Saturday, July 2, 2016

Substance Use Disorder

Not Substance Abuse v. Dependence

By Mario Antonio Pena Zapatería ( [CC BY-SA 2.0 (], via Wikimedia Commons

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is used by medical professionals to diagnose and classify mental disorders. More importantly for the sake of the Drunk Lawyer Blog, it is used to classify and diagnose those with drug and alcohol problems.

Prior to 2013, the DSM separated those drug and alcohol problems into either substance abuse or substance dependent. Individuals with at least one out of four possible symptoms could be diagnosed as alcohol abusers. An individual with at least three out of seven possible symptoms could be diagnosed as addicted.

The symptoms for substance abuse could be:
  1. Substance use resulting in a recurrent failure to fulfill work, school, or home obligations (work absences, substance-related school suspensions, neglect of children).
  2. Substance use in physically hazardous situations such as driving or operating machinery.
  3. Substance use resulting in legal problems such as drug-related arrests.
  4. Continued substance use despite negative social and relationship consequences of use.
The seven symptoms, at least three of which had to be met during a given 12-month period, for the diagnosis of substance dependence, were:
  1. Tolerance, as defined either by the need for increasing amounts of the substance to obtain the desired effect or by experiencing less effect with extended use of the same amount of the substance.
  2. Withdrawal, as exhibited either by experiencing unpleasant mental, physiological, and emotional changes when drug-taking ceases or by using the substance as a way to relieve or prevent withdrawal symptoms.
  3. Longer duration of taking substance or use in greater quantities than was originally intended.
  4. Persistent desire or repeated unsuccessful efforts to stop or lessen substance use.
  5. A relatively large amount of time spent in securing and using the substance, or in recovering from the effects of the substance.
  6. Important work and social activities reduced because of substance use.
  7. Continued substance use despite negative physical and psychological effects of use.
The DSM-5 no longer uses the terms substance abuse and substance dependence.  Instead it identifies substance use disorders. A substance use disorder can be mild, moderate, or severe to indicate the level of severity, which is determined by the number of diagnostic criteria met by an individual. 

Substance use disorders occur when the recurrent use of alcohol or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. According to the DSM-5, a diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria.

Impaired Control

  • Alcohol is often taken in larger amounts or over a longer period than was intended. 
  • There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
  • A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
  • Craving, or a strong desire or urge to use alcohol. 

Social Impairment

  • Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
  • Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
  • Important social, occupational, or recreational activities are given up or reduced because of alcohol use.  

Risky Use of the Substance

  • Recurrent alcohol use in situations in which it is physically hazardous.
  • Alcohol 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 alcohol.
Pharmacological Criteria

  • Tolerance, as defined by either a) a need for markedly increased amounts of
  • alcohol to achieve intoxication or desired effect, or b) a markedly diminished effect with continued use of the same amount of alcohol.
  • Withdrawal, as manifested by either a) the characteristic withdrawal syndrome for alcohol, or b) alcohol (or a closely related substance) is taken to relieve or avoid withdrawal symptoms
Mildly affected individuals have two or three symptoms, while moderately affected individuals have four or five. Physicians identify a severe substance use disorder in people with six or more symptoms of abuse/addiction.

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