MDMA or related drug dependence, including MDA

Essential (Required) Features:

• A pattern of recurrent episodic or continuous use of MDMA or related drugs with evidence of impaired regulation of MDMA or related drug use that is manifested by two or more of the following:
• Impaired control over MDMA or related drug use (i.e., onset, frequency, intensity, duration, termination, context);
• Increasing precedence of MDMA or related drug use over other aspects of life, including maintenance of health, and daily activities and responsibilities, such that MDMA or related drug use continues or escalates despite the occurrence of harm or negative consequences (e.g., repeated relationship disruption, occupational or scholastic consequences, negative impact on health);
• Physiological features indicative of neuroadaptation to the substance, including: 1) tolerance to the effects of MDMA or related drugs or a need to use increasing amounts of MDMA or related drugs to achieve the same effect; 2) withdrawal symptoms following cessation or reduction in use of MDMA or related drugs (see MDMA or Related Drug Withdrawal), or 3) repeated use of MDMA or related drugs or pharmacologically similar substances to prevent or alleviate withdrawal symptoms.
• The features of dependence are usually evident over a period of at least 12 months but the diagnosis may be made if use is continuous (daily or almost daily) for at least 3 months.

Course Specifiers:

A specifier is also used to describe the pattern of substance use in the context of MDMA or Related Drug Dependence. Unlike alcohol, separate codes for continuous and episodic current use are not provided.

6C4C.20 MDMA or Related Drug Dependence including MDA, current use

Current MDMA or Related Drug Dependence with episodic or continuous use of MDMA or related drugs within the past month.

6C4C.21 MDMA or Related Drug Dependence, including MDA, early full remission

After a diagnosis of MDMA or Related Drug Dependence and often following a treatment episode or other intervention (including self-help intervention), the individual has been abstinent from MDMA or related drugs during a period lasting from between 1 and 12 months.

6C4C.22 MDMA or Related Drug Dependence, including MDA, sustained partial remission

After a diagnosis of MDMA or Related Drug Dependence, and often following a treatment episode or other intervention (including self-help intervention), there is a significant reduction in MDMA or related drug use for more than 12 months, such that even though intermittent or continuous use has occurred during this period, the diagnostic requirements for dependence have not been met.

6C4C.22 MDMA or Related Drug Dependence, including MDA, sustained full remission

After a diagnosis of MDMA or Related Drug Dependence, and often following a treatment episode or other intervention (including self-intervention), the person has been abstinent from MDMA or related drugs for 12 months or longer.

6C4C.2Z MDMA or Related Drug Dependence, including MDA unspecified

Additional Clinical Features:

• A subjective sensation of urge or craving to use MDMA or related drugs often, but not always, accompanies the Essential Features of MDMA or Related Drug Dependence.
• When present as an aspect of MDMA or Related Drug Dependence, withdrawal symptoms must be consistent with the known withdrawal state for MDMA or related drugs (see MDMA or Related Drug Withdrawal).
• Tolerance varies as a function of individual factors (e.g., substance use history, genetics) and should be differentiated from initial levels of response during intoxication, which also exhibit significant individual variability. Laboratory testing that reveals high levels of the substance in bodily fluids with no evidence of significant symptoms of intoxication may be suggestive of tolerance. Tolerance to the effects to substances as indicated by different psychophysiological responses can develop at varying rates (e.g., tolerance to respiratory depression caused by opioid intoxication may develop prior to tolerance to the sedating effects of the drug). With abstinence, tolerance effects diminish over time.
• Individuals with certain comorbid medical conditions (e.g., chronic liver disease) typically have reduced tolerances to substances.
• Physical or mental health consequences (beyond the Essential Features of Substance Dependence) typically occur in persons with Substance Dependence but are not required for the diagnosis. Similarly, functional impairment in one or several domains of life (e.g., work, domestic responsibilities, child-rearing) is commonly seen in persons with Substance Dependence, but is not required in order to assign the diagnosis.
• Individuals with Substance Dependence have elevated rates of many other mental disorders, including Conduct-Dissocial Disorder, Attention Deficit Hyperactivity Disorder, Impulse Control Disorders, Post-Traumatic Stress Disorder, Social Anxiety Disorder, Generalized Anxiety Disorder, Mood Disorders, Psychotic Disorders, and Personality Disorder with prominent dissocial features, as well as subthreshold symptoms. The specific pattern of co-occurrence depends on the specific substance involved, and reflects common risk factors and common causal pathways. These are distinguished from Substance-Induced Mental Disorders, in which the symptoms are a result of the direct physiological effects of the substance on the central nervous system.
• A pattern of substance use that includes frequent or high dose administration occurs more often among certain subgroups (e.g., adolescents). In these cases, peer group dynamics may contribute to the maintenance of substance use. Regardless of the social contributions to the behaviour, a pattern of substance use that is consistent with subgroup norms should not be considered as presumptive evidence of Substance Dependence unless all diagnostic requirements for the disorder are met.

Boundary with Normality (Threshold):

• Frequent or even daily substance use of MDMA or related drugs does not automatically imply a diagnosis of MDMA or Related Drug Dependence. There must also be evidence of the Essential Features of MDMA or Related Drug Dependence such as impaired control over use, increasing precedence of use over other life priorities, or physiological features.
• The presence of physiological features such as tolerance and withdrawal is sometimes referred to as ‘physiological dependence’. These features may occur, for example, in response to prolonged therapeutic use of certain medications, such as in patients who are appropriately prescribed opioid analgesics for cancer pain. By themselves, however, these features are not sufficient for a diagnosis of MDMA or Related Drug Dependence, which also requires either impaired control over substance use or increasing precedence of MDMA or related drug use over other activities.

Course Features:

• The course of Substance Dependence varies by substance, frequency, intensity, and duration of use. The central features of the dependence syndrome may be overshadowed by the harms to physical and mental health that patients with dependence often experience and for which they frequently seek treatment. Numerous medical conditions can occur due to substance use in the course of Substance Dependence. These conditions tend to be specific for each substance, although some are shared across substances. Negative consequences to physical health reflect either the known pharmacological effects of the relevant substance, the toxic effects of the substance on tissues and organs, or the route of administration (e.g., intravenous self-administration). Examples include alcoholic cirrhosis, infective endocarditis, and HIV/AIDS. Medical conditions caused by substance use should be diagnosed separately.

Developmental Presentations:

• Substance Dependence may develop more rapidly during adolescence than is usual during adulthood, especially when there are familial or other risk factors for Substance Dependence.
• Tolerance to psychoactive substances may develop rapidly in adolescents and young adults, and decline equally rapidly when substance use ceases or is reduced in quantity or frequency.
• Withdrawal symptoms are well recognized in neonates born to women with Substance Dependence who have used psychoactive substances during pregnancy. However, the presence of a withdrawal state in a neonate should not be the sole basis for a diagnosis of Substance Dependence in the mother.
• Older adults often have reduced tolerance to substances.

Sex- and/or Gender-Related Features:

• Substance Dependence has similar features in men and women, although the intensity of substance use and duration of use necessary to result in dependence may differ by sex.
• Women are less likely to be involved with the legal system in relation to substance use and therefore may be less likely to come to clinical attention than men. In clinical contexts, women may be reluctant to admit using substances due to prevailing social attitudes and proscriptions.
• In some societies it may be culturally unacceptable for women to admit to substance use. Specific probing may be necessary to elicit a history of substance use and dependence.

Boundaries with Other Disorders and with Normality:

• Boundary with MDMA or Related Drug Intoxication, including MDA: Episodic or continuous intoxication with MDMA or related drugs is a typical feature of MDMA or Related Drug Dependence, but is not an Essential Feature. Conversely, even if frequent and severe, MDMA or Related Drug Intoxication alone is not a basis for a diagnosis of MDMA or Related Drug Dependence. If all diagnostic requirements of both conditions are met for the same episode of care, MDMA or Related Drug Dependence should be assigned as the primary diagnosis, with an associated diagnosis of MDMA or Related Drug Intoxication (e.g., MDMA or Related Drug Dependence with MDMA or Related Drug Intoxication) if appropriate to the specific clinical situation (e.g., in emergency settings).
• Boundary with Harmful Use of MDMA or Related Drugs, including MDA: MDMA or Related Drug Dependence is often associated with physical and mental health consequences, such as those seen in Harmful Pattern of Use of MDMA or Related Drugs. In the absence of the Essential Features of MDMA or Related Drug Dependence, a diagnosis of Harmful Use of MDMA or Related Drugs can be given when there has been demonstrable harm to the individual’s physical or mental health or that of others. Harmful Pattern of Use of MDMA or Related Drugs and MDMA or Related Drug Dependence should not be diagnosed together.
• Boundary with MDMA or Related Drug Withdrawal, including MDA: Many individuals with MDMA or Related Drug Dependence develop MDMA or Related Drug Withdrawal upon cessation or reduction in the amount of MDMA or related drugs consumed. In such cases, both MDMA or Related Drug Dependence and MDMA or Related Drug Withdrawal should be diagnosed. However, MDMA or Related Drug Withdrawal can be diagnosed in the absence of a diagnosis of MDMA or Related Drug Dependence.
• Boundary with MDMA or Related Drug-Induced Mental Disorders, including MDA: The impact of repeated or continuous use of substances characteristic of MDMA or Related Drug Dependence may include MDMA or Related Drug-Induced Mental Disorders, in which case both MDMA or Related Drug Dependence and the relevant MDMA or Related Drug-Induced Mental Disorder should be diagnosed (e.g., MDMA or Related Drug Dependence with MDMA or Related Drug-Induced Delirium).