Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Polysubstance Dependence


Related Terms

  • Mixed Addictions
  • Polysubstance Abuse
  • Polysubstance Addiction

Differential Diagnosis

Specialists

  • Addiction Psychiatrist
  • Cardiovascular Internist
  • Clinical Psychologist
  • Endocrinologist
  • Gastroenterologist
  • Internal Medicine Physician
  • Neurologist
  • Occupational Therapist
  • Physical Therapist
  • Psychiatrist

Comorbid Conditions

Factors Influencing Duration

The length of disability is influenced by the duration and severity of the substance dependence; the presence or absence of organ damage; any underlying mental illness; the individual's motivation to change, compliance with treatment, and social support system; the appropriateness of the treatment choice; and the adequacy of ongoing care.

Medical Codes

ICD-9-CM:
304.70 - Combinations of Opioid Type Drug with Any Other; Unspecified
304.71 - Combinations of Opioid Type Drug with Any Other; Continuous
304.72 - Combinations of Opioid Type Drug with Any Other; Episodic
304.80 - Combinations of Drug Dependence Excluding Opioid Type Drugs; Unspecified
304.81 - Combinations of Drug Dependence Excluding Opioid Type Drugs; Continuous
304.82 - Combinations of Drug Dependence Excluding Opioid Type Drugs; Episodic

Overview

Polysubstance dependence is defined as the repeated use of multiple substances. It has become increasingly rare for individuals to abuse a single substance in isolation. Because alcohol is legal and widely available, it was once common to find "pure" alcoholics who would never consider using other drugs. However, the use of multiple substances is currently the norm among addicts. In the DSM-5, the broad topic of substance abuse/dependency is called Substance-Related and Addictive Disorders. Typically, for each substance that might be abused, there are four categories in DSM-5: use disorder, intoxication, withdrawal, and unspecified (DSM-5). These issues are taken up elsewhere in these return-to-work guidelines.

There are four general patterns of polysubstance dependence: the indiscriminate use of any mood-altering substance, either alone or in combination; the use of substances with opposing physiological properties, such as alcohol and cocaine; the use of drugs with physiologically similar profiles, such as tranquilizers and alcohol; and the substitution of one substance perceived as safer or less of a problem for another, such as marijuana for alcohol.

An individual with polysubstance dependence continues to abuse multiple substances despite legal or work-related problems caused by substance abuse. For example, such an individual may engage in binge drinking on weekends, obtain codeine prescriptions in order to use more than the originally prescribed dose, snort cocaine several times a month, and smoke marijuana each time cocaine is used.

Incidence and Prevalence: According to the 2012 National Survey on Drug Use and Health, 17.7 million individuals (6.8% of the US population) reported alcohol dependence or abuse, down from 18.1 million (7.7%) in 2002.

Also in 2012, approximately 4.3 million Americans had become dependent on or had abused marijuana in the past year. That is more than double the number who depend on or abuse prescription pain relievers (2.1 million) and four times the number who abuse or depend on cocaine (1.1 million).

Individuals in their late teens and twenties use drugs at the highest rates, and those over age 50 are increasing their use of drugs.

Less than 10% of Americans who need treatment for drug or alcohol problems actually get it: about 2.5 million out of 23.1 million got treatment at a "specialty facility" (National Institute on Drug Abuse).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Many individuals with bipolar disorder or schizophrenia may have drug or alcohol problems. Those with post-traumatic stress disorder are especially likely to abuse alcohol or drugs (Gore).

Source: Medical Disability Advisor



Diagnosis

History: A diagnosis of polysubstance dependence is based on criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR). The diagnosis of polysubstance dependence applies to individuals who repeatedly use at least 3 groups of substances (excluding caffeine and nicotine), without predominance of a single substance, within a year. Furthermore, during this period, the individual meets the dependence criteria for substances as a group but not for any specific substance.

A diagnosis of polysubstance dependence would apply, for example, to an individual who missed work because of heavy alcohol drinking, continued to use cocaine despite experiencing depressions after heavy consumption, and was repeatedly unable to comply with self-imposed limits regarding use of codeine. In this case, although the pervasiveness of the troubles associated with the use of any one substance was not enough to justify the diagnosis of dependence, the individual's overall use of substances caused significant impairment of functioning and thus warranted the diagnosis of dependence on the substances as a group. Such a pattern might be observed in a situation in which there was a high prevalence of substance use but the substances changed frequently.

When there is a pattern of troubles associated with multiple substances and the individual meets the criteria for more than one specific substance-related disorder (e.g., cocaine dependence, alcohol dependence, and cannabis dependence), each diagnosis should be made.

Physical exam: A mental status exam may reveal confusion or disorientation. If the individual is in withdrawal from opioids such as heroin, there may be muscle cramps, nausea and vomiting, diarrhea, increased blood pressure, and needle insertion marks on the arms or other body areas. Significant weight loss may accompany use of amphetamines, cocaine, or heroin.

Tests: A urine drug screen may show the presence of cocaine, marijuana, opioids, codeine, or other substances if the test is performed after the individual recently used a substance. Physiologic effects of chronic substance abuse may include gastrointestinal, cardiovascular, neurological, immunologic, and endocrine involvement.

Note: It must be kept in mind that just because a physical diagnosis cannot be established as the cause of the presenting symptomatology, it does not necessarily mean that the cause is a mental one. That is to say that the presence of medically unexplained symptomatology does not necessarily establish the presence of a psychiatric condition. The first step in identifying the presence of a mental disorder is excluding the presence of malingering and/or of factitious disorder. Although factitious disorder is conscious and purposeful, it is classified as a psychiatric disorder. The strong need for this step is especially true whenever there is a medicolegal context associated with the presenting problem(s). Additionally, using DSM-5 and/or ICD-9-CM or ICD-10-CM, the clinician will find that many presentations fail to fit completely within the boundaries of a single mental disorder. There are systematic ways to go about making psychiatric diagnoses, however.

Source: Medical Disability Advisor



Treatment

Abstinence is the treatment goal. Sedative, hypnotic, anxiolytic, and, sometimes, opioid abuse may require hospitalization to facilitate safe withdrawal.

Other factors that may require inpatient substance abuse treatment are severe anxiety and/or depression or psychotic symptoms lasting beyond 1 to 3 days after abstinence or repeated failures of outpatient treatment. Hospitalization may be necessary if the individual is having severe withdrawal symptoms during detoxification or is violent toward him- or herself or others.

One approach to heroin treatment is called Ultra Rapid Opioid Detox (UROD) and involves the use of opiate antagonists and general anesthesia, allowing individuals to be safely detoxified within a few hours. This technique greatly shortens the time of detoxification, avoids the pain and other discomforts of withdrawal, allows earlier entry into the rehabilitation phase of a recovery program, minimizes time lost from work and family, and reduces the relatively high percentage of individuals who leave conventional detoxification programs prematurely. However, it is a high-risk procedure that requires careful medical monitoring. Even though the success rate of this 1- to 2-day detoxification process is high, the actual measure of success is whether the individual remains abstinent over a period of time, usually after involvement with traditional outpatient addiction treatment programs.

Addiction recovery occurs in four phases. The acute phase focuses on alleviating symptoms of physiological withdrawal and typically lasts 3 to 5 days. The next phase consists of a 1-month period of abstinence during which the individual focuses on changing behavior. The early remission phase can last up to 12 months, and the sustained remission phase lasts as long as the individual refrains from alcohol or substance use and no longer meets the criteria for substance dependence. Treatment for the 1-month abstinence and early remission phases may include education on the physical, emotional, and mental aspects of addiction and recovery; identification of stressors and stress management skills; training to improve coping skills; assertiveness training; and relaxation training. Cognitive behavioral therapy that focuses on correcting maladaptive attitudes and behaviors can be helpful.

Ongoing structured self-help programs such as Alcoholics Anonymous, Narcotics Anonymous, and Rational Recovery are recommended as an adjunct to treatment services. Regular but random drug screens may be part of the treatment process. It should also be understood that relapse may occur and even be part of the recovery process.

Source: Medical Disability Advisor



Prognosis

Some individuals respond to treatment and stay in remission from substance dependence for many years. However, some experience periods of relapse, during which they begin substance use after a period of remission and again meet the criteria for substance dependence. Other individuals can never abstain from substance use and do not experience any periods of remission.

Motivation to change is probably the most important predictor of outcome. Chronic illness because of liver or gastrointestinal complications, neurological disability related to alcohol abuse, or death from overdose, suicide, or homicide may all result from polysubstance dependence.

Source: Medical Disability Advisor



Complications

Other psychiatric illnesses may complicate treatment of both the chemical dependency and the other illness (dual diagnosis). Drug abuse may cause psychiatric symptoms, such as the suspiciousness (paranoid psychoses) frequently seen with chronic amphetamine or cocaine abuse. Depression is commonly seen in alcohol, marijuana, or sedative dependence. Individuals who use intravenous drugs such as heroin are at increased risk for contracting hepatitis and HIV.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Many employers have systems in place for individuals recovering from alcohol or substance dependence disorders that allow them to return to work under special contracts or conditions. These conditions usually include routine or random testing of blood and urine levels for identified substances and work performance and substance abuse treatment guidelines for the recovering individual. Depending upon the nature of the addiction, as well as job-specific issues, an employer may or may not have legal obligations to accommodate a claimed disability relating to an addiction. Legal counsel should be consulted when considering accommodation and return to work.

Temporary work restrictions may include reducing or eliminating activities in which the safety of self or others is contingent upon a constant and/or high level of alertness, such as driving motor vehicles, operating complex machinery, or handling dangerous chemicals; introducing the individual to new or stressful situations gradually under individually appropriate supervision; allowing some flexibility in scheduling to attend therapy appointments (which normally should occur during the employee's personal time); promoting planned, proactive management of identified problem areas; and offering timely feedback on job performance issues. It will be helpful if accommodations are documented in a written plan designed to promote a timely, safe transition back to full work productivity.

If the individual has chronic side effects of prolonged alcohol or substance use, such as cardiac, liver, or nervous system damage, restriction to sedentary activities may be necessary. Opportunities to obtain substances of abuse should be minimized; that is, individuals should not work in establishments serving liquor or in pharmacies where drugs are available.

Risk: An individual with substance abuse problems may display a general lack of judgment that presents a safety risk for both the individual and his or her coworkers; therefore, such individuals must be closely monitored. Risk of recurrence may be reduced by eliminating exposure to substances the individual may be addicted to in the workplace, by scheduling regular yet random blood and/or urine tests to ensure compliance with the work contract, and by encouraging participation in therapy and support groups during the individual's personal time.

Capacity: Capacity is unaffected unless the individual comes to work under the influence, in which case he or she should be prevented from working. Excessive prolonged substance abuse may contribute to chronic illnesses that may reduce productivity and work safety over time.

Tolerance: Tolerance is typically not a concern with this diagnosis.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 6 months of treatment or less.

Note: MMI is estimated under the assumption that the vagaries involved in psychiatric diagnoses have been taken into consideration.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual display any one of the four general patterns for polysubstance dependence?
  • Was a comprehensive assessment of this type completed on this individual? If not, what areas were omitted?
  • Have all underlying medical and psychiatric disorders been identified?

Regarding treatment:

  • What does individual's current treatment plan include?
  • Would addition of other modalities be beneficial?
  • What phase of recovery is individual currently experiencing? Have setbacks occurred?
  • Is individual participating in 12-step programs such as Alcoholics or Narcotics Anonymous?
  • Was hospitalization required?

Regarding prognosis:

  • Is individual currently involved in a support group?
  • Does individual participate in a formal support group? What other support systems does individual have in place? Family? Friends? Social?
  • Is individual receiving the needed tools, skills, and encouragement to move ahead with his or her life?

Source: Medical Disability Advisor



References

Cited

"DrugFacts: Nationwide Trends." National Institute on Drug Abuse. Jan. 2014. National Institutes of Health (NIH). 4 May 2015 <http://www.drugabuse.gov/publications/drugfacts/nationwide-trends>.

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Association, 2013.

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Gore, Allen T., et al. "Posttraumatic Stress Disorder." eMedicine. 12 Nov. 2014. Medscape. 4 May 2015 <http://emedicine.medscape.com/article/288154-overview>.

Source: Medical Disability Advisor






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