144 - Harmful pattern of psychoactive substance use

Harmful pattern of psychoactive substance use

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Boundary with substance intoxication Substance intoxication is defined by substance use that results in clinically significant transient substance-specific symptoms (see Table 6.15, p. 475). Recovery from substance intoxication is generally complete and without physical or mental sequelae. If there is continuing damage or harm (e.g. the effects of hypoxia, the effects of prolonged hyperactivity or inactivity, tissue damage) due to an episode of substance intoxication, a diagnosis of episode of harmful psychoactive substance use may be assigned. If relevant at the time of the clinical encounter (e.g. in emergency settings), episode of harmful psychoactive substance use may be diagnosed with an associated diagnosis of substance intoxication. Boundary with substance-induced mental disorders Substance-induced mental disorders can be associated with a single episode of substance use. If a substance-induced mental disorder has occurred as a form of harm resulting from a single episode of substance use, both episode of harmful psychoactive substance use and the relevant substance-induced mental disorder should be diagnosed (e.g. episode of harmful cocaine use with cocaine-induced psychotic disorder). Note: specific substance-induced mental disorders are only applicable for some substances or substance classes (see Table 6.14, p. 454). Boundary with overdose When ingestion of psychoactive substances results in symptoms of overdose (e.g. coma, lifethreatening cardiac or respiratory suppression), a diagnosis from the grouping of harmful effects of substances in Chapter 22 on injury, poisoning or certain other consequences of external causes should also be assigned. Harmful pattern of psychoactive substance use Available categories by substance class 6C40.1 Harmful pattern of use of alcohol 6C41.1 Harmful pattern of use of cannabis 6C42.1 Harmful pattern of use of synthetic cannabinoids 6C43.1 Harmful pattern of use of opioids 6C44.1 Harmful pattern of use of sedatives, hypnotics or anxiolytics 6C45.1 Harmful pattern of use of cocaine 6C46.1 Harmful pattern of use of stimulants, including amfetamines, methamfetamine and methcathinone 6C47.1 Harmful pattern of use of synthetic cathinones 6C48.1 Harmful pattern of use of caffeine 6C49.1 Harmful pattern of use of hallucinogens 6C4A.1 Harmful pattern of use of nicotine 6C4B.1 Harmful pattern of use of volatile inhalants 6C4C.1 Harmful pattern of use of MDMA or related drugs, including MDA 6C4D.1 Harmful pattern of use of dissociative drugs, including ketamine and PCP 6C4E.1 Harmful pattern of use of other specified psychoactive substance 6C4F.1 Harmful pattern of use of multiple specified psychoactive substances 6C4G.1 Harmful pattern of use of unknown or unspecified psychoactive substances Diagnostic requirements for disorders due to substance use | Harmful pattern of psychoactive substance use

459 Disorders due to substance use or addictive behaviours Essential (required) features • A pattern of continuous, recurrent or sporadic use of a psychoactive substance that has caused clinically significant damage to a person’s physical health (e.g. bloodborne infection from intravenous self-administration) or mental health (e.g. substance-induced mood disorder), or has resulted in behaviour leading to harm to the health of others is required for diagnosis. • Harm to the health of the individual occurs due to one or more of the following: behaviour related to intoxication (see Table 6.15, p. 475); direct or secondary toxic effects on body organs and systems; or a harmful route of administration. • Harm to the health of others includes any form of physical harm, including trauma, or mental disorder that is directly attributable to behaviour related to substance intoxication on the part of the person to whom the diagnosis of harmful pattern of psychoactive substance use applies. • The pattern of use of the relevant substance is evident over a period of at least 12 months if substance use is episodic, or at least 1 month if use is continuous. • The harm to health is not better accounted for by another medical condition or another mental disorder, including another disorder due to substance use (e.g. substance withdrawal). Note: harm to the health of the person to whom the diagnosis applies includes injuries caused by behaviour related to intoxication (e.g. impulsive aggressive behaviour, psychomotor impairment leading to injury; see Table 6.15, p. 475); acute health problems resulting from substance use (e.g. overdose, acute gastritis, the effects of hypoxia or prolonged hyperactivity or inactivity), and exacerbation or decompensation of pre-existing chronic health problems (e.g. hypertension, liver disease, or peptic ulceration). Harm may also result from a harmful route of administration (e.g. injecting drug use causing bloodborne virus infections, cocaine use causing a perforated nasal septum). The relevant diagnostic codes from other ICD-11 chapters – including Chapter 22 on injury, poisoning or certain other consequences of external causes – should be used to describe the specific health consequences of the harmful substance use. Harm to the health of others includes any form of physical harm, including trauma (e.g. impaired driving causing a motor vehicle accident, assaultive behaviour leading to bodily harm to another person) or mental disorder (e.g. post-traumatic stress disorder arising from an assault by the intoxicated individual) that is directly attributable to behaviour due to substance intoxication on the part of the person to whom the diagnosis of harmful pattern of psychoactive substance use applies. Diagnostic requirements for disorders due to substance use | Harmful pattern of psychoactive substance use

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Course specifiers A specifier is used to further describe the harmful pattern of substance use, using a fifth-character code. The x below corresponds to the fourth-character code indicating the substance class (0 for alcohol, 1 for cannabis, 2 for synthetic cannabinoids and so on). Harmful pattern of psychoactive substance use, episodic This category is assigned when all the diagnostic requirements for harmful pattern of psychoactive substance use are met, and there is evidence of a pattern of recurrent episodic or intermittent use of the relevant psychoactive substance over a period of at least 12 months that has caused clinically significant harm to a person’s physical or mental health or has resulted in behaviour leading to harm to the health of others. Harmful pattern of psychoactive substance use, continuous This category is assigned when all the diagnostic requirements for harmful pattern of psychoactive substance use are met, and there is evidence of a pattern of continuous substance use (daily or almost daily) of the relevant psychoactive substance over a period of at least 1 month that has caused clinically significant harm to a person’s physical or mental health or has resulted in behaviour leading to harm to the health of others. Harmful pattern of psychoactive substance use, unspecified Additional clinical features • There must be explicit evidence of harm to the individual’s physical or mental health, or of behaviour due to substance intoxication that has led to harm to the physical or mental health of others. There must also be a clear causal relationship between the harm to health and the episodic or continuous use of a substance. • The likelihood of harm to self or others due behaviour related to intoxication varies substantially by substance (see Table 6.15, p. 475). For example, such behaviour is unlikely to arise from caffeine or nicotine intoxication. • A diagnosis of harmful pattern of use of unknown or unspecified psychoactive substances can be assigned if the substance consumed is initially unknown. As more information becomes available (e.g. laboratory results, report from a collateral informant) the diagnosis should be changed to indicate the substance(s) involved in the harmful pattern of psychoactive substance use. • As more information becomes available about symptoms and behaviours related to the pattern of substance use, as well as physiological features indicative of neuroadaptation 6C4x.10 6C4x.11 6C4x.1Z Diagnostic requirements for disorders due to substance use | Harmful pattern of psychoactive substance use

461 Disorders due to substance use or addictive behaviours to the substance, the diagnosis may be changed to substance dependence if diagnostic requirements are met. Boundary with normality (threshold) • The diagnosis of harmful pattern of psychoactive substance use requires clinically significant harm to the individual’s physical or mental health or the health of others. Examples of impact on physical or mental health that would not be considered clinically significant include mild hangovers, brief episodes of vomiting, or transient depressed mood. • A pattern of psychoactive substance use may cause a range of problems in functioning (e.g. missed appointments, arguments with loved ones) that are not sufficiently severe to constitute clinically significant harm to physical or mental health. Such problems are not a sufficient basis for a diagnosis of harmful pattern of psychoactive substance use. Developmental presentations • Harmful pattern of psychoactive substance use is often a characteristic of late adolescence and young adulthood, and injuries and the consequences of aggressive behaviour are particularly common in this age group. • Harmful pattern of psychoactive substance use in older adults may cause injuries and fractures due to the combination of lowered tolerance, psychomotor impairment induced by a substance, and disorders associated with ageing such as osteoporosis and dementia. Sex- and/or gender-related features • The prevalence of harmful pattern of psychoactive substance use is higher in males, but the gender differential is smaller in countries where women play a greater role in the workforce. Gender differences in injuries and other forms of harm due to substance use are recognized. Boundaries with other disorders and conditions (differential diagnosis) Boundary with hazardous substance use Hazardous substance use is classified in Chapter 24 on factors influencing health status or contact with health services and not in this chapter on mental, behavioural and neurodevelopmental disorders. hazardous substance use appreciably increases the risk of harmful physical or mental health consequences, to the user or to others, to an extent that warrants attention and advice from Diagnostic requirements for disorders due to substance use | Harmful pattern of psychoactive substance use

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders health professionals, but has not resulted in specific identifiable harm and therefore does not meet the diagnostic requirements for harmful pattern of psychoactive substance use. Boundary with episode of harmful psychoactive substance use If the harm to health is a result of a single episode of use rather than a pattern of substance use, whether episodic or continuous, a diagnosis of episode of harmful psychoactive substance use should be assigned. Substance use is generally considered to be following a pattern if there has been at least episodic or intermittent use over a period of at least 12 months. If harm is caused by use of a substance but no information is available about the pattern or history of substance use, a diagnosis of episode of harmful psychoactive substance use may be assigned until such time as evidence for a pattern of use is ascertained. Boundary with substance dependence In substance dependence, individuals use a substance or substances persistently, despite harm and adverse consequences. Harm caused by such use may be similar to that observed in harmful pattern of psychoactive substance use. However, substance dependence also includes additional features of impaired ability to control use and increasing priority given to the substance use over other activities. Physiological features (e.g. tolerance) may also be present for applicable substances. If all diagnostic requirements for substance dependence are met for a particular substance, Harmful pattern of psychoactive substance use should not be assigned for that substance. Note: substance dependence is only applicable for some substances or substance classes (see Table 6.13, p. 450). Boundary with substance intoxication Substance intoxication is defined by substance use that results in clinically significantly, transient substance-specific symptoms (see Table 6.15, p. 475). Recovery from substance intoxication is generally complete and absent of physical or mental sequelae. A pattern or repeated intoxication may or may not result in harm to a person’s physical or mental health or to the health of others. If there is continuing damage or harm (e.g. the effects of hypoxia, the effects of prolonged hyperactivity or inactivity, tissue damage) as a result of repeated or continuous use of a psychoactive substance, a diagnosis of harmful pattern of psychoactive substance use may be assigned. If relevant at the time of the clinical encounter (e.g. in emergency settings), harmful pattern of psychoactive substance use may be diagnosed with an associated diagnosis of substance intoxication. Boundary with substance withdrawal Substance withdrawal occurs upon cessation or reduction of a substance in the context of physiological dependence, or when a substance has been taken for a prolonged period or in large amounts. Some features of substance withdrawal may include physical or mental harm (e.g. seizures, delusions, hallucinations, anxiety). If the symptoms are entirely explained by the withdrawal syndrome for the relevant substance (see Table 6.16, p. 484), an additional diagnosis of harmful pattern of psychoactive substance use is not warranted. However, if the symptoms substantially exceed the expected withdrawal syndrome in duration or type or severity, and the diagnostic requirements for substance dependence are not met, harmful pattern of psychoactive substance use can be assigned as the primary diagnosis, with an associated diagnosis of substance withdrawal (e.g. harmful pattern of use of opioids with opioid withdrawal). Note: substance withdrawal is only applicable for some substances or substance classes (see Table 6.13, p. 450). Boundary with substance-induced mental disorders If a substance-induced mental disorder has occurred as a form of harm resulting from a pattern of substance use, both harmful pattern of psychoactive substance use and the relevant substanceinduced mental disorder should be diagnosed (e.g. harmful pattern of cocaine use with cocaineinduced anxiety disorder). Note: specific substance-induced mental disorders are only applicable for some substances or substance classes (see Table 6.14, p. 454). Diagnostic requirements for disorders due to substance use | Harmful pattern of psychoactive substance use