Prescribing drugs of dependence in general practice, Part A


4.2 Assessment of patient risk

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All drugs of dependence have the potential to be misused. Even when used as prescribed, they can cause harms. Before prescribing or continuing to prescribe them to any patient, the patient should be assessed and their needs and risks determined.

More detailed information will be available in the RACGP’s separate guidelines on benzodiazepines and opioids.

4.2.1 General assessment

Drug-seeking patients can often provide well-developed clinical histories which may seem very ‘real’. There is often a strong aim to work on the desire of doctors to minimise the distress of patients. Rather than being aggressive, many will be very pleasant with a credible story.

In addition, not all drug-seeking patients are faking symptoms. They may have a legitimate complaint and, over time, have become dependent or tolerant and require larger doses of medication to function in their daily life.

In patient presentations where drugs of dependence may be indicated, a full assessment includes:

  • a full history, including the use of alcohol and other drugs (including over-the-counter medications medicines containing codeine combined with ibuprofen or paracetamol), psychiatric comorbidity, family history and family/social situation – this also helps identify people at higher risk of developing problems
  • adequate physical examination (including looking for signs of intoxication or withdrawal or intravenous drug use)
  • problem/diagnosis list
  • management plan
  • communication with other providers (eg methadone prescriber, pharmacist, other GP)
  • prescription shopper communication (refer to Section 3.8  of the PDF version for more information)
  • consider urine drug screening/testing (refer to Appendix H of the PDF version).

This should enable a diagnosis of a patient with genuine medical need and no dependence, a patient with genuine medical need and dependence,* or a patient that may be looking for drugs of dependence for non-medical use.

Once a full assessment, including assessment of dependence (refer to 4.2.2 Assessment of substance use disorder), has been carried out, a care or treatment plan can be established.

*This may also be pseudo-addiction where a patient with undiagnosed and/or inadequately treated painful condition adopts drug-seeking behaviour in an attempt to achieve relief.60

4.2.2 Assessment of substance use disorder

Patients who have current or previous substance-related problems have a greater risk of harm and ongoing problematic use, therefore specialist support and advice should be considered as part of ongoing management.

The new Diagnostic and Statistical Manual of Mental Disorders (5th edition) (DSM-5) criteria combine the old DSM-IV categories of substance abuse and substance dependence into a single condition of SUD, which is measured on a continuum from mild to severe.61 This diagnosis can be applied across all drugs of dependence (as well as drugs such as nicotine and alcohol) and should reduce confusion associated with the terms dependence, addiction and abuse (which have been inconsistently and often incorrectly used to describe points on a spectrum of disordered use).

The essential feature of SUD is a cluster of cognitive, behavioural and physiological symptoms indicating the individual continues using the substance despite significant substance-related problems.61

Diagnosing SUD requires the presence of at least two of 11 criteria, across four categories: impaired control, social impairment, risky use and pharmacology. Based on the total number of criteria the patient has, the SUD can be classified as mild (2–3 symptoms), moderate (4–5 symptoms) or severe (6 or more symptoms). It is hoped these severity classifiers may potentially help clarify treatment options (Table 3).

Although the term SUD is a helpful addition, the term addiction will necessarily be used when discussing any drugs of dependence.

Table 3. DSM-5 criteria for diagnosing an SUD

A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following 11 criteria, occurring within a 12-month period:

Impaired control criteria

  1. Substances are often taken in larger amounts or over a longer period than was intended
  2. There is a persistent desire or unsuccessful efforts to cut down or control substance use
  3. A great deal of time is spent in activities necessary to obtain the substance; use the substance; or recover from its effects
  4. Craving or strong desire or urge to use the substance

Social impairment criteria

  1. Recurrent substance use resulting in a failure to fulfil major role obligations at work, school or home (eg repeated absences from work or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; neglect of children or household)
  2. Continued substance use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of substances (eg arguments with a spouse about consequences of intoxication; physical fights)
  3. Important social, occupational or recreational activities are given up or reduced because of substance use

Risky use criteria

  1. Recurrent substance use in situations in which it is physically hazardous (eg driving an automobile or operating a machine when impaired by sedative, hypnotic or anxiolytic use)
  2. Substance use is continued despite knowledge of having persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

Pharmacological criteria

  1. Tolerance, as defined by either of the following:
    1. A need for markedly increasing amounts of the substance to achieve intoxication or desired effect
    2. A markedly diminished effect with continued use of the same amount of the substance

Note: This criterion is not considered to be met for individuals taking substances under medical supervision

  1. Withdrawal, as manifested by either one of the following:
    1. The characteristic withdrawal syndrome for substance
    2. Substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms

Specifiers:
In early remission: After full criteria for SUD were previously met, none of the criteria for SUD have been met for at least 3 months but for less than 12 months (with the exception that criterion 4 may be met)
In sustained remission: After full criteria for SUD were previously met, none of the criteria for SUD have been met at any time during a period of 12 months or longer (with the exception that criterion 4 may be met)
In a controlled environment: This additional specifier is used if the individual is in an environment where access to substance is restricted

Current severity:
Mild: Presence of 2–3 symptoms
Moderate: Presence of 4–5 symptoms
Severe: Presence of 6 or more symptoms

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©2013). American Psychiatric Association. All Rights Reserved.

  1. Clubb B. The drug seeking patient. Brisbane: Professor Tess Cramond Multidisciplinary Pain Clinic, Royal Brisbane and Women’s Hospital; 2009.
  2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th edition. Arlington: American Psychiatric Publishing; 2013.