Module Components

• Overview
• Learning Activities

Topics

• History
• Differential Diagnoses
• Treatment
• Pediatric Considerations

NDNP 870 - Diagnosis and Management 1: Differential Diagnosis of Mental Disorders Across the Lifespan

Module 5: Substance Use Disorders

History

The DSM-5 TR lists these diagnoses under Substance Related and Addictive Disorders:

These drugs have individual diagnoses: alcohol, caffeine, cannabis, phencyclidine or other hallucinogens, inhalants, opioids, sedative, hypnotic or anxiolytics, stimulants, and tobacco. When listing substance use disorder diagnoses, use the specific drug. For example, clonazepam use disorder

Substance use disorder includes 4 areas, impulse control, social impairment, risky use and pharmacological criteria.

Diagnostic Criteria: It must be a problematic pattern of use leading to clinically significant impairment or distress with at least 2 of the criteria with a 12 month period:

1. Take substance in large amounts/over long time than intended
2. Persistent desire to decrease to control use
3. Great deal of time obtaining it, using or recovering
4. Cravings
5. Failure to fulfill major role obligations work school or home
6. Continue use despite social/interpersonal problems
7. Activities given up or reduced
8. Physically hazardous
9. Continue despite knowledge of having persistent physical/psychological problems exacerbated by use
10. Tolerance
11. Withdrawal

ICD 10 codes are based on current severity (mild, moderate, severe) based on the number of criteria met.

Specifiers: Early remission---No SUD criteria met for at least 3, but <12 mo. Sustained remission- No SUD criteria met for >12 mo. On maintenance therapy--Prescribed an agonist, partial-agonist, and antagonist. In a controlled environment--Inpatient setting—Incarcerated

F10.20 Alcohol Use Disorder, Severe in early remission

Epidemiology

Addiction should be understood as a chronic recurring illness that requires treatment. Drugs of abuse target the dopamine pathways (nucleus accumbens, ventral tegmental area and frontal cortex) which are known as the pleasure centers of the brain. Substance use disorders have genetic and environment components. The earlier age of substance use increases the risk of developing an addiction. Individuals with substance use disorders usually have multiple psychiatric co-morbidities.

Patterns of use differ depending on the population. Adolescence use marijuana, while non-medical use of prescription drugs, binge drinking and cigarette use is higher in active military personnel than civilians. (http://www.drugabuse.gov/publications/drugfacts/substance-abuse-in-military
In the older adult, 2.5% reported heavy alcohol use in the last month, 1.6% reported having an alcohol abuse disorder and 1.3% reported misuse of opioids during the past year.

The National Institute on Drug Abuse’s Commonly Abused Drugs chart including street names, forms, ways taken, short and long term health effects and treatment options.

Assessing for Substance Use

It is helpful to have a detailed history from as many sources as possible. State to the individual why you are asking these questions “I ask all my patients so I can know how best to treat your mental health issue”. Ask the questions in a non-judgmental way: “Do you have a drink now and then?” or “How much alcohol do you drink?” It is important to quantify use “How many drinks do you have?” “What size?” If the individual reports no alcohol use, ask about recreational drugs and non-medical use of prescription drugs: an example would be “Do you use any recreational drugs like marijuana, LSD, or cocaine?” “Have you used prescription medications such as opioids, stimulants or anxiety medications that are not prescribed to you?”

If a person endorses drinking alcohol, ask about other drugs: “Aside from your drinking, what other recreational drugs do you use regularly? Cocaine? Marijuana? Speed? Heroin?”

The CAGE questions are 4 questions to assess for alcohol use disorder. Two or more YES answers are predictive and 1 or more indicate hazardous drinking.

This video is an example of asking about substance use with a woman with a possible alcohol use disorder. Note that the psychiatrist asks her at the beginning, “How are you doing?” which opens the door for the conversation. He also asks the CAGE questions in a conversational manner. He also addressed this issue at a follow up appointment based on lab results.

F16.983 Hallucinogen Persisting Perception Disorder includes following the cessation of hallucinogens the re-experiencing one or more perceptual symptoms that were experienced while intoxicated with hallucinogens

F63.0 Gambling Disorder has much comorbidity. They are more likely to have substance use disorders, MDD, dysthymia, manic episodes, GAD, panic disorder and specific phobias than non-pathological gamblers. Sports gamblers tended to be young men with high rates of addiction comorbidity, while slot machine gamblers tended to be older women with higher rates of psychiatric comorbidity and later onset of gambling.

Gambling screening questions: