At Any Age, It Does Matter:
Substance Abuse and Older Adults (for Professionals)

Supplements

ICD-10 Diagnostic Criteria for Clinical Use

Harmful Use

A pattern of psychoactive substance use that is causing damage to health. The damage may be physical (as in cases of hepatitis from the self-administration of injected drugs) or mental (e.g., episodes of depressive disorder secondary to heavy consumption of alcohol).

The diagnosis requires that actual damage should have been caused to the mental or physical health of the user. Harmful patterns of use are often criticized by others and frequently associated with adverse social consequences of various kinds.

The fact that a pattern of use or particular substance is disapproved of by another person or by the culture or may have led to socially negative consequences such as arrest or marital arguments is not in itself evidence of harmful use.

Acute intoxication or "hangover" is not in itself sufficient evidence of the damage to health required for coding harmful use. Harmful use should not be diagnosed if dependence syndrome, a psychotic disorder, or another specific form of drug- or alcohol-related disorder is present.

Dependence Syndrome

A definite diagnosis of dependence should usually be made only if three or more of the following have been experienced or exhibited at some time during the previous year:

  1. A strong desire or sense of compulsion to take the substance.
  2. Difficulties in controlling substance-taking behavior in terms of its onset, termination, or levels of use.
  3. A physiological withdrawal state when substance use has ceased or been reduced, as evidenced by the characteristic withdrawal syndrome for the substance or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms.
  4. Evidence of tolerance such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses (clear examples of this are found in alcohol- and opiate-dependent individuals who may take daily doses sufficient to incapacitate or kill nontolerant users).
  5. Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amounts of time necessary to obtain or take the substance or recover from its effects.
  6. Persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related impairment of cognitive functioning. Efforts should be made to determine that the user was actually, or could be expected to be, aware of the nature and extent of harm.

Narrowing of the personal repertoire of patterns of psychoactive substance use has also been described as a characteristic feature (e.g., a tendency to drink alcoholic drinks in the same way on weekdays and weekends, regardless of social constraints that determine appropriate drinking behavior).

It is an essential characteristic of the dependence syndrome that either psychoactive substance taking or a desire to take a particular substance should be present. The subjective awareness of compulsion to use drugs is most commonly seen during attempts to stop or control substance use. This diagnostic requirement would exclude, for instance, surgical patients given opioid drugs for the relief of pain. They may show signs of an opioid withdrawal state when drugs are not given but have no desire to continue taking drugs.

The dependence syndrome may be present for:

The diagnosis of the dependence syndrome may be further specified by the following (the following roughly correspond to the course modifiers and relapse section of DSM-IV):

Source: U.S. Congress, Office of Technology Assessment. Technologies for Understanding and Preventing Substance Abuse and Addiction, OTA-EHR-597. Washington, DC: U.S. Government Printing Office, September 1994.

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