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Section XV: Addressing the Complexities - Substance Use Disorders


Statistic: Alcohol use is the fourth leading source of disease burden in established market (Murray & Lopez, 1996).


Statistic: Approximately 15 percent of all adults who have a mental illness in any given year also experience a co-occurring substance abuse disorder, which complicates treatment (SGRMH, 1999). 

We have addressed some of the major changes from the DSM-IV-TR to the DSM-5 with regard to addiction and substance use: 1) the discontinuation of the distinction between substance abuse and substance dependence - all problems related to the use of psychoactive substances are now considered Substance Use Disorders; 2) The discontinuation of the diagnosis for Polysubstance Abuse - clinicians must now list each of the substances being misused by the client in order to provide a more complete clinical picture. 

We have also mentioned the addition of three new disorders, based upon updated thinking from research: 1) Tobacco Use Disorder; 2) Cannabis Withdrawal; 3) Caffeine Withdrawal.  

With the movement towards a separate diagnosis for each substance that is being misused, it is now important to review the guidelines for each substance carefully. There will be separate guidelines for substance intoxication, substance withdrawal, and substance use problems that will present with different levels of severity. In general, a determination of the level of severity for substance use problems will be based upon the presence of the following symptoms within any 12-month period:


Substance Use Disorder Signs and Symptoms

(1) The substance is often taken in larger amounts or over a longer period than was intended.

(2) There is a persistent desire or unsuccessful efforts to cut down or control use of the substance.

(3) A great deal of time is spent in activities necessary to obtain the substance, use the, or recover from its effects.

(4) Craving, or a strong desire to use the substance.

(5) Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home.

(6) Continued use of the substance despite having persistent or recurrent social or interpersonal problems cause or exacerbated by the effects of the substance.

(7) Important social, occupational, or recreational activates are given up or reduced because of use of the substance.

(8) Recurrent use of the substance in situations in which it is physically hazardous.

(9) 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.

(10) 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.
(11) Withdrawal, as manifested by either of the following:
        (a) The characteristic withdrawal syndrome for the substance
        (b) The same substance is taken to relieve or avoid withdrawal symptoms.

The presence of 2-3 symptoms indicates a Mild severity level, 4-5 symptoms indicate a Moderate severity level, and 6 or more symptoms indicate a Severe level of severity. There are also some important specifiers related to substance use disorders and the level of remission. If remission has been attained for more than 3 months but less than 12 months, then the specifier “In early remission” would be used. If remission has been attained for more than 12 months, then the specifier “In sustained remission” would be indicated.

If the remission for the use of the substance has been generated while the client is in an environment in which access to the substance is limited or restricted, it would also be appropriate to utilize the following specifier: “In a controlled environment”. This may provide a clearer picture of whether the remission of the problem is primarily attributable to the increased relapse prevention capabilities of the client, or whether the remission has been achieved in an environment that provides additional support for abstinence.

If the substance in question is an opioid, an additional specifier must be considered: “On maintenance therapy”. This specifier is used in two different situations. First, if a client is taking a prescribed opioid agonist, such as methadone, for conditions such as chronic pain, and the development of symptoms of tolerance / withdrawal occurs without any of the other conditions being met for a substance use disorder, then this specifier would be appropriate to best describe the nature of the problems that occur with the use of an addictive substance for medical purposes.

Second, this specifier is applicable in situations where a client has entered treatment for opioid misuse, and maintenance therapy is being used to prevent a return to a full-blown opioid use disorder. This specifier may be used if the client is being maintained on a partial agonist (e.g., methadone), an agonist/antagonist, or a full antagonist such as Naltrexone. Because some of the substances used for maintenance therapy may themselves be abused, having this information in the client’s chart has important implications for the client’s medical and legal status.

This specifier may also be used for clients who are attempting to discontinue the use of tobacco and who are using nicotine replacement medication. This specifier is appropriate if the only symptoms present are tolerance or withdrawal - without any of the other conditions being met for a substance use disorder. Given that Tobacco Use Disorder is a new diagnosis, it will require some time and practice to learn and understand the diagnosis complications for this substance use problem.

There are two other important complications to be found in this section of the DSM-5. First, the Diagnosis of Other (or Unknown) Substance-Related Disorders (Use Disorder, Intoxication, or Withdrawal) may be somewhat more likely to be needed at some point in a clinician’s career. There has been a profound increase in the numbers and types of designer drugs that are currently being used and misused in the club drug scene. The precise chemical formulation and the potential effects of these substances may not be known by the client and fully understood by the clinician.

In such instances, a diagnosis of Other (or Unknown) Substance Use Disorder (F10.10 – Mild; F10.20 – Moderate or Severe) would be noted in the record if the use of the substance was ongoing. For Withdrawal, the ICD-10 diagnosis would be F19.239, and for Intoxication F19.129 for Mild, F19.229 for Moderate or Severe.

The diagnosis of Gambling Disorder has also been included in this section of the DSM-5, reflecting a belief that problems with gambling are similar enough in nature to substance use disorders that they may be considered a form of addictive behavior. While this diagnosis was not added without some controversy, it is a diagnosis that must be known in the current clinical environment.

In addition to the specifiers applied to other diagnoses in this section, there are two specifiers unique to Gambling User Disorder. Clinicians are asked to specify if the problem is Episodic (symptoms subsiding between periods of gambling) or Persistent (continuous symptoms to meet criteria for multiple years).


The DSM outlines the following diagnostic criteria for substance abuse.


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, DUI convictions)
(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). 

Substance dependence is defined based on the particular substance used, such as alcohol, cocaine, heroin, etc. Each type of substance dependence has a different code found in the DSM-IV. Substance dependence often co-occurs with other mental illnesses, so it is important to thoroughly assess each patient. It is also important to list each substance being abused separately, with the substance most actively being abused listed as the first diagnosis.

This raises the other common area of confusion in the diagnosis of substance abuse or dependence. When is it appropriate to utilize the diagnosis for 304.80, polysubstance dependence, versus listing separately each substance being abused by the patient? 

Typically, polysubstance dependence is only used as a diagnosis when a dependence on drugs or alcohol has been established, but the patient has not established a clear preference for any one substance over the others. In such cases, the patient will often seek out any substance that is available, rather than seeking out one or two preferred drugs of choice.