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Pathways of Addiction: Opportunities in Drug Abuse Research C Diagnostic Criteria TABLE C.1 Diagnostic Criteria for Substance Abuse and Dependence (DSM-IV) 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: (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) B. The symptoms have never met the criteria for Substance Dependence for this class of substance.
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Pathways of Addiction: Opportunities in Drug Abuse Research 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 anytime in the same twelve month period: (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 (2) Withdrawal, as manifested by either of the following: (a) the characteristic withdrawal syndrome for the substance (b) the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms (3) The substance is often taken in larger amounts or over a longer period than was intended (4) There was a persistent desire or unsuccessful efforts to cut down or control substance use (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., chainsmoking), or recover from its effects (6) Important social, occupational, or recreational activities are given up or reduced because of substance use (7) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to be 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) 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). SOURCE: American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. (DSM-IV). Washington, DC: American Psychiatric Association.
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Pathways of Addiction: Opportunities in Drug Abuse Research TABLE C.2 Diagnostic Criteria for Harmful Use and Dependence (ICD-10) Harmful Use: A pattern of psychoactive substance use that is causing damage to health. The damage may be physical (as in cases of hepatitis from the self-administration of injected drugs) or mental (e.g. episodes of depressive disorder secondary to heavy consumption of alcohol). Diagnostic Guidelines: The diagnosis requires that actual damage should have been caused to the mental or physical health of the user. Harmful patterns of use are often criticized by others and frequently associated with adverse social consequences of various kinds. The fact that a pattern of use or particular substance is disapproved of by another person or by the culture, or may have led to socially negative consequences such as arrest or marital arguments is not in itself evidence of harmful use. Acute intoxication or ''hangover" is not in itself sufficient evidence of the damage to health required for coding harmful use. Harmful use should not be diagnosed if dependence syndrome, a psychotic disorder, or another specific form of drug- or alcohol-related disorder is present. Dependence Syndrome: Diagnostic Guidelines: A definite diagnosis of dependence should usually only be made if three or more of the following have been experienced or exhibited at some time during the previous year: (i) A strong desire or sense of compulsion to take the substance. (ii) Difficulties in controlling substance-taking behavior in terms of its onset, termination, or levels of use. (iii) A physiological withdrawal state when substance use has ceased or been reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms. (iv) Evidence of tolerance such that increased doses of the substance are required in order to achieve effects originally produced by lower doses. (Clear examples of this are found in alcohol- and opiate-dependent individuals who may take daily doses sufficient to incapacitate or kill nontolerant users.) (v) Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amounts of time necessary to obtain or take the substance or recover from its effects. (vi) Persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related impairment of
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Pathways of Addiction: Opportunities in Drug Abuse Research cognitive functioning; efforts should be made to determine that the user was actually, or could be expected to be, aware of the nature and extent of harm. Narrowing of the personal repertoire of patterns of psychoactive substance use has also been described as a characteristic feature (e.g. a tendency to drink alcoholic drinks in the same way on weekdays and weekends, regardless of social constraints that determine appropriate drinking behavior). It is an essential characteristic of the dependence syndrome that either psychoactive substance taking or a desire to take a particular substance should be present; the subjective awareness of compulsion to use drugs is most commonly seen during attempts to stop or control substance use. This diagnostic requirement would exclude, for instance, surgical patients given opioid drugs for the relief of pain, who may show signs of an opiate withdrawal state when drugs are not given, but who have no desire to continue taking drugs. The dependence syndrome may be present for a specific substance (e.g., tobacco or diazepam), for a class of substances (e.g., opioid drugs); or for a wider range of different substances (as for those individuals who feel a sense of compulsion regularly to use whatever drugs are available and who show distress, agitation, and/ or physical signs of a withdrawal state upon abstinence). The diagnosis of the dependence syndrome may be further specified by the following: • Currently abstinent • Currently abstinent, but in a protected environment (e.g., in hospital, in a therapeutic community, in prison, etc.) • Currently on a clinically supervised maintenance or replacement regime (e.g., with methadone; nicotine-gum or patch) • Currently abstinent, but receiving treatment with aversive or blocking drugs (e.g. naltrexone or disulfiram) • Currently using the substance (active dependence) • Continuous use • Episodic use (dipsomania) SOURCE: WHO (World Health Organization). 1992. International Statistical Classification of Diseases and Related Health Problems. 10th Revision. Geneva: WHO. WHO. 1990. Draft of chapter V: mental and behavioural disorders. Clinical descriptions and diagnostic guidelines. International Classification of Diseases. 10th Revision. Geneva: WHO. As cited in: O'Brien CP, Jaffe JH, eds. Addictive States. New York: Raven Press.
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