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Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2004. (Treatment Improvement Protocol (TIP) Series, No. 40.)

Cover of Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction.

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Appendix C DSM‐IV‐TR Material

Criteria for Substance Dependence

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12‐month period (emphasis ours):

  1. Tolerance, as defined by either of the following:
    1. A need for markedly increased amounts of the substance to achieve intoxication or desired effect
      or
    2. Markedly diminished effect with continued use of the same amount of the substance
  2. Withdrawal, as manifested by either of the following:
    1. The characteristic withdrawal syndrome for the substance
      or
    2. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  3. The substance is often taken in larger amounts or over a longer period than was intended
  4. There is a persistent desire or unsuccessful efforts to cut down or control substance use
  5. A great deal of time is spent on activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain‐smoking), or recover from its effects
  6. Important social, occupational, or recreational activities are given up or reduced because of substance use
  7. The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine‐induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

Specify if:

With Physiological Dependence: Evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is present)

Without Physiological Dependence: No evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present)

Substance Dependence Course Specifiers

Six course specifiers are available for Substance Dependence. The four Remission specifiers can be applied only after none of the criteria for Substance Dependence or Substance Abuse have been present for at least 1 month. The definition of these four types of Remission is based on the interval of time that has elapsed since the cessation of Dependence (Early versus Sustained Remission) and whether there is continued presence of one or more of the items included in the criteria sets for Dependence or Abuse (Partial versus Full Remission). Because the first 12 months following Dependence is a time of particularly high risk for relapse, this period is designated Early Remission. After 12 months of early Remission have passed without relapse to Dependence, the person enters into Sustained Remission. For both Early Remission and Sustained Remission, a further designation of Full is given if no criteria for Dependence or Abuse have been met during the period of remission; a designation of Partial is given if at least one of the criteria for Dependence or Abuse has been met, intermittently or continuously, during the period of remission. The differentiation of Sustained Full Remission from recovered (no current Substance Abuse Disorder) requires consideration of the length of time since the last period of disturbance, the total duration of the disturbance, and the need for continued evaluation. If, after a period of remission or recovery, the individual again becomes dependent, the application of the Early Remission specifier requires that there again be at least 1 month in which no criteria for Dependence or Abuse are met. Two additional specifiers have been provided: On Agonist Therapy and In a Controlled Environment. For an individual to qualify for Early Remission after cessation of agonist therapy or release from a controlled environment, there must be a 1‐month period in which none of the criteria for Dependence of Abuse are met.

The following Remission specifiers can be applied only after no criteria for Dependence or Abuse have been met for at least 1 month. Note that these specifiers do no apply if the individual is on agonist therapy or in a controlled environment (see below).

Early Full Remission: This specifier is used if, for at least 1 month, but for less than 12 months, no criteria for Dependence or Abuse have been met.

Early Partial Remission: This specifier is used if, for at least 1 month, but less than 12 months, one or more criteria for Dependence or Abuse have been met (but the full criteria for Dependence have not been met).

Sustained Full Remission: This specifier is used if none of the criteria for Dependence or Abuse have been met at any time during a period of 12 months or longer.

Sustained Partial Remission: This specifier is used if full criteria for Dependence have not been met for a period of 12 months or longer; however, one or more criteria for Dependence or Abuse have been met.

On Agonist Therapy: This specifier is used if the individual is on a prescribed agonist medication, and no criteria for Dependence or Abuse have been met for that class of medication for at least the past month (except tolerance to, or withdrawal from, the agonist). This category also applies to those being treated for Dependence using a partial agonist or an agonist/antagonist.

In a Controlled Environment: This specifier is used if the individual is in an environment where access to alcohol and controlled substances is restricted, and no criteria for Dependence or Abuse have been met for at least the past month. Examples of these environments are closely supervised and substance‐free jails, therapeutic communities, or locked hospital units.

Criteria for Substance Abuse

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12‐month period:

  • Recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance‐related absences, suspensions, or expulsions from school; neglect of children or household
  • Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  • Recurrent substance‐related legal problems (e.g., arrests for substance‐related disorderly conduct)
  • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequence of intoxication, physical fights)

The symptoms have never met the criteria for Substance Dependence for this class of substance.

Opioid Dependence

Refer, in addition, to the text and criteria for Substance Dependence. Most individuals with Opioid Dependence have significant levels of tolerance and will experience withdrawal on abrupt discontinuation of opioid substances. Opioid Dependence includes signs and symptoms that reflect compulsive, prolonged self‐administration of opioid substances that are used for no legitimate medical purpose or, if a general medical condition is present that requires opioid treatment, that are used in doses that are greatly in excess of the amount needed for pain relief. Persons with Opioid Dependence tend to develop such regular patterns of compulsive drug use that daily activities are typically planned around obtaining and administering opioids. Opioids are usually purchased on the illegal market but may also be obtained from physicians by faking or exaggerating general medical problems, or by receiving simultaneous prescriptions from several physicians. Health care professionals with Opioid Dependence will often obtain opioids by writing prescriptions for themselves or by diverting opioids that have been prescribed for patients or from pharmacy supplies.

Other DSM‐IV Substance‐Related Disorders

ICD‐9‐CM

  1. 292.82 Persisting Dementia
  2. 292.83 Persisting Amnestic Disorder
  3. 292.11 Psychotic Disorder with Delusions
  4. 292.12 Psychotic Disorder with Hallucinations
  5. 292.84 Mood Disorder
  6. 292.89 Anxiety Disorder
  7. 292.89 Sleep Disorder
  8. 292.89 Sexual Dysfunction
  9. 292.89 Persisting Perception Disorder (Flashbacks)
  10. 292.9 Disorder Not Otherwise Specified

Substance Related Disorders

  1. 305.01 Alcohol abuse, continuous
  2. 305.02 Alcohol abuse, episodic
  3. 305.03 Alcohol abuse, remission
  4. 305.00 Alcohol abuse, unspec.
  5. 303.00 Alcohol intoxication, acute, unspec.
  6. 291.81 Alcohol withdrawal
  7. 303.91 Alcoholism, chronic, continuous
  8. 304.41 Amphetamine dependence, continuous
  9. 304.11 Barbiturate dependence, continuous
  10. 305.22 Cannabis abuse, episodic
  11. 304.31 Cannabis dependence, continuous
  12. 305.62 Cocaine abuse, episodic
  13. 304.21 Cocaine dependence, continuous
  14. 305.90 Drug abuse, unspec.
  15. 305.92 Drug abuse, unspec., episodic
  16. 304.90 Drug dependence, unspec.
  17. 292.11 Drug‐induced paranoia
  18. 305.52 Opioid abuse, episodic
  19. 304.01 Opioid dependence, continuous
  20. 305.1 Tobacco abuse

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision. Copyright 2000. (American Psychiatric Association 2000).

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