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Sunday, September 03, 2006

Substance Abuse Definitions

Operational Definitions

"Use" is operationally defined by the quantity of substance consumed, which can then be categorized as "low," "medium," or "high" according to current clinical standards.

"Permanent" recovery is ideally defined as lifetime abstinence from problematic substances. Due to the limitations of available data, retrospective reports of any prior treatment by age are used here to model lifetime recovery. Because recovery is a complex concept and subject to measurement error, to define it as abstinence from all psychoactive substances for the rest of one's life is not realistic when psychoactives are the recommended treatment for an array of medical diagnoses. Moreover, to define it as abstinence from illegal substances is not always useful because legal substances (such as alcohol, tobacco, and some medications) are the largest contributors to the Nation's substance-related problems.

"Recovery," as used here, refers to abstinence or near abstinence from substances that have previously created problems. National survey data are available describing the number of prior treatment episodes by age, and these data have been used to estimate national recovery rates. Defining recovery must take into account these four possibilities: (a) recovery is permanent, meaning lifetime, for all problematic psychoactive substances (this is the ideal); (b) recovery is short term and relapse quickly ensues; (c) recovery from one substance is replaced by use or abuse of another; and (d) recovery is counterfeit with continued drug use successfully concealed.

"Death rate" is defined as the national poisoning rate attributable to psychoactive substances (Fingerhut & Cox, 1998). This is a conservative estimate based on medical examiner, coroner, and physician opinions on the cause of death. To date, it is the only comprehensive analysis of deaths for psychoactives. It must be noted that all substances with abuse liability are psychoactive, but not all psychoactives have abuse liability. For example, it is difficult to maintain persons on antipsychotic medications due to their unpleasant side effects.

Definition of Adults With a Serious Mental Illness

Adults with a serious mental illness are defined pursuant to Section 1912(c) of the Public Health Service Act, as amended by Public Law 102-321, as follows:

"Adults with a serious mental illness are persons: age 18 and over, who currently or at any time during the past year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM-III-R, that has resulted in functional impairment which substantially interferes with or limits one or more major life activities."

The following is an analysis of this definition:

• SMIs include any mental disorders (including those of biological etiology) listed in DSM III (now DSM-IV) or their ICD-9-CM equivalent (and subsequent revisions), with the exception of DSM-IV "V" codes, substance use disorders, and developmental disorders, which are excluded unless they co-occur with another diagnosable serious mental illness.

• All SMIs have episodic, recurrent, or persistent features; however, they vary in terms of severity and disabling effects.

• Functional impairment is defined as difficulties that substantially interfere with or limit role functioning in one or more major life activities including the following:

- Basic daily living skills (e.g., eating, bathing, dressing);

- Instrumental living skills (e.g., maintaining a household, managing money, getting around the community, taking prescribed medication); and

- Functioning in social, family, and vocational/educational contexts.

• Adults who would have met functional impairment criteria during the referenced year without the benefit of treatment or other support services are considered to have serious mental illnesses.



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