Transcript Substance Use Disorders.

DSM-5 in Action:
™
Diagnostic and Treatment Implications
Section 2, Chapters 5–13
PART 2 of Section 2
Chapters 8–16
by Sophia F. Dziegielewski, PhD, LCSW
© 2014 S. Dziegielewski
© 2014 S. Dziegielewski
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Substance Abuse: viewed as the less severe,
continued use knowing it is causing harm, does not
apply to caffeine and nicotine
Substance Dependence: taking larger amounts with
unsuccessful attempts to quit
Substance Intoxication: the development of a
substance-specific (reversible) syndrome, condition
related to recent ingestion of psychoactive
substance
Substance Withdrawal: follows termination of a
psychoactive substance (Abstinence Syndrome)
© 2014 S. Dziegielewski
Types of Substances Include:
alcohol, amphetamines, cocaine, caffeine,
hallucinogens, inhalants, nicotine, opioids,
phencyclidine (PCP), cannabis, and
sedatives-hypnotics-anxiolytics
 Be sure the relationship between
dependence and withdrawal is noted
 Almost always when dependence is an issue
treat the substance first
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DSM-IV-TR, Polysubstance
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Dependence Intoxication Withdrawal
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No such diagnosis of polysubstance abuse
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Uses at least THREE different classes of substances
indiscriminately and does not have a favorite drug
that qualifies for dependence alone.
All three used in the same 12-month period.
Polysubstance dependence use only when the
pattern of multiple drug use is such that it fails to
meet the criteria for dependence on any one class
of drug.
In such settings, the only way to assign a diagnosis
of dependence is to consider all the substances
that the person uses taken together as a whole.
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An individual for a year or more has the pattern:
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Smokes crack
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Illegal sedative use regularly
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Smokes several joints a day to level out
This diagnosed is reserved for:
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Uses at least three substances indiscriminately
together, no drug of choice, none predominate
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Meets criteria for substance dependence when
taken together as a whole, not separately
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Use over a 12-month period
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The work group retitled the category
Substance-Related and Addictive
Disorders.
The work group had extensive discussions
on the use of the word addiction and the
phrase Medical Necessity for Chronic Pain.
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Alcohol-Related Disorders
Caffeine-Related Disorders
Cannabis-Related Disorders
Hallucinogen-Related Disorders
Inhalant-Related Disorders
Opioid-Related Disorders
Sedative- Hypnotic- or Anxiolytic-Related Disorders
Stimulant-Related Disorders
Tobacco-Related Disorders
Other (or Unknown) Substance-Related Disorders
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Non-Substance-Related Disorders—Gambling Disorder
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Want to avoid using the label “dependence”
when compulsive, out-of-control drug use
remains problematic.
Clients with normal tolerance and
withdrawal are often labeled addicts.
This has resulted in withholding adequate
doses of opioids for severe pain because of
fear of producing addiction.
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If medically prescribed as part of pain
management it will not be considered a
substance disorder.
The presence of tolerance and withdrawal
symptoms (numbers 10 and 11 of the
criteria) will not be counted for the
diagnosis of substance use disorder when
occurring in the context of appropriate
medical treatment with prescribed
medications.
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The word dependence will be limited to
physiological dependence only, recognizing
this is often a normal response to repeated
doses of many medications, including betablockers, antidepressants, opioids, antianxiety
agents, and other drugs.
Tolerance and withdrawal symptoms are NOT
counted as symptoms for the diagnosis of
substance use disorder when occurring in the
context of appropriate medical treatment with
prescribed medications.
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Combine Abuse and Dependence into one
category —Substance Use Disorders.
This new category will have graded clinical
severity.
Elimination of “Legal Problems Criterion for
Substance Use Disorder Diagnosis.”
Add criteria for CRAVING— defined as a
strong desire for a substance, tending to be
present on the severe end of the severity
spectrum.
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Can include all 10 substances except Caffeine
Alcohol
Cannabis
Hallucinogens (Phencyclidine, other hallucinogens)
Inhalants
Opioids
Sedatives/hypnotics/anxiolytics
Stimulants (cocaine, etc.)
Tobacco
Other or Unknown
© 2014 S. Dziegielewski
A maladaptive pattern of substance use leading to
clinically significant impairment or distress, as
manifested by two (or more) of the following,
occurring within a 12-month period:
There are 11 areas identified, and the individual
must have two or more. (SERIES OF SLIDES TO
FOLLOW WILL SHOW 11 AREAS.)
Identify the Severity specifiers:
◦ Mild 2 or 3 of the 11 criteria are positive
◦ Moderate 4 or 5 of the 11 criteria are positive
◦ Severe 6 or more
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Noted over four areas:
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Impaired Control (Numbers 1-4)
Social Impairment (Numbers 5-7)
Risky Use (Numbers 8-9)
Pharmacological Criteria (10-11)
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A maladaptive pattern of substance use
leading to clinically significant impairment or
distress, as manifested by two (or more) of
the following, occurring within a 12-month
period:
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1. The individual may take the substance in
larger amounts or over a longer period of time
than originally intended.
2. A persistent desire to cut down or regulate
the substance with multiple unsuccessful
attempts to regulate, decrease of discontinued
use.
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3. Excessive time obtaining the substance,
using the substance, or recovering from its
effects.
4. In more severe substance use, virtually all of
the individual’s daily activities revolve around
the substance; craving is manifested with an
intense desire or urge for the drug that may
occur at any time but more likely when in an
environment where the drug previously was
obtained or used.
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5. Recurrent substance use may result in a
failure to fulfill major role obligations at work,
school, or home.
6. Continues using despite recurrent social or
interpersonal problems caused by or
exacerbated by the effects of the substance.
7. Important social or occupational recreational
activities may be given up or reduced because
of substance use.
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8. May take the form of recurrent substance
use in situations where it is physically
hazardous.
9. The individual my continue substance use
despite knowledge of having physical/
psychological problems that are likely to be
caused or exacerbated by the substance.
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10. Tolerance, as defined by either of the
following:
◦ A need for markedly increased amounts of
the substance to achieve intoxication or
desired effect.
◦ Markedly diminished effect with continued
use of the same amount of the substance.
(Does not include medications taken
under medical supervision.)
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11. Withdrawal, as manifested by either of the
following:
 A syndrome that occurs when blood or tissue
concentrations of a substance decline in an individual
who has maintained prolonged heavy use of the
substance.
 Needs to consume the substance to relieve the
symptoms.
a. The characteristic withdrawal syndrome for the
substance as defined in each class can vary across
the substance used.
b. The same (or a closely related) substance is taken
to relieve or avoid withdrawal symptoms
(Note: Does not include medications taken under medical
supervision.)
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Severity specifiers:
Mild: 2 or 3 criteria positive
Moderate: 4 or 5 criteria positive
Severe: 6 or 7 criteria positive
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In early remission
 In sustained remission
 In a controlled environment
 With perpetual disturbances
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Further breakdown to ensure each
drug will have its own category
Discontinuation syndromes: related to
TCAs and the SSRIs
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Nonsubstance Addictions to be added
include:
Gambling disorder (currently called
pathological gambling, under impulse
control disorders).
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Internet Gaming Disorder is in Section
3 for further study.
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Uses increasingly higher amounts of the drugs
over time in order to achieve the same drug
effect
Finds that the same amount of the drug has
much less of an effect over time than before.
After using several different drugs regularly, an
individual may find that he or she needs to use at
least 50% more of the amount he or she began
using in order to get the same effect
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Interference with Daily Activities: Reduction
because of drug use affecting the amount of
time involved in recreational activities, social
activities, or occupational activities. Uses
drugs instead of engaging in hobbies,
spending time with friends, or going to work.
Inability to Stop Using: Unsuccessfully
attempted to cut down or stop using the
drugs or persistent desire to stop using.
Despite efforts to stop using drugs on
weekdays, he or she is unable to do so.
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Clearly identify the addictive disorder
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Gather a comprehensive history
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Identify problems or factors to ensure client safety.
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Formulate a plan of action to address the problem
areas.
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Establish a plan for monitoring and follow-up.
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Develop a support system that will assist in
addressing problem behaviors.
*Note severity of the disorder and how it interferes with
functioning.
*Note medical factors, risk behaviors, and peer family and
social supports.
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Axis I
Alcohol dependence with physiological dependence 303.90.
Cocaine dependence 304.20.
Cannabis abuse 305.20.
Axis II:
V71.09 No diagnosis.
Axis III: Liver cirrhosis, history of seizures, Allergy to sulfa drugs.
Axis IV: 1. Multiple legal problems with possible incarceration.
2. Medical concerns, chronic and debilitating conditions.
3. Occupational difficulties with loss of career and current
unemployment.
4. Inadequate support system, with substance-using peers.
5. Marital conflict with current separation of 1 year.
6. Social isolation.
7. Lack of housing.
Axis V: 45 (current).
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How to document in DSM-5
© 2014 S. Dziegielewski
Substance Use Disorders
 Record the specific substance.
 When using other substance use disorder,
document the substance in brackets.
 (e.g., mild anabolic steroids)
 If unknown substance, code it unknown.
 The word addiction is deleted from the “use”
category (not recommended, although some
use it to document severe forms)
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Alcohol Use Disorder (principal diagnosis)
Cocaine Use Disorder (principal diagnosis?)
Liver Cirrhosis (another medical condition)
History of Seizures (patient self-report).
List Relevant V or Z Codes
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Alcohol Use 303.90 (F10.20) Moderate (has
4-5 symptoms) (principal diagnosis)
Cocaine (Stimulant Use Disorder) 305.60
(F14.10) Mild (has2-3 symptoms)
Cannabis Use Disorder 305.20 (F12.10) Mild
(has 2-3 symptoms)
Any Other Conditions That May Be the Focus
of Clinical Attention
© 2014 S. Dziegielewski