Opioid-Related Disorders Opioid Use Disorder Opioid Intoxication Opioid Withdrawal Other Opioid-Induced Disorders Unspecified Opioid-Related Disorder

Opioid Use Disorder

Diagnostic Criteria A. A problematic pattern of opioid use leading to clinically significant impairment or distress. as manifested by at least two of the following, occurring within a 12-month period: 1. Opioids are often ta en in larger amounts or o!er a longer period than was intended. 2. "here is a persistent desire or unsuccessful efforts to cut down or control opioid use. #. A great deal of time is spent in acti!ities necessary to obtain the opioid, use the opioid, or reco!er from its effects. $. Cra!ing, or a strong desire or urge to use opioids. %. &ecurrent opioid use resulting in a failure to fulfill ma'or role obligations at wor , school, or home. (. Continued opioid use despite ha!ing persistent or recurrent social or interpersonal problems caused or e)acerbated by the effects of opioids. *. +mportant social, occupational, or recreational acti!ities are gi!en up or reduced because of opioid use. ,. &ecurrent opioid use in situations in which it is physically ha-ardous. .. Continued opioid use despite nowledge of ha!ing a persistent or recurrent physical or psychological problem that is li ely to ha!e been caused or e)acerbated by the substance. 1/. "olerance, as defined by either of the following: a0 A need for mar edly increased amounts of opioids to achie!e into)ication or desired effect. b0 A mar edly diminished effect with continued use of the same amount of an opioid. Note: "his criterion is not considered to be met for those ta ing opioids solely under appropriate medical super!ision. 11. 1ithdrawal, as manifested by either of the following: a0 "he characteristic opioid withdrawal syndrome 2refer to Criteria A and 3 of the criteria set for opioid withdrawal, pp. %$*-%$,0. b0 Opioids 2or a closely related substance0 are ta en to relie!e or a!oid withdrawal symptoms. Note: "his criterion is not considered to be met for those indi!iduals ta ing opioids solely under appropriate medical super!ision.

Specify if:
In early remission: After full criteria for opioid use disorder were pre!iously met, none of the criteria for opioid use disorder ha!e been met for at least # months but for less than 12 months 2with the e)ception that Criterion A$, 4Cra!ing, or a strong desire or urge to use opioids,4 may be met0.

In sustained remission: After full criteria for opioid use disorder were pre!iously met, none of the criteria for opioid use disorder ha!e been met at any time during a period of 12 months or longer 2with the e)ception that Criterion A$, 4Cra!ing, or a strong desire or urge to use opioids,4 may be met0.

Specify if:
On maintenance therapy: "his additional specifier is used if the indi!idual is ta ing a prescribed agonist medication such as methadone or buprenorphine and none of the criteria for opioid use disorder ha!e been met for that class of medication 2e)cept tolerance to, or withdrawal from, the agonist0. "his category also applies to those indi!id uals being maintained on a partial agonist, an agonist5antagonist, or a full antagonist such as oral naltre)one or depot naltre)one. In a controlled environment: "his additional specifier is used if the indi!idual is in an en!ironment where access to opioids is restricted. Coding ased on current severity: 6ote for +CD-1/-C7 codes: +f an opioid into)ication, opioid withdrawal, or another opioid-induced mental disorder is also present, do not use the codes below for opioid use disorder. +nstead, the comorbid opioid use disorder is indicated in the $th character of the opioid-induced disorder code 2see the coding note for opioid into)ication, opioid withdrawal, or a specific opioid-induced mental disorder0. 8or e)ample, if there is comorbid opioid-induced depressi!e disorder and opioid use disorder, only the opioid-induced depressi!e disorder code is gi!en, with the $th character indicating whether the comorbid opioid use disorder is mild, moderate, or se!ere: 811.1$ for mild opioid use disorder with opioid-induced depressi!e disorder or 811.2$ for a moderate or se!ere opioid use disorder with opioid-induced depressi!e disorder. Specify current se!erity: !"#$#" %&''$'"( )ild: 9resence of 2-# symptoms. !"*$"" %&''$+"( )oderate: 9resence of $-% symptoms. !"*$"" %&''$+"( ,evere: 9resence of ( or more symptoms.

,pecifiers
"he 4on maintenance therapy4 specifier applies as a further specifier of remission if the indi!idual is both in remission and recei!ing maintenance therapy. 4+n a controlled en!ironment4 applies as a further specifier of remission if the indi!idual is both in remission and in a controlled en!ironment 2i.e., in early remission in a controlled en!ironment or in sustained remission in a controlled en!ironment0. :)amples of these en!ironments are closely super!ised and substance-free 'ails, therapeutic communities, and loc ed hospital units. Changing se!erity across time in an indi!idual is also reflected by reductions in the fre;uency 2e.g., days of use per month0 and5or dose 2e.g., in'ections or number of pills0 of an opioid, as assessed by the indi!idual<s self-report, report of nowledgeable others, clinician<s obser!ations, and biological testing.

Diagnostic &eatures
Opioid use disorder includes signs and symptoms that reflect compulsi!e, prolonged selfadministration of opioid substances that are used for no legitimate medical purpose or, if another medical condition is present that re;uires opioid treatment, that are used in doses greatly in e)cess of the amount needed for that medical condition. 28or e)ample, an

indi!idual prescribed analgesic opioids for pain relief at ade;uate dosing will use significantly more than prescribed and not only because of persistent pain.0 +ndi!iduals with opioid use disorder tend to de!elop such regular patterns of compulsi!e drug use that daily acti!ities are planned around obtaining and administering opioids. Opioids are usually purchased on the illegal mar et but may also be obtained from physicians by falsifying or e)aggerating general medical problems or by recei!ing simultaneous prescriptions from se!eral physicians. =ealth care professionals with opioid use disorder will often obtain opioids by writing prescriptions for themsel!es or by di!erting opioids that ha!e been prescribed for patients or from pharmacy supplies. 7ost indi!iduals with opioid use disorder ha!e significant le!els of tolerance and will e)perience withdrawal on abrupt discontinuation of opioid substances. +ndi!iduals with opioid use disorder often de!elop conditioned responses to drug-related stimuli 2e.g., cra!ing on seeing any heroin powder-li e substance0 a phenomenon that occurs with most drugs that cause intense psychological changes. "hese responses probably contribute to relapse, are difficult to e)tinguish, and typically persist long after deto)ification is completed.

-ssociated &eatures ,upporting Diagnosis

opioid use disorder can be associated with a history of drug-related crimes 2e.g., possession or distribution of drugs, forgery, burglary, robbery, larceny, recei!ing stolen goods0. Among health care professionals and indi!iduals who ha!e ready access to controlled substances, there is often a different pattern of illegal acti!ities in!ol!ing problems with state licensing boards, professional staffs of hospitals, or other administrati!e agencies. 7arital difficulties 2including di!orce0, unemployment, and irregular employment are often associated with opioid use disorder at all socioeconomic le!els.

.revalence
"he 12-month pre!alence of opioid use disorder is appro)imately /.#*> among adults age 1, years and older in the community population. "his may be an underestimate because of the large number of incarcerated indi!iduals with opioid use disorders. &ates are higher in males than in females 2/.$.> !s. /.2(>0, with the male-to-female ratio typically being 1.%:1 for opioids other than heroin 2i.e., a!ailable by prescription0 and #:1 for heroin. 8emale adolescents may ha!e a higher li elihood of de!eloping opioid use disorders. "he pre!alence decreases with age, with the pre!alence highest 2/.,2>0 among adults age 2. years or younger, and decreasing to /./.> among adults age (% years and older. Among adults, the pre!alence of opioid use disorder is lower among African Americans at /.1,> and o!er represented among 6ati!e Americans at 1.2%>. +t is close to a!erage among whites 2/.#,>0, Asian or 9acific +slanders 2/.#%>0, and =ispanics 2/.#.>0. Among indi!iduals in the ?nited @tates ages 12-1* years, the o!erall 12-month pre!alence of opioid use disorder in the community population is appro)imately 1./>, but the pre!alence of heroin use disorder is less than /.1>. 3y contrast, analgesic use disorder is pre!alent in about 1./> of those ages 12-1* years, spea ing to the importance of opioid analgesics as a group of substances with significant health conse;uences. "he 12-month pre!alence of problem opioid use in :uropean countries in the community population ages 1%-($ years is between /.1> and /.,>. "he a!erage pre!alence of problem opioids use in the :uropean ?nion and 6orway is between /.#(> and /.$$>.

Development and Course

Opioid use disorder can begin at any age, but problems associated with opioid use are most commonly first obser!ed in the late teens or early 2/s. Once opioid use disorder de!elops, it usually continues o!er a period of many years, e!en though brief periods of abstinence are fre;uent. +n treated populations, relapse following abstinence is common. :!en though relapses do occur, and while some long-term mortality rates may be as high as no per year, about 2/>-#/> of indi!iduals with opioid use disorder achie!e long-term abstinence. An e)ception concerns that of military ser!ice personnel who became dependent on opioids in AietnamB o!er ./> of this population who had been dependent on opioids during deployment in Aietnam achie!ed abstinence after they returned, but they e)perienced increased rates of alcohol or amphetamine use disorder as well as increased suicidality. +ncreasing age is associated with a decrease in pre!alence as a result of early mortality and the remission of symptoms after age $/ years 2i.e., 4maturing out40. =owe!er, many indi!iduals continue ha!e presentations that meet opioid use disorder criteria for decades.

Ris/ and .rognostic &actors

Cenetic and physiological. "he ris for opiate use disorder can be related to indi!idual, family, peer, and social en!ironmental factors, but within these domains, genetic factors play a particularly important role both directly and indirectly. 8or instance, impulsi!ity and no!elty see ing are indi!idual temperaments that relate to the propensity to de!elop a substance use disorder but may themsel!es be genetically determined. 9eer factors may relate to genetic predisposition in terms of how an indi!idual selects his or her en!ironment.

Culture-Related Diagnostic Issues

Despite small !ariations regarding indi!idual criterion items, opioid use disorder diagnostic criteria perform e;ually well across most race5ethnicity groups. +ndi!iduals from ethnic minority populations li!ing in economically depri!ed areas ha!e been o!errepresented among indi!iduals with opioid use disorder. =owe!er, o!er time, opioid use disorder is seen more often among white middle-class indi!iduals, especially females, suggesting that differences in use reflect the a!ailability of opioid drugs and that other social factors may impact pre!alence. 7edical personnel who ha!e ready access to opioids may be at increased ris for opioid use disorder.

Diagnostic )ar/ers
&outine urine to)icology test results are often positi!e for opioid drugs in indi!iduals with opioid use disorder. ?rine test results remain positi!e for most opioids 2e.g., heroin, morphine, codeine, o)ycodone, propo)yphene0 for 12-#( hours after administration. 8entanyl is not detected by standard urine tests but can be identified by more speciali-ed procedures for se!eral days. 7ethadone, buprenorphine 2or buprenorphine5nalo)one combination0, and DAA7 2D-alpha-acetylmethadol0 ha!e to be specifically tested for and will not cause a positi!e result on routine tests for opiates. "hey can be detected for se!eral days up to more than 1 wee . Daboratory e!idence of the presence of other substances 2e.g., cocaine, mari'uana, alcohol, amphetamines, ben-odia-epines0 is common. @creening test results for hepatitis A, 3, and C !irus are positi!e in as many as ,/> - ./> of in'ection opioid users, either for hepatitis antigen 2signifying acti!e infection0 or for hepatitis antibody 2signifying past infection0. =+A is pre!alent in in'ection opioid users as well. 7ildly ele!ated li!er

function test results are common, either as a result of resol!ing hepatitis or from to)ic in'ury to the li!er due to contaminants that ha!e been mi)ed with the in'ected opioid. @ubtle changes in cortisol secretion patterns and body temperature regulation ha!e been obser!ed for up to ( months following opioid deto)ification.

,uicide Ris/
@imilar to the ris generally obser!ed for all substance use disorders, opioid use disorder is associated with a heightened ris for suicide attempts and completed suicides. 9articularly notable are both accidental and deliberate opioid o!erdoses. @ome suicide ris factors o!erlap with ris factors for an opioid use disorder. +n addition, repeated opioid into)ication or withdrawal may be associated with se!ere depressions that, although temporary, can be intense enough to lead to suicide attempts and completed suicides. A!ailable data suggest that nonfatal accidental opioid o!erdose 2which is common0 and attempted suicide are distinct clinically significant problems that should not be mista en for each other.

&unctional Conse0uences of Opioid Use Disorder

Opioid use is associated with a lac of mucous membrane secretions, causing dry mouth and nose. @lowing of gastrointestinal acti!ity and a decrease in gut motility can produce se!ere constipation. Aisual acuity may be impaired as a result of pupillary constriction with acute administration. +n indi!iduals who in'ect opioids, sclerosed !eins 24trac s40 and puncture mar s on the lower portions of the upper e)tremities are common. Aeins sometimes become so se!erely sclerosed that peripheral edema de!elops, and indi!iduals switch to in'ecting in !eins in the legs, nec , or groin. 1hen these !eins become unusable, indi!iduals often in'ect directly into their subcutaneous tissue 24s in-popping40, resulting in cellulitis, abscesses, and circular-appearing scars from healed s in lesions. "etanus and Clostridium botulinum infections are relati!ely rare but e)tremely serious conse;uences of in'ecting opioids, especially with contaminated needles. +nfections may also occur in other organs and include bacterial endocarditis, hepatitis, and =+A infection. =epatitis C infections, for e)ample, may occur in up to ./> of persons who in'ect opioids. +n addition, the pre!alence of =+A infection can be high among indi!iduals who in'ect drugs, a large proportion of whom are indi!iduals with opioid use disorder. =+A infection rates ha!e been reported to be as high as (/> among heroin users with opioid use disorder in some areas of the ?nited @tates or the &ussian 8ederation. =owe!er, the incidence may also be 1/> or less in other areas, especially those where access to clean in'ection material and paraphernalia is facilitated. "uberculosis is a particularly serious problem among indi!iduals who use drugs intra!enously, especially those who are dependent on heroinB infection is usually asymptomatic and e!ident only by the presence of a positi!e tuberculin s in test. =owe!er, many cases of acti!e tuberculosis ha!e been found, especially among those who are infected with =+A. "hese indi!iduals often ha!e a newly ac;uired infection but also are li ely to e)perience reacti!ation of a prior infection because of impaired immune function. +ndi!iduals who sniff heroin or other opioids into the nose 24snorting40 often de!elop irritation of the nasal mucosa, sometimes accompanied by perforation of the nasal septum. Difficulties in se)ual functioning are common. 7ales often e)perience erectile dysfunction during into)ication or chronic use. 8emales commonly ha!e disturbances of reproducti!e function and irregular menses. +n relation to infections such as cellulitis, hepatitis, =+A infection, tuberculosis, and endocarditis, opioid use disorder is associated with a mortality rate as high as 1.%E$-2> per

year. Death most often results from o!erdose, accidents, in'uries, A+D@, or other general medical complications. Accidents and in'uries due to !iolence that is associated with buying or selling drugs are common. +n some areas, !iolence accounts for more opioid-related deaths than o!erdose or =+A infection. 9hysiological dependence on opioids may occur in about half of the infants born to females with opioid use disorderB this can produce a se!ere withdrawal syndrome re;uiring medical treatment. Although low birth weight is also seen in children of mothers with opioid use disorder, it is usually not mar ed and is generally not associated with serious ad!erse conse;uences.

Differential Diagnosis
Opioid-induced mental disorders. Opioid-induced disorders occur fre;uently in indi!iduals with opioid use disorder. Opioid-induced disorders may be characteri-ed by symptoms 2e.g., depressed mood0 that resemble primary mental disorders 2e.g., persistent depressi!e disorder FdysthymiaG !s. opioid-induced depressi!e disorder, with depressi!e features, with onset during into)ication0. Opioids are less li ely to produce symptoms of mental disturbance than are most other drugs of abuse. Opioid into)ication and opioid withdrawal are distinguished from the other opioid-induced disorders 2e.g., opioid-induced depressi!e disorder, with onset during into)ication0 because the symptoms in these latter disorders predominate the clinical presentation and are se!ere enough to warrant independent clinical attention. Other su stance intoxication. Alcohol into)ication and sedati!e, hypnotic, or an)iolytic into)ication can cause a clinical picture that resembles that for opioid into)ication. A diagnosis of alcohol or sedati!e, hypnotic, or an)iolytic into)ication can usually be made based on the absence of pupillary constriction or the lac of a response to nalo)one challenge. +n some cases, into)ication may be due both to opioids and to alcohol or other sedati!es. +n these cases, the nalo)one challenge will not re!erse all of the sedati!e effects. Other withdrawal disorders. "he an)iety and restlessness associated with opioid withdrawal resemble symptoms seen in sedati!e-hypnotic withdrawal. =owe!er, opioid withdrawal is also accompanied by rhinorrhea, lacrimation, and papillary dilation, which are not seen in sedati!e-type withdrawal. Dilated pupils are also seen in hallucinogen into)ication and stimulant into)ication. =owe!er, other signs or symptoms of opioid withdrawal, such as nausea, !omiting, diarrhea, abdominal cramps, rhinorrhea, or lacrimation, are not present.

Comor idity
"he most common medical conditions associated with opioid use disorder are !iral 2e.g., =+A, hepatitis C !irus0 and bacterial infections, particularly among users of opioids by in'ection. "hese infections are less common in opioid use disorder with prescription opioids. Opioid use disorder is often associated with other substance use disorders, especially those in!ol!ing tobacco, alcohol, cannabis, stimulants, and ben-odia-epines, which are often ta en to reduce symptoms of opioid withdrawal or cra!ing for opioids, or to enhance the effects of administered opioids. +ndi!iduals with opioid use disorder are at ris for the de!elopment of mild to moderate depression that meets symptomatic and duration criteria for persistent depressi!e disorder 2dysthymia0 or, in some cases, for ma'or depressi!e disorder. "hese symptoms may represent an opioid-induced depressi!e disorder or an e)acerbation of a pree)isting primary depressi!e disorder. 9eriods of depression are especially common during chronic into)ication or in association with physical or psychosocial stressors that are related to the opioid use disorder. +nsomnia is common, especially during withdrawal. Antisocial personality disorder is much more common in indi!iduals with opioid use disorder than in the general population. 9osttraumatic stress disorder is also seen with increased fre;uency. A

history of conduct disorder in childhood or adolescence has been identified as a significant ris factor for substance-related disorders, especially opioid use disorder.

Opioid Intoxication
Diagnostic Criteria A. &ecent use of an opioid. 3. Clinically significant problematic beha!ioral or psychological changes 2e.g., initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired 'udgment0 that de!eloped during, or shortly after, opioid use. C. 9apillary constriction 2or papillary dilation due to ano)ia from se!ere o!erdose0 and one 2or more0 of the following signs or symptoms de!eloping during, or shortly after, opioid use: 1. Drowsiness or coma. 2. @lurred speech. #. +mpairment in attention or memory. D. "he signs or symptoms are not attributable to another medical condition and are not better e)plained by another mental disorder, including into)ication with another substance. Specify if: With perceptual distur ances: "his specifier may be noted in the rare instance in which hallucinations with intact reality testing or auditory, !isual, or tactile illusions occur in the absence of a delirium. Coding note: "he +CD-.-C7 code is 2.2.,.. "he +CD-1/-C7 code depends on whether or not there is a comorbid opioid use disorder and whether or not there are perceptual disturbances. &or opioid intoxication without perceptual distur ances: +f a mild opioid use disorder is comorbid, the +CD-1/-C7 code is 811.12., and if a moderate or se!ere opioid use disorder is comorbid, the +CD-1/-C7 code is 811.22.. +f there is no comorbid opioid use disorder, then the +CD-1/-C7 code is 811..2.. &or opioid intoxication with perceptual distur ances: +f a mild opioid use disorder is comorbid, the +CD-1/-C7 code is 811.122, and if a moderate or se!ere opioid use disorder is comorbid, the +CD-1/-C7 code is 811.222. +f there is no comorbid opioid use disorder, then the +CD-1/-C7 code is 811..22.

Diagnostic &eatures
"he essential feature of opioid into)ication is the presence of clinically significant problematic beha!ioral or psychological changes 2e.g., initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired 'udgment0 that de!elop during, or shortly after, opioid use 2Criteria A and 30. +nto)ication is accompanied by pupillary constriction 2unless there has been a se!ere o!erdose with conse;uent ano)ia and pupillary dilation0 and one or more of the following signs: drowsiness 2described as being 4on the nod40, slurred speech, and impairment in attention or memory 2Criterion C0B drowsiness may progress to coma. +ndi!iduals with opioid into)ication may demonstrate inattention to the en!ironment, e!en to the point of ignoring potentially harmful e!ents. "he signs or symptoms must not be attributable to another medical condition and are not better e)plained by another mental disorder 2Criterion D0.

Differential Diagnosis
Other su stance intoxication. Alcohol into)ication and sedati!e-hypnotic into)ication can cause a clinical picture that resembles opioid into)ication. A diagnosis of alcohol or sedati!e hypnotic into)ication can usually be made based on the absence of pupillary constriction or the lac of a response to a nalo)one challenge. +n some cases, into)ication may be due both to opioids and to alcohol or other sedati!es. +n these cases, the nalo)one challenge will not re!erse all of the sedati!e effects. Other opioid-related disorders. Opioid into)ication is distinguished from the other opioid induced disorders 2e.g., opioid-induced depressi!e disorder, with onset during into)ication0 because the symptoms in the latter disorders predominate in the clinical presentation and meet full criteria for the rele!ant disorder.

Opioid Withdrawal
Diagnostic Criteria +1+$" %&''$+!( A. 9resence of either of the following: 1. Cessation of 2or reduction in0 opioid use that has been hea!y and prolonged 2i.e., se!eral wee s or longer0. 2. Administration of an opioid antagonist after a period of opioid use. 3. "hree 2or more0 of the following de!eloping within minutes to se!eral days after Criterion A: 1. Dysphoric mood. 2. 6ausea or !omiting. #. 7uscle aches. $. Dacrimation or rhinorrhea. %. 9upillary dilation, piloerection, or sweating. (. Diarrhea. *. Hawning. ,. 8e!er. .. +nsomnia. C. "he signs or symptoms in Criterion 3 cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. "he signs or symptoms are not attributable to another medical condition and are not better e)plained by another mental disorder, including into)ication or withdrawal from another substance. Coding note: "he +CD-.-C7 code is 2.2./. "he +CD-1/-C7 code for opioid withdrawal is 811.2#. 6ote that the +CD-1/-C7 code indicates the comorbid presence of a moderate or se!ere opioid use disorder, reflecting the fact that opioid withdrawal can only occur in the presence of a moderate or se!ere opioid use disorder. +t is not permissible to code a comorbid mild opioid use disorder with opioid withdrawal.

Diagnostic &eatures
"he essential feature of opioid withdrawal is the presence of a characteristic withdrawal syndrome that de!elops after the cessation of 2or reduction in0 opioid use that has been hea!y and prolonged 2Criterion Al0. "he withdrawal syndrome can also be precipitated by administration of an opioid antagonist 2e.g., nalo)one or naltre)one0 after a period of opioid use 2Criterion A20. "his may also occur after administration of an opioid partial agonist such as buprenorphine to a person currently using a full opioid agonist.

Opioid withdrawal is characteri-ed by a pattern of signs and symptoms that are opposite to the acute agonist effects. "he first of these are sub'ecti!e and consist of complaints of an)iety, restlessness, and an 4achy feeling4 that is often located in the bac and legs, along with irritability and increased sensiti!ity to pain. "hree or more of the following must be present to ma e a diagnosis of opioid withdrawal: dysphoric moodB nausea or !omitingB muscle achesB lacrimation or rhinorrheaB pupillary dilation, piloerection, or increased sweatingB diarrheaB yawningB fe!erB and insomnia 2Criterion 30. 9iloerection and fe!er are associated with more se!ere withdrawal and are not often seen in routine clinical practice because indi!iduals with opioid use disorder usually obtain substances before withdrawal becomes that far ad!anced. "hese symptoms of opioid withdrawal must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 2Criterion C0. "he symptoms must not be attributable to another medical condition and are not better e)plained by another mental disorder 2Criterion D0. 7eeting diagnostic criteria for opioid withdrawal alone is not sufficient for a diagnosis of opioid use disorder, but concurrent symptoms of cra!ing and drug-see ing beha!ior are suggesti!e of comorbid opioid use disorder. +CD-1/-C7 codes only allow a diagnosis of opioid withdrawal in the presence of comorbid moderate to se!ere opioid use disorder. "he speed and se!erity of withdrawal associated with opioids depend on the half-life of the opioid used. 7ost indi!iduals who are physiologically dependent on short-acting drugs such as heroin begin to ha!e withdrawal symptoms within (-12 hours after the last dose. @ymptoms may ta e 2-$ days to emerge in the case of longer-acting drugs such as methadone, DAA7 2D-alpha-acetylmethadol0, or buprenorphine. Acute withdrawal symptoms for a shortacting opioid such as heroin usually pea within 1-# days and gradually subside o!er a period of %-* days. Dess acute withdrawal symptoms can last for wee s to months. "hese more chronic symptoms include an)iety, dysphoria, anhedonia, and insomnia.

-ssociated &eatures ,upporting Diagnosis

7ales with opioid withdrawal may e)perience piloerection, sweating, and spontaneous e'aculations while awa e. Opioid withdrawal is distinct from opioid use disorder and does not necessarily occur in the presence of the drug-see ing beha!ior associated with opioid use disorder. Opioid withdrawal may occur in any indi!idual after cessation of repeated use of an opioid, whether in the setting of medical management of pain, during opioid agonist therapy for opioid use disorder, in the conte)t of pri!ate recreational use, or following attempts to self-treat symptoms of mental disorders with opioids.

.revalence
Among indi!iduals from !arious clinical settings, opioid withdrawal occurred in (/> of indi!iduals who had used heroin at least once in the prior 12 months.

Development and Course

Opioid withdrawal is typical in the course of an opioid use disorder. +t can be part of an escalating pattern in which an opioid is used to reduce withdrawal symptoms, in turn leading to more withdrawal at a later time. 8or persons with an established opioid use disorder, withdrawal and attempts to relie!e withdrawal are typical.

Differential Diagnosis

Other withdrawal disorders. "he an)iety and restlessness associated with opioid withdrawal resemble symptoms seen in sedati!e-hypnotic withdrawal. =owe!er, opioid withdrawal is also accompanied by rhinorrhea, lacrimation, and pupillary dilation, which are not seen in sedati!e-type withdrawal. Other su stance intoxication. Dilated pupils are also seen in hallucinogen into)ication and stimulant into)ication. =owe!er, other signs or symptoms of opioid withdrawal, such as nausea, !omiting, diarrhea, abdominal cramps, rhinorrhea, and lacrimation, are not present. Other opioid-induced disorders. Opioid withdrawal is distinguished from the other opioidinduced disorders 2e.g., opioid-induced depressi!e disorder, with onset during withdrawal0 because the symptoms in these latter disorders are in e)cess of those usually associated with opioid withdrawal and meet full criteria for the rele!ant disorder.

Other Opioid-Induced Disorders

"he following opioid-induced disorders are described in other chapters of the manual with disorders with which they share phenomenology 2see the substance5medication-induced mental disorders in these chapters0: opioid-induced depressi!e disorder 24Depressi!e Disorders40B opioid-induced an)iety disorder 24An)iety Disorders40B opioid-induced sleep disorder 24@leep-1a e Disorders40B and opioid-induced se)ual dysfunction 24@e)ual Dysfunctions40. 8or opioid into)ication delirium and opioid withdrawal delirium, see the criteria and discussion of delirium in the chapter 46eurocogniti!e Disorders.4 "hese opioidinduced disorders are diagnosed instead of opioid into)ication or opioid withdrawal only when the symptoms are sufficiently se!ere to warrant independent clinical attention.

Unspecified Opioid-Related Disorder

+1+$1 %&''$11( "his category applies to presentations in which symptoms characteristic of an opioid-related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any specific opioid-related disorder or any of the disorders in the substance-related and addicti!e disorders diagnostic class.

,edative-2 3ypnotic-2 or -nxiolytic-Related Disorders

,edative2 3ypnotic2 or -nxiolytic Use Disorder ,edative2 3ypnotic2 or -nxiolytic Intoxication ,edative2 3ypnotic2 or -nxiolytic Withdrawal Other ,edative-2 3ypnotic-2 or -nxiolytic-Induced Disorders Unspecified ,edative-2 3ypnotic-2 or -nxiolytic-Related Disorder

,edative2 3ypnotic2 or -nxiolytic Use Disorder

Diagnostic Criteria A. A problematic pattern of sedati!e, hypnotic, or an)iolytic use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. @edati!es, hypnotics, or an)iolytics are often ta en in larger amounts or o!er a longer period than was intended. 2. "here is a persistent desire or unsuccessful efforts to cut down or control sedati!e,

hypnotic, or an)iolytic use. #. A great deal of time is spent in acti!ities necessary to obtain the sedati!e, hypnotic, or an)iolyticB use the sedati!e, hypnotic, or an)iolyticB or reco!er from its effects. $. Cra!ing, or a strong desire or urge to use the sedati!e, hypnotic, or an)iolytic. %. &ecurrent sedati!e, hypnotic, or an)iolytic use resulting in a failure to fulfill ma'or role obligations at wor , school, or home 2e.g., repeated absences from wor or poor wor performance related to sedati!e, hypnotic, or an)iolytic useB sedati!e-, hypnotic, or an)iolytic-related absences, suspensions, or e)pulsions from schoolB neglect of children or household0. (. Continued sedati!e, hypnotic, or an)iolytic use despite ha!ing persistent or recurrent social or interpersonal problems caused or e)acerbated by the effects of sedati!es, hypnotics, or an)iolytics 2e.g., arguments with a spouse about conse;uences of into)icationB physical fights0. *. +mportant social, occupational, or recreational acti!ities are gi!en up or reduced because of sedati!e, hypnotic, or an)iolytic use. ,. &ecurrent sedati!e, hypnotic, or an)iolytic use in situations in which it is physically ha-ardous 2e.g., dri!ing an automobile or operating a machine when impaired by sedati!e, hypnotic, or an)iolytic use0. .. @edati!e, hypnotic, or an)iolytic use is continued despite nowledge of ha!ing a persistent or recurrent physical or psychological problem that is li ely to ha!e been caused or e)acerbated by the sedati!e, hypnotic, or an)iolytic. 1/. "olerance, as defined by either of the following: a0 A need for mar edly increased amounts of the sedati!e, hypnotic, or an)iolytic to achie!e into)ication or desired effect. b0 A mar edly diminished effect with continued use of the same amount of the sedati!e, hypnotic, or an)iolytic. Note: "his criterion is not considered to be met for indi!iduals ta ing sedati!es, hypnotics, or an)iolytics under medical super!ision. 11. 1ithdrawal, as manifested by either of the following: a0 "he characteristic withdrawal syndrome for sedati!es, hypnotics, or an)iolytics 2refer to Criteria A and 3 of the criteria set for sedati!e, hypnotic, or an)iolytic withdrawal, pp. %%*-%%,0. b0 @edati!es, hypnotics, or an)iolytics 2or a closely related substance, such as alcohol0 are ta en to relie!e or a!oid withdrawal symptoms. Note: "his criterion is not considered to be met for indi!iduals ta ing sedati!es, hypnotics, or an)iolytics under medical super!ision. Specify if: In early remission: After full criteria for sedati!e, hypnotic, or an)iolytic use disorder were pre!iously met, none of the criteria for sedati!e, hypnotic, or an)iolytic use disorder ha!e been met for at least # months but for less than 12 months 2with the e)ception that Criterion A$, 4Cra!ing, or a strong desire or urge to use the sedati!e, hypnotic, or an)iolytic,4 may be met0. In sustained remission: After full criteria for sedati!e, hypnotic, or an)iolytic use disorder were pre!iously met, none of the criteria for sedati!e, hypnotic, or an)iolytic use disorder ha!e been met at any time during a period of 12 months or longer 2with the e)ception that Criterion A$, 4Cra!ing, or a strong desire or urge to use the sedati!e, hypnotic, or an)iolytic,4 may be met0.

Specify if: In a controlled environment4 "his additional specifier is used if the indi!idual is in an en!ironment where access to sedati!es, hypnotics, or an)iolytics is restricted. Coding ased on current severity: 6ote for +CD-1/-C7 codes: +f a sedati!e, hypnotic, or an)iolytic into)icationB sedati!e, hypnotic, or an)iolytic withdrawalB or another sedati!e-, hypnotic-, or an)iolytic-induced mental disorder is also present, do not use the codes below for sedati!e, hypnotic, or an)iolytic use disorder. +nstead the comorbid sedati!e, hypnotic, or an)iolytic use disorder is indicated in the $th character of the sedati!e-, hypnotic-, or an)iolytic-induced disorder 2see the coding note for sedati!e, hypnotic, or an)iolytic into)icationB sedati!e, hypnotic, or an)iolytic withdrawalB or specific sedati!e-, hypnotic-, or an)iolytic-induced mental disorder0. 8or e)ample, if there is comorbid sedati!e-, hypnotic-, or an)iolytic-induced depressi!e disorder and sedati!e, hypnotic, or an)iolytic use disorder, only the sedati!e-, hypnotic-, or an)iolytic-induced depressi!e disorder code is gi!en with the $th character indicating whether the comorbid sedati!e, hypnotic, or an)iolytic use disorder is mild, moderate, or se!ere: 81#.1$ for mild sedati!e, hypnotic, or an)iolytic use disorder with sedati!e-, hypnotic-, or an)iolytic-induced depressi!e disorder or 81#.2$ for a moderate or se!ere sedati!e, hypnotic, or an)iolytic use disorder with sedati!e-, hypnotic-, or an)iolyticinduced depressi!e disorder. @pecify current se!erity: !"#$*" %&'!$'"( )ild: 9resence of 2-# symptoms. !"*$'" %&'!$+"( )oderate: 9resence of $-% symptoms. !"*$'" %&'!$+"( ,evere: 9resence of ( or more symptoms.

,pecifiers
4+n a controlled en!ironment4 applies as a further specifier of remission if the indi!idual is both in remission and in a controlled en!ironment 2i.e., in early remission in a controlled en!ironment or in sustained remission in a controlled en!ironment0. :)amples of these en!ironments are closely super!ised and substance-free 'ails, therapeutic communities, and loc ed hospital units.

Diagnostic &eatures
@edati!e, hypnotic, or an)iolytic substances include ben-odia-epines, ben-odia-epine li e drugs 2e.g., -olpidem, -aleplon0, carbamates 2e.g., glutethimide, meprobamate0, barbiturates 2e.g., secobarbital0, and barbiturate-li e hypnotics 2e.g., glutethimide, metha;ualone0. "his class of substances includes all prescription sleeping medications and almost all prescription antian)iety medications. 6onben-odia-epine antian)iety agents 2e.g., buspirone, gepirone0 are not included in this class because they do not appear to be associated with significant misuse. Di e alcohol, these agents are brain depressants and can produce similar substance5 medication-induced and substance use disorders. @edati!e, hypnotic, or an)iolytic substances are a!ailable both by prescription and illegally. @ome indi!iduals who obtain these substances by prescription will de!elop a sedati!e, hypnotic, or an)iolytic use disorder, while others who misuse these substances or use them for into)ication will not de!elop a use disorder. +n particular, sedati!es, hypnotics, or an)iolytics with rapid onset and5or short to intermediate lengths of action may be ta en for into)ication purposes, although longer acting substances in this class may be ta en for into)ication as well. Cra!ing 2Criterion A$0, either while using or during a period of abstinence, is a typical

feature of sedati!e, hypnotic, or an)iolytic use disorder. 7isuse of substances from this class may occur on its own or in con'unction with use of other substances. 8or e)ample, indi!iduals may use into)icating doses of sedati!es or ben-odia-epines to 4come down4 from cocaine or amphetamines or use high doses of ben-odia-epines in combination with methadone to 4boost4 its effects. &epeated absences or poor wor performance, school absences, suspensions or e)pulsions, and neglect of children or household 2Criterion A%0 may be related to sedati!e, hypnotic, or an)iolytic use disorder, as may the continued use of the substances despite arguments with a spouse about conse;uences of into)ication or despite physical fights 2Criterion A(0. Dimiting contact with family or friends, a!oiding wor or school, or stopping participation in hobbies, sports, or games 2Criterion A*0 and recurrent sedati!e, hypnotic, or an)iolytic use when dri!ing an automobile or operating a machine when impaired by sedati!e, hypnotic, or an)iolytic use 2Criterion A,0 are also seen in sedati!e, hypnotic, or an)iolytic use disorder. Aery significant le!els of tolerance and withdrawal can de!elop to the sedati!e, hypnotic, or an)iolytic. "here may be e!idence of tolerance and withdrawal in the absence of a diagnosis of a sedati!e, hypnotic, or an)iolytic use disorder in an indi!idual who has abruptly discontinued use of ben-odia-epines that were ta en for long periods of time at prescribed and therapeutic doses. +n these cases, an additional diagnosis of sedati!e, hypnotic, or an)iolytic use disorder is made only if other criteria are met. "hat is, sedati!e, hypnotic, or an)iolytic medications may be prescribed for appropriate medical purposes, and depending on the dose regimen, these drugs may then produce tolerance and withdrawal. +f these drugs are prescribed or recommended for appropriate medical purposes, and if they are used as prescribed, the resulting tolerance or withdrawal does not meet the criteria for diagnosing a substance use disorder. =owe!er, it is necessary to determine whether the drugs were appropriately prescribed and used 2e.g., falsifying medical symptoms to obtain the medicationB using more medication than prescribedB obtaining the medication from se!eral doctors without informing them of the others< in!ol!ement0. Ci!en the unidimensional nature of the symptoms of sedati!e, hypnotic, or an)iolytic use disorder, se!erity is based on the number of criteria endorsed. -ssociated &eatures ,upporting Diagnosis sedati!e, hypnotic, or an)iolytic use disorder is often associated with other substance use disorders 2e.g., alcohol, cannabis, opioid, stimulant use disorders0. @edati!es are often used to alle!iate the unwanted effects of these other substances. 1ith repeated use of the substance, tolerance de!elops to the sedati!e effects, and a progressi!ely higher dose is used. =owe!er, tolerance to brain stem depressant effects de!elops much more slowly, and as the indi!idual ta es more substance to achie!e euphoria or other desired effects, there may be a sudden onset respiratory depression and hypotension, which may result in death. +ntense or repeated sedati!e, hypnotic, or an)iolytic into)ication may be associated with se!ere depression that, rough temporary, can lead to suicide attempt and completed suicide. .revalence the 12-month pre!alences of D@7-+A sedati!e, hypnotic, or an)iolytic use disorder are estimated to be /.#> among 12- to 1*-year-olds and /.2> among adults age 1, years and older. &ates of D@7-+A sedati!e, hypnotic, or an)iolytic use disorder are slightly greater song adult males 2/.#>0 than among adult females, but for 12- to 1*-year-olds, the rate for females 2/.$>0 e)ceeds that for males 2/.2>0. "he 12-month pre!alence of D@7-+A sedati!e,

hypnotic, or an)iolytic use disorder decreases as a function of age and is great.: among 1,- to 2.-year-olds 2/.%>0 and lowest among indi!iduals (% years and older 0.04%). "wel!e-month pre!alence of sedati!e, hypnotic, or an)iolytic use disorder !aries across racial5ethnic subgroups of the ?.@. population. 8or 12- to 1*-year-olds, rates are greatest song whites 2/.#>0 relati!e to African Americans 2/.2>0, =ispanics 2/.2>0, 6ati!e Americans 2/.1>0, and Asian Americans and 9acific +slanders 2/.1>0. Among adults, 12-month pre!alence is greatest among 6ati!e Americans and Alas a 6ati!es 2/.,>0, with rates of appro)imately /.2> among African Americans, whites, and =ispanics and /.1> among Asian Americans and 9acific +slanders. Development and Course "he usual course of sedati!e, hypnotic, or an)iolytic use disorder in!ol!es indi!iduals in their teens or 2/s who escalate their occasional use of sedati!e, hypnotic, or an)iolytic ogents to the point at which they de!elop problems that meet criteria for a diagnosis. "his pattern may be especially li ely among indi!iduals who ha!e other substance use disorder 2e.g., alcohol, opioids, stimulants0. An initial pattern of intermittent use socially 2e.g., at parties0 can lead to daily use and high le!els of tolerance. Once this occurs, an increasing le!el of interpersonal difficulties, as well as increasingly se!ere episodes of cogniti!e dysfunction and physiological withdrawal, can be e)pected. "he second and less fre;uently obser!ed clinical course begins with an indi!idual who originally obtained the medication by prescription from a physician, usually for the treatment of an)iety, insomnia, or somatic complaints. As either tolerance or a need for higher doses of the medication de!elops, there is a gradual increase in the dose and fre;uency of self-administration. "he indi!idual is li ely to continue to 'ustify use on the basis of his or her original symptoms of an)iety or insomnia, but substance-see ing beha!ior becomes more prominent, and the indi!idual may see out multiple physicians to obtain sufficient supplies of the medication. "olerance can reach high le!els, and withdrawal 2including sei-ures and withdrawal delirium0 may occur. As with many substance use disorders, sedati!e, hypnotic, or an)iolytic use disorder generally has an onset 2-luring adolescence or early adult life. "here is an increased ris for misuse and problems from many psychoacti!e substances as indi!iduals age. +n particular, cogniti!e impairment increases as a side effect with age, and the metabolism of sedati!es, hypnotics, or an)iolytics decreases with age among older indi!iduals. 3oth acute and chronic to)ic effects of these substances, especially effects on cognition, memory, and motor coordination, are li ely to increase with age as a conse;uence of pharmacodynamic and pharmaco inetic age- related changes. +ndi!iduals with ma'or neurocogniti!e disorder 2dementia0 are more li ely to de!elop into)ication and impaired physiological functioning at lower doses. Deliberate into)ication to achie!e a 4high4 is most li ely to be obser!ed in teenagers and indi!iduals in their 2/s. 9roblems associated with sedati!es, hypnotics, or an)iolytics are also seen in indi!iduals in their $/s and older who escalate the dose of prescribed medications. +n older indi!iduals, into)ication can resemble a progressi!e dementia. Ris/ and .rognostic &actors 5emperamental. +mpulsi!ity and no!elty see ing are indi!idual temperaments that relate to the propensity to de!elop a substance use disorder but may themsel!es be genetically

determined. 6nvironmental. @ince sedati!es, hypnotics, or an)iolytics are all pharmaceuticals, a ey ris factor relates to a!ailability of the substances. +n the ?nited @tates, the historical patterns of sedati!e, hypnotic, or an)iolytic misuse relate to the broad prescribing patterns. 8or instance, a mar ed decrease in prescription of barbiturates was associated with an increase in ben-odia-epine prescribing. 9eer factors may relate to genetic predisposition in terms of how indi!iduals select their en!ironment. Other indi!iduals at heightened ris might include those with alcohol use disorder who may recei!e repeated prescriptions in response to their complaints of alcohol-related an)iety or insomnia. 7enetic and physiological. As for other substance use disorders, the ris for sedati!e, hypnotic, or an)iolytic use disorder can be related to indi!idual, family, peer, social, and en!ironmental factors. 1ithin these domains, genetic factors play a particularly important role both directly and indirectly. O!erall, across de!elopment, genetic factors seem to play a larger role in the onset of sedati!e, hypnotic, or an)iolytic use disorder as indi!iduals age through puberty into adult life. Course modifiers. :arly onset of use is associated with greater li elihood for de!eloping a sedati!e, hypnotic, or an)iolytic use disorder.

Culture-Related Diagnostic Issues

"here are mar ed !ariations in prescription patterns 2and a!ailability0 of this class of substances in different countries, which may lead to !ariations in pre!alence of sedati!e, hypnotic, or an)iolytic use disorders. 7ender-Related Diagnostic Issues 8emales may be at higher ris than males for prescription drug misuse of sedati!e, hypnotic, or an)iolytic substances.

Diagnostic )ar/ers
Almost all sedati!e, hypnotic, or an)iolytic substances can be identified through laboratory e!aluations of urine or blood 2the latter of which can ;uantify the amounts of these agents in the body0. ?rine tests are li ely to remain positi!e for up to appro)imately + wee after the use of long-acting substances, such as dia-epam or flura-epam.

&unctional Conse0uences of ,edative2 3ypnotic2 or -nxiolytic Use Disorder

"he social and interpersonal conse;uences of sedati!e, hypnotic, or an)iolytic use disorder mimic those of alcohol in terms of the potential for disinhibited beha!ior. Accidents, interpersonal difficulties 2such as arguments or fights0, and interference with wor or school performance are all common outcomes. 9hysical e)amination is li ely to re!eal e!idence of a mild decrease in most aspects of autonomic ner!ous system functioning, including a slower pulse, a slightly decreased respiratory rate, and a slight drop in blood pressure 2most li ely to occur with postural changes0. At high doses, sedati!e, hypnotic, or an)iolytic substances can be lethal, particularly when mi)ed with alcohol, although the lethal dosage !aries considerably among the specific substances. O!erdoses may be associated with a deterioration in !ital signs that signals an impending medical emergency 2e.g., respiratory arrest from barbiturates0. "here may be

conse;uences of trauma 2e.g., internal bleeding or a subdural hematoma0 from accidents that occur while into)icated. +ntra!enous use of these substances can result in medical complications related to the use of contaminated needles 2e.g., hepatitis and =+A0. Acute into)ication can result in accidental in'uries and automobile accidents. 8or elderly indi!iduals, e!en short-term use of these sedating medications at prescribed doses can be associated with an increased ris for cogniti!e problems and falls. "he disinhibiting effects of these agents, li e alcohol, may potentially contribute to o!erly aggressi!e beha!ior, with subse;uent interpersonal and legal problems. Accidental or deliberate o!erdoses, similar to those obser!ed for alcohol use disorder or repeated alcohol into)ication, can occur. +n contrast to their wide margin of safety when used alone, ben-odia-epines ta en in combination with alcohol can be particularly dangerous, and accidental o!erdoses are reported commonly. Accidental o!erdoses ha!e also been reported in indi!iduals who deliberately misuse barbiturates and other nonben-odia-epine sedati!es 2e.g., metha;ualone0, but since these agents are much less a!ailable than the ben-odia-epines, the fre;uency of o!erdosing is low in most settings.

Differential Diagnosis
Other mental disorders or medical conditions. +ndi!iduals with sedati!e-, hypnotic-, or an)iolytic-induced disorders may present with symptoms 2e.g., an)iety0 that resemble primary mental disorders 2e.g., generali-ed an)iety disorder !s. sedati!e-, hypnotic-, or an)iolyticinduced an)iety disorder, with onset during withdrawal0. "he slurred speech, +ncoordination, and other associated features characteristic of sedati!e, hypnotic, or an)iolytic into)ication could be the result of another medical condition 2e.g., multiple sclerosis0 or of a prior head trauma 2e.g., a subdural hematoma0. -lcohol use disorder$ @edati!e, hypnotic, or an)iolytic use disorder must be differentiated from alcohol use disorder. Clinically appropriate use of sedative2 hypnotic2 or anxiolytic medications$ +ndi!iduals may continue to ta e ben-odia-epine medication according to a physician<s direction for a legitimate medical indication o!er e)tended periods of time. :!en if physiological signs of tolerance or withdrawal are manifested, many of these indi!iduals do not de!elop symptoms that meet the criteria for sedati!e, hypnotic, or an)iolytic use disorder because they are not preoccupied with obtaining the substance and its use does not interfere with their performance of usual social or occupational roles.

Comor idity
6onmedical use of sedati!e, hypnotic, or an)iolytic agents is associated with alcohol use disorder, tobacco use disorder, and, generally, illicit drug use. "here may also be an o!er lap between sedati!e, hypnotic, or an)iolytic use disorder and antisocial personality disorderB depressi!e, bipolar, and an)iety disordersB and other substance use disorders, such as alcohol use disorder and illicit drug use disorders. Antisocial beha!ior and antisocial personality disorder are especially associated with sedati!e, hypnotic, or an)iolytic use disorder when the substances are obtained illegally.

,edative2 3ypnotic2 or -nxiolytic Intoxication

Diagnostic Criteria A. &ecent use of a sedati!e, hypnotic, or an)iolytic. Clinically significant maladapti!e beha!ioral or psychological changes 2e.g., inappropriate se)ual or aggressi!e beha!ior, mood lability, impaired 'udgment0 that de!eloped during, or shortly after, sedati!e, hypnotic, or an)iolytic use.
B.

One 2or more0 of the following signs or symptoms de!eloping during, or shortly after, sedati!e, hypnotic, or an)iolytic use: 1. @lurred speech. 2. +ncoordination. 3. ?nsteady gait. 4. 6ystagmus. 5. +mpairment in cognition 2e.g., attention, memory0. 6. @tupor or coma. D$ "he signs or symptoms are not attributable to another medical condition and are not better e)plained by another mental disorder, including into)ication with another substance. Coding note: "he +CD-.-C7 code is 2.2.,.. "he +CD-1/-C7 code depends on whether there is a comorbid sedati!e, hypnotic, or an)iolytic use disorder. +f a mild sedati!e, hypnotic, or an)iolytic use disorder is comorbid, the +CD-1/-C7 code is 81#.12., and if a moderate or se!ere sedati!e, hypnotic, or an)iolytic use disorder is comorbid, the +CD-1/-C7 code is 81#.22.. +f there is no comorbid sedati!e, hypnotic, or an)iolytic use disorder, then the +CD-1/-C7 code is 81#..2..
C.

Diagnostic &eatures
"he essential feature of sedati!e, hypnotic, or an)iolytic into)ication is the presence of clinically significant maladapti!e beha!ioral or psychological changes 2e.g., inappropriate se)ual or aggressi!e beha!ior, mood lability, impaired 'udgment, impaired social or occupational functioning0 that de!elop during, or shortly after, use of a sedati!e, hypnotic, or an)iolytic 2Criteria A and 30. As with other brain depressants, such as alcohol, these beha!iors may be accompanied by slurred speech, incoordination 2at le!els that can interfere with dri!ing abilities and with performing usual acti!ities to the point of causing falls or automobile accidents0, an unsteady gait, nystagmus, impairment in cognition 2e.g., attentional or memory problems0 , and stupor or coma 2Criterion C0. 7emory impairment is a prominent feature of sedati!e, hypnotic, or an)iolytic into)ication and is most often characteri-ed by an anterograde amnesia that resembles 4alcoholic blac outs,4 which can be disturbing to the indi!idual. "he symptoms must not be attributable to another medical condition and are not better e)plained by another mental disorder 2Criterion D0. +nto)ication may occur in indi!iduals who are recei!ing these substances by prescription, are borrowing the medication from friends or relati!es, or are deliberately ta ing the substance to achie!e into)ication.

-ssociated &eatures ,upporting Diagnosis

Associated features include ta ing more medication than prescribed, ta ing multiple different medications, or mi)ing sedati!e, hypnotic, or an)iolytic agents with alcohol, which can mar edly increase the effects of these agents.

.revalence

"he pre!alence of sedati!e, hypnotic, or an)iolytic into)ication in the general population is

unclear. =owe!er, it is probable that most nonmedical users of sedati!es, hypnotics, or an)iolytics would at some time ha!e signs or symptoms that meet criteria for sedati!e, hypnotic, or an)iolytic into)icationB if so, then the pre!alence of nonmedical sedati!e, hypnotic, or an)iolytic use in the general population may be similar to the pre!alence of sedati!e, hypnotic, or an)iolytic into)ication. 8or e)ample, tran;uili-ers are used non- medically by 2.2> of Americans older than 12 years.

Differential Diagnosis
-lcohol use disorders. @ince the clinical presentations may be identical, distinguishing sedati!e, hypnotic, or an)iolytic into)ication from alcohol use disorders re;uires e!idence for recent ingestion of sedati!e, hypnotic, or an)iolytic medications by self-report, informant report, or to)icological testing. 7any indi!iduals who misuse sedati!es, hypnotics, or an)iolytics may also misuse alcohol and other substances, and so multiple into)ication diagnoses are possible. Alcohol into)ication. Alcohol into)ication may be distinguished from sedati!e, hypnotic, or an)iolytic into)ication by the smell of alcohol on the breath. Otherwise, the features of the two disorders may be similar. Other sedative-2 hypnotic-2 or anxiolytic-induced disorders. @edati!e, hypnotic, or an)iolytic into)ication is distinguished from the other sedati!e-, hypnotic-, or an)iolyticinduced disorders 2e.g., sedati!e-, hypnotic-, or an)iolytic-induced an)iety disorder, with onset during withdrawal0 because the symptoms in the latter disorders predominate in the clinical presentation and are se!ere enough to warrant clinical attention. Neurocognitive disorders. +n situations of cogniti!e impairment, traumatic brain in'ury, and delirium from other causes, sedati!es, hypnotics, or an)iolytics may be into)icating at ;uite low dosages. "he differential diagnosis in these comple) settings is based on the predominant syndrome. An additional diagnosis of sedati!e, hypnotic, or an)iolytic into)ication may be appropriate e!en if the substance has been ingested at a low dosage m the setting of these other 2or similar0 co-occurring conditions.

,edative2 3ypnotic2 or -nxiolytic Withdrawal

Diagnostic Criteria A. Cessation of 2or reduction in0 sedati!e, hypnotic, or an)iolytic use that has been prolonged. B. "wo 2or more0 of the following, de!eloping within se!eral hours to a few days after the cessation of 2or reduction in0 sedati!e, hypnotic, or an)iolytic use described in Criterion A: 1. Autonomic hyperacti!ity 2e.g., sweating or pulse rate greater than 1// bpm0. 2. =and tremor. 3. +nsomnia. 4. 6ausea or !omiting. 5. "ransient !isual, tactile, or auditory hallucinations or illusions. 6. 9sychomotor agitation. 7. An)iety. 8. Crand mal sei-ures. "he signs or symptoms in Criterion 3 cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C.

D. "he signs or symptoms are not attributable to another medical condition and are not better e)plained by another mental disorder, including into)ication or withdrawal from another substance. Specify if: 1ith perceptual disturbances: "his specifier may be noted when hallucinations with intact reality testing or auditory, !isual, or tactile illusions occur in the absence of a delirium. Coding note: "he +CD-.-C7 code is 2.2./. "he +CD-1/-C7 code for sedati!e, hypnotic, or an)iolytic withdrawal depends on whether or not there is a comorbid moderate or se!ere sedati!e, hypnotic, or an)iolytic use disorder and whether or not there are perceptual disturbances. 8or sedati!e, hypnotic, or an)iolytic withdrawal without perceptual disturbances, the +CD-1/-C7 code is 81#.2#.. 8or sedati!e, hypnotic, or an)iolytic withdrawal with perceptual disturbances, the +CD-1/-C7 code is 81#.2#2. 6ote that the +CD-1/-C7 codes indicate the comorbid presence of a moderate or se!ere sedati!e, hypnotic, or an)iolytic use disorder, reflecting the fact that sedati!e, hypnotic, or an)iolytic withdrawal can only occur in the presence of a moderate or se!ere sedati!e, hypnotic, or an)iolytic use disorder. +t is not permissible to code a comorbid mild sedati!e, hypnotic, or an)iolytic use disorder with sedati!e, hypnotic, or an)iolytic withdrawal. 6ote: 8or information on De!elopment and CourseB &is and 9rognostic 8actorsB Culture&elated Diagnostic +ssuesB 8unctional Conse;uences of @edati!e, =ypnotic, or An)iolytic 1ithdrawalB and Comorbidity, see the corresponding sections in sedati!e, hypnotic, or an)iolytic use disorder.

Diagnostic &eatures

"he essential feature of sedati!e, hypnotic, or an)iolytic withdrawal is the presence of a characteristic syndrome that de!elops after a mar ed decrease in or cessation of inta e after se!eral wee s or more of regular use 2Criteria A and 30. "his withdrawal syndrome is characteri-ed by two or more symptoms 2similar to alcohol withdrawal0 that include autonomic hyperacti!ity 2e.g., increases in heart rate, respiratory rate, blood pressure, or body temperature, along with sweating0B a tremor of the handsB insomniaB nausea, sometimes accompanied by !omitingB an)ietyB and psychomotor agitation. A grand mal sei-ure may occur in perhaps as many as 2/>-#/> of indi!iduals undergoing untreated withdrawal from these substances. +n se!ere withdrawal, !isual, tactile, or auditory hallucinations or illusions can occur but are usually in the conte)t of a delirium. +f the indi!idual<s reality testing is intact 2i.e., he or she nows the substance is causing the hallucinations0 and the illusions occur in a clear sensorium, the specifier 4with perceptual disturbances4 can be noted. 1hen hallucinations occur in the absence of intact reality testing, a diagnosis of substance5medication-induced psychotic disorder should be considered. "he symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 2Criterion C0. "he symptoms must not be attributable to another medical condition and are not better e)plained by another mental disorder 2e.g., alcohol withdrawal or generali-ed an)iety disorder0 2Criterion D0. &elief of withdrawal symptoms with administration of any sedati!e-hypnotic agent would support a diagnosis of sedati!e, hypnotic, or an)iolytic withdrawal.

-ssociated &eatures ,upporting Diagnosis

"he timing and se!erity of the withdrawal syndrome will differ depending on the specific substance and its pharmaco inetics and pharmacodynamics. 8or e)ample, withdrawal from shorter-acting substances that are rapidly absorbed and that ha!e no acti!e metabolites 2e.g., tria-olam0 can begin within hours after the substance is stoppedB withdrawal from substances with long-acting metabolites 2e.g., dia-epam0 may not begin for 1-2 days or longer. "he withdrawal syndrome produced by substances in this class may be characteri-ed by the de!elopment of a delirium that can be life-threatening. "here may be e!idence of tolerance and withdrawal in the absence of a diagnosis of a substance use disorder in an indi!idual who has abruptly discontinued ben-odia-epines that were ta en for long periods of time at prescribed and therapeutic doses. =owe!er, +CD-1/-C7 codes only allow a diagnosis of sedati!e, hypnotic, or an)iolytic withdrawal in the presence of comorbid moderate to se!ere sedati!e, hypnotic, or an)iolytic use disorder. "he time course of the withdrawal syndrome is generally predicted by the half-life of the substance. 7edications whose actions typically last about 1/ hours or less 2e.g., lora-epam, o)a-epam, tema-epam0 produce withdrawal symptoms within (-, hours of decreasing blood le!els that pea in intensity on the second day and impro!e mar edly by the fourth or fifth day. 8or substances with longer half-li!es 2e.g., dia-epam0, symptoms may not de!elop for more than 1 wee , pea in intensity during the second wee , and decrease mar edly during the third or fourth wee . "here may be additional longer-term symptoms at a much lower le!el of intensity that persist for se!eral months. "he longer the substance has been ta en and the higher the dosages used, the more li ely it is that there will be se!ere withdrawal. =owe!er, withdrawal has been reported with as little as 1% mg of dia-epam 2or its e;ui!alent in other ben-odia-epines0 when ta en daily for se!eral months. Doses of appro)imately $/ mg of dia-epam 2or its e;ui!alent0 daily are more li ely to produce clinically rele!ant withdrawal symptoms, and e!en higher doses 2e.g., 1// mg of dia-epam0 are more li ely to be followed by withdrawal sei-ures or delirium. @edati!e, hypnotic, or an)iolytic withdrawal delirium is characteri-ed by disturbances in consciousness and cognition, with !isual, tactile, or auditory hallucinations. 1hen present, sedati!e, hypnotic, or an)iolytic withdrawal delirium should be diagnosed instead of withdrawal.

.revalence
"he pre!alence of sedati!e, hypnotic, or an)iolytic withdrawal is unclear. Diagnostic )ar/ers @ei-ures and autonomic instability in the setting of a history of prolonged e)posure to sedati!e, hypnotic, or an)iolytic medications suggest a high li elihood of sedati!e, hypnotic, or an)iolytic withdrawal. Differential Diagnosis Other medical disorders$ "he symptoms of sedati!e, hypnotic, or an)iolytic withdrawal may be mimic ed by other medical conditions 2e.g., hypoglycemia, diabetic etoacidosis0. +f sei-ures are a feature of the sedati!e, hypnotic, or an)iolytic withdrawal, the differential diagnosis includes the !arious causes of sei-ures 2e.g., infections, head in'ury, poisonings0. 6ssential tremor. :ssential tremor, a disorder that fre;uently runs in families2 may erroneously suggest the tremulousness associated with sedati!e, hypnotic, or an)iolytic withdrawal. -lcohol withdrawal. Alcohol withdrawal produces a syndrome !ery similar to that of sedati!e,

hypnotic, or an)iolytic withdrawal. Other sedative-2 hypnotic-2 or anxiolytic-induced disorders . @edati!e, hypnotic, or an)yiolytic withdrawal is distinguished from the other sedati!e-, hypnotic-, or an)iolyticinduced disorders 2e.g., sedati!e-, hypnotic-, or an)iolytic-induced an)iety disorder, with onset during withdrawal0 because the symptoms in the latter disorders predominate in the clinical presentation and are se!ere enough to warrant clinical attention. -nxiety disorders. &ecurrence or worsening of an underlying an)iety disorder produces a syndrome similar to sedati!e, hypnotic, or an)iolytic withdrawal. 1ithdrawal would be suspected with an abrupt reduction in the dosage of a sedati!e, hypnotic, or an)iolytic medication. 1hen a taper is under way, distinguishing the withdrawal syndrome from the underlying an)iety disorder can be difficult. As with alcohol, lingering withdrawal symptoms 2e.g., an)iety, moodiness, and trouble sleeping0 can be mista en for non-substance5medicationinduced an)iety or depressi!e disorders 2e.g., generali-ed an)iety disorder0.

Other ,edative-2 3ypnotic-2 or -nxiolytic-Induced Disorders

"he following sedati!e-, hypnotic-, or an)iolytic-induced disorders are described in other chapters of the manual with disorders with which they share phenomenology 2see the substance5medication-induced mental disorders in these chapters0: sedati!e-, hypnotic-, or an)iolytic-induced psychotic disorder 24@chi-ophrenia @pectrum and Other 9sychotic Disorders40B sedati!e-, hypnotic-, or an)iolytic-induced bipolar disorder 243ipolar and &elated Disorders40B sedati!e-, hypnotic-, or an)iolytic-induced depressi!e disorder 24Depressi!e Disorders40B sedati!e-, hypnotic-, or an)iolytic-induced an)iety disorder 24An)iety Disorders40B sedati!e-, hypnotic-, or an)iolytic-induced sleep disorder 24@leep- 1a e Disorders40B sedati!e-, hypnotic-, or an)iolytic-induced se)ual dysfunction 24@e)ual Dysfunctions40B and sedati!e-, hypnotic-, or an)iolytic-induced ma'or or mild neurocogniti!e disorder 246eurocogniti!e Disorders40. 8or sedati!e, hypnotic, or an)iolytic into)ication delirium and sedati!e, hypnotic, or an)iolytic withdrawal delirium, see the criteria and discussion of delirium in the chapter 46eurocogniti!e Disorders.4 "hese sedati!e-, hypnotic-, or an)iolytic-induced disorders are diagnosed instead of sedati!e, hypnotic, or an)iolytic into)ication or sedati!e, hypnotic, or an)iolytic withdrawal only when the symptoms are sufficiently se!ere to warrant independent clinical attention. Unspecified ,edative-2 3ypnotic-2 or -nxiolytic-Related Disorder 2.2.. 281#...0 "his category applies to presentations in which symptoms characteristic of a sedati!e, hypnotic-, or an)iolytic-related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any specific sedati!e-, hypnotic-, or an)iolytic-related disorder or any of the disorders in the substance-related and addicti!e disorders diagnostic class.