Disorders due to Substance Use: General Approaches

Substance use disorders (SUDs) in ICD-11 are separated into dependence and harmful use, while DSM-5 does not include harmful use as a separate disorder and SUD are diagnosed and their severity is gauged by meeting >2 of its 11 criteria, which include craving, but not legal problems. Overall, ICD-11 will identify about 11% fewer cases of lifetime substance use disorders such as alcohol use than occur with DSM-5. Tolerance and withdrawal are among SUD criteria, but substance-induced conditions like intoxication are separate categories. Urine toxicology and screening tools help indicate SUD diagnoses. The broader differential diagnosis must always consider depressive disorders and not prematurely diagnose antisocial and borderline personality disorders. Drug withdrawal symptoms frequently overlap with depressive symptoms, and depressive symptoms can persist for 4–6 weeks after acute detoxification from stimulants, sedatives, and alcohol. Treatment for overdoses and suicidality requires immediate management using medications like naloxone for opioids. However, engaging the patient is slower and the clinician needs flexibility in approaching developmental differences ranging from adolescent to geriatric patients and in providing care that is culturally congruent with patients’ attitudes and expectations toward drug use. This flexibility maintains the patient in treatment with the overall goal of abstinence, and “controlled use” of an abused drug is typically unrealistic. However, agonist maintenance (e.g., methadone or buprenorphine) can be highly effective when sustained for many months or years as psychosocial rehabilitation occurs.