DIAGNOSIS OF DRUG ABUSE: DIAGNOSTIC CRITERIA

Diagnosis is the process of identifying and labeling specific disease conditions. The signs and symptoms used to classify a sick person as having a disease are called diagnostic criteria. Diagnostic criteria and classification systems are useful for making clinical decisions, estimating disease prevalence, understanding the causes of disease, and facilitating scientific communication.

Diagnostic classification provides the treating clinician with a basis for retrieving information about a patient's probable symptoms, the likely course of an illness, and the biological or psychological process that underlies the disorder. For example, the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (1987) is a classification of mental disorders that provides the clinician with a systematic description of each disorder in terms of essential features, age of onset, probable course, predisposing factors, associated features and differential diagnosis. Mental health professionals can use this system to diagnose substance use disorders in terms of the following categories: acute Intoxication, Abuse, Dependence, Withdrawal, Delirium, and other disorders. In contrast to screening, diagnosis typically involves a broader evaluation of signs, symptoms, and laboratory data as these relate to the patient's illness. The purpose of diagnosis is to provide the clinician with a logical basis for planning Treatment and estimating prognosis.

Another purpose of classification is the collection of statistical information on a national and international scale. The primary purpose of the International Classification of Diseases (ICD), for example, is the enumeration of morbidity and mortality data for public health planning (World Health Organization, 1992). In addition, a good classification will facilitate communication among scientists and provide the basic concepts needed for theory development. Both ICD and DSM have been used extensively to classify persons for scientific research. Classification provides a common frame of reference in communicating scientific findings.

Diagnosis also may serve a variety of administrative purposes. When a patient is suspected of having a substance use disorder, diagnostic procedures are needed to exclude "false positives" (i.e., people who appear to have the disorder but who really do not) and borderline cases. Insurance reimbursement for medical treatment increasingly demands that a formal diagnosis be confirmed according to standard procedures or criteria. The need for uniform reporting of statistical data, as well as the generation of prevalence estimates for epidemiological research, often requires a diagnostic classification of the patient.

CLASSIFICATION SYSTEMS

Alcoholism and drug Addiction have been variously defined as medical diseases, mental disorders, social problems, and behavioral conditions. In some cases, they are considered the symptom of an underlying mental disorder (Babor, 1992). Some of these definitions permit the classification of alcoholism and drug dependence within standard nomenclatures such as the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders. The recent revisions of both of these diagnostic systems has resulted in a high degree of compatibility between the classification criteria used in the United States and those used internationally. Both systems now diagnose dependence according to the elements first proposed by Edwards and Gross (1976). They also include a residual category (harmful alcohol use [ICD-10]; alcohol abuse [DSM-III-R]) that allows classification of psychological, social, and medical consequences directly related to substance use.

Some diagnostic classification systems are used primarily for epidemiological and clinical research. These include the Feighner Criteria (Feighner et al., 1972) and the Research Diagnostic Criteria (Robins, 1981). Other classifications are intended primarily for clinical care (DSM-III-R; see American Psychiatric Association, 1987) or statistical reporting (ICD-10; see World Health Organization, 1992).

HISTORY TAKING

Obtaining accurate information from patients with alcohol and drug problems is often difficult because of the stigma associated with substance abuse and the fear of legal consequences. At times they want help for the medical complications of substance use (such as injuries, or depression) but are ambivalent about giving up alcohol or drug use entirely. It is often the case that these patients are evasive and attempt to conceal or minimize the extent of their alcohol or drug use. Acquiring accurate information about the presence, severity, duration and effects of alcohol and drug use therefore requires a considerable amount of clinical skill.

The medical model for history taking is the most widely used approach to diagnostic evaluation. This consists of identifying the chief complaint, evaluating the present illness, reviewing past history, conducting a review of biological systems (e.g., gastrointestinal, cardiovascular), asking about family history of similar disorders, and discussing the patient's psychological and social functioning. A history of the present illness begins with questions on use of alcohol, drugs, and Tobacco. The questions should cover Prescription Drugs as well as illicit drugs, with additional elaboration of the kind of drugs, the amount used, and the mode of administration (e.g., smoking, injection). Questions about alcohol use should refer specifically to the amount and frequency of use of major beverage types (wine, spirits, Beer). A thorough physical examination is important because each substance has specific pathological effects on certain organs and body systems. For example, alcohol affects the liver, stomach, and cardiovascular system. Drugs often produce abnormalities in "vital signs" such as temperature, pulse, and blood pressure. A mental status examination frequently gives evidence of substance use disorders because of poor personal hygiene, inappropriate affect (sad, euphoric, irritable, Anxious), illogical or delusional thought processes, and memory problems. The physical examination can be supplemented by laboratory tests, which sometimes aid in early diagnosis before severe or irreversible damage has taken place. Laboratory tests are useful in two ways (1) alcohol and drugs can be measured directly in blood, urine, and exhaled air; (2) biochemical and psychological functions known to be affected by substance use can be assessed. Many drugs can be detected in the urine for twelve to forty-eight hours after their consumption. An estimate of Blood Alcohol Concentration (BAC) can be made directly by blood test or indirectly by means of a breath or saliva test. Elevated gamma glutamyl transpeptidase (GGTP), a liver enzyme, is a sensitive indicator of chronic, heavy alcohol intake.

In addition to the physical examination and laboratory tests, a variety of diagnostic interview procedures have been developed to provide objective, empirically based, reliable diagnoses of substance use disorders in various clinical populations. One type, exemplified by the Diagnostic Interview Schedule (DIS; see Robins et al., 1981) and the Composite International Diagnostic Interview (CIDI; see Robins et al., 1988), is highly structured and requires a minimum of clinical judgment by the interviewer. These interviews provide information not only about substance use disorders, but also about physical conditions and psychiatric disorders that are commonly associated with substance abuse. A second type of diagnostic interview is exemplified by the Structured Clinical Interview for DSM-III-R (SCID), which is designed for use by mental health professionals (Spitzer et al., 1992). The SCID assesses thirty-three of the more commonly occurring psychiatric disorders described in DSM-III-R. Among these are depression, schizophrenia, and the substance use disorders. A similar clinical interview, which has been designed for international use, is the Schedules for Clinical Assessment in Neuropsychiatry (SCAN; see Wing et al., 1990). The SCID and SCAN interviews allow the experienced clinician to tailor questions to fit the patient's understanding, to ask additional questions that clarify ambiguities, to challenge inconsistencies, and to make clinical judgments about the seriousness of symptoms. They are both modeled on the standard medical history practiced by many mental health professionals. Questions about the chief complaint, past episodes of psychiatric disturbance, treatment history, and current functioning all contribute to a thorough and orderly psychiatric history that is extremely useful for diagnosing substance use disorders.

In recent years there has been interest in researching and developing a system of self-reporting to aid in the diagnosing of drug use severity. There has been resistance to this kind of diagnostic tool because of clinical suspicion that individuals with substance-use disorders often are not capable of reporting their symptoms accurately. The result of which is a reliance on clinicians or trained interviewers over self-reporting, paper/pencil measures to determine a patient's drug use severity. However, patient-reported data on outcomes and effectiveness of substance abuse treatments is becoming an increasing necessity. Additionally, according to a recent investigation of methodological studies, self-report measures appear to be neither inherently reliable nor unreliable. Certainly the information reported can be imprecise because of memory loss and under- or overreporting, among other variables. Also a variety of conditions can render self-report measurements susceptible to measurement error and systematic response bias but there is no empirical evidence to definitively show that self-reported data is more problematic than interviewer formats. Research has shown that format can create systematic bias but this can be accounted for by combining the data from alternate forms (Heithoff & Wiseman, 1996).

DIAGNOSIS OF ABUSE AND HARMFUL USE

A major diagnostic category that has received increasing attention in research and clinical practice is substance abuse in contrast to dependence. This category permits the classification of mal-adaptive patterns of alcohol or drug use that do not meet criteria for dependence. The diagnosis of abuse is designed primarily for persons who have recently begun to experience Alcohol or drug problems, and for chronic users whose substance-related consequences develop in the absence of marked dependence symptoms. Examples of situations in which this category would be appropriate include (1) a pregnant woman who keeps drinking alcohol even though her physician has told her that it could be responsible for Fetal damage; (2) a college student whose weekend binges result in missed classes, poor grades, and alcohol-related traffic Accidents; (3) a middle-aged beer drinker regularly consuming a six-pack each day who develops high blood pressure and fatty liver in the absence of alcohol-dependence symptoms, and (4) an occasional Marijuana smoker who has an accidental injury while intoxicated.

In the latest version of the Diagnostic and Statistical Manual (DSM IV; see American Psychiatric Association, 1994), substance abuse is defined as a maladaptive pattern of alcohol or drug use leading to clinically significant impairment or distress, as manifested by one or more of the symptoms listed in Table 1. For comparative purposes, the table also lists the criteria for harmful use in ICD-10 and for alcohol abuse in DSM-III-R. To assure that the diagnosis is based on clinically meaningful symptoms rather than the results of an occasional excess, the duration criterion specifies how long the symptoms must be present to qualify for a diagnosis.

In ICD-10, the term harmful use refers to a pattern of using one or more Psychoactive substances that causes damage to health. The damage may be (1) physical (physiological)—such as fatty liver, pancreatitis from alcohol, or hepatitis from needle-injected drugs; or (2) mental (psychological)—such as depression related to heavy drinking or drug use. Adverse social consequences often accompany substance use, but are not in themselves sufficient to result in a diagnosis of harmful use. The key issue in the definition of this term is the distinction between perceptions of adverse effects (e.g., wife complaining about husband's drinking) and actual health consequences (e.g., trauma due to accidents during drug intoxication). Since the purpose of ICD is to classify diseases, injuries, and causes of death, harmful use is defined as a pattern of use already causing damage to health.

Harmful patterns of use are often criticized by others and sometimes legally prohibited by governments. The fact that alcohol or drug intoxication is disapproved by another person or by the user's culture is not in itself evidence of harmful use—unless socially negative consequences have actually occurred at dosage levels that also result in psychological and physical consequences. This is the major difference that distinguishes ICD-10's harmful use from DSM-IV's substance abuse—the latter category includes social consequences in the diagnosis of abuse.

THE DEPENDENCE SYNDROME CONCEPT

The diagnosis of substance use disorders in ICD-10 and DSM-IV is based on the concept of a dependence syndrome, which is distinguished from disabilities caused by substance use (Edwards, Arif, & Hodgson, 1981). An important diagnostic issue is the extent to which dependence is sufficiently distinct from abuse or harmful use to be considered a separate condition. In DSM-IV, substance abuse is a residual category that allows the clinician to classify clinically meaningful aspects of a patient's behavior when that behavior is not clearly associated with a dependence syndrome. In ICD-10, harmful substance use implies identifiable substance-induced medical or psychiatric consequences that occur in the absence of a dependence syndrome. In both classification systems, dependence is conceived as an underlying condition that has much greater clinical significance because of its implications for understanding etiology, predicting course, and planning treatment. This will become clear in the following discussion of the assumptions behind the dependence-syndrome concept.

The dependence syndrome is seen as an interrelated cluster of cognitive, behavioral, and physiological symptoms. Table 2 summarizes the criteria used to diagnose dependence in ICD-10, DSM-III-R, and DSM-IV. A diagnosis of dependence in all systems is made if three or more of the criteria have been experienced at some time in the previous twelve months.

The dependence syndrome may be present for a specific substance (e.g., tobacco, alcohol, or diazepam), for a class of substances (e.g., opioid drugs), or for a wider range of various substances. A diagnosis of dependence does not necessarily imply the presence of physical, psychological, or social consequences, although some form of harm is usually present. There are some differences among these classification systems, but the criteria are very similar, making it unlikely that a patient diagnosed in one system would be diagnosed differently in the other.

The syndrome concept implicit in the diagnosis of alcohol and drug dependence in ICD and DSM is a way of describing the nature and severity of addiction (Babor, 1992). Table 2 describes four dependence syndrome elements in relation to the criteria for DSM-III-R, DSM-IV, and ICD-10. The same elements apply to the diagnosis of dependence on all psychoactive substances, including alcohol, marijuana, opiates, cocaine, sedatives, phencycledine, other hallucinogens, and tobacco. The elements represent biological, psychological (cognitive), and behavioral processes. This helps to explain the linkages and interrelationships that account for the coherence of signs and symptoms. The co-occurrence of signs and symptoms is the essential feature of a syndrome. If three or more criteria do occur repeatedly during the same period, it is likely that dependence is responsible for the amount, frequency, and pattern of the person's substance use.

Salience.

Salience means that drinking or drug use is given a higher priority than other activities in spite of its negative consequences. This is reflected in the emergence of substance use as the preferred activity from a set of available alternative activities. In addition, the individual does not respond well to the normal processes of social control. For example, when drinking to intoxication goes against the tacit social rules governing the time, place, or amount typically expected by the user's family or friends, this may indicate increased salience.

A characteristic of salience is that drinking or drug use persists in spite of its negative consequences. This implies that substance use has become the preferred activity in the person's life. One indication of this is the amount of time or effort devoted to obtaining, using or recovering from substance use. For example, people who spend a great deal of time at parties, bars, or business lunches give evidence of the increased salience of drinking over nondrinking activities.

Chronic drinking and drug intoxication interfere with the person's ability to conform to tacit social rules governing daily activities, such as keeping appointments, caring for children, or performing a job properly, that are typically expected by the person's reference group. Substance use also results in mental and medical consequences. Thus, a key aspect of the dependence syndrome is the persistence of substance use in spite of social, psychological, or physical harm, such as loss of employment, marital problems, depressive symptoms, accidents, and liver disease. This indicates that substance use is given a higher priority than other activities, in spite of its negative consequences.

One explanation for the salience of drug and alcohol-seeking behavior despite negative consequences is the relative reinforcement value of immediate and long-term consequences. For many alcoholics and drug abusers, the immediate positive reinforcing effects of the substance, such as euphoria or stimulation, far outweigh the delayed negative consequences, which may occur either infrequently or inconsistently.

Impaired Control.

The main characteristic of impaired control is the lack of success in limiting the amount or frequency of substance use. For example, the alcoholic wants to stop drinking, but repeated attempts have been unsuccessful. Typically, rules and other stratagems are used to avoid alcohol entirely or to limit the frequency of drinking. Resumption of heavy drinking after receiving professional help for a drinking problem is evidence of lack of success. The symptom is considered present if the drinker has repeatedly failed to abstain or has only been able to control drinking with the help of treatment, mutual-help groups, or removal to a controlled environment (e.g., prison).

In addition to an inability to abstain, impaired control is also reflected in the failure to regulate the amount of alcohol or drug consumed on a given occasion. The cocaine addict vows to snort only a small amount but then continues until the entire supply is used up. For the alcoholic, impaired control includes inability to prevent spontaneous onset of drinking bouts as well as failure to stop drinking before intoxication. This behavior should be distinguished from situations in which the drinker's "control" over the onset or amount of drinking is regulated by social or cultural factors, such as occur during college beer parties or fiesta drinking occasions. One way to judge the degree of impaired control is to determine whether the drinker or drug user has made repeated attempts to limit the quantity of substance use by making rules or imposing limits on access to alcohol or drugs. The more these attempts have failed, the more the impaired control is present.

Tolerance.

Tolerance is a decrease in response to a psychoactive substance that occurs with continued use. For example, increased doses of heroin are required to achieve effects originally produced by lower doses. Tolerance may be physical, behavioral, or psychological. Physical tolerance is a change in cellular functioning. The effects of a dependence-producing substance are reduced, even though the cells normally affected by the substance are subjected to the same concentration. A clear example is the finding that alcoholics can drink amounts of alcohol (e.g., a quart of vodka) that would be sufficient to incapacitate or kill nontolerant drinkers. Tolerance may also develop at the psychological and behavioral levels, independent of the biological adaptation that takes place. Psychological tolerance occurs when the marijuana smoker or heroin user no longer experiences a "high" after the initial dose of the substance. Behavioral tolerance is a change in the effect of a substance because the person has learned to compensate for the impairment caused by a substance. Some alcoholics, for example, can operate machinery at moderate doses of alcohol without impairment.

Withdrawal Signs and Symptoms.

A withdrawal state is a group of symptoms occurring after cessation of substance use. It usually occurs after repeated, and usually prolonged drinking or drug use. Onset and course of the withdrawal symptoms are related to type of substance and dose being used immediately prior to abstinence. Table 3 lists some common withdrawal symptoms associated with different psychoactive substances. Some drugs, such as Cannabis (Marijuana) and Hallucinogens do not typically produce a withdrawal syndrome after cessation of use.

Alcohol withdrawal symptoms follow the cessation or reduction of prolonged heavy drinking within hours. These include tremors, hyperactive reflexes, rapid heartbeat, hypertension, general malaise, nausea, and vomiting. Seizures and convulsions may occur, particularly in people with a preexisting seizure disorder. Patients may have Hallucinations, illusions, or vivid nightmares. Sleep is usually disturbed. In addition to physical withdrawal symptoms, anxiety and depression are also common. Some chronic drinkers never have a long enough period of abstinence to permit withdrawal to occur.

The use of a substance with the intention of relieving withdrawal symptoms and with an awareness that this strategy is effective are cardinal symptoms of dependence. Morning drinking to relieve nausea or the "shakes" is one of the most common manifestations of physical dependence in alcoholics.

Other Features of Dependence. To be labeled dependence, symptoms must have persisted for at least one month or must have occurred repeatedly (two or more times) over a longer period of time. The patient does not need to be using the substance continually to have recurrent or persistent problems. Some symptoms (e.g., the desire to cut down) may occur repeatedly whether the person is using the substance or not.

Many patients with a history of dependence experience rapid reinstatement of the syndrome following resumption of substance use after a period of abstinence. Rapid reinstatement is a powerful diagnostic indicator of dependence. It points to the impairment of control over substance use, the rapid development of tolerance, and (frequently) physical withdrawal symptoms.

Patients who receive Opiates or other drugs for Pain relief following surgery (or for a malignant disease like cancer) sometimes show signs of a withdrawal state when these drugs are ended. The great majority have no desire to continue taking such drugs and therefore do not fulfill the criteria for dependence. The presence of a physical withdrawal syndrome does not necessarily indicate dependence but rather a state of neuroadaptation to the drug that was being administered.

It is commonly assumed that severe dependence is not reversible—an assumption indicated by the rapid reinstatement of dependence symptoms when drinking or drug use is resumed after a period of detoxification.

(See also: Addiction: Concepts and Definitions ; Alcoholism: Origin of the Term ; Causes of Substance Abuse ; Disease Concept of Alcoholism and Drug Abuse ; Tolerance and Physical Dependence ; Wikler's Pharmacologic Theory of Drug Addiction )

BIBLIOGRAPHY

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders-4th edition. Washington, DC: Author.

American Pyschiatric Association. (1987). Diagnostic and statistical manual of mental disorders-3rd edition-revised. Washington, D.C.: Author.

Babor, T. F. (1992). Nosological considerations in the diagnosis of substance use disorders. In M. Glantz &R. Pickens (Eds.), Vulnerability to drug abuse. Washington DC: American Psychological Association.

Edwards, G., Arif, A., & Hodgson, R. (1981). Nomenclature and classification of drug- and alcohol-related problems: A WHO memorandum. Bulletin of the World Health Organization, 59 (2), 225-242.

Edwards, G., & Gross, M. M. (1976). Alcohol dependence: Provisional description of a clinical syndrome. British Medical Journal, 1, 1058-1061.

Feighner, J., et al. (1972). Diagnostic criteria for use in psychiatric research. Archives of General Psychiatry, 26, 57-63.

Heithoff, K. A.& Wiseman, E. J. (1996). Reliability of paper-pencil assessment of drug use severity. American Journal of Drug and Alcohol Abuse, 22, no. 1, 109-123.

Robins, L. (1981). The diagnosis of alcoholism after DSM III. In R. E. Meyer ct al., Evaluation of the alcoholic: Implications for research, theory and treatment. NIAAA Research Monograph no. 5, DHHS Publication no. (ADM) 81-1033. Washington, DC: U.S. Government Printing Office.

Robins, L. N., et al. (1988). The composite international diagnostic interview: An epidemiological instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Archives of General Psychiatry, 45, 1069-1077.

Robins, L. N., et al. (1981). National Institute of Mental Health diagnostic interview schedule. Archives of General Psychiatry, 38, 381-389.

Spitzer, R. L., et al. (1992). The structured clinical interview for DSM-III-R (SCID), I. History, rationale and description. Archives of General Psychiatry, 49 (8), 624-629.

Tarter, R. E.& Kirisci, L. (1997). The drug use screening inventory for adults: Psychometric structure and discriminative survey. American Journal of Drug and Alcohol Abuse, 23, no. 2, 207-220.

Wing, J. K., et al. (1990). SCAN: Schedules for clinical assessment in neuropsychiatry. Archives of General Psychiatry, 47, 589-593.

Winters, K. C., Latimer, W.& Stinchfield, R. D. (1999). The DSM-IV criteria for adolescent alcohol and cannabis use disorders. Journal of Studies on Alcohol, 60, issue 3, 337.

World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: Author.

Thomas F. Babor

Revised by Chris Lopez