Disorders Due to Use of Non-Psychoactive Substances (ICD-11: 6C4H)

1. Introduction

Disorders due to use of non-psychoactive substances represent a diagnostic category frequently underestimated in contemporary clinical practice. Unlike disorders related to psychoactive substances such as alcohol, cannabis or opioids, this condition involves the non-medical use of substances that do not directly alter mental state or consciousness, but that can cause significant damage to physical health due to their direct or secondary toxic effects.

This category includes substances such as laxatives, anabolic steroid hormones, growth hormone, erythropoietin, non-steroidal anti-inflammatory drugs, over-the-counter medications and various home remedies. The inadequate use of these substances has grown considerably in recent decades, driven by ease of access, self-treatment culture, pursuit of physical and aesthetic enhancement, and availability through unregulated channels.

The clinical importance of these disorders lies in the fact that, although they do not cause chemical dependence in the traditional sense, they can result in serious medical complications, including hepatic, renal, cardiovascular, endocrine and infectious damage. Inadequate route of administration, such as self-administered intravenous injection without sterile technique, adds significant risks of local and systemic infections.

Correct coding of these disorders is critical for epidemiological surveillance, planning of public health interventions, adequate resource allocation, and to ensure that patients receive appropriate treatment. The clear distinction between psychoactive and non-psychoactive substances in ICD-11 allows greater diagnostic precision and facilitates research on patterns of use and health consequences.

2. Correct ICD-11 Code

Code: 6C4H

Description: Disorders due to use of non-psychoactive substances

Parent category: Disorders due to substance use

Official definition: Disorders due to use of non-psychoactive substances are characterized by the pattern and consequences of non-medical use of non-psychoactive substances. Non-psychoactive substances include laxatives, steroid hormones, growth hormone, erythropoietin, and non-steroidal anti-inflammatory drugs. They may also include proprietary or over-the-counter medications and home remedies. Non-medical use of these substances may be associated with harm to the individual due to direct toxic effects or secondary effects of the non-psychoactive substance on organs and body systems or to a dangerous route of administration (for example, infections due to self-administered intravenous use). They are not associated with intoxication or dependence or withdrawal syndrome and are not recognized causes of substance-induced mental disorders.

This code represents an important innovation in international classification, recognizing that problematic substance use is not limited to those with psychoactive properties. The inclusion of this category reflects contemporary understanding that patterns of inappropriate use of various substances may constitute significant health problems, even in the absence of alterations in mental state or phenomena of chemical dependence.

3. When to Use This Code

The code 6C4H should be applied in specific clinical situations where there is clear evidence of non-medical use of non-psychoactive substances with adverse health consequences. Below are detailed practical scenarios:

Scenario 1: Use of Anabolic Steroids for Physical Enhancement

A male patient, a bodybuilding practitioner, presents with gynecomastia, severe acne, alterations in liver enzymes, and left ventricular hypertrophy. Investigation reveals prolonged use of multiple anabolic steroids obtained without medical prescription, with the objective of gaining muscle mass. The patient does not present significant psychiatric symptoms, but suffers direct physical consequences from the use of these substances. This is a classic case for 6C4H coding.

Scenario 2: Laxative Abuse with Metabolic Complications

A patient presents with severe hypokalemia, chronic dehydration, recurrent electrolyte alterations, and intestinal dysfunction. The clinical history reveals excessive daily use of laxatives for several years, initially started for weight control. The pattern of use persists despite knowledge of adverse consequences. There is no evidence of a primary eating disorder that would justify another coding. The code 6C4H is appropriate for documenting the disorder related to laxative use.

Scenario 3: Non-Medical Use of Erythropoietin by an Athlete

A professional cyclist develops secondary polycythemia, blood hyperviscosity, and thromboembolic events after self-administration of erythropoietin to improve athletic performance. The use was done without medical supervision, with inadequate dosages and without hematocrit monitoring. Complications include deep venous thrombosis and increased risk of cerebrovascular accident. This case exemplifies the use of a non-psychoactive substance with serious physical consequences, appropriate for 6C4H.

Scenario 4: Chronic Use of Nonsteroidal Anti-inflammatory Drugs with Renal Damage

A patient with a history of prolonged self-medication with high doses of nonsteroidal anti-inflammatory drugs develops chronic kidney disease, recurrent gastric ulcers, and anemia. The use was maintained for years without medical guidance, for chronic musculoskeletal pain. The pattern of use continued even after medical warnings about the risks. The code 6C4H appropriately documents the disorder related to inadequate use of these substances.

Scenario 5: Infectious Complications from Intravenous Self-Administration of Growth Hormone

A patient who self-administers growth hormone intravenously, without proper technique, develops recurrent local abscesses, cellulitis, and an episode of bacteremia. The use was motivated by anti-aging objectives and aesthetic improvement, without legitimate medical indication. Complications result from both the substance and the inadequate route of administration. This scenario fully justifies the use of code 6C4H.

Scenario 6: Use of Multiple Supplements and Home Remedies with Hepatotoxicity

A patient develops severe toxic hepatitis after prolonged use of multiple herbal supplements, megadose vitamins, and home remedies obtained through unregulated sources. The combination and doses used resulted in significant liver damage. There is no use of psychoactive substances. The code 6C4H appropriately captures this pattern of problematic use of non-psychoactive substances.

4. When NOT to Use This Code

It is fundamental to distinguish situations where code 6C4H is not appropriate, avoiding incorrect coding:

Legitimate Medical Use with Complications: When a patient develops adverse effects from prescribed medications used according to medical guidance, even if non-psychoactive, this does not constitute a disorder due to substance use. In these cases, codes for medication complications or adverse drug effects should be used.

Psychoactive Substance Disorders: If the substance in question has psychoactive properties (alcohol, cannabis, opioids, stimulants, sedatives), specific codes for each substance should be used (6C40 for alcohol, 6C41 for cannabis, etc.), even if the patient also presents use of non-psychoactive substances.

Primary Eating Disorders: When the use of laxatives or other substances occurs exclusively in the context of a diagnosed eating disorder (anorexia nervosa, bulimia nervosa), the eating disorder should be the primary diagnosis, and substance use is considered a behavior secondary to the primary disorder.

Accidental Acute Intoxication: Cases of accidental intoxication or poisoning by non-psychoactive substances should be coded as intoxications or poisonings, not as disorders due to substance use, which imply a pattern of use over time.

Self-Medication for Legitimate Medical Condition: When a patient uses over-the-counter medications appropriately to treat a real medical condition, even without continuous medical supervision, this does not constitute non-medical use. Code 6C4H requires that use be inappropriate, excessive, or cause harm disproportionate to the intended benefit.

Single Use or Experimental Use: An isolated episode or experimental use of non-psychoactive substances, without an established pattern and without significant adverse consequences, does not justify this diagnosis. The code implies a pattern of problematic use with health consequences.

5. Step-by-Step Coding Process

Step 1: Assess Diagnostic Criteria

Confirmation of diagnosis requires a comprehensive clinical evaluation that documents:

Detailed history of substance use: Specifically identify which non-psychoactive substances are being used, including brand names, dosages, frequency, duration of use, and routes of administration. Investigate the motivation for use (physical enhancement, self-treatment, aesthetic goals, beliefs about health).

Pattern of non-medical use: Confirm that use occurs outside of legitimate medical guidance, with inadequate dosages, dangerous combinations, or for unestablished indications. Document whether there has been dose escalation or persistence of use despite medical warnings.

Adverse health consequences: Conduct complete clinical evaluation including detailed physical examination and relevant laboratory investigations. Document damage to organs and systems (hepatic, renal, cardiovascular, endocrine, gastrointestinal, musculoskeletal). Identify complications related to the route of administration (infections, abscesses, thromboses).

Exclusion of psychoactive properties: Confirm that the substances used do not have primary psychoactive properties and that there is no intoxication, dependence, or withdrawal syndrome. Verify that there are no substance-induced mental disorders.

Step 2: Verify Specifiers

Although code 6C4H does not have extensive formal subtypes in ICD-11, clinical documentation should include:

Type of substance: Clearly specify which non-psychoactive substance is involved (anabolic steroids, laxatives, growth hormone, erythropoietin, anti-inflammatory drugs, supplements, home remedies).

Severity of consequences: Document the extent of physical damage, ranging from asymptomatic laboratory alterations to severe organ failure or potentially fatal complications.

Duration of use pattern: Record how long the problematic use has been occurring, differentiating recent use from prolonged use lasting years.

Route of administration: Especially important when involving parenteral routes or other forms of administration that add specific risks.

Step 3: Differentiate from Other Codes

6C40 - Disorders due to use of alcohol: The fundamental difference is that alcohol is a psychoactive substance that causes acute intoxication, can lead to dependence with potentially severe withdrawal syndrome, and causes substance-induced mental disorders. Code 6C4H is used exclusively for substances without these psychoactive properties.

6C41 - Disorders due to use of cannabis: Cannabis is a psychoactive substance with effects on perception, mood, and cognition, potentially causing characteristic intoxication and dependence. Substances under code 6C4H do not alter mental state in this way, focusing instead on direct physical effects on organs and systems.

6C42 - Disorders due to use of synthetic cannabinoids: Like natural cannabis, synthetic cannabinoids are potent psychoactive substances. The clear distinction is that 6C4H does not involve alterations in consciousness or psychoactive effects, only physical consequences of use of non-psychoactive substances.

Other psychoactive substance codes (6C43-6C4G): All codes in this range refer to substances with psychoactive properties (opioids, sedatives, stimulants, hallucinogens, etc.). Code 6C4H is reserved specifically for substances that do not share these psychoactive properties.

Step 4: Required Documentation

Checklist of mandatory information for the medical record:

Specific identification of the non-psychoactive substance(s) used
Dosages, frequency, and duration of use
Route(s) of administration
Source of obtaining the substances
Reported motivation for use
Previous attempts to discontinue or modify use
Patient's knowledge of risks and consequences
Relevant physical examination findings
Results of complementary tests documenting organic damage
Medical complications resulting from use
Assessment of medical and psychiatric comorbidities
Confirmation of absence of psychoactive properties
Exclusion of other disorders that could explain the clinical presentation
Proposed therapeutic plan

6. Complete Practical Example

Clinical Case

Initial Presentation:

A 28-year-old male patient, an avid weightlifter for 5 years, presents to the emergency department with complaints of chest pain, palpitations, and dyspnea on moderate exertion. He also reports progressive onset of bilateral gynecomastia over the last 18 months, severe acne on the trunk and face, and episodes of aggression that have caused problems in his personal relationships.

Evaluation Performed:

On physical examination: blood pressure 165/95 mmHg, heart rate 98 bpm, bilateral grade III gynecomastia, nodular acne on face and trunk, violaceous striae in the pectoral and axillary regions. Cardiovascular examination reveals laterally displaced apical impulse.

Complementary tests requested revealed: elevated liver enzymes (AST 156 U/L, ALT 203 U/L), altered lipid profile (total cholesterol 285 mg/dL, HDL 28 mg/dL, LDL 198 mg/dL, triglycerides 295 mg/dL), suppressed total testosterone (45 ng/dL), suppressed LH and FSH. Echocardiogram demonstrated moderate concentric left ventricular hypertrophy with preserved ejection fraction.

During detailed history taking, the patient admitted to use of multiple anabolic steroids over the last 3 years, including testosterone cypionate, nandrolone, stanozolol, and oxandrolone, in cycles of 12 to 16 weeks, with progressively increasing doses. The substances were obtained through gyms and online suppliers, without prescription or medical supervision. The patient reported that he initiated use to "accelerate muscle gains" and continued despite noticing adverse effects because "everyone at the gym uses them" and feared losing acquired muscle mass.

Diagnostic Reasoning:

The clinical presentation demonstrates multiple adverse consequences of prolonged anabolic steroid use, non-psychoactive substances used in a non-medical manner. Complications include: cardiovascular damage (arterial hypertension, left ventricular hypertrophy, severe dyslipidemia), hepatotoxicity (elevation of liver enzymes), endocrine dysfunction (suppression of the hypothalamic-pituitary-gonadal axis, gynecomastia), and dermatological changes (severe acne, striae).

Although the patient reports episodes of aggression, these do not constitute a substance-induced mental disorder in the sense of ICD-11, but rather behavioral effects secondary to the androgenic effects of the substances. There is no evidence of acute intoxication, chemical dependence with withdrawal syndrome, or alterations in level of consciousness characteristic of psychoactive substances.

The pattern of use is clearly non-medical, with dose escalation, persistence despite adverse consequences, and motivation by non-therapeutic physical enhancement objectives. The substances were obtained illegally and used without adequate supervision.

Coding Justification:

This case meets all criteria for code 6C4H:

Use of non-psychoactive substances (anabolic steroids)
Non-medical use (without prescription or legitimate therapeutic indication)
Significant damage to organs and body systems
Absence of primary psychoactive properties
Absence of intoxication, dependence, or withdrawal syndrome in the classical sense
Persistent pattern of use despite adverse consequences

Step-by-Step Coding

Primary Code: 6C4H - Disorders due to use of non-psychoactive substances

Complete Justification: The patient presents with a disorder characterized by prolonged and non-medical use of multiple anabolic steroids (non-psychoactive substances) with serious and documented adverse consequences to cardiovascular, hepatic, endocrine, and dermatological health. The pattern of use persisted for years despite knowledge of adverse effects, constituting a disorder due to use of non-psychoactive substances as defined in ICD-11.

Complementary Codes:

Code for left ventricular hypertrophy
Code for secondary arterial hypertension
Code for dyslipidemia
Code for toxic hepatopathy
Code for secondary hypogonadism
Code for gynecomastia

These additional codes document the specific complications resulting from the disorder, allowing complete tracking of health consequences and facilitating multidisciplinary therapeutic planning.

7. Related Codes and Differentiation

Within the Same Category

6C40: Disorders due to use of alcohol

When to use 6C40: For patients with a problematic pattern of alcohol consumption, a psychoactive substance that causes characteristic acute intoxication, can lead to dependence with potentially severe withdrawal syndrome (tremors, seizures, delirium), and causes various induced mental disorders (alcoholic psychosis, alcoholic dementia, amnestic disorders).

Main difference vs. 6C4H: Alcohol is a psychoactive substance with depressant effects on the central nervous system, causing alterations in mental state, consciousness, and behavior. It can cause physiological dependence with withdrawal syndrome. Code 6C4H is used for substances without these psychoactive properties, focusing on direct toxic effects on organs without primarily altering mental state.

6C41: Disorders due to use of cannabis

When to use 6C41: For patients with problematic use of cannabis (marijuana), a psychoactive substance that alters perception, mood, cognition, short-term memory, and motor coordination. It can cause acute intoxication with characteristic symptoms (euphoria, anxiety, memory impairment, perceptual alterations) and dependence.

Main difference vs. 6C4H: Cannabis has pronounced psychoactive properties, directly altering brain functioning and mental state. It can cause induced mental disorders such as cannabinoid psychosis. Substances under code 6C4H do not have these effects on the central nervous system, causing damage primarily through systemic or local toxicity.

6C42: Disorders due to use of synthetic cannabinoids

When to use 6C42: For disorders related to use of synthetic cannabinoids (chemical substances that mimic cannabis effects but often with much greater potency), which are potent psychoactive substances causing severe intoxication, severe mental alterations, and risk of dependence.

Main difference vs. 6C4H: Synthetic cannabinoids are psychoactive substances that act on cannabinoid receptors in the brain, causing significant alterations in mental state, behavior, and perception. Code 6C4H does not include substances with these psychoactive properties, limiting itself to substances that cause physical harm without primary psychoactive effects.

Differential Diagnoses

Eating Disorders: The use of laxatives, diuretics, or other substances for weight control may occur in the context of anorexia nervosa or bulimia nervosa. In these cases, if the eating disorder is the primary diagnosis and substance use is a behavior secondary to the eating disorder, this should be the primary diagnosis. Code 6C4H is more appropriate when use of non-psychoactive substances occurs independently of an eating disorder.

Body Dysmorphic Disorder: Patients with body dysmorphic disorder may use non-psychoactive substances (such as steroids) in an attempt to modify appearance perceived as defective. The distinction depends on whether the primary focus is dysmorphic concern or the pattern of substance use with its consequences.

Adverse Effects of Prescribed Medications: When complications arise from appropriate use of prescribed medications as directed by medical guidance, adverse effect codes are more appropriate than 6C4H, which requires non-medical use.

Acute Intoxications: Isolated episodes of intoxication or poisoning by non-psychoactive substances should be coded as intoxications, not as disorders due to substance use, which imply a persistent pattern.

8. Differences with ICD-10

In ICD-10, there was no specific and well-defined category for disorders due to the use of non-psychoactive substances. These cases were frequently coded inconsistently, using codes for non-dependent drug abuse (F55) or codes for specific complications without adequately capturing the pattern of problematic use.

Closest ICD-10 code: F55 - Abuse of substances that do not produce dependence

Main changes in ICD-11:

ICD-11 brought greater clarity and specificity by creating code 6C4H dedicated specifically to disorders due to the use of non-psychoactive substances. The definition is more precise, specifying examples of substances included (laxatives, steroids, growth hormone, erythropoietin, non-steroidal anti-inflammatory drugs) and clarifying that there is no associated intoxication, dependence, or withdrawal syndrome.

The new classification also emphasizes that damage may result from both direct toxic effects and dangerous routes of administration, recognizing the complexity of these disorders. The ICD-11 structure allows better differentiation between psychoactive and non-psychoactive substances, facilitating epidemiological research and intervention planning.

Practical impact: The greater specificity of code 6C4H allows more precise identification of these cases in health information systems, facilitating epidemiological surveillance, research on usage patterns and consequences, and development of targeted preventive and therapeutic strategies. Health professionals now have a clearer diagnostic tool to document these disorders, which previously could be underreported or coded inconsistently.

9. Frequently Asked Questions

1. How is the diagnosis of disorders due to the use of non-psychoactive substances made?

The diagnosis is essentially clinical, based on a detailed history that documents the non-medical use of non-psychoactive substances, pattern of use over time, and adverse health consequences. The evaluation includes a complete history regarding which substances are used, dosages, frequency, duration, source of obtaining, and motivation for use. Physical examination seeks signs of complications specific to each substance. Complementary tests (laboratory, imaging, functional) document damage to organs and systems. There are no specific tests that "diagnose" the disorder, but rather evidence that, taken together, characterizes the pattern of problematic use with adverse consequences.

2. Is treatment available in public health systems?

The availability of treatment varies among different health systems and regions. Generally, treatment of medical complications (hepatic, renal, cardiovascular, endocrine damage) is available in general medical services. Support for modification of use behavior may include psychological interventions, counseling, and health education. Some systems offer specialized programs for users of anabolic steroids or other specific substances. Access may be more limited in areas with restricted resources, but treatment of medical complications is generally considered part of essential medical care.

3. How long does treatment last?

The duration of treatment varies significantly depending on the severity of complications, the type of substance used, the duration of use, and individual response. Treatment of acute complications may require days to weeks of intensive intervention. Recovery from organic damage (such as hepatopathy, endocrine dysfunction, cardiac hypertrophy) may take months to years, and some damage may be irreversible. Behavioral support for cessation of use and relapse prevention often requires prolonged follow-up, potentially for several months. Monitoring of long-term complications may be necessary indefinitely in cases of permanent damage.

4. Can this code be used in medical certificates?

Yes, code 6C4H can be used in official medical documentation, including certificates, when appropriate. However, considerations regarding confidentiality and potential stigmatization should be weighed. In some contexts, it may be more appropriate to document specific complications (hepatopathy, cardiopathy, etc.) without explicitly specifying the disorder related to substance use, depending on the purpose of the certificate and local regulations on medical privacy. The decision should balance the need for accurate documentation with the protection of patient privacy and rights.

5. Can non-psychoactive substances cause dependence?

In the classical sense of chemical dependence with physiological withdrawal syndrome, the non-psychoactive substances included in code 6C4H do not cause dependence. However, there may be psychological or behavioral dependence, where the individual feels compulsion to continue use despite adverse consequences, often related to goals of physical enhancement, fear of losing gains obtained, or social pressure. This psychological dependence does not involve withdrawal syndrome with severe physical symptoms as occurs with alcohol or opioids, but can make cessation of use challenging.

6. Is complete recovery possible after stopping use?

The possibility of complete recovery depends on several factors: type of substance used, duration and intensity of use, extent of organic damage, patient age, and presence of comorbidities. Some changes may reverse completely with cessation of use (such as mild laboratory alterations, acne, some aspects of endocrine dysfunction). Other damage may be partially reversible (such as moderate cardiac hypertrophy, hepatopathy in early stages). Some damage may be permanent or irreversible (such as advanced hepatic fibrosis, severe renal dysfunction, some cardiovascular effects). Early intervention is generally associated with better prognosis for recovery.

7. How to approach patients who do not recognize the problem?

The approach requires sensitivity, empathy, and motivational interviewing techniques. It is important to avoid judgment, establish a trusting therapeutic relationship, and provide objective information about risks and consequences. Presenting concrete evidence of health damage (test results, clinical findings) can help increase awareness of the problem. Exploring motivations for use and identifying ambivalences can facilitate behavioral change. In some cases, involvement of family members or significant others may be helpful. The approach should be gradual, respecting patient autonomy while offering consistent support.

8. Which medical specialties generally treat these disorders?

Treatment often involves multiple specialties depending on complications present. Family physicians and general practitioners often perform initial evaluation and coordinate care. Endocrinologists may be involved for hormonal dysfunctions (especially in cases of steroids). Cardiologists treat cardiovascular complications. Hepatologists or gastroenterologists manage hepatic and gastrointestinal damage. Nephrologists treat renal dysfunction. Psychiatrists or psychologists can offer support for behavioral and psychological aspects. Sports medicine specialists may have particular experience with anabolic steroid use. A multidisciplinary approach generally offers the best results.

Conclusion: Code 6C4H of ICD-11 represents an important advance in the classification of disorders related to substance use, recognizing that significant health damage can result from non-medical use of substances without psychoactive properties. Precise coding of these disorders is essential for epidemiological surveillance, public health planning, and ensuring that patients receive appropriate treatment. Health professionals should be alert to these patterns of use, conduct comprehensive evaluations, and offer evidence-based interventions to prevent and treat associated complications.

External References

This article was prepared based on reliable scientific sources:

References verified on 2026-02-03

Disorders due to the use of non-psychoactive substances

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