2.3 Stages and Patterns of Substance Use Disorders

Task C: patterns and stages, not one inevitable staircase

Domain I Task C asks counselors to identify behavior, patterns, and progressive stages of substance use disorders. Two different 'stage' languages show up in ADC prep, and mixing them is a common way to miss an item.

1. Use-pattern language describes what the substance use looks like: experimental, regular, harmful, dependent; binge versus daily. This is the behavior you hear in an intake.
2. Readiness-to-change language (Prochaska and DiClemente's transtheoretical model) describes how the person thinks about changing that behavior: precontemplation through maintenance.

A person can be in a dependent pattern and still be in precontemplation. A person can binge only on weekends and already be in action. Pattern ≠ stage of change. Keep them on separate maps.

A third language — Jellinek's progressive phases of alcoholism — is historical. Treat it as context about how the field once narrated alcohol problems, not as the diagnostic system you use in 2026.

Experimental, regular, harmful, and dependent patterns

These labels are descriptive. They help you hear a history. They are not extra DSM-5-TR diagnoses, and they are not ASAM levels of care. Diagnosis and placement belong to Domain II. Task C is asking whether you can recognize the pattern in a vignette.

Experimental (or initiation) use is limited, often curiosity- or peer-driven, with little or no accumulated harm. A single trial of cannabis at a party, or two beers at a wedding for someone who does not otherwise drink, sits here. Experimentation is still not risk-free: a first-time opioid or a first binge can cause overdose or a crash. 'Experimental' describes frequency and intent, not safety.

Regular (or habitual) use is repeated and patterned — Friday nights, after work, every payday — without the counselor yet having clear evidence of a full dependence syndrome. Regular use may still be culturally normal in the client's group. Your job is not to moralize Friday-night beer. Your job is to ask what the pattern costs and whether control is slipping.

Harmful use (language that tracks older ICD 'harmful use' ideas and everyday clinical speech) is recurring use that is already producing health, legal, occupational, or relationship damage. Blackouts, a second DUI, pancreatitis, missing rent, or using at work can appear here even if the person still believes they 'can stop anytime' and even if withdrawal is not yet prominent. Harmful use is the pattern many court-referred clients present with: the system saw the harm before the client accepted a disorder label.

Dependent use is compulsive, hard to control, and organized around obtaining and recovering from the substance. Tolerance, withdrawal or relief use, craving, and continued use despite harm cluster here. This pattern is what NIDA's 'addiction' language and a severe SUD picture look like in behavior. Do not wait for a stereotyped 'rock bottom' to name it.

Worked vignette: Priya drinks nothing Monday to Thursday, then consumes a bottle of wine plus shots every Friday and Saturday, has been late to work twice after blackouts, and still says she is a social drinker. That is a harmful binge pattern, not experimental use, and not proof of daily physical dependence. If she also shakes on Sunday nights, you may be seeing dependence features on a binge schedule — still Task C, and a reminder that 'I don't drink daily' is not a clean bill of health.

Binge versus daily patterns

Daily (or near-daily) use is frequent, often morning-to-night in advanced alcohol or opioid dependence, and is the pattern families recognize as 'they always have to have it.' Physical dependence and withdrawal are easier to spot because the interval without the substance is short.

Binge use is episodic high-quantity use with days of little or no use in between. NIAAA describes binge drinking in quantity terms for alcohol (a pattern that brings blood alcohol concentration to 0.08% or above — commonly about 4 drinks for women or 5 for men in about 2 hours). For other drugs, 'binge' means a run: a methamphetamine weekend, a cocaine night, a cluster of opioid pills after a paycheck. Binges produce acute medical risk (overdose, trauma, cardiac events, unsafe sex) even when Tuesday looks abstinent.

Exam trap: an option that says only daily use can be a substance use disorder is false. DSM-5-TR diagnosis (Domain II) is about criteria met, not about a calendar that is full every day. Task C still wants you to name binge versus daily because withdrawal timing, overdose risk, and the story the client tells ('I only use on weekends') all change with the pattern.

Another trap: treating binge as 'less serious' than daily. A weekend fentanyl binge can kill; daily cannabis may not. Seriousness follows substance, dose, route, and context, not the adjective 'daily.'

Jellinek-style progression — historical context, not diagnostic gospel

E. M. Jellinek's mid-20th-century work on alcoholism, including phase models taught for decades in counselor education (often summarized as prodromal, crucial, and chronic phases, with increasing loss of control, blackouts, and organic damage), shaped how many programs still talk about 'progressive disease.' Students met charts that showed a descending curve from social drinking to death unless the person hit bottom and recovered.

Use that history correctly:

• It captured a pattern some people with alcohol problems actually lived: more loss of control, more consequences, worse health over time.
• It is not the current diagnostic system. DSM-5-TR uses 11 criteria, severity bands (mild 2–3, moderate 4–5, severe 6+), and course specifiers. Those details are Domain II. Do not grade a 2026 vignette by asking which Jellinek phase it is.
• It is not true that every SUD follows one staircase. Cannabis, stimulants, and alcohol can plateau, remit, relapse, or shift patterns. Some people never match the old 'chronic skid-row' picture and still meet severe SUD criteria.
• 'Progressive' on the ADC blueprint means counselors should recognize that use patterns can worsen and that stages can be described. It does not mean you must apply Jellinek as gospel.

If an item offers Jellinek phases as if they were DSM, treat that option as historical teaching, not current diagnosis. If an item asks what 'progressive stages' meant in older alcoholism education, you can name the phase idea — then return to patterns and stages of change for clinical work.

Prochaska and DiClemente: stages of change

The transtheoretical model (Prochaska, DiClemente, and colleagues) is the readiness map IC&RC samples. Counselors use it to match interventions to the person's current stance, not to the counselor's urgency.

Relapse or recurrence is often drawn as a loop back to an earlier stage, not as a separate personality type and not as proof that treatment 'failed forever.' Termination (some versions) means the person has high confidence and low temptation; many SUD presentations never need that word on an exam item.

The IC&RC ADC sample item is the one to internalize without copying its wording as if it were your only vignette: a client is referred because of legal issues, disagrees with the referral, and does not see their (in their view, minimal) drug use as a problem requiring counseling. The keyed stage is precontemplation. The logic is the rejection of the problem and of the referral, not the presence of a court paper. Court pressure can put a precontemplative person in your office; it does not move them to action by itself. Action would require actual behavior change, not mere attendance.

Worked vignette: A probation officer refers Devin after a cocaine possession charge. Devin says it is 'just weekends,' friends exaggerate, and counseling is a waste of time. That is precontemplation. If Devin later says 'maybe the weekends are getting expensive, I will think about cutting down,' that is contemplation. If Devin schedules an intake and asks about evening groups starting next week, that is preparation. Showing up and stopping weekend use is action. Six months of the new pattern with a plan for high-risk Saturdays is maintenance.

Exam traps:

• Do not call precontemplation 'denial' as if it were a moral insult. It is a stage. Motivational work (Domain III) is built for it.
• Do not call court-mandated attendance 'action.' Action is change in the substance behavior (or the specific target behavior), not compliance with a waiting room.
• Do not confuse contemplation with preparation. Thinking about change is not a plan.
• Do not use Jellinek phases as if they were stages of change. One is an old alcoholism-progression story; the other is readiness.

Task C sits with Tasks A and B inside Domain I's 25% scientific-principles weight: first the brain, then who is vulnerable, then what the use looks like and whether the person is ready to treat it as a problem. Screening instruments and DSM criteria come next in Domain II — after you can already hear the pattern.