How the ICD-11 and the CDDR address the public health dimensions of substance use

IF 73.3 1区 医学 Q1 Medicine
World Psychiatry Pub Date : 2024-09-16 DOI:10.1002/wps.21252
María Elena Medina-Mora, Rebeca Robles
{"title":"How the ICD-11 and the CDDR address the public health dimensions of substance use","authors":"María Elena Medina-Mora, Rebeca Robles","doi":"10.1002/wps.21252","DOIUrl":null,"url":null,"abstract":"<p>The use of psychoactive substances is highly prevalent and contributes substantially to risk behaviours, morbidity and mortality. The United Nations Office on Drugs and Crime World Drug Report<span><sup>1</sup></span> estimated that, in 2021, one in every 17 people aged 15-64 in the world had used an illicit drug in the year before. Users increased from 240 million in 2011 to 296 million in 2021, substantially more than accounted for by population growth.</p>\n<p>Cannabis continued to be the most used illicit drug (219 million users, 4.3% of the global adult population); 36 million people had used amphetamines, 22 million cocaine, and 20 million methylenedioxymethamphetamine (MDMA or “ecstasy”) or related drugs in the previous year. An estimated 60 million people engaged in non-medical opioid use, 31.5 million of whom used opiates (i.e., non-synthetic opioids; mainly heroin).</p>\n<p>Globally, there is very limited implementation of efficient and effective prevention strategies for substance use<span><sup>2</sup></span>, and there is a substantial treatment gap for disorders due to this use<span><sup>3</sup></span>. Global evidence has called attention to the need for a new and comprehensive conceptualization of substance use disorders that incorporates the full range of relevant conditions, from risky consumption to mental disorders linked to harmful drug use<span><sup>4</sup></span>.</p>\n<p>In response to these challenges, the World Health Organization (WHO) adopted a public health approach to the development of the classification of disorders due to substance use in the ICD-11. By public health approach, we refer to a broader perspective that integrates health and social aspects, aiming to benefit affected individuals and their community, and focusing on population well-being<span><sup>5</sup></span>.</p>\n<p>From a public health perspective, it is essential to identify persons who exhibit a hazardous use of substances that increases the risk of harmful psychological or medical consequences, but whose symptoms do not meet the diagnostic requirements for substance use disorders. These individuals can benefit from education, prevention, and community interventions. People with diagnosable disorders need harm reduction and treatment services of differing intensities and settings, depending on the nature of their condition and the substance involved. Those who suffer physical or psychological harm due to others’ substance use should also be identified and may require services<span><sup>6</sup></span>.</p>\n<p>In line with this perspective, the range of psychoactive substances classified in the ICD-11 section on disorders due to substance use has been expanded, reflecting changes in the substances associated with public health impact in different parts of the world. An extended set of substance classes will help track patterns more accurately, in order to formulate appropriate clinical and social policy responses nationally and globally. For example, a new set of categories for disorders due to synthetic cannabinoids has been added. Synthetic cannabinoids are sprayed on natural herb mixtures to mimic the euphoric effect of cannabis, and can produce respiratory depression<span><sup>7</sup></span>. Their use is reported in high-income countries, but little information is available for low- and middle-income countries<span><sup>1</sup></span>.</p>\n<p>As described in the Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders (CDDR)<span><sup>8</sup></span>, four primary conditions are identified for each class of psychoactive substances, which are hierarchically and mutually exclusive from one another: a) <i>hazardous substance use</i>, which is conceptualized as a pattern of substance use that is sufficient in frequency or quantity to increase the risk of harmful physical or mental health consequences to the user or to others; since it involves incremental risk for harm that has not yet occurred, it is not considered a mental disorder (rather, it appears in the ICD-11 chapter on “Factors influencing health status or contact with health services”, facilitating early attention and advice from health professionals); b) <i>episode of harmful substance use</i>, which refers to an episode that has already caused harm to a person's physical or mental health or has resulted in behaviour leading to harm to the health of others, but in the absence of a known pattern of substance use; c) <i>harmful pattern of substance use</i>, a sub-dependence diagnosis, characterized by a persistent and repetitive pattern of substance use that has directly caused harm to the person or to someone else through the person's behaviour; and d) <i>substance dependence</i>, when a disorder of substance use regulation has arisen from repeated or continuous use of a substance, typically accompanied by a strong internal drive to use it.</p>\n<p>In the ICD-11, the substance dependence diagnosis has been simplified with respect to the ICD-10. It is based on the presence of at least two of three key features: a) impaired control over substance use, b) increasing priority given to substance use over other activities, and c) physiological features of tolerance or withdrawal. Physical and mental harm is very commonly seen in substance dependence, but is not a required feature.</p>\n<p>The CDDR indicate that clinicians may assign other substance use diagnoses in addition to one of the four primary diagnoses, depending on the specific clinical situation, including substance intoxication, substance withdrawal, and a range of substance-induced mental disorders (delirium; psychotic, mood, anxiety, obsessive-compulsive, and impulse control disorders)<span><sup>8</sup></span>. Additional medical diagnoses can be assigned as appropriate to describe the consequences of substance use. Clinicians can also apply a range of specifiers offering more precision in diagnosis according to the severity, course, or other manifestations of the primary and additional diagnoses.</p>\n<p>The classification of conditions related to substance use in the ICD-11 clearly corresponds to different types of intervention needs, consistent with the WHO services pyramid framework describing the optimal mix of services for mental health<span><sup>9</sup></span>. Hazardous use is an appropriate target for brief interventions as well as for public health programs and primary prevention. Harmful use can be responded to in generalist settings, such as primary care, using mild or more intensive interventions depending on whether the problem is a single episode or a harmful pattern of use, and on the substance involved. The most severe cases of substance dependence are appropriately treated in more intensive specialized settings, but they represent only a small portion of the overall disease burden related to substance use. Accordingly, the ICD-11 and the CDDR will help clinicians conceptualize and communicate the most appropriate forms of treatment for specific disorders, and support public health interventions for more common but less severe presentations.</p>\n<p>Overall, the ICD-11 and the CDDR are valuable tools for helping to reduce the gap between those who need treatment and those who receive it. They will also support improvements in drug and health policies through better characterization of different groups of people affected by substance use, who experience different types of harm and have different needs. This includes improvements in the treatment system to provide more effective alternatives for severe alcohol and drug dependence.</p>\n<p>Implementing the new diagnostic requirements can also support a better referral system that matches the needs of different users to the services provided. It can also support improved epidemiological studies and generate more valuable data for WHO member states by providing better categories that accurately reflect substance use outcomes. Finally, and importantly, the new classification supports implementing a public health model rather than focusing only on punishment and incarceration.</p>","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":null,"pages":null},"PeriodicalIF":73.3000,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"World Psychiatry","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1002/wps.21252","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"Medicine","Score":null,"Total":0}
引用次数: 0

Abstract

The use of psychoactive substances is highly prevalent and contributes substantially to risk behaviours, morbidity and mortality. The United Nations Office on Drugs and Crime World Drug Report1 estimated that, in 2021, one in every 17 people aged 15-64 in the world had used an illicit drug in the year before. Users increased from 240 million in 2011 to 296 million in 2021, substantially more than accounted for by population growth.

Cannabis continued to be the most used illicit drug (219 million users, 4.3% of the global adult population); 36 million people had used amphetamines, 22 million cocaine, and 20 million methylenedioxymethamphetamine (MDMA or “ecstasy”) or related drugs in the previous year. An estimated 60 million people engaged in non-medical opioid use, 31.5 million of whom used opiates (i.e., non-synthetic opioids; mainly heroin).

Globally, there is very limited implementation of efficient and effective prevention strategies for substance use2, and there is a substantial treatment gap for disorders due to this use3. Global evidence has called attention to the need for a new and comprehensive conceptualization of substance use disorders that incorporates the full range of relevant conditions, from risky consumption to mental disorders linked to harmful drug use4.

In response to these challenges, the World Health Organization (WHO) adopted a public health approach to the development of the classification of disorders due to substance use in the ICD-11. By public health approach, we refer to a broader perspective that integrates health and social aspects, aiming to benefit affected individuals and their community, and focusing on population well-being5.

From a public health perspective, it is essential to identify persons who exhibit a hazardous use of substances that increases the risk of harmful psychological or medical consequences, but whose symptoms do not meet the diagnostic requirements for substance use disorders. These individuals can benefit from education, prevention, and community interventions. People with diagnosable disorders need harm reduction and treatment services of differing intensities and settings, depending on the nature of their condition and the substance involved. Those who suffer physical or psychological harm due to others’ substance use should also be identified and may require services6.

In line with this perspective, the range of psychoactive substances classified in the ICD-11 section on disorders due to substance use has been expanded, reflecting changes in the substances associated with public health impact in different parts of the world. An extended set of substance classes will help track patterns more accurately, in order to formulate appropriate clinical and social policy responses nationally and globally. For example, a new set of categories for disorders due to synthetic cannabinoids has been added. Synthetic cannabinoids are sprayed on natural herb mixtures to mimic the euphoric effect of cannabis, and can produce respiratory depression7. Their use is reported in high-income countries, but little information is available for low- and middle-income countries1.

As described in the Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders (CDDR)8, four primary conditions are identified for each class of psychoactive substances, which are hierarchically and mutually exclusive from one another: a) hazardous substance use, which is conceptualized as a pattern of substance use that is sufficient in frequency or quantity to increase the risk of harmful physical or mental health consequences to the user or to others; since it involves incremental risk for harm that has not yet occurred, it is not considered a mental disorder (rather, it appears in the ICD-11 chapter on “Factors influencing health status or contact with health services”, facilitating early attention and advice from health professionals); b) episode of harmful substance use, which refers to an episode that has already caused harm to a person's physical or mental health or has resulted in behaviour leading to harm to the health of others, but in the absence of a known pattern of substance use; c) harmful pattern of substance use, a sub-dependence diagnosis, characterized by a persistent and repetitive pattern of substance use that has directly caused harm to the person or to someone else through the person's behaviour; and d) substance dependence, when a disorder of substance use regulation has arisen from repeated or continuous use of a substance, typically accompanied by a strong internal drive to use it.

In the ICD-11, the substance dependence diagnosis has been simplified with respect to the ICD-10. It is based on the presence of at least two of three key features: a) impaired control over substance use, b) increasing priority given to substance use over other activities, and c) physiological features of tolerance or withdrawal. Physical and mental harm is very commonly seen in substance dependence, but is not a required feature.

The CDDR indicate that clinicians may assign other substance use diagnoses in addition to one of the four primary diagnoses, depending on the specific clinical situation, including substance intoxication, substance withdrawal, and a range of substance-induced mental disorders (delirium; psychotic, mood, anxiety, obsessive-compulsive, and impulse control disorders)8. Additional medical diagnoses can be assigned as appropriate to describe the consequences of substance use. Clinicians can also apply a range of specifiers offering more precision in diagnosis according to the severity, course, or other manifestations of the primary and additional diagnoses.

The classification of conditions related to substance use in the ICD-11 clearly corresponds to different types of intervention needs, consistent with the WHO services pyramid framework describing the optimal mix of services for mental health9. Hazardous use is an appropriate target for brief interventions as well as for public health programs and primary prevention. Harmful use can be responded to in generalist settings, such as primary care, using mild or more intensive interventions depending on whether the problem is a single episode or a harmful pattern of use, and on the substance involved. The most severe cases of substance dependence are appropriately treated in more intensive specialized settings, but they represent only a small portion of the overall disease burden related to substance use. Accordingly, the ICD-11 and the CDDR will help clinicians conceptualize and communicate the most appropriate forms of treatment for specific disorders, and support public health interventions for more common but less severe presentations.

Overall, the ICD-11 and the CDDR are valuable tools for helping to reduce the gap between those who need treatment and those who receive it. They will also support improvements in drug and health policies through better characterization of different groups of people affected by substance use, who experience different types of harm and have different needs. This includes improvements in the treatment system to provide more effective alternatives for severe alcohol and drug dependence.

Implementing the new diagnostic requirements can also support a better referral system that matches the needs of different users to the services provided. It can also support improved epidemiological studies and generate more valuable data for WHO member states by providing better categories that accurately reflect substance use outcomes. Finally, and importantly, the new classification supports implementing a public health model rather than focusing only on punishment and incarceration.

ICD-11 和 CDDR 如何解决药物使用的公共卫生问题
精神活性物质的使用非常普遍,是导致危险行为、发病率和死亡率的重要因素。据联合国毒品和犯罪问题办公室《世界毒品报告》1 估计,到 2021 年,全世界每 17 个 15-64 岁的人中就有一人在前一年使用过非法药物。大麻仍然是使用最多的非法药物(2.19 亿使用者,占全球成年人口的 4.3%);上一年有 3,600 万人使用过苯丙胺,2,200 万人使用过可卡因,2,000 万人使用过亚甲二氧基甲基苯丙胺(MDMA 或 "摇头丸")或相关药物。据估计,有 6,000 万人使用过非医用类阿片,其中 3,150 万人使用过阿片剂(即非合成类阿片;主要是海洛因)。在全球范围内,针对药物使用的高效和有效预防战略的实施非常有限2 ,而针对药物使用导致的失调症的治疗存在巨大差距3。全球证据表明,有必要对药物使用失调症进行新的、全面的概念化,将从危险消费到与有害药物使用相关的精神障碍等所有相关情况纳入其中4。为应对这些挑战,世界卫生组织(WHO)采用了公共卫生方法来制定 ICD-11 中药物使用失调症的分类。我们所说的公共卫生方法,指的是一种将健康和社会方面结合起来的更广阔的视角,旨在使受影响的个人及其社区受益,并关注人口福祉5。从公共卫生的角度来看,有必要识别那些表现出有害使用药物,从而增加了有害心理或医疗后果风险,但其症状并不符合药物使用失调诊断要求的人。这些人可以从教育、预防和社区干预中受益。有可诊断病症的人需要不同强度和环境的减低危害和治疗服务,这取决于他们的病症性质和所涉及的物质。那些因他人使用药物而遭受身体或心理伤害的人也应被识别出来,并可能需要服务6。根据这一观点,ICD-11 中关于药物使用引起的失调部分所分类的精神活性物质的范围已经扩大,反映了世界不同地区与公共健康影响相关的物质的变化。扩展后的物质类别将有助于更准确地跟踪模式,以便在国家和全球范围内制定适当的临床和社会政策应对措施。例如,新增了一组合成大麻素引起的失调类别。合成大麻素被喷洒在天然草药混合物上,以模仿大麻的兴奋效果,并可产生呼吸抑制作用7。高收入国家报告了合成大麻素的使用情况,但中低收入国家的资料很少1。正如《ICD-11 精神、行为和神经发育障碍的临床描述和诊断要求》(CDDR)8 中所述,每一类精神活性物质都有四种主要病症,这些病症按等级划分,相互排斥:a) 危险物质使用,其概念是一种在频率或数量上足以增加对使用者或他人的身体或精神 健康造成有害后果的风险的物质使用模式;由于它涉及尚未发生的伤害的递增风险,因 此不被视为精神障碍(相反,它出现在 ICD-11 关于 "影响健康状况或与医疗服务接触的因 素 "的章节中,便于医疗专业人员及早关注并提供建议);b) 有害药物使用发作,指已经对个人的身体或精神健康造成伤害,或导致伤害他人健康的行为,但不存在已知的药物使用模式;c) 有害的物质使用模式,这是一种亚依赖诊断,其特点是持续和重复的物质使用模式,通过个人行为直接对个人或他人造成伤害;以及 d) 物质依赖,即由于重复或持续使用某种物质而导致的物质使用调节障碍,通常伴有使用该物质的强烈内驱力。在 ICD-11 中,药物依赖诊断比 ICD-10 有所简化。它基于三个关键特征中至少两个特征的存在:a) 对药物使用的控制能力受损;b) 药物使用越来越优先于其他活动;c) 耐受或戒断的生理特征。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
求助全文
约1分钟内获得全文 求助全文
来源期刊
World Psychiatry
World Psychiatry Nursing-Psychiatric Mental Health
CiteScore
64.10
自引率
7.40%
发文量
124
期刊介绍: World Psychiatry is the official journal of the World Psychiatric Association. It aims to disseminate information on significant clinical, service, and research developments in the mental health field. World Psychiatry is published three times per year and is sent free of charge to psychiatrists.The recipient psychiatrists' names and addresses are provided by WPA member societies and sections.The language used in the journal is designed to be understandable by the majority of mental health professionals worldwide.
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
确定
请完成安全验证×
copy
已复制链接
快去分享给好友吧!
我知道了
右上角分享
点击右上角分享
0
联系我们:info@booksci.cn Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。 Copyright © 2023 布克学术 All rights reserved.
京ICP备2023020795号-1
ghs 京公网安备 11010802042870号
Book学术文献互助
Book学术文献互助群
群 号:481959085
Book学术官方微信