Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

General Principles of Substance Use Disorders


DEFINITIONS OF SUBSTANCE USE DISORDERS AND DIAGNOSTIC EVALUATIONS

Although persons with a substance use disorder (SUD) use drugs or alcohol, using these substances does not necessarily mean that a given person meets SUD diagnostic criteria. Indeed, in 2012, the American Psychiatric Association’s Diagnostic and Statistical Manual, 5th Edition (DSM-5) set diagnostic phenomenological parameters for SUD diagnoses. These replace older diagnoses of substance abuse and substance dependence from the DSM’s previous editions.

DSM-5 definition of SUD: A maladaptive substance use pattern leading to significant impairment or distress. This definition is met when a person meets at least two of the following 11 diagnostic criteria within a 12-month period:

Loss of Control
1. Substance taken in larger amount or for a longer period than intended
2. Persistent desire or unsuccessful efforts to control or stop substance use
3. Craving or a strong desire or urge to use the substance
4. Use continues despite knowledge of resultant physical or psychological problems
5. Continued use in situations in which it is physically hazardous
Adverse Consequences
6. Great deal of time spent to obtain, use, or recover from effects
7. Use resulting in a failure to fulfill major role obligations
8. Continued use despite recurrent social or interpersonal problems
9. Use resulting in important social, occupational, or recreational activities given up or reduced
Physiological Dependence
10. Tolerance
11. Withdrawal

Note that for individuals developing tolerance or withdrawal to a medically prescribed substance, tolerance and withdrawal do not count in diagnosing a SUD.

SUD severity is assessed by the number of diagnostic criteria (2–3: mild; 4–5: moderate; 6 or more: severe), not by the severity of substance use or the severity of any individual criteria.

A SUD diagnosis can be further qualified as:

  • ■

    Early remission: When a person who previously met diagnostic criteria for SUD has not met any diagnostic criteria (except for craving) for longer than three months.

  • ■

    Sustained remission: When a person who previously met SUD, diagnostic criteria has not met any diagnostic criteria (except for craving) for longer than 12 months.

  • ■

    On maintenance therapy: When a person who previously met diagnostic criteria for SUD has not met any diagnostic criteria (except for tolerance or withdrawal) as a result of being prescribed maintenance medications (referring to full or partial agonists and antagonist medications such as naltrexone, buprenorphine, or methadone).

  • ■

    In a controlled environment: When a person who previously met diagnostic criteria for SUD is abstinent as a result of no longer having access to the substance when in an environment where access to the substance is restricted (such as correctional detention or residential rehabilitation programs).

Physiological dependence refers to the state resulting from repeated use of a substance marked by tolerance and/or withdrawal symptoms:

  • ■

    Tolerance to a given substance is a phenomenon marked by requiring a higher dose of the substance to achieve the same intoxicating effect (alternatively, it can be conceptualized as experiencing a reduced effect if the individual consumed their usual dose).

  • ■

    Withdrawal is a syndrome occurring following discontinuation or reduction of substance use marked by symptoms opposite to the expected effects of that substance. Resuming substance use would reverse the withdrawal and relieve these symptoms.

The 4 C’s is another commonly used working descr­iption of the components of SUD.

Working Definitions of Addiction:

  • ■

    Compulsion

  • ■

    Loss of Control

  • ■

    Consequences

  • ■

    Craving

Know This:

  • 1

    Rebound symptoms and pseudo-withdrawal are two phenomena that are distinct from substance withdrawal. Rebound symptoms refer to situations in which symptoms preceding the drug use affected by the use worsen after discontinuation (e.g., persons with insomnia using benzodiazepines to sleep might experience worsening insomnia after benzodiazepines discontinuation). Pseudo-withdrawal refers to placebo-type symptoms experienced when a person using a substance considers or expects the substance’s discontinuation. These symptoms resemble symptoms that would likely occur with drug discontinuation.

  • 2

    Conditioned (or learned) tolerance refers to a different phenomenon than the physiological tolerance described earlier. Conditioned tolerance refers to the presence of conditioned compensatory responses in response to using a substance in a novel environment, rather than their familiar place of use. Conditioned tolerance can be seen for example when a person with opioid use disorder experiences an opioid overdose when they use heroin in a new environment.

  • 3

    Incentive salience refers to yet another phenomenon. With incentive salience, specific environmental sensory or experiential cues become associated with using a given substance (such as smells, places of use, or persons with whom one uses). This leads to a physical state of expectation of substance use when encountering these cues. For example, someone using cocaine at a nightclub will experience a strong urge to use cocaine again every time they go to the nightclub.

  • 4

    Incentive salience is driven by operant conditioning (conditioning using positive or negative reinforcement) or classical conditioning (Pavlovian conditioning).

SUD severity and patient placement criteria

The American Society of Addiction Medicine (ASAM) patient placement criteria (PPC-2R) offer a standardized approach to connect a person’s SUD severity and characteristics with the treatment level they require. Using the PPC-2R, persons with SUD are assessed for their treatment needs in six dimensions (each scored 0–4 based on the associated complication risks):

  • ■

    Dimension 1: Intoxication and withdrawal potential

  • ■

    Dimension 2: Biomedical conditions and complications

  • ■

    Dimension 3: Emotional, behavioral, or cognitive complications

  • ■

    Dimension 4: Readiness to change (trans-theoretical model of change or stages of change)

  • ■

    Dimension 5: Relapse or continued use potential

  • ■

    Dimension 6: Recovery environment (including social, legal, vocational, educational, financial, and housing factors)

  • Treatment type needs for every dimension are determined and classified by level:

  • ■

    Level 0?

  • ■

    Level 0.5: Early intervention

  • ■

    Level I: Outpatient treatment

  • ■

    Level II.1: Intensive outpatient

  • ■

    Level II.5: Partial hospitalization

  • ■

    Level III.1: Clinically managed low-intensity residential services

  • ■

    Level III.3: Clinically managed medium-intensity residential treatment

  • ■

    Level III.5: Clinically managed high-intensity residential treatment

  • ■

    Level III.7: Medically monitored intensive inpatient treatment

  • ■

    Level IV: Medically managed intensive inpatient treatment

When applicable, subspecifiers are used to denote treatment types further:

  • ■

    D: Detoxification

  • ■

    OMT: Opioid maintenance treatment

  • ■

    BIO: Capable of managing complex medical comorbidity

  • ■

    AOD: Alcohol or drug treatment only

  • ■

    DDC: Dual diagnosis capable (the treatment facility can identify co-occurring psychiatric problems and refer to outside mental health treatment centers)

  • ■

    DDE: Dual diagnosis enhanced, capable on-site of managing patients with co-occurring psychiatric problems

    The PPC-2R model is presented as a matrix grid in which illness dimensions are listed on the Y-axis and treatment types on the X-axis.

For example, a patient with alcohol use disorder and depression seeking treatment might require initial care in a Level IV-D (inpatient detoxification) followed by a II.5-DDE (partial hospital program that is dual diagnosis enhanced)

Know This:

  • 1

    The role of coercion in treatment or the impact of one’s experienced adverse consequences of substance use affects their motivation for treatment and is assessed in Dimension 4 (readiness to change).

  • 2

    Do not confuse placement matching and modality matching . “Placement matching” refers to the required intensity of treatment resources as identified in the PPC-2R, whereas “modality matching” refers to whichever clinical approach might be optimal in treating a patient’s problems (such as using contingency management for stimulant use disorders, buprenorphine for opioid use disorder, or dialectical behavioral therapy [DBT] for borderline personality disorder).

Child and adolescent levels of care utilization services (CALOCUS) is a model similar to PPC-2R that is specific for identifying necessary levels of care for adolescent SUD. Basic services or prevention represent the least restrictive level of care in the CALOCUS model (Level 0), whereas a secure 24-hour medical management program is the most restrictive level (Level 6).

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts