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.

Sedative, Hypnotic or Anxiolytic Dependence


Related Terms

  • Antianxiety Drug Dependence
  • Barbiturate Dependence
  • Benzodiazepine Addiction
  • Prescription Drug Abuse
  • Prescription Drug Dependence
  • Tranquilizer Dependence

Differential Diagnosis

Specialists

  • Clinical Psychologist
  • Psychiatrist

Comorbid Conditions

Factors Influencing Duration

The following may influence the outcome: the individual's readiness to change, the severity of the abuse or dependence/SHA use disorder, the success of the treatment program, appropriate patient-treatment matching, stable history of employment, and the presence of any physical complications.

Medical Codes

ICD-9-CM:
304.10 - Sedative, Hypnotic or Anxiolytic Dependence; Unspecified
304.11 - Sedative, Hypnotic or Anxiolytic Dependence; Continuous
304.12 - Sedative, Hypnotic or Anxiolytic Dependence; Episodic
304.13 - Sedative, Hypnotic or Anxiolytic Dependence; in Remission

Overview

Sedative, Hypnotic or Anxiolytic use disorder is a condition where individuals become dependent on or abuse substances used for their calming effect (sedatives), sleep-inducing effect (hypnotics), and anti-anxiety effect (anxiolytics). This includes all sleeping medications and almost all prescription antianxiety medications. These substances (SHA) include benzodiazepine, carbamate, and barbiturate medications, and are commonly used to treat anxiety, insomnia, muscle tension (spasticity), seizures (convulsions), and to aid in alcohol/drug withdrawal. They are sometimes used to treat high blood pressure (hypertension). Occasionally, an individual who is prescribed one of these medications will abuse it or develop SHA dependence/SHA use disorder. At high doses, agents in the SHA category can be lethal, particularly when mixed with alcohol. These medications may also be sold on the street and used for recreational purposes. An individual may misuse SHA category medications in conjunction with other substances. For instance, a person may use intoxicating doses of sedatives to "come down" from cocaine or amphetamines or use high doses of benzodiazepines in combination with methadone to "boost" its effects (DSM-5).

A physiologic dependence upon the medication, which is being taken as prescribed and necessary, is not in itself considered substance abuse. Nonbenzodiazepine antianxiety agents (e.g., buspirone, gepirone) are not included in this class because they do not appear to be associated with significant misuse.
In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the section Sedative-, Hypnotic-, or Anxiolytic-Related Disorders includes Sedative, Hypnotic, or Anxiolytic Use Disorders (Dependence and Abuse); and Sedative-, Hypnotic-, or Anxiolytic-Induced Disorders (Intoxication, Withdrawal [Specify if: With Perceptual Disturbances], Intoxication Delirium, and Withdrawal Delirium, as well as Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Dementia, Persisting Amnestic Disorder, Psychotic Disorder [With Delusions or With Hallucinations], Mood Disorder, Anxiety Disorder, Sexual Dysfunction, and Sleep Disorder, and finally Sedative-, Hypnotic-, or Anxiolytic-Related Disorder NOS).

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the section Sedative-, Hypnotic-, or Anxiolytic-Related Disorders includes Sedative, Hypnotic, or Anxiolytic Use Disorder, Intoxication, and Withdrawal, Other Sedative-, Hypnotic-, or Anxiolytic-Induced Disorders, and Unspecified Sedative-, Hypnotic-, or Anxiolytic-Related Disorder.

Note: For the substance/medication-induced disorders approach established by the DSM-IV-TR, and the DSM-5, please see the following topics: Substance/Medication-Induced Anxiety Disorder, Substance/Medication-Induced Bipolar and Related Disorder, Substance/Medication-Induced Depressive Disorder, Substance/Medication-Induced Major or Mild Neurocognitive Disorder, Substance/Medication-Induced Obsessive-Compulsive and Related Disorder, Substance/Medication-Induced Psychotic Disorder, Substance/Medication-Induced Sexual Dysfunction, and Substance/Medication-Induced Sleep Disorder.

Incidence and Prevalence: Even though up to 90% of hospitalized individuals are given one of the SHA and more than 15% of American adults use these medications during any 1 year, less than 1% of individuals are identified has having abuse or dependence problems associated with their use (DSM-IV-TR). Despite failure to identify a substance abuse problem, more than 12% of the US population uses an anxiolytic each year. Reportedly, greater than 50% of these medications are prescribed by primary care physicians. International data indicates that usage rates for hypnotics in the course of a year approach 25% to 30% in Western Europe and some Asian countries (Scher).
According to the DSM-5, estimated 12-month prevalence of SHA use disorder is 0.3% among 12- to 17-year-olds and 0.2% among adults age 18 years and older. Rates of SHA use disorder, according to DSM-IV, are slightly greater among adult males (0.3%) than among adult females; for 12- to 17-year-olds, the rate for females (0.4%) is higher than that for males (0.2%). The 12-month prevalence of SHA use disorder decreases as a function of age; is greatest among 18- to 29-year-olds (0.5%) and lowest among individuals 65 years and older (0.04%) (DSM-5).

Twelve-month prevalence of SHA use disorder for 12- to 17-year-olds is greatest among whites (0.3%), followed by African Americans (0.2%), Hispanics (0.2%), Native Americans (0.1%), and Asian Americans and Pacific Islanders (0.1%). Among adults, 12-month prevalence is greatest among Native Americans and Alaska Natives (0.8%), with rates of about 0.2% among African Americans, whites, and Hispanics and 0.1% among Asian Americans and Pacific Islanders (DSM-5).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Caucasians are at greatest risk for addiction to and abuse of sedatives, hypnotics or anxiolytics. There has been shown a 3:1 predilection of females to males (Scher).

Source: Medical Disability Advisor



Diagnosis

History: The possibility of substance abuse or dependency needs to be considered in any situation in which the individual has consistent, ongoing, or deteriorating problems in the presence of continuing use. The clinician needs to develop sensitivity to the diagnostic clues of impairment of social, emotional, occupational, or psychological functioning. Individuals frequently deny that a problem exists despite obvious signs of intoxication.

When the problems associated with SHA use coexist with evidence of tolerance, withdrawal, or compulsive behavior related to obtaining and administering the sedative, hypnotic or anxiolytic, a diagnosis of sedative, hypnotic or anxiolytic dependence rather than sedative, hypnotic or anxiolytic abuse should be entertained. However, individuals with abuse but not dependence can have some symptoms of tolerance, withdrawal, or compulsive use; hence it is important to determine whether the full criteria for dependence are met (DSM-IV-TR).

Individuals with SHA use disorder have a problematic pattern of SHA use leading to clinically significant impairment or distress, as manifested by 2 or more (as specified in the DSM-5) and at least 3 (as specified in the DSM-IV-TR) of the following, occurring within a one-year period: (1) sedatives, hypnotics, or anxiolytics are often taken in larger amounts or over a longer period than was intended; (2) there is a persistent desire or failed efforts to reduce or control SHA use; (3) much time is spent in activities necessary to obtain SHA, use SHA, or recover from its effects; (4) there is craving (a strong desire or urge to use SHA); (5) there is recurrent SHA use that results in a failure to fulfill major role obligations at work, school, or home; (6) there is continued SHA use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of SHA; (7) the individual gives up or reduces important social, occupational, or recreational activities because of SHA use; (8) there is recurrent SHA use when it is physically hazardous (driving an automobile or operating machinery when impaired by SHA use); (9) the individual continues SHA use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by SHA; (10) there is tolerance (a need for markedly increased amounts of SHA to achieve intoxication or desired effect, or a markedly diminished effect with continued use of the same amount of SHA); (11) there is withdrawal syndrome for SHA (see below) and the individual takes SHA (or a closely related substance, such as alcohol) to relieve or avoid withdrawal symptoms.

It is also necessary to specify the current severity: mild (presence of 2 to 3 symptoms), moderate (4 to 5 symptoms), or severe (6 or more symptoms) (DSM-5).

Severe physiological dependence, characterized by both tolerance and withdrawal, can develop to the sedatives, hypnotics, and anxiolytics. The timing and severity of the withdrawal syndrome will differ with the specific substance and its pharmacokinetics and pharmacodynamics. Evidence of tolerance and withdrawal may be present in the absence of a diagnosis of substance dependence if an individual takes benzodiazepines for long periods at prescribed and therapeutic doses, and discontinues them abruptly. The diagnosis of substance dependence should be considered only when the individual using the substance, in addition to having physiological dependence, shows evidence of a range of problems (e.g., drug-seeking behavior to the extent that important activities are given up or reduced to obtain the substance). In summary, the criteria of tolerance and withdrawal are not sufficient evidence of dependence for individuals taking sedatives, hypnotics, or anxiolytics under medical supervision (DSM-5).

Withdrawal syndrome for SHA appears after cessation of SHA use, and consists in at least two of the following: Autonomic hyperactivity (sweating or pulse rate greater than 100 bpm); hand tremor; insomnia; nausea or vomiting; transient visual, tactile, or auditory hallucinations or illusions; psychomotor agitation; anxiety; and grand mal seizures. The signs or symptoms develop within several hours to a few days after the cessation of SHA use; cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; are not attributable to another medical condition, and are not better accounted for by another mental disorder, including intoxication or withdrawal from another substance. It is necessary to specify if the syndrome courses with perceptual disturbances (DSM-5).

The course specifiers are: early full remission, early partial remission, sustained full remission, sustained partial remission, on agonist therapy, and in a controlled environment.

Physical exam: Physical exam may reveal signs of SHA dependence or prolonged use, including decreased heart rate (bradycardia), respiratory rate (bradypnea), and blood pressure (hypotension). Constant, involuntary, jerking movement of the eyeballs (nystagmus) is the single most useful finding seen in SHA dependence or intoxication. Physical signs of intoxication may include slurred speech; unsteady gait; loss of coordination; impaired thinking, memory, or attention; sluggishness; and tremor. Physical signs of withdrawal are hyperthermia, sweating, increased heart rate (tachycardia), increased hand tremor, insomnia, nausea or vomiting, transient hallucinations, psychomotor agitation, anxiety, or seizures. Characteristics of overdose include slow shallow breathing (respiratory depression), clammy skin, hypotension, stupor, shock, and coma. Death can follow if the hypotension and respiratory depression are not treated.

Tests: A polydrug urine screen should be ordered in case the individual is using drugs other than sedatives. Levels of specific SHA may also be determined. Both blood and urine samples may be used, but urine testing is generally the method of choice. A positive drug screen should always be confirmed by a second test, since it may result in serious consequences for the individual.

Additional tests are also recommended: blood for electrolyte disturbances, hypoglycemia, metabolic acidosis, hypoxia, hypercarbia; neurologic studies such as computed tomography (CT), electroencephalogram (EEG), or magnetic resonance imaging (MRI) for identifying other causes of the individual's condition such as structural brain lesions or seizure activity; and examination of cerebrospinal fluid (lumbar puncture) if an infectious cause of the condition is being considered.

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

Recovery from SHA dependence/SHA use disorder occurs in four phases. The acute phase focuses on alleviating symptoms of physiological withdrawal, and typically lasts for 3 days to 2 weeks or more, since the SHA drugs can stay in the body for fairly long periods after the individual has stopped using them. During the second phase, a 1-month period of abstinence, the individual focuses on changing behaviors. The early remission phase can last up to 12 months, and the sustained remission phase lasts as long as the individual abstains from using or abusing these medications.

Treatment during the acute phase requires close observation for at least 72 to 96 hours for the emergence of withdrawal symptoms while SHA is withheld. Medication therapy in the acute phase may include the use of benzodiazepines to decrease tremors and reduce or prevent increased blood pressure and heart rate; however, if the individual is a chronic abuser of benzodiazepines, a benzodiazepine antagonist may be used in low doses. Medications for other symptoms, such as diarrhea or muscle aches, are given as needed. Most individuals are admitted to a hospital or a specialized unit for the first few days of treatment. If withdrawal symptoms appear during treatment, a long-acting barbiturate may be prescribed and then slowly reduced over time. Most individuals will complete detoxification in 4 to 8 weeks (Scher).

Treatment for the 1-month abstinence and early remission phases may include education about physical, emotional, and mental aspects of addiction and recovery, identification of stressors and stress management skills, assistance with improved coping skills, assertiveness training, and relaxation training. The individual should be encouraged to avoid people, places and things related to SHA use. Drug urine tests should be administered periodically. A narcotic antagonist, such as naltrexone, which diminishes the effects of alcohol or sedatives, can be used to help some individuals remain abstinent. Self-help groups that provide long-term support can be crucial in preventing a relapse. Whereas twelve-step programs generally involve a spiritual dimension, Rational Recovery is a self-help group based on cognitive rather than spiritual principles.

Source: Medical Disability Advisor



Prognosis

Some individuals respond to treatment and stay in remission, while others experience periods of relapse, in which they begin SHA use/abuse after a period of remission, and again meet the criteria for substance dependence/SHA use disorder. Some individuals are never able to abstain from use, and do not experience any periods of remission. Outcome is improved if the individual seeks treatment early in the disease process and has adequate social support systems in place. However, a significant number of individuals experience at least one relapse after treatment, and some individuals never seek treatment. Long-term follow-up statistics suggest that up to 46% of patients who completed drug treatment programs for sedative-hypnotic abuse continued to use them (Scher).

Source: Medical Disability Advisor



Complications

Sudden withdrawal of the SHA can lead to hallucinations, grand mal seizures, heart arrhythmias, delirium, or death. The acute phase of withdrawal requires close medical supervision. The use of SHA with similar substances, such as alcohol, multiplies their effect and greatly increases the risk of death. Complications of SHA dependence/SHA use disorder include pneumonia, sepsis, liver failure, kidney failure, and nervous system dysfunction (peripheral neuropathy) in the arms and legs, in addition to the risk of accidental injury.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Many employers have systems in place for individuals recovering from substance dependence/substance use disorder disorders to return to work under special contracts or conditions. These contracts usually provide guidelines for testing blood and urine levels of identified substances, for evaluating work performance, and for treating substance abuse.

Temporary work accommodations may include reducing or eliminating activities where the safety of self or others is contingent upon a constant and/or high level of alertness, such as driving a motor vehicle, 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 timely and safe transition back to full work productivity.

Risk: Individuals with SHA dependence may be distracted from performing their jobs adequately by drug-seeking thoughts and behaviors, which presents a safety risk to themselves and their coworkers. Risk of recurrence may be reduced by scheduling regular yet random urine tests to ensure compliance with the work contract, and by encouraging attendance in substance abuse treatment and support groups during the individual's personal time.

Capacity: Capacity may be affected by SHA intoxication while on the job (e.g., unsteady gait; loss of coordination; impaired thinking, memory, or attention; sluggishness; tremor), SHA withdrawal (e.g., tachycardia, nausea or vomiting, hallucinations, psychomotor agitation, anxiety, seizures), or SHA overdose (e.g., respiratory depression, hypotension, stupor, shock).

Tolerance: Tolerance of the job duties is typically not a concern with this diagnosis. Individuals who exhibit a readiness to change may be more successful in attaining remission.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 3 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:

  • Did individual have a comprehensive psychiatric evaluation, which is essential in developing a treatment plan? If not, what areas were omitted? Would this information affect the current treatment plan? If so, what changes can be made?
  • Has diagnosis of SHA dependence/SHA use disorder been confirmed?
  • Was SHA dependence/SHA use disorder distinguished from SHA use as prescribed for medical conditions, from occasional use for recreational purposes, and from repeated episodes of intoxication?
  • Have conditions with similar symptoms been ruled out?
  • Have all underlying psychiatric and medical disorders been identified?

Regarding treatment:

  • Was detoxification successful? If not, would addition of a longer-acting, less-addictive drug to decrease withdrawal symptoms be beneficial?
  • Was treatment approach matched to the particular needs of the individual?
  • Were individual's preferences, the medical issues to be addressed, associated psychiatric disorders, and the individual's past response to various forms of treatment taken into consideration?
  • Has individual's life focused predominantly on substance use?
  • If individual does not meet clinical criteria for hospitalization, would the individual benefit from admission to a residential treatment program?
  • Since concurrent use of or withdrawal from other substances can complicate treatment, is the individual being monitored for the presence of other substances?
  • Are underlying psychiatric disorders being identified and treated concurrently?
  • Did comprehensive rehabilitation program include education about physical, emotional, and mental aspects of addiction and recovery, identification of stressors and stress management skills, assistance with improved coping skills, assertiveness training, and relaxation training?
  • While individual should be encouraged to avoid people, places and things related to SHA use, is individual receiving the long-term support that self-help groups provide?

Regarding prognosis:

  • What support system does individual have in place to provide external support and motivation to continue in treatment beyond the initial stage of detoxification?
  • Does individual have the necessary tools, skills, and encouragement to move ahead with his or her life?

Source: Medical Disability Advisor



References

Cited

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.

Scher, Lorin M. , et al. "Sedative, Hypnotic, Anxiolytic Use Disorders." eMedicine. 18 Feb. 2014. Medscape. 6 May 2015 <http://emedicine.medscape.com/article/290585-overview>.

Source: Medical Disability Advisor






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