Chapter 9 After my husband died, I drank more and more to numb the pain. It started out with a few glasses of wine a day, which then turned into a few bottles. I would wake up in the middle of the night and have a glass of wine. I would drink before work and during lunch. That was before I stopped going to work altogether. My family and friends wanted me to get help, but I didn’t care. The only thing that made me feel better was drinking. —Susan Substance-related disorders include 10 classes of drugs (alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants; tobacco; and other/unknown substances) that activate the brain’s reward system (APA, 2013a). Use of these substances often leads to impairments in multiple areas of functioning that occur at a clinical level and represent diagnosable disorders. There are three classifications: use, intoxication, and withdrawal (APA, 2013a). Prevalence rates of substance use are extremely high, with 22.6 million individuals in the United States reporting use of illegal substances within the past month; this represents 8.9% of the total population over 12 years of age (SAMHSA, 2011b). Additionally, according to SAMHSA (2011b), a staggering 131.3 million people (51.8%) ages 12 and older had used alcohol and 69.6 million (27.4%) had used tobacco in the past month. During the same year, 23.5 million people ages 12 or older needed treatment for an illicit drug or alcohol abuse problem; this represents 9.3% of the U.S. population age 12 or older (SAMHSA, 2011b). According to the American Society of Addictive Medicine (ASAM, 2013), Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. (para. 1) Addiction is ongoing and often cyclical, with many negative effects on psychological and physiological wellness. Addiction is present and problematic within and across social, cultural, and economic groups (ASAM, 2013; SAMHSA, 2011b). The cost of addiction is enormous, with a price tag of $559 billion annually for illegal substances, alcohol, and tobacco (National Institute on Drug Abuse, 2011). Because of the devastating impact and high prevalence rates of individuals with diagnosable substance-related and addictive disorders, virtually all counselors—regardless of their professional settings—will work directly with this population or provide services for the family members and loved ones of individuals with the disorders. Substance-related and addictive disorders appear throughout the life span in people of all socioeconomic status levels, educational attainment, gender, culture, ethnicity, and religion. It is critical that counselors possess a strong understanding of criteria for substance-related disorders. To help establish this framework, the following section provides an overview of the changes from the DSM-IV-TR to the DSM-5. The DSM-5 includes significant restructuring to the categorization of substance-related disorders. One of the biggest changes in the DSM-5 is removal of the distinction between abuse and dependence. The prior classification of abuse and dependence was based on the notion that there is a biaxial difference between the two and that abuse was a less severe form of dependence. The bimodal theory did not hold true in research and practice, so the classification was revised to address substance use disorders as existing on a fluid, continuous spectrum (APA, 2013a; Dawson, Goldstein, & Grant, 2013; Keyes, Krueger, Grant, & Hasin, 2011). This resulted in the new substance use disorders section. Once clinicians note the presence of a substance use disorder, they may specify severity of the addiction using ratings of mild, moderate, and severe. Research supports an increasing spectrum of severity across addictions and addictive behaviors that occurs as a continuous variable; this represents the predominant reason for the move from abuse versus dependence to severity ratings (APA, 2013a; Dawson et al., 2013; Keyes et al., 2011). In addition, the removal of the terms abuse and dependence supports the fluid and progressive nature of substance use disorders as conceptualized in the manual. It is important to note that concerns related to specific substances in the Substance-Related and Addictive Disorders chapter of the DSM-5 (and enumerated in this chapter) are viewed as distinctive disorders. For example, caffeine-related disorders are separate from cannabis-related disorders. However, despite being distinctly separate diagnoses, all substance use disorders are based on the same criteria. Substance use criteria are also separate from substance-specific intoxication and withdrawal criteria. For example, there is alcohol use disorder, alcohol intoxication, and alcohol withdrawal, which are all coded separately. The only exception is hallucinogen-related and inhalant-related disorders, because symptoms of withdrawal have not been sufficiently documented for these substances so the withdrawal criterion has been eliminated. All other criteria for hallucinogen-related and inhalant-related disorders are the same. This modification in the diagnostic process for substance use disorders represents one of the most substantive changes to a diagnostic category in the DSM-5. As discussed in Chapter 2, unlike the discrete categories in the DSM-IV-TR, many disorders within the DSM-5 were revised to represent a continuum. In the Substance-Related and Addictive Disorders chapter of the DSM-5, this continuum is represented by replacing distinct categories of substance abuse and dependence with 11 standard enumerated criteria for substance use disorders (APA, 2013a). Two to three criteria must be present for the severity indicator of mild, four to five for moderate, and six or more for severe. Additionally, craving has been included as a criterion, and legal difficulties has been excluded as a criterion. The APA Substance-Related Disorders Work Group found research that collaborates the development of the substance use spectrum (APA, 2013a). According to Compton, Dawson, Goldstein, and Grant (2013), 80.5% of individuals who met the criteria for alcohol dependence in the DSM-IV-TR also met the criteria for alcohol use disorder (moderate to severe) in the DSM-5. Dawson et al. (2013) and Keyes et al. (2011) also found support for this new unimodal, fluid approach. A second substantive change is that other addictive disorders have been included as part of this chapter, although at this time the DSM-5 only includes gambling disorder in this category. Pathological gambling was listed in the DSM-IV-TR in the Impulse-Control Disorders Not Elsewhere Classified section but has now been relabeled and classified with substance-related disorders. The addition of gambling disorder represents the first time a process-related addictive behavior has been included alongside use of substances. This is due to an abundance of research that shows that gambling activates the brain’s reward system in ways that are consistent with substance use (APA, 2013a; Ko et al., 2013; Moran, 2013). The symptoms of gambling disorder also hold similarities to substance use disorders, and gambling disorder possesses similar etiology in terms of presentation, biological underpinnings, and treatment. Internet gaming disorder, listed in Section III of the DSM-5 under the chapter Conditions for Further Study, may be added as an addictive disorder to subsequent iterations of the manual. Other types of “behavioral addictions” such as exercise, shopping, or sex addictions have not yet been shown to identify a diagnostic profile or similar developmental course. These may also be considered for inclusion in future editions of the manual (APA, 2013a; Ko et al., 2013; Moran, 2013). Some scholars have taken umbrage with the wordsmithing of the chapter title, pointing out that Substance-Related and Addictive Disorders implies that being diagnosed with a substance use disorder means the client has an addiction (Kaminer & Winters, 2012). There has also been concern over the removal of the abuse category. Kaminer and Winters (2012) posited that the category of abuse is particularly applicable for adolescents; they discussed a body of knowledge coined the “biobehavioral developmental perspective” that asserts the course of the substance use is heterogeneously progressive and fits a categorical model of abuse versus dependence. The authors worried that removal of the abuse category in the DSM-5 will affect treatment services for this population. However, other scholars believed modifications will increase access to services (Dawson et al., 2013; Keyes et al., 2011; Mewton, Slade, McBride, Grove, & Teeson, 2011). Several other changes are reflected in the Substance-Related and Addictive Disorders chapter. Specifically, early remission is now defined as at least 3 but not more than 12 months’ absence of meeting diagnostic criteria for substance use disorders. Craving can still be present as a symptom, even with remission, because individuals continue to experience craving, or a strong desire, for the substance. The specifier with physiological dependence is not included in the DSM-5 nor is the diagnosis of polysubstance dependence. Newly included codable disorders are caffeine withdrawal and cannabis withdrawal (APA, 2013a). The DSM-5 includes specific criteria sets for each substance and applicable disorders related to that substance (e.g., use, intoxication, and withdrawal). All diagnostic labels include the name of the specific substance, such as cannabis use disorder, cannabis intoxication, and cannabis withdrawal. If an individual meets the criteria for multiple substance-related diagnoses, they are all listed. The manual is explicit in noting the likelihood of comorbidity of substance-related disorders (APA, 2013a; SAMHSA, 2011b). According to APA (2013a), “a substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems” (p. 483). In severe and long-term use, these changes may be observed through underlying changes in brain circuits (Agrawal et al., 2012). The first four criteria for substance use disorders encompass impaired control, social impairment, risky use, and pharmacological criteria. Criteria 5 to 7 cover social, occupational, and interpersonal problems. Criteria 8 and 9 focus on risk taking surrounding use of the substance, and Criteria 10 and 11 are tolerance and withdrawal, respectively. Assuming an individual meets the general requirement for “clinically significant impairment or distress” related to pattern of use, just two specific criteria must be met to justify assignment of a clinical diagnosis. The predominant change to the overall diagnostic criteria for substance use disorder is the inclusion of craving and the exclusion of recurrent legal problems. Craving is included in ICD-10 criteria (WHO, 2007) and has been supported through epidemiological studies as a highly prominent and core feature of substance use disorders (Kavanaugh, 2013; Keyes et al., 2011; Ko et al., 2013; Mewton et al., 2011; Sinha, 2013). Functional magnetic resonance imaging (fMRI) has shown that there are certain brain regions directly related to craving (Ko et al., 2013). Presence of cues, negative moods, and stress reactions often lead to an increase in craving. Mindfulness training has been shown to reduce craving in that it can address awareness of the emotion and redirection of thoughts. From Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2013, pp. 490–491. Copyright 2013 by the American Psychiatric Association. All rights reserved. Reprinted with permission. Note The diagnostic criteria for alcohol use disorder are used as an example because the criteria are identical for all of the disorders with the exception of Criterion 11, which does not apply to hallucinogen-related and inhalant-related use disorders. Substance intoxication is a syndrome that develops temporarily after ingestion of a substance. The subsequent psychological changes result from the physiological effects of the substance. Intoxication often includes alterations in attention, thinking, judgment, perception, interpersonal behavior, psychomotor behavior, and wakefulness. The diagnosis of substance intoxication is separate from substance use disorder, and the specific substance of intoxication is listed in the disorder. The DSM-5 includes criteria sets specific to intoxication for each substance category. ICD-10-CM coding will change on the basis of the comorbidity of a substance use disorder. For example, there are different codes for alcohol intoxication with comorbid alcohol use disorder, mild (F10.129), than for alcohol intoxication with comorbid alcohol use disorder, moderate (F10.229), or alcohol intoxication without comorbid alcohol use disorder (F10.929). Substance withdrawal includes physiological and psychological effects from stopping or reducing substance utilization after significant, prolonged use. Withdrawal can be distinctly unpleasant and trigger a cycle of renewed use to counterbalance the deleterious effects of the withdrawal. An individual can become intoxicated by, and have withdrawal from, more than one substance concomitantly. The DSM-5 includes criteria sets specific to withdrawal from each substance; generally, withdrawal criteria are opposite what one would expect with substance intoxication for the substance. As with substance intoxication, the diagnosis of substance withdrawal can occur with or without the comorbid diagnosis of a substance use disorder (APA, 2013a). There are separate diagnostic codes for all substance-related disorders (see list below). In making a diagnosis for a substance-related disorder, counselors must identify specifiers accurately. In addition to specification of substance use disorders as mild, moderate, or severe as discussed earlier, specifiers include in early remission, in sustained remission, on maintenance therapy, and in a controlled environment, with the last being an additional specifier for remission. Jails, locked hospital units, and therapeutic living settings are examples of controlled environments. Counselors use the codes that apply to the specific substances with the name of the specific substance included, for example, alcohol use disorder, mild (ICD-9-CM, 305.00; ICD-10-CM, F10.10). Other substance use disorder should be used if a substance does not fit into one of the enumerated classes. It should be noted that there are separate codes for use and withdrawal for ICD-9-CM, whereas there is one unified code for ICD-10-CM.
Substance-Related and Addictive Disorders
Major Changes From DSM-IV-TR to DSM-5
Substance-Related Disorders
Essential Features
Diagnostic Criteria (Alcohol Use Disorder Example)
Substance Intoxication and Withdrawal
Coding, Recording, and Specifiers
Diagnostic Codes for Substance Use Disorders
Alcohol-Related Disorders
305.00 (F10.10)
Alcohol use disorder, mild
303.90 (F10.20)
Alcohol use disorder, moderate
303.90 (F10.20)
Alcohol use disorder, severe
303.00 (F10.129)
Alcohol intoxication with use disorder, mild
303.00 (F10.229)
Alcohol intoxication with use disorder, moderate or severe
303.00 (F10.929)
Alcohol intoxication without use disorder
291.81 (F10.239)
Alcohol withdrawal without perceptual disturbances
291.81 (F10.232)
Alcohol withdrawal with perceptual disturbances
291.9 (F10.99)
Unspecified alcohol-related disorders
Caffeine-Related Disorders
305.90 (F15.92)
Caffeine intoxication
292.0 (F15.33)
Caffeine withdrawal
292.9 (F15.99)
Unspecified caffeine-related disorder
Cannabis-Related Disorders
305.20 (F12.10)
Cannabis use disorder, mild
303.90 (F12.20)
Cannabis use disorder, moderate
303.90 (F12.20)
Cannabis use disorder, severe
292.89 (F12.129)
Cannabis intoxication without perceptual disturbance with use disorder, mild
292.89 (F10.229)
Cannabis intoxication without perceptual disturbance with use disorder, moderate or severe
292.89 (F10.929)
Cannabis intoxication without perceptual disturbance without use disorder
292.89 (F12.122)
Cannabis intoxication with perceptual disturbance with use disorder, mild
292.89 (F12.222)
Cannabis intoxication with perceptual disturbance with use disorder, moderate or severe
292.89 (F12.922)
Cannabis intoxication with perceptual disturbance without use disorder
292.0 (F12.288)
Cannabis withdrawal
292.9 (F12.99)
Unspecified cannabis-related disorders
Hallucinogen-Related Disorders
305.90 (F16.10)
Phencyclidine use disorder, mild
304.60 (F16.20)
Phencyclidine use disorder, moderate
304.60 (F16.20)
Phencyclidine use disorder, severe
305.30 (F16.10)
Other hallucinogen use disorder, mild Related posts:
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