGICAL
    (1) Dependence on substance(s) as primary means of coping
    (2) Dependence on substance(s) to relieve stress and negative feelings
    (3) Stress/difficulties as a result of abusing substances(s)
    (4) Established pattern of loss of control of quantity and frequency
    (5) Further impairment of judgment and reasoning abilities
    (6) Inability to discriminate different feelings
    (7) Denial/rationalization of substance(s) abuse
    (8) Established pattern of substance(s) abuse to maintain feeling of "normalcy"
    (9) Projection onto other people, places and/or things
  3. SOCIAL
    (1) Serious difficulties with family and significant others as a result of repeated substance(s) abuse
    (2) Several problems in areas such as financial, legal, housing, employment and educational as a result of substance(s) abuse
    (3) Changes in social relationships that allow repeated substance abuse
    (4) Social activities generally limited to substance using situations

6. Treatment Modality Recommended Duration and Frequency of Treatment

  1. Possible detoxification 18 contact hours over 120-day period
  2. Day Residential Rehabilitation or
  3. Residential Rehabilitation Completion of a Residential Rehabilitation Program
  4. Outpatient and
  5. Aftercare 4 contact hours over a 30-day period

7. LATE STAGE

This person's entire life typically revolves around substance use and abuse. The person displays continual use of substances and many chronic physical symptoms of such use. Psychologically, his cognitive and emotional states are dulled and confused by substance use. Usually the person has lost the defensive denial or rationalization of substance abuse found in earlier stages. Normal social and other relations have been seriously disrupted.

Treatment in this stage almost always requires detoxification due to the patterns of substance abuse. This should be followed by residential rehabilitation. If the person has experienced many treatment contacts and requires more extensive treatment, halfway house treatment is recommended. This should be followed by 6 contact hours over a
45-day period from discharge.

If the person has not had prior treatment experience and has some family or social supports, halfway house treatment may not be necessary. In this case, residential treatment should be followed up by 30 contact hours over a 180-day period of continuing outpatient treatment.

Continued aftercare is also recommended.

  1. PHYSICAL
    (1) Close prolonged abuse of substance(s)
    (2) Experiencing physical injury/disorders as a result of continual abuse
    (3) Unpleasant/fearful experiences become expected and tolerated
    (4) Physical addiction evident
    (5) Inability to tolerate substance(s) evident [appropriate substance(s)]
    (6) Prolonged loss of memory
    (7) Prolonged incapacitation
  2. PSYCHOLOGICAL
    (1) Substance(s) provide only means of (temporary) relief
    (2) Prolonged dependence on substance(s) to relieve stress and negative feeling
    (3) Substance(s) abuse without consideration of risks
    (4) Severe inability to identify different feelings
    (5) Severe confusion as evidenced by a state of disorder, embarrassment and failure to distinguish between personal values as a result of substance(s) abuse
    (6) Minimal denial or rationalization of substance(s) abuse
  3. SOCIAL
    (1) Serious disruption of relationships with family and significant others as a result of continual substance(s) abuse
    (2) Financial, legal, housing, employment and educational areas disintegrate as a result of continual substance(s) abuse
    (3) Withdrawal from social relationships except association with late and final stage abusers
    (4) Acceptance of prolonged substance(s) abuse

8. Treatment Modality Recommended Duration and Frequency of Treatment

  1. Late Stage A 
    (1) Detoxification
    (2) Residential Rehabilitation 21 to 30 days of residential rehabilitation and/or 3 to 6 months halfway house followed by
    (3) Halfway House
    (4) Outpatient
    (5) Aftercare 6 contact hours over a 45-day period after discharge from halfway house or one year documented sobriety
  2. Late Stage B 
    (1) Detoxification
    (2) Residential Rehabilitation 21 to 30 days of residential rehabilitation followed by 30 contact hours over a 180-day period.
    (3) Outpatient
    (4) Aftercare

9. FINAL STAGE

Individuals in this stage are not likely to have much opportunity to drive since their social and financial position is commonly so severely disrupted. They display continuous abuse of substances with accompanying life threatening physical deterioration. They are totally disengaged from society and their social world is restricted to fellow final stage abusers and the commercial and social systems that serve them.

Since these individuals are often homeless, they need shelter that may become a necessary part of the treatment plan. Detoxification is certainly necessary. This should be followed by extended care and then possibly by halfway house treatment. This should be followed by a period of outpatient contact prior to issuance of a renewed license to drive.

Given the extreme deterioration of these individuals, their treatment plans should be individually reviewed by DEEP staff with the approved provider.

  1. PHYSICAL
    (1) Abuse of substance(s) without voluntary interruption
    (2) Life threatening physical deterioration
    (3) Physical injury/disorders as a result of continuous abuse
    (4) Unpleasant/fearful experiences accepted
    (5) Physical addiction evident
    (6) Absence of tolerance to substance(s) [appropriate substance(s)]
    (7) Loss of memory for prolonged periods of time without interruption
    (8) Incapacitation without voluntary interruption
  2. PSYCHOLOGICAL
    (1) Complete dependence on substance(s) as a means of living
    (2) Substance(s) abuse without voluntary interruption or consideration of risks
    (3) Substance induced psychological deterioration
    (4) No denial or justification of abuse
    (5) Emotional disorganization
  3. SOCIAL
    (1) Complete disintegration of meaningful social relationships
    (2) Behavior acceptable to only final stage substance(s) abusers
    (3) Inability to be self-supporting as a result of continuous substance(s) abuse/chemical addiction
    (4) All resources, regardless of origin, are used to maintain continuous substance(s) abuse/chemical addiction
    (5) Unattached and may be transient

10. Treatment Modality Recommended Duration and Frequency of Treatment

  1. Shelter/Detoxification
  2. Extended Care
  3. Halfway House
  4. Outpatient
  5. Aftercare Individually reviewed by DEEP with the approved agency or provider.

Substantial treatment and/or self-help/aftercare involvement for an extensive period of time previous to completing.