UBC Objectives: Addiction Medicine

​By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Identify, in a safe and non-judgmental fashion, individuals with substance use disorders
• Identify addiction as a chronic disease

In my last post I mentioned how it's important to ask patients about substance use, but at what point does someone go from using a substance to having a substance use disorder? The simple answer is when the use of the substance is creating problems for the person.

Now for the more detailed answer: The DSM-V has diagnostic criteria for substance use disorders. The diagnostic criteria for different substances are very similar, so I will give the criteria for a diagnosis of Opioid Use Disorder (OUD) as an example. 

Of the following criteria, if the patient meets a minimum of 2 of a total possible number of 10, from any category, they qualify for a diagnosis of OUD. The 4 categories and 10 constituent criteria are as follows:

1. Impaired control
   1. Opioids used in larger amounts or for longer than intended
   2. Unsuccessful efforts or desire to cut back or control opioid use
   3. Excessive amount of time spent obtaining, using, or recovering from opioids
   4. Craving to use opioids
2. Social Impairment
   1. Failure to fulfill major role obligations at work, school, or home as a result of recurrent opioid use
   2. Persistent or recurrent social or interpersonal problems that are exacerbated by opioids or continued use of opioids despite these problems
   3. Reduced or given up important social, occupational, or recreational activities because of opioid use
3. Risky Use
   1. Opioid use in physically hazardous situations
   2. Continued opioid use despite knowledge of persistent physical or psychological problem that is likely caused by opioid use
4. Pharmacological Properties
   1. Tolerance as demonstrated by increased amounts of opioids needed to achieve desired effect; diminished effect with continued use of the same amount
   2. Withdrawal as demonstrated by symptoms of opioid withdrawal syndromes; opioids taken to relieve or avoid withdrawal

Depending on the number of total criteria met, the diagnosis is qualified by a severity score, which is as follows:

1. Mild: Presence of 2–3 symptoms.
2. Moderate: Presence of 4–5 symptoms.
3. Severe: Presence of 6 or more symptoms.

Patients have sometimes previously qualified for a diagnosis of OUD but no longer meet the necessary minimum 2 criteria anymore for a diagnosis of active OUD, or else they are possibly receiving treatment for it, and may or may not meet the minimum criteria for an active OUD diagnosis at this time. In situations like this, there are specifiers to attach to the label of OUD, so as to keep track of where a patient is at once they've ever been given a diagnosis of OUD. These specifiers are:

1. In early remission (3 months of no criteria being met [with the exception of cravings]) or sustained remission (12 months or longer [with the exception of cravings])
2. On maintenance therapy
3. In a controlled environment (where access to opioids is restricted)

The reason we don't just drop this diagnosis from a patient's medical chart if they no longer meet the minimum 2 criteria is because OUD is recognised as a chronic disease, much like any other chronic physical illness. Although sustained remission for many years or even a lifetime is possible, relapse is much more the norm than the exception. This is why many clinicians such as myself advocate for opioid agonist therapy (OAT) such as with buprenorphine/naloxone, methadone, slow-release oral morphine, or cutting-edge injectable opioid agonist therapy (iOAT). Patients with active OUD who go through detox without additional OAT relapse 90% of the time! The addiction is powerful, and with numbers like that, it would be pure stupidity to think an individual who can't overcome the addiction lacks willpower. More than just relapsing into reusing, this also goes along with all the havoc that is wreaked by the disorder in their lives, with further entrenchment in the negative cycles that one falls into when a victim of this disorder. OAT has been shown to make significant gains in helping people lead lives where they can reintegrate into society, have stability and enhanced quality of life, and not suffer the immense increase in morbidity and mortality secondary to street drug use. There is the possibility that some patients may eventually be able to taper off the OAT altogether, but sustained use also has it's place, and it's all about balancing the risks versus the benefits for the individual patient. Just like a patient with high blood pressure could potentially exercise more, adopt a better diet, lose weight, and decrease the stress in their life, so as to achieve a normal blood pressure again, this is often not actually achieved by the large majority of people with this disorder. So we put them on blood pressure medication to reduce the risk of heart attack, stroke, and end-organ disease that they are at significantly elevated risk for when walking around with uncontrolled high blood pressure. The use of OAT is much the same for the patient with OUD as a blood pressure pill is for the patient with hypertension.

Although the following is an article from CBS, an American news corporation, and although it is not the most recent, being published in November 2016, I appreciate it for the context it provides for a basic understanding of the public health phenomenon of substance use disorders. See the article by clicking here.