Department of Human Services (DHS)Division of Addiction Services (DAS)Information Systems Management Unit (ISM)
Data Entry Form on Paper for
Norman G. Hoffmann, Ph.D. All rights reserved - 2001
No part of these materials may be adapted, photocopied or reproduced in any form. Such duplication is a violation of copyright and constitutes unprofessional conduct.
LOCI-2R is to be used as an instrument for determination of Level of Care service for substance abuse patients within NJSAMS Real-time Web Based Data System only.
NJSAMS Training and Demonstration Site
http://samsdev.rutgers.edu/samstraining/mainhome.htm
NJSAMS Real-time Data System (Do not use training or demo. purposes)
https://njsams.rutgers.edu/samsmain/mainhome.htm
If you have any questions please call customer service at:-
Phone: 609-292-3331; 609-943-5905; 609-292-1466 or Fax: 609-292-1045
Email: or
Updated: 01/01/2011
Name of the client: ______
Date of Evaluation: ______
Dependence AbuseSubstance / D1 / D2 / D3 / D4 / D5 / D6 / D7 / A1 / A2 / A3 / A4 / Abuse(A1..A4)
Alcohol / A1=Role Obligations
Marijuana-Hashish / A2=Hazardous Use
Cocaine / A3=Legal Problems
Opioids / A4=Social Problems
Amphetemine(or)
Methamphetamines
Sedatives/Hypnotic/
Anxiolytic / Dependence (D1..D7)
Hallucinogens / D1=Tolerance
PCP / D3=Excessive Use
Inhalants / D4=Desire/Attempts to stop
Poly/Unspecified / D5=Times pent using
Club Drugs / D6=Sacrificing activities to use
Steroids / D7=Physical/Psychological consequences
Tobacco
Other:specify
If the client is not diagnosed and the counselors/Clinicians want to see the client meets any criteria from LOCI, check the box and click on “Continue LOCI” button.
DIMENSION 1: ACUTE INTOXICATION/WITHDRAWAL
____ a. There is no recent use; OR
____ b. No indication of acute intoxication or withdrawal problems.
LEVEL I-D – OUTPATIENT DETOXIFICATION
Status characterized by (a) and (b) and (c):
a. Minimal risk for severe withdrawal as evidenced by any of the following:
1. .CIWA-Ar < 8 after 8-24 hours of abstinence from alcohol; OR
2. Any recent use of sedative hypnotics was at therapeutic levels and not complicated by daily use of
a. alcohol or other drugs known to have a significant withdrawal syndrome; OR
3. withdrawing from therapeutic doses of sedative hypnotics, but no evidence of other active
a. alcohol/drug abuse or dependence, and withdrawal symptoms have responded to, or are likely to
b. respond to, substitute doses of sedative-hypnotics in the therapeutic range within 2 hours; OR
4. Injectable or smoked heroin has not been used daily for more than 2 weeks preceding admission or use of opiates is near the therapeutically recommended level; OR
5. Gradual detoxification of opioid maintenance therapy, or treatment for mild withdrawal symptoms; OR
6. Stimulant withdrawal with some lethargy, agitation, paranoia, mild psychotic symptoms, or depression,
but impulse control is good; OR
7. Nicotine withdrawal requires nicotine replacement therapies or non-nicotine agents for symptomatic
treatment.
AND
b. Has withdrawal symptoms, but is at minimal risk for severe withdrawal syndrome and is likely to
complete detoxification and enter continued treatment or self-help recovery as evidence by (1) and
either(2) or (3):
1. Willing to accept recommendation for treatment; AND
2. Adequate understanding of ambulatory detox and has commitment to enter treatment; OR
3. Has adequate support services to ensure commitment to detox and ongoing treatment.
AND
c. Shows positive response to emotional support and comfort as evidenced by both (1) and (2):
1. Has decreased emotional symptoms by close of the initial treatment session; AND
2. Patient and/or support person have clear understanding of instructions for care and both the ability and
Resources to follow these instructions.
LEVEL II-D – AMBULATORY DETOXIFICATION WITH EXTENDED ON-SITE MONITORING
Status characterized by (a) and (b) and (c):
a. Moderate risk of severe withdrawal syndrome outside the program setting; AND
b. Free of severe physical and psychiatric complications and would safely respond to several hours of
monitoring, medication, and treatment as evidenced by any of the following:
1. CIWA-Ar score of 8 to 15; OR
2. Current withdrawal from sedative hypnotics without evidence of other active alcohol/drug abuse or
Dependence. Withdrawal symptoms, have responded to, or should respond to substitute doses of
Sedative-hypnotics in the therapeutic range within the observable hours of the program; OR
3. Used sedative-hypnotics in excess of therapeutic levels daily for at least 4 weeks, but risk of seizures,
hallucinations, or other complications during unobserved periods outside th e program assessed as
minimal. Close hourly monitoring is available if needed. There are no accompanying chronic mental or
physical disorders posing a danger during withdrawal; OR
4. Used sedative-hypnotics at or below therapeutic levels daily for at least 6 months, in combination with
daily alcohol use or regular use of another drug known to have its own dangerous withdrawal syndrome.
nonetheless, risk of seizures, hallucinations, dissociation or severe affective symptoms outside the program
is minimal; OR
5. Opiate abstinence syndrome( vital signs, physical discomfort, or craving) can be stabilized by the end of
each day’s monitoring , so that such symptoms can be managed at home with appropriate supervision; OR
6. Opiate withdrawal signs and symptoms are of such severity or instability that extended monitoring is
Required to determine the appropriate dosage; OR
7. Stimulant withdrawal with significant lethargy, agitation, paranoia, psychotic symptoms, or depression
Requiring extended outpatient monitoring to determine impulse control; OR
8. No additional biomedical problems. AND
c. Patient is likely to complete detoxification and enter continued treatment or self-help recovery as evidenced
by meeting(1) and either(2) or (3) or (4):
1. Patient or support persons clearly understand instructions for care and are able to follow instructions; AND
2. Has an adequate understanding of ambulatory detoxification and has expressed commitment or enter such
a program; OR
3. Has adequate support services to ensure commitment to completion of detoxification and ongoing treatment or recovery; OR
4. Willing to accept a recommendation (e.g. attend outpatient sessions or self-help groups) for treatment once
Withdrawal has been managed.
LEVEL III.2-D - CLINICALLY MANAGED RESIDENTIAL DETOXIFICATION
Status characterized by both (a) and (b):
a. Not at risk for severe withdrawal, and moderate withdrawal is safely manageable at this level of surface as evidenced by any of the following.
1. Intoxicated or is withdrawing from alcohol and CIWA-Ar less than 8 at admission, and monitoring is available to assure that it remains below this level; OR
2. Opiate withdrawal signs and symptoms are distressing but do not require medication for reasonable withdrawal discomfort, and patient is impulsive and lacks skills needed to prevent immediate continued drug use; OR
3. stimulant withdrawal – marked lethargy, hypersomnolence, paranoia or mild psychotic symptoms, and these are still present beyond period of outpatient monitoring available in Level II-D
AND
b. Assessed as not requiring medication, but does require this level of service to complete detoxification and enter into continued treatment or self-help recovery because of inadequate home supervision or support structure as evidenced by meeting (1) or (2) or (3):
1. Lacks coping skills to deal with a recovery environment that is not supportive of detoxification and entry into treatment; OR
2. Has a recent history of detoxification at less intensive levels of service marked by inability to complete detoxification; OR
3. Recently has demonstrated an inability to complete detoxification at less intensive levels of service.
LEVEL III.7-D – MEDICALLY MONITORED INPATIENT DETOXIFICATION
Status characterized by either (a) or (b):
a. severe withdrawal risk that is manageable at this level of service as evidenced by any of the following:
1. CIWA-Ar score = 10 or greater by the end of the period of outpatient monitoring available in level II-D; OR
2. Daily use of sedative-hypnotics at more than therapeutic levels for more than 4 weeks and is unresponsive to appropriate efforts to maintain dose at therapeutic levels; OR
3. daily use of sedatives above a therapeutic level for more than four weeks, plus daily alcohol use of regular use of another drug known to pose a severe risk of withdrawal. Signs and symptoms of withdrawal are of moderate severity, and cannot be stabilized by the end of the period of outpatient monitoring available at Level II-D; OR
4. Marked lethargy or hypersomnolence due to intoxication with alcohol or other drugs, and a history of severe withdrawal, or the altered level of consciousness has not stabilized at the end of the period of outpatient monitoring available at level II-D; OR
5. Daily use of injectable opiates for more than two weeks and a history of inability to complete withdrawal as an outpatient or without medication at Level III.2-D; OR
6. Antagonist medication is to be used in withdrawal in a brief but intensive detoxification (as in multi-day pharmacological induction onto naltrexone); OR
7. Marked lethargy, hypersomnolence, agitation, paranoia, depression or mild psychotic symptoms due to stimulant withdrawal, and has poor impulse control and/or coping skills to prevent immediate continue drug use.
OR
__ b. This level of care is required to complete detoxification and enter into treatment or self-help recovery as evidenced by any of
the following:
1. Requires medication and has a recent history of detoxification at a less intensive level of care, marked by inability to complete detoxification. And enter into continuing addiction treatment, and continues to have insufficient skills or supports to complete detoxification; OR
2. Has a recent history of detox at a less intensive level of care, marked by inability to complete detox. And enter into continuing addiction treatment, and continues to have insufficient skills or supports to complete detox.; OR
3. Comorbid physical, emotional, behavioral or cognitive condition that increases clinical severity of the withdrawal and complicates detox. Is manageable in a Level III.7-D setting.
LEVEL IV-D – MEDICALLY MANAGED INTENSIVE INPATIENT DETOXIFICATION.
Patient must meet (a) or (b);
a. Risk of severe withdrawal as evidence by any of the following:
1. Alcohol withdrawal and CIWA-Ar score is 10 or greater. The patient requires: monitoring more often than hourly; intravenous medication or infusions; or close behavioral monitoring due to high levels of agitation, confusion or extremes of vital signs; OR
2. Alcohol and sedative-hypnotic withdrawal with seizures, delirium tremens or severe, persistent hallucinations; OR
3. Daily sedative-hypnotic use at more than therapeutic levels for more than 4 weeks, and has accompanying acute mental or physical disorder complicating withdrawal; OR
4. Daily sedative-hypnotic use for at least 6 months, in combination with daily alcohol use or regular use of another mind-altering drug known to pose a severe withdrawal syndrome, and accompanying acute mental or physical disorder complicating withdrawal; OR
5. Severe opiate withdrawal that has not been stabilized or managed at a less intensive level of service; OR
6. Antagonist medication is to be used in a rapid withdrawal ( as in pharmacological induction and resolution of opiate withdrawal with naloxone in 6 Hours; OR
7. Stimulant intoxication or withdrawal requires psychiatric or medical monitoring more frequently than hourly because of psychotic impulsive behavior or depressive suicidality; OR
8. Recent (within 24 hours) serious head trauma or loss of consciousness, with persistent mental status or neurological changes resulting in need for at least close hourly observation; OR
9. Drug overdose or intoxication has compromised patient’s mental status, cardiac function, or vital signs or functions; OR
10. Significant acute biomedical disorder poses substantial risk of serious or life-threatening consequences during withdrawal; OR
11. Drug overdose compromises mental status, cardiac functioning, or other vital signs.
OR
b. requires medical support and comfort care in this level of care for either of the following reasons:
1. Detoxification regimen or response to the regimen requires monitoring or intervention more frequently than hourly;
OR
2. Detoxification or stabilization is required while patient is pregnant until she can be safely treated in a less intensive
level of care.
DIMENSION 2: BIOMEDICAL CONDITIONS/COMPLICATIONS
There are no biomedical problems requiring attention.
GENERAL OUTPATIENT CRITERIA
(Levels I and II.1)
Status characterized by (a) and (b) and (c):
a. Any biomedical conditions are stable enough to permit outpatient treatment; AND
b. Biomedical problems will not interfere with treatment; AND
c. Biomedical problems do not warrant inpatient services.
LEVEL I- OUTPATIENT TREATMENT
Meets General outpatient criteria noted above plus:
Any clinical monitoring can be provided by this program with fewer than 9 hours of contact per week or through concurrent arrangement for medical care.
LEVEL II.1 – INTENSIVE OUTPATIENT TREATMENT
Meets General Outpatient criteria noted above plus:
Any medical monitoring or management can be provided by this program with 9 or more hours of contact per week or through concurrent arrangement for medical care.
LEVEL II.5 – PARTIAL HOSPITALIZATION
Status characterized by (a) and (b) and (c):
a. All biomedical conditions are stable enough to permit outpatient treatment; AND
b. Biomedical problems are severe enough to distract from recovery efforts but do not warrant inpatient treatment; AND
c. Medical monitoring and/or medical management can be provided in the partial hospitalization environment or through a concurrent arrangement for medical care.
LEVEL III.1 – CLINICALLY MANAGED LOW-INTENSITY RESIDENTIAL and
LEVEL III.3 – CLINICALLY MANAGED MEDIUM INTENSITY RESIDENTIAL TREATMENT
Status characterized by (a) or (b) or (c):
a. All biomedical conditions are stable, any required medical or nurse monitoring or management can be
provided at this level of care and any prescribed medications are self-administered; OR
b. Concurrent biomedical condition, though not severe enough to warrant inpatient treatment, will distract
from treatment or recovery efforts without medical monitoring provided by this program or through
established arrangement to provide necessary services; OR
c. This is a biomedical-enhanced program that can address the biomedical condition and provide necessary staff attention at this level of care.
LEVEL III.5 – CLINICALLY MANAGED HIGH-INTENSITY RESIDENTIAL TREATMENT
Status characterized by (a) or (b) or (c):
a. All biomedical conditions are stable, require less than 24-hour medical monitoring or management, and
any prescribed medications are self-administered; OR