Management of substance abuse

Dependence syndrome

Definition

The Tenth Revision of the International Classification of Diseases and Health Problems (ICD-10) defines the dependence syndrome as being a cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take the psychoactive drugs (which may or not have been medically prescribed), alcohol, or tobacco. There may be evidence that return to substance use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with nondependent individuals.

In 1964 a WHO Expert Committee introduced the term ‘dependence’ to replace the terms ‘addiction’ and ‘habituation’. The term can be used generally with reference to the whole range of psychoactive drugs (drug dependence, chemical dependence, substance use dependence), or with specific reference to a particular drug or class of drugs (e.g. alcohol dependence, opioid dependence). While ICD-10 describes dependence in terms applicable across drug classes, there are differences in the characteristic dependence symptoms for different drugs.

In unqualified form, dependence refers to both physical and psychological elements. Psychological or psychic dependence refers to the experience of impaired control over drinking or drug use while physiological or physical dependence refers to tolerance and withdrawal symptoms. In biologically-oriented discussion, dependence is often used to refer only to physical dependence.

Dependence or physical dependence is also used in the psychopharmacological context in a still narrower sense, referring solely to the development of withdrawal symptoms on cessation of drug use. In this restricted sense, cross-dependence is seen as complementary to cross-tolerance, with both referring only to physical symptomatology (neuroadaptation).

ICD-10 Clinical description

A cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take psychoactive drugs (which may or may not have been medically prescribed), alcohol, or tobacco. There may be evidence that return to substance use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with nondependent individuals

ICD-10 Diagnostic guidelines

A definite diagnosis of dependence should usually be made only if three or more of the following have been present together at some time during the previous year:

  • A strong desire or sense of compulsion to take the substance;
  • Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use;
  • A physiological withdrawal state when substance use has ceased or have 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;
  • Evidence of tolerance, such that increased doses of the psychoactive 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);
  • Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects;
  • 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 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 the harm.

ICD-10 Diagnostic criteria for research

Three or more of the following manifestations should have occurred together for at least 1 month or, if persisting for periods of less than 1 month, should have occurred together repeatedly within a 12-month period:

  • A strong desire or sense of compulsion to take the substance;
  • Impaired capacity to control substance-taking behaviour in terms of its onset, termination, or levels of use, as evidenced by the substance being often taken in larger amounts or over a longer period than intended, or by a persistent desire or unsuccessful efforts to reduce or control substance use;
  • A physiological withdrawal state when substance use is reduced or ceased, as evidenced by the characteristic withdrawal syndrome for the substance, or by use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms;
  • Evidence of tolerance to the effects of the substance, such that there is a need for significantly increased amounts of the substance to achieve intoxication or the desired effect, or a markedly diminished effect with continued use of the same amount of the substance;
  • Preoccupation with substance use, as manifested by important alternative pleasures or interests being given up or reduced because of substance use; or a great deal of time being spent in activities necessary to obtain, take or recover from the effects of the substance;
  • Persistent substance use despite clear evidence of harmful consequences as evidenced by continued use when the individual is actually aware, or may be expected to be aware, of the nature and extent of harm.
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