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DIAGNOSTIC AND SwisiicAL MANUAL OF MENTAL D1SORDE16 (THIRD EDITION - REVISED) DSW s .a -4 Published by the • American Psychiatric Association Washington, DC 1987 Ii1A

I I I I I I I I I I I I I I I I I 150 OrQanic mernai Svndromes and Disorders Diagnostic criteria for 305.90 Inhalant Intoxication continued - (4) slurred speech (5) unsteady gait (6) lethargy (7) depressed reflexes (8) psychomotor retardation (9) tremor (10) generalized muscle weakness (11) blurred vision or diplopia (12) stupor or coma (13) euphoria D. Not due to any physical or other mental disorder. Note: When the differential diagnosis must be made without a clear-cut history or toxicologic analysis of body fluids, it may be qualified as "Provisional." NICOTINE-INDUCED ORGANIC MENTAL DISORDER 292.00 Nicotine Withdrawal See p. 181 for a description of the different forms of nicotine and Nicotine Depen- dence. The essential feature of this disorder is a characteristic withdrawal syndrome due to the abrupt cessation of or reduction in the use of nicotine-containing substances (e.g., cigarettes, cigars, and pipes, chewing tobacco, or nicotine gum) that has been at least moderate in duration and amount. The syndrome includes craving for nicotine; irritabil- ity, frustration, or anger; anxiety; difficulty concentrating; restlessness; decreased heart rate; and increased appetite or weight gain. In many heavy cigarette-smokers, changes in mood and performance that are related to withdrawal can be detected within two hours after the last tobacco use. The sense of craving appears to reach a peak within the first 24 hours after cessation of tobacco use, and gradually declines thereafter over a few days to several weeks. In any given case it is difficult to distinguish a withdrawal effect from the emergence of psychological traits that were suppressed, controlled, or altered by the effects of nico- tine or from a behavioral reaction (e.g., frustration) to the loss of a reinforcer. Mild symptoms of withdrawal may occur after switching to low tar/nicotine ciga- rettes and after stopping the use of smokeless (chewing) tobacco or nicotine gum. Associated features. Increased slow rhythms on an EEG, decreased catechol- amines, decreased metabolic rate, tremor, increased coughing, REM change, gastroin- testinal disturbance, headaches, insomnia, and impairment of performance on tasks requiring vigilance are commonly associated features of Nicotine Withdrawal. Course. The symptoms begin within 24 hours of cessation of or reduction in nicotine use and usually decrease in intensity over a period of a few days to several weeks. Some former nicotine users report that craving for the substance continues for longer periods.

Opioid Intoxication 151 I I I I I I I I I I I I I I I I I Complications. Whether severe Nicotine Withdrawal decreases the ability to stop smoking or remain abstinent from smoking is unknown. Differential diagnosis. The diagnosis of Nicotine Withdrawal is usually self-evident from the person's history, and disappearance of the symptoms if smoking is resumed is confirmatory. However, withdrawal from other psychoactive substances may take place simultaneously, and produce similar symptoms. Diagnostic criteria for 292.00 Nicotine Withdrawal A. Daily use of nicotine for at least several weeks. B. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours by at least four of the following signs: (1) craving for nicotine (2) irritability, frustration, or anger (3) anxiety (4) difficulty concentrating (5) restlessness (6) decreased heart rate (7) increased appetite or weight gain OPIOID-INDUCED ORGANIC MENTAL DISORDERS See p. 182 for a description of substances in this class and Opioid Dependence and Abuse. 305.50 Opioid Intoxication The essential features of this disorder are mafadaptive behavioral changes and specific neurologic signs due to the recent use of an opioid. The initial maladaptive behavioral changes from intravenous opioids occur within 2 to 5 minutes after use and often include euphoria that may last 10 to 30 minutes. This is followed by a longer period (two to six hours, depending upon the type of opioid, the dose, and the previous history of drug-taking) of lethargy, somnolence, and apathy or dysphoria. Other maladaptive behavioral effects during the period of intoxication include impaired judgment and impaired social and occupational functioning. Unlike in Alcohol Intoxication, aggression and violence are rare. Pupillary constriction is always present (or dilation due to anoxia from a severe overdose). Other neurologic signs commonly observed are drowsiness, slurred speech, and impairment in attention and memory. Associated features. Pupillary constriction may lead to reduced visual acuity. The inhibitory effect of the psychoactive substance on gastrointestinal motility may cause constipation. There may be analgesia. For many people, the effect of taking an opioid for the first time is dysphoric rather than euphoric, and nausea and vomiting may result. I

I I I I.:.scription of Inhalant g, through the mouth ices such as gasoline, ~ are the halogenated pray-can propellants I ycols. These volatile ts, and may be used ?nce. There may be iifferent compounds, , iish among them. All !!/ substances that can ices, it is difficult to ~ ss there is clear evi- eral term "inhalant" I I I I I I I I I :e patterns resulting 1-acting vasodilators 0 Psychoactive Sub- cating vapors. Most th and nose and the ar or plastic bag, and -tly from containers, orts of using heating lungs, bloodstream, d with varying con- le concentrations in considerable family hoactive Substance ency, truancy, poor icidence of inhalant is, although depen- ~conomic groups. ed to age. Inhalants rally with a group of it use may increase , and the peer group j young adults who ibstances as adoles- s have become the idence in industrial )mpounds. In these for its psychoactive dence. Nicotine Dependence 181 Associated features. Users of inhalants nearly always use other psychoactive sub- stances as well. When Inhalant Dependence exists, however, it is usually clear that inhalants are the preferred substance, and inhalants are used regularly whereas other substances are used only sporadically. Even occasional users of inhalants are likely to have significant physical and mental problems. Course. Younger children diagnosed as having Inhalant Dependence may use inhalants several times a week, often on weekends and after school. Severe depen- dence in young adults may involve varying periods of intoxication throughout each day and occasional periods of heavier use that may last several days. This pattern may persist for many years, with recurrent need for treatment. Users of inhalants may have a preferred level or degree of intoxication, and the method of administration allows a user to maintain that specific level for several hours. Chronic heavy users of inhalants may develop renal and hepatic complications. Tolerance to inhalants has been reported, but may be merely increased use over time, with more periods of intoxication and increased preference for higher levels of intoxication. Withdrawal has also been reported, but there is inadequate evidence to substantiate its existence. Prevalence. No information. 305.10 Nicotine Dependence See Nicotine-Induced Organic Mental Disorders (p. 150) for a description of Nicotine Withdrawal. Patterns of use. At present, the most common form of Nicotine Dependence is associated with the inhalation of cigarette smoke. Pipe- and cigar-smoking, the use of snuff, and the chewing of tobacco are less likely to lead to Nicotine Dependence. The more rapid onset of nicotine effects with cigarette-smoking leads to a more intensive habit pattern that is more difficult to give up because of the frequency of reinforcement and the greater physical dependence on nicotine. Associated features. People with this disorder are often distressed because of their inability to stop nicotine use, particularly when they have serious physical symptoms that are aggravated by nicotine. Some people who have Nicotine Dependence may have difficulty remaining in social or occupational situations in which smoking is pro- hibited. Course. The course of Nicotine Dependence is variable. Most people repeatedly .attempt to give up nicotine use without success. In some the dependence is brief, in that when they experience concern about nicotine use, they promptly make an effort to stop smoking and are successful, though in many cases they may experience a period of Nicotine Withdrawal lasting from days to weeks. Studies of treatment out- come suggest that the relapse rate is greater than 50% in the first 6 months, and at least .70% within the first 12 months. After a year's abstinence, subsequent relapse is un- tikely. 'f, The difficulty in giving up nicotine use definitively, particularly cigarettes, may be „due to the unple;.sant nature of the withdrawal syndrome, the deeply engrained nature ,of -the habit, the repeated effects of nicotine, which rapidly follow the inhalation of cigarette smoke (75,000 puffs per year for a pack-a-day smoker), and the likelihood that ,a desire to use nicotine is elicited by environmental cues, such as the ubiquitous

182 Psychoactive Substance Use Disorder; I I I I I I I I I I I I I I I I presence of other smokers and the widespread availability of cigarettes. When efforts to give up smoking are made, Nicotine Withdrawal may develop. Impairment. Since nicotine, unlike alcohol, rarely causes any clinically significant state of intoxication, there is no impairment in social or occupational functioning as an immediate and direct consequence of its use. Complications. The most common complications are bronchitis, emphysema, cor- onary artery disease, peripheral vascular disease, and a variety of cancers. Prevalence and sex ratio. A large proportion of the adult population of the United States has Nicotine Dependence, the prevalence among males being greater than that among females. Among teen-age smokers, males are affected approximately as often as females. Familial pattern. Cigarette smoking among first-degree biologic relatives of people with Nicotine Dependence is more common than among the general population. Evidence for a genetic factor has been documented, but the effect is modest. 304.00 Opioid Dependence 305.50 Opioid Abuse See Opioid-induced Organic Mental Disorders (p. 151) for a description of Opioid Intoxication and Withdrawal. This group includes natural opioids, such as heroin and morphine, and synthetics with morphinelike action, which act on opiate receptors. These compounds are pre- scribed as analgesics, anesthetics, or cough-suppressants. They include codeine, hydromorphone, meperidine, methadone, oxycodone, and others. Several other com- pounds that have both direct opiatelike agonist effects and antagonist effects are included in this class of substances because they often produce the same physiologic and behavioral effects as pure opioids, e.g., pentazocine and buprenorphine. Prescrip- tion opiates are typically taken orally in pill form, but can also be taken intravenously; heroin is typically taken intravenously, but can also be taken by nasal inhalation or smoking. Regular use of these substances leads to remarkably high levels of tolerance. Although methadone is included in this class, people properly supervised in a methadone maintenance program should not develop any of the Opioid-induced Organic Mental Disorders. When the criteria for one of these diagnoses are met, this indicates that there has been nonmedical use of methadone, in which case the appro- priate diagnosis should be made. Patterns of use. There are two patterns of development of dependence and abuse. In one, which is relatively infrequent, the person originally obtained an opioid by prescription, from a physician, for the treatment of pain or cough-suppression, but has gradually increased the dose and frequency of use on his or her own. The person continues to justify the substance use on the basis of treatment of symptoms, but substance-seeking behavior becomes prominent, and the person may go to several physicians in order to obtain sufficient supplies of the substance. A second pattem that leads to dependence or abuse involves young people in their teens or early 20s who, with a group of peers, use opioids obtained from illegal sources. Some use an opioid alone to obtain a "high," or euphoria. Others use these substances in combination with amphetamines, cannabis, hallucinogens, or sedatives to enhance the euphoria or to counteract the depressant effect of the opioid. In this I