Drug dependence and abuse

Accurate clinical diagnosis and correct coding of drug and alcohol disorders require very precise and rather complex terminology. Terms such as “abuse”, “dependence”, and “pattern of use” must be clearly defined and properly applied to each case; the definitions are different depending on whether the substance in question is a drug or alcohol.

For coding purposes, the term “addiction” is not used, but is treated as synonymous with “dependence.” Likewise, “alcoholism” is described as “alcohol dependence.” It is also essential to identify all of the specific drugs involved (if known) and to document the presence of any withdrawal syndrome or symptoms if they occur.

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Dependence. Use of the term “dependence” (whether applied to drugs or alcohol) means that, in the physician's opinion, a withdrawal syndrome or withdrawal symptoms are likely to occur when use is discontinued. Whenever drug or alcohol withdrawal actually does occur and is documented, it will typically be coded as a significant comorbid clinical condition influencing the severity of illness.

Drug dependence may be further described as a chronic mental and physical condition related to the patient's pattern of drug use. It is characterized by behavioral and physiological responses that include a compulsion to take the drug, to experience its psychic effects, or to avoid the discomfort of its absence. There is increased tolerance and an inability to stop the use of the drug even with strong incentives.

It is very important to recognize and document continuous use drug dependence (see “Pattern of use”, below) because it is considered a significant clinical comorbidity contributing to the severity of illness and complexity of care that affects DRG assignment. It is also crucial to remember that this description applies not only to illegal drugs, illicit use of prescription drugs, and methadone maintenance, but also to dependence on legitimate prescription use, including, for example, in cancer patients and those with chronic pain syndromes.

Alcohol dependence is a chronic condition in which the patient has become dependent on alcohol, has increased tolerance, and is unable to stop its use even with such strong incentives as impairment of health, deteriorated social interactions, and interference with job performance. It may also be clinically useful to document alcohol intoxication when present, but neither alcohol dependence nor alcohol intoxication has any bearing on severity of illness classification.

Abuse. The term “abuse” indicates that withdrawal symptoms are not likely to occur when use is discontinued and is separately defined for drugs and alcohol. Drug abuse describes a maladaptive pattern of drug-taking and includes patients who take drugs illegally or to excess, but have not reached a stage of dependence on the drug(s). Alcohol abuse describes problem drinking and includes patients who drink to excess, but have not reached a stage of physical dependency on alcohol. Drug and alcohol abuse are not considered significant inpatient comorbidities for DRG assignment.

Pattern of use. This terminology is less familiar to most physicians outside the psychiatric and drug rehabilitation domain. Nevertheless, it is extremely important to understand in order to capture the severity of illness of hospital patients whose comorbidities include continuous use drug dependence.

The four patterns of use are defined as follows:

1. Continuous use of

  • Drugs: daily or almost daily use
  • Alcohol: daily intake of large amounts of alcohol or regular heavy drinking on weekends or days off from work

2. Episodic use of

  • Drugs: short periods between drug use or use on weekends
  • Alcohol: alcoholic binges lasting weeks or months, followed by long periods of sobriety

3. Remission: A complete cessation of alcohol or drug intake or a period of time during which a decrease toward cessation is taking place

4. Unspecified: Unknown or not documented by physician

In summary, physicians should recognize and apply the correct clinical terminology for drug and alcohol dependence and abuse. Identify and document any drug or alcohol withdrawal syndromes or symptoms when they occur. Remember the importance of documenting continuous use drug dependence, including for patients taking appropriate therapeutic doses for legitimate purposes on a daily (or almost daily) basis, such as cancer patients and those with chronic pain syndromes.