Unknown or unspecified psychoactive substance dependence

Essential (Required) Features:

• A pattern of recurrent episodic or continuous use of unknown or unspecified psychoactive substances with evidence of impaired regulation of unknown or unspecified psychoactive substance use that is manifested by two or more of the following:
• Impaired control over unknown or unspecified psychoactive substance use (i.e., onset, frequency, intensity, duration, termination, context);
• Increasing precedence of unknown or unspecified psychoactive substance use over other aspects of life, including maintenance of health, and daily activities and responsibilities, such that unknown or unspecified psychoactive substance 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 unknown or unspecified psychoactive substances or a need to use increasing amounts of unknown or unspecified psychoactive substances to achieve the same effect; 2) withdrawal symptoms following cessation or reduction in use of unknown or unspecified psychoactive substances (see Unknown or Unspecified Psychoactive Substance Withdrawal), or 3) repeated use of unknown or unspecified psychoactive substances or pharmacologically similar substances to prevent or alleviate withdrawal symptoms. Physiological features are only applicable for certain substances.
• 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 Unknown or Unspecified Psychoactive Substance Dependence. Unlike alcohol, separate codes for continuous and episodic current use are not provided.

6C4G.20 Unknown or Unspecified Psychoactive Substance Dependence, current use

Current Unknown or Unspecified Psychoactive Substance Dependence with episodic or continuous use of unknown or unspecified psychoactive substances within the past month.

6C4G.21 Unknown or Unspecified Psychoactive Substance Dependence, early full remission

After a diagnosis of Unknown or Unspecified Psychoactive Substance Dependence and often following a treatment episode or other intervention (including self-help intervention), the individual has been abstinent from unknown or unspecified psychoactive substances during a period lasting from between 1 and 12 months.

6C4G.22 Unknown or Unspecified Psychoactive Substance Dependence, sustained partial remission

After a diagnosis of Unknown or Unspecified Psychoactive Substance Dependence, and often following a treatment episode or other intervention (including self-help intervention), there is a significant reduction in unknown or unspecified psychoactive substance 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.

6C4G.22 Unknown or Unspecified Psychoactive Substance Dependence, sustained full remission

After a diagnosis of Unknown or Unspecified Psychoactive Substance Dependence, and often following a treatment episode or other intervention (including self-intervention), the person has been abstinent from unknown or unspecified psychoactive substances for 12 months or longer.

6C4G.2Z Unknown or Unspecified Psychoactive Substance Dependence, unspecified

Additional Clinical Features:

• A subjective sensation of urge or craving to use unknown or unspecified psychoactive substances often, but not always, accompanies the Essential Features of Unknown or Unspecified Psychoactive Substance Dependence.
• When present as an aspect of Unknown or Unspecified Psychoactive Substance Dependence, withdrawal symptoms must be consistent with the known withdrawal state for unknown or unspecified psychoactive substances (see Unknown or Unspecified Psychoactive Substance Withdrawal). Onset and course of withdrawal are time-limited and are related to the type of substance and the dose used immediately before cessation or reduction in amount.
• 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 unknown or unspecified psychoactive substances does not automatically imply a diagnosis of Unknown or Unspecified Psychoactive Substance Dependence. There must also be evidence of the Essential Features of Unknown or Unspecified Psychoactive Substance 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 Unknown or Unspecified Psychoactive Substance Dependence, which also requires either impaired control over substance use or increasing precedence of unknown or unspecified psychoactive substance 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 Unknown or Unspecified Psychoactive Substance Intoxication: Episodic or continuous intoxication with unknown or unspecified psychoactive substances is a typical feature of Unknown or Unspecified Psychoactive Substance Dependence, but is not an Essential Feature. Conversely, even if frequent and severe, Unknown or Unspecified Psychoactive Substance Intoxication alone is not a basis for a diagnosis of Unknown or Unspecified Psychoactive Substance Dependence. If all diagnostic requirements of both conditions are met for the same episode of care, Unknown or Unspecified Psychoactive Substance Dependence should be assigned as the primary diagnosis, with an associated diagnosis of Unknown or Unspecified Psychoactive Substance Intoxication (e.g., Unknown or Unspecified Psychoactive Substance Dependence with Unknown or Unspecified Psychoactive Substance Intoxication) if appropriate to the specific clinical situation (e.g., in emergency settings).
• Boundary with Harmful Use of Unknown or Unspecified Psychoactive Substances: Unknown or Unspecified Psychoactive Substance Dependence is often associated with physical and mental health consequences, such as those seen in Harmful Pattern of Use of Unknown or Unspecified Psychoactive Substances. In the absence of the Essential Features of Unknown or Unspecified Psychoactive Substance Dependence, a diagnosis of Harmful Use of Unknown or Unspecified Psychoactive Substances 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 Unknown or Unspecified Psychoactive Substances and Unknown or Unspecified Psychoactive Substance Dependence should not be diagnosed together.
• Boundary with Unknown or Unspecified Psychoactive Substance Withdrawal: Many individuals with Unknown or Unspecified Psychoactive Substance Dependence develop Unknown or Unspecified Psychoactive Substance Withdrawal upon cessation or reduction in the amount of unknown or unspecified psychoactive substances consumed. In such cases, both Unknown or Unspecified Psychoactive Substance Dependence and Unknown or Unspecified Psychoactive Substance Withdrawal should be diagnosed. However, Unknown or Unspecified Psychoactive Substance Withdrawal can be diagnosed in the absence of a diagnosis of Unknown or Unspecified Psychoactive Substance Dependence.
• Boundary with Unknown or Unspecified Psychoactive Substance-Induced Mental Disorders: The impact of repeated or continuous use of substances characteristic of Unknown or Unspecified Psychoactive Substance Dependence may include Unknown or Unspecified Psychoactive Substance-Induced Mental Disorders, in which case both Unknown or Unspecified Psychoactive Substance Dependence and the relevant Unknown or Unspecified Psychoactive Substance-Induced Mental Disorder should be diagnosed (e.g., Unknown or Unspecified Psychoactive Substance Dependence with Unknown or Unspecified Psychoactive Substance-Induced Delirium).