Substance Use Disorders

On this page

• Definition
• Categories of Substances Considered for Entitlement
• Criteria for Consideration of Entitlement of a Substance
• Criteria Sets for Substance Use Disorders
• Diagnostic Standard
• Entitlement Considerations
• References

Definition

Substance-Related Disorders

Substance-Related and Addictive Disorders is a category of conditions in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5).

The Substance-Related and Addictive Disorders included in this Entitlement Eligibility Guideline (EEG) is Substance-Related Disorders.

Substance-Related Disorders are divided into two categories: Substance Use Disorders and Substance-Induced Disorders.

Substance Use Disorder is the primary condition for which entitlement may be granted.

The Substance-Induced Disorders are considered under Section B or Section C in the Entitlement Considerations of this EEG.

The essential feature of Substance Use Disorder is a cluster of cognitive, behavioral, and physiologic symptoms indicating that the individual continues using the substance despite significant substance-related problems.

Note: Alcohol Use Disorders are addressed in the Alcohol Use Disorder EEG.

Categories of Substances Considered for Entitlement

• Amphetamine-type substances
• Cannabis/ Cannabinoids
• Cocaine
• Opioids
• Sedative, Hypnotics and Anxiolytics

NOTE: Cannabis (Marijuana) Versus Cannabinoids

Marijuana is the common term for cannabis. Cannabis is the dried plant Cannabis sativa. It is a highly complex material with hundreds of chemicals of many different chemical classes. The properties of many of these chemicals are not well understood.

One of the chemical classes contained in cannabis is Cannabinoids. Cannabinoids are single molecules. There are many different cannabinoids in cannabis. The best studied cannabinoid in cannabis is delta 9- tetrahydrocannabinol (THC). THC is likely responsible for much of the physical and psychotropic effects of cannabis.

Marijuana authorized for medical purposes does not meet the safety and efficacy standards required by the Food and Drug Regulations (FDR) and is not sold as a medication in Canada and does not have a DIN.

There are cannabinoids with a DIN sold as medications in Canada. Oral Cesamet (Nabilone) is used to treat severe nausea and vomiting associated with cancer treatment. The oromucosal spray Sativex (Nabiximols) is an extract of cannabis and is used to treat spacticity and neuropathic pain in multiple sclerosis and for pain relief in advanced cancer.

Criteria for Consideration of Entitlement of a Substance

Not all substances within a category are considered for entitlement by Veterans Affairs Canada (VAC).

Substances considered for entitlement must meet the criteria established by VAC.

Substances considered for entitlement by VAC are limited to:

1. Medications available under Canadian law for which a Drug Identification Number (DIN) was issued by Health Canada, was legally prescribed under Canadian law and authorized by a qualified health professional for the purposes of treatment of the client’s medical or dental condition;
2. Non-prescription medications available under Canadian law for which a DIN was issued by Health Canada.
3. Marijuana for medical purposes legally authorized under Canadian law.

The substance(s) must be identified in the application for Substance Use Disorder.

Each substance is considered on an individual basis in accordance with the criteria for substances considered for entitlement by VAC.

The substance(s) accepted by VAC is/are identified in the entitlement decision as a substance category.

The substance category is not all inclusive. The substance(s) included in the entitled substance category are limited to the substance(s) which meet the criteria for entitlement by VAC.

For example:
An application is submitted for Substance Use Disorder. The substance identified is Oxycodone. The condition is accepted by VAC and entitled as Substance Use Disorder (Opioids).

Examples of other substances which could meet the criteria for inclusion in the entitlement of Substance Use Disorder (Opioids) are Codeine and Morphine.

An example of a substance which would not meet the criteria for inclusion in the entitlement of Substance Use Disorder (Opioids) is Heroin.

Criteria Sets for Substance Use Disorders

The Substance Use Disorder criteria set is derived from the DSM-5.

Substance Use Disorder

Whether or not a substance is being used for legitimate medical reasons may also affect the diagnosis. When the substance(s) is taken as indicated for a medical condition, symptoms of tolerance and withdrawal will naturally occur and should not be used as the primary criteria for determining the diagnosis of a Substance Use Disorder.

Criterion A

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

1. Substance is 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 a strong desire or urge to use the substance.
5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.
7. Important social, occupational, or recreational activities are given up or reduced because of substance use.
8. Recurrent substance use in situations in which it is physically hazardous.
9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10. Tolerance, as defined by either of the following:
    1. A need for markedly increased amounts of the substance to achieve intoxication or the 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 those taking the substance solely under appropriate medical supervision.
       
       
11. Withdrawal, as manifested by either of the following:
    1. The characteristic withdrawal syndrome* for the substance.
    2. The same (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.
       
       Note: This criterion is not considered to be met for those taking the substance solely under appropriate medical supervision.

*Refer to the DSM-5 for the diagnostic criteria for Substance Withdrawal of specific substances.

Diagnostic Standard

A diagnosis from a qualified medical practitioner ( family physician or psychiatrist ) or a registered/licensed psychologist is required. The exception is any diagnosis provided by a psychologist registered/licensed in the province of Quebec. VAC requires any diagnosis provided by a psychologist in the province of Quebec to be co-signed by a qualified medical practitioner ( family physician or psychiatrist ).

The diagnosis is made clinically. Supporting documentation should be as comprehensive as possible.

If a claim for a substance addiction is submitted, VAC will rule on Substance Use Disorder, if the DSM-5 criteria are met. Consultation with Medical Advisory for diagnosis clarification is strongly recommended.

NOTE: Entitlement should be granted for a chronic condition only. For VAC purposes, "chronic" means that the signs and symptoms of the condition have existed for at least six months. Signs and symptoms are generally expected to persist despite medical attention, although they may wax and wane over the six month period and thereafter.

Entitlement Considerations

A. Causes and / or Aggravation

Causal or Aggravating Factors versus Predisposing Factors

Causal or aggravating factors directly result in the onset or aggravation of the claimed psychiatric condition.

Predisposing factors do not cause a claimed condition. Predisposing factors are experiences or exposures which affect the individual's ability to cope with stress. Predisposing factors makes an individual more susceptible to developing the claimed condition. For example, the presence of a remote history of severe childhood abuse may be a predisposing factor in the onset of a significant psychiatric condition later in life.

Partial entitlement should only be considered for non-service related causal or aggravating factors.

Partial entitlement should not be considered for predisposing factors.

If it is unclear if a factor is a causal or aggravating factor versus a predisposing factor consultation with Medical Advisory is strongly recommended.

NOTE: The factors listed in Section A of the Entitlement Considerations include specific timelines for the clinical onset or aggravation of a Substance Use Disorder. The timelines are not binding. Each case should be adjudicated on the evidence provided and its own merits. If the medical evidence indicates an alternate timeline, consultation with Medical Advisory is strongly recommended.

NOTE: The following list of factors is not all inclusive. Factors, other than those listed in Section A, may be claimed to cause or aggravate a Substance Use Disorder. Other factors may be considered based on the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

1. Having a clinically significant psychiatric condition at the time of clinical onset or aggravation of a Substance Use Disorder
   A clinically significant psychiatric condition is a mental disorder as defined in the DSM-5.

2. Directly experiencing a traumatic event(s) within the five years before the clinical onset or aggravation of a Substance Use Disorder
   
   Traumatic events include, but are not limited to:
   1. exposure to military combat
   2. hreatened physical assault or being physically assaulted
   3. threatened sexual assault or being sexually assaulted
   4. being kidnapped
   5. being taken hostage
   6. being in a terrorist attack
   7. being tortured
   8. incarceration as a prisoner of war
   9. being in a natural or human-made disaster
   10. being in a severe motor vehicle accident
   11. killing or injuring a person in a non-criminal act
   12. experiencing a sudden, catastrophic medical incident

3. Witnessing, in person, a traumatic event(s) as it occurred to another person(s) within the five years before the clinical onset or aggravation of a Substance Use Disorder
   
   Witnessed traumatic events include, but are not limited to:
   1. threatened or serious injury to another person
   2. an unnatural death
   3. physical or sexual abuse of another person
   4. a medical catastrophe in a close family member or close friend.

4. Experiencing repeated or extreme exposure to aversive details of a traumatic event(s) before the clinical onset or aggravation of a Substance Use Disorder
   
   Exposures include, but are not limited to:
   1. viewing and/ or collecting human remains
   2. viewing and/or participating in the clearance of critically injured casualties
   3. repeated exposure to the details of abuse and / or atrocities inflicted on another person(s)
   4. dispatch operators exposed to violent or accidental traumatic event(s)
      
      Note: Factor 4 applies to exposure through electronic media, television, movies and pictures only if the exposure is work related.

5. Living or working in a hostile or life-threatening environment for a period of at least four weeks before the clinical onset or aggravation of Substance Use Disorder
   
   Situations or settings which have a pervasive threat to life or bodily integrity including but not limited to:
   1. being under threat of artillery, missile, rocket, mine or bomb attack
   2. being under threat of nuclear, biologic or chemical agent attack
   3. being involved in combat or going on combat patrols
      
      
6. Having a medical, surgical or psychiatric condition for which a course of opioid,sedative, hypnotic, anxiolytic, amphetamine, cannabis or cocaine medications were prescribed at the time of clinical onset or aggravation of a Substance Use Disorder
7. Having a medical illness or injury which is life-threatening or which results in serious physical or cognitive disability within thefive years before the clinical onset or aggravation of a Substance Use Disorder
8. Experiencing the death of a close family member or close friend withinthefive years before the clinical onset or aggravation of a Substance Use Disorder
9. Having experienced severe childhood abuse before the clinical onset of a Substance Use Disorder
   
   Severe childhood abuse is:
   1. serious physical, emotional, psychological or sexual harm to a child under the age of 16 years; or
   2. neglect involving a serious failure to provide the necessities for health, physical and emotional development, or well being of a child under the age of 16 years;
      Where such serious harm or neglect has been perpetrated by a parent, a care provider, an adult who works with or around the child, or any other adult in contact with the child.
      
      
10. Inability to obtain appropriate clinical management of a Substance Use Disorder

B. Medical Conditions which are to be included in Entitlement / Assessment

NOTE: If specific conditions are listed for a category, only these conditions are included in the entitlement and assessment of Substance Use Disorder.

If no conditions are listed for a category, all conditions within the category are included in the entitlement and assessment of Substance Use Disorder.

• Substance Intoxication
• Substance Withdrawal
• Other Substance-Related and Addictive Disorders
• Trauma- and Stressor-Related Disorders
• Anxiety Disorders
• Obsessive-Compulsive and Related Disorders
• Depressive Disorders
• Bipolar and Related Disorders
• Schizophrenia Spectrum and other Psychotic Disorders
• Personality Disorders
• Feeding and Eating Disorders
• Dissociative Disorders
• Somatic Symptom and Related Disorders
  • Somatic Symptom Disorder
  • Illness Anxiety Disorder
  • Conversion Disorder
• Pain Disorders/Chronic Pain Syndrome (DSM-IV-TR Axis I Diagnosis)
• Sleep-Wake Disorders
  • Insomnia Disorder
  • Hypersomnolence Disorder
• Neurodevelopmental Disorders
  • Attention-Deficit/Hyperactivity Disorder
• Decreased Libido - if the medical information indicates decreased libido is a symptom of a psychiatric condition.

Separate entitlement is required for a DSM-5 condition not included in Section B of the Substance Use Disorder Entitlement Eligibility Guideline.

C. Common Medical Conditions which result in whole or in part from Substance Use Disorder and/or its Treatment

Substance Use Disorder is entitled as a substance category. The substance categoryis not all inclusive. The substances included in the entitled substance category are limited to the substances which meet the criteria for entitlement by VAC. 

Only conditions which are caused or aggravated by substances which meet the criteria for entitlement will be considered for consequential entitlement decisions. 

Consultation with Medical Advisory is strongly recommended for conditions considered for consequential entitlement decisions.

References for Substance Use Disorders

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision (DSM-IV-TR) Washington: American Psychiatric Association, 2000. 
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition ( DSM-5 ) Washington: American Psychiatric Association, 2013.
3. Australia. (2009). Statement of principles concerning drug dependence and drug abuse. No. 3 of 2009.
4. Australia. (2009). Statement of principles concerning drug dependence and drug abuse. No. 4 of 2009.
5. Australia. (2014). Amendment statement of principles concerning substance use disorder. No. 31 of 2014.
6. Australia. (2014). Amendment statement of principles concerning substance use disorder abuse. No. 32 of 2014.
7. Regier D. A., Farmer M. E., Rae D. S., Locke B. Z., Keith S. J., Judd L. L., et al. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA .