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Substance-Related Disorders
Includes:
Drugs (or alcohol) of abuse
Side effects of a medication
Toxin Exposure
Substance-Related Disorders
Substance refers to a
drug of abuse,
medication,
or
toxin
Substance-Related Disorders
Volatile substances (paint, fuel) are classified as inhalants if used for intoxication; they are toxins if exposure is accidental or part of intentional poisoning.
Substance Dependence
A cluster of
cognitive symptoms,
behavioral symptoms,
and
physiological symptoms
Substance Dependence
indicating that the person continues to use the substance despite significant substance-related problems.
Substance Dependence
Tolerance, withdrawal, and compulsive drug-taking behavior may result.
Substance Dependence
Substance Dependence can apply to every class of substance except caffeine.
Substance Dependence
Heavy users of opioids (Heroin) and stimulants can develop substantial tolerance (e.g. 10-fold), often to a dosage that be lethal to a nonuser.
Substance Dependence Remission Specifiers
Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy
In a Controlled Environment
Substance Dependence Remission Specifiers
Agonist: a drug that has the same or similar effect as another drug or group of drugs.
Partial agonist: A drug with lower intrinsic activity than a full agonist produces a lower maximum effect.
Substance Dependence Remission Specifiers
Antagonist: a drug that counteracts the effect of another drug or group of drugs.
Mixed agonist/antagonist: A drug that both has the same or similar effect as another drug or group of drugs and to some extent counteracts that effect.
Criteria for Substance Dependence
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
Criteria for Substance Dependence
(1) tolerance, as defined by either of the following: (a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect (b) markedly diminished effect with continued use of the same amount of the substance
Criteria for Substance Dependence
(2) Withdrawal, as manifested by either of the following: (a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances) (b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
Criteria for Substance Dependence
(3) the substance is often taken in larger amounts or over a longer period than was intended
(4) there is a persistent desire or unsuccessful efforts to cut down or control substance use
Criteria for Substance Dependence
(5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
(6) important social, occupational, or recreational activities are given up or reduced because of substance use
Criteria for Substance Dependence
(7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
Criteria for Substance Dependence
Specify if:
With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is present)
Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present)
Criteria for Substance Dependence
Course specifiers (see text for definitions):
Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy
In a Controlled Environment
Betel Nut
Betel nuts are chewed and harvested by millions of people from India, Vietnam, Sri Lanka, Indonesia, Philippines, Marianas, American Samoa, Beleau, Bangladesh.
Betel chewing has been claimed to produce a sense of well-being, euphoria, heightened alertness, sweating, salivation, a hot sensation in the body and increased capacity to work.
Betel chewing produces an increase in heart rate, blood pressure, sweating and body temperature.
Betel chewing also leads to habituation, addiction and withdrawal. Betel chewing is addictive, and some practicioners consume vast quantities of the drug.
When consumed on a regular basis betel chewing is likely to have harmful effects on health including cancers of the stomach and mouth and damage to gums.
Criteria for Substance Abuse
A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
Criteria for Substance Abuse
(1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
(2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) (3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
(4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of Intoxication, physical fights)
Criteria for Substance Intoxication
A. The development of a reversible substance-specific syndrome due to recent ingestion of (or exposure to) a substance.
B. Clinically significant maladaptive behavioral or psychological changes that are due to the effect of the substance on the central nervous system (e.g., belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or occupational functioning) and develop during or shortly after use of the substance.
C. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
Substance Intoxication
The expectations of the person as to the substance’s effects can affect the clinical picture.
Substance Withdrawal
A. The development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and prolonged.
Substance Withdrawal
B. The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Substance Withdrawal
C. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
When possible, use additional sources of information (medical records, a spouse, relative, or close friend) when diagnosing Substance Dependence.
When criteria for more than one Substance-Related Disorder are met, the diagnosis of Polysubstance Dependence should NOT be used. Specify individual substances instead – Opioid Dependence, Alcohol Dependence,….
Intoxication with amphetamines or cocaine Increased Blood Pressure Respiratory Rate Pulse Body Temperature
Intoxication with sedative, hypnotic, anxiolytic substances or opioid medication Decreased Blood Pressure Respiratory Rate Pulse Body Temperature
Anxiolytic drugs are drugs having anti-anxiety effects. They are sometimes referred to as minor tranquilizers.
Use the code that applies to the class of substances, but record the name of the specific substance rather than the name of the class. 292.0 Secobarbital Withdrawal instead of: 292.0 Sedative, Hypnotic, or Anxiolytic Withdrawal
292.0 Heroin Withdrawal instead of 292.0 Opioid Withdrawal
When taken as prescribed, specific medications can be coded by listing the appropriate E-code on Axis I. I. 292.81 Tamazepam-Induced Delirium E939.4 Tamazepam II. V71.09 No diagnosis
Impaired sleep can be seen for months after a person with Alcohol Dependence stops drinking.
Once criteria for Substance Dependence are met, a subsequent diagnosis of Substance Abuse cannot be given for any substance in the same class. For a person with Substance Dependence in full remission, any relapses that meet criteria for Substance Abuse would be considered Dependence in partial remission.
On Jan 1, 2007, Marty has this diagnosis: I. 304.00 Heroin Dependence, Sustained Full Remission (Notice the specific substance is written instead of Opioid) meaning no criteria for Dependence or Abuse have been present for over 12 months. What is wrong with this diagnosis?
Hint?
See top of page 271 of the DSM-IV-TR,
What is missing?
It is missing the specifier of With Physiological Dependence or Without Physiological Dependence
On Jan 1, 2007, Marty has this diagnosis: I. 304.00 Heroin Dependence, Without Physiological Dependence, Sustained Full Remission
We would know that Marty has not met any of the criteria for Dependence or Abuse for at least the past 12 months and that he is not on Methodone maintenance.
Let’s say he abuses prescription cough medicine (opioid) on Feb 1, 2007 for two weeks but is not physiologically dependent to the codeine in the cough medicine. If he is seen on Feb 15, 2007, the diagnosis changes, but Substance Abuse is not written, because he is abusing an opioid and Heroin is also an opioid. His diagnosis changes to:
I. 304.00 Heroin Dependence, Early Partial Remission, Without Physiological Dependence
Let’s say on March 1st, he begins using Heroin daily and this continues each day. You see him on May 8, 2007.
If he is seen on May 8, 2007, and once again meets the full criteria for Substance Dependence and physiological dependence, the diagnosis changes to:
I. 304.00 Heroin Dependence, With Physiological Dependence If he presented with intoxication from the Heroin at the interview the additional diagnosis of I. 292.89 Heroin Intoxication would be given.
If he begins to abuse alcohol along with continuing his Heroin use and meets alcohol abuse criteria, then the diagnosis would change to: I. 304.00 Heroin Dependence, With Physiological Dependence 305.00 Alcohol Abuse Note that since alcohol is a different class the additional abuse diagnosis would be written. Also note that Alcohol Abuse would likely be placed second in order.
I. 304.00 Heroin Dependence, With Physiological Dependence 305.00 Alcohol Abuse (Reason for Visit) If Marty visits your outpatient clinic on October 1, 2007 for alcohol abuse, (Reason for Visit) could be specified, although it seems arbitrary since you’d most likely be treating him for both diagnoses.
About 20%(or more) of those with Alcohol Dependence become permanently abstinent, usually following a severe life stress (pg 206).
Perhaps 10% of individuals with Substance Dependence commit suicide (pg. 207).
The children of individuals with Alcohol Dependence do NOT have a predisposition to developing Substance Dependence on all substances; they are only at higher risk for Alcohol Dependence (pg. 207).
