Statement of Principles

concerning

SUBSTANCE USE DISORDER
(Reasonable Hypothesis)

(No. 59 of 2017)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated 3 November 2017

Contents

1 Name

2 Commencement

3 Authority

4 Revocation

5 Application

6 Definitions

7 Kind of injury, disease or death to which this Statement of Principles relates

8 Basis for determining the factors

9 Factors that must exist

10 Relationship to service

11 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1               Name

This is the Statement of Principles concerning substance use disorder (Reasonable Hypothesis) (No. 59 of 2017).

2               Commencement

              This instrument commences on 4 December 2017.

3               Authority

This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.

4               Revocation

The Statement of Principles concerning substance use disorder No. 3 of 2009, as amended, made under subsections 196B(2) and (8) of the VEA is revoked.

5               Application

This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.

6               Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

7               Kind of injury, disease or death to which this Statement of Principles relates

(1)          This Statement of Principles is about substance use disorder and death from substance use disorder.

Meaning of substance use disorder

(2)          For the purposes of this Statement of Principles, substance use disorder means a disorder of mental health that meets the following diagnostic criteria (derived from DSM-5):

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

1. Substances are 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 substances.
5. Recurrent substance use resulting in a failure to fulfil 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 substances.
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. Continued substance use 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:

(i)            a need for markedly increased amounts of substances to achieve intoxication or desired effect; or

(ii)         a markedly diminished effect with continued use of the same amount of a substance.

Note:  This criterion is not considered to be met for those individuals taking substances solely under appropriate medical supervision.

K.        For substances other than hallucinogens or inhalants, withdrawal, as manifested by either of the following:

(i)            the characteristic substance withdrawal syndrome; or

(ii)         substances (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

Note:  This criterion is not considered to be met for those individuals taking substances solely under appropriate medical supervision.

Note:  The definition of substance use disorder excludes alcohol use disorder and acute substance intoxication in the absence of substance use disorder.

Note:  DSM-5 and substance are defined in the Schedule 1 - Dictionary.

Death from substance use disorder

(3)          For the purposes of this Statement of Principles, substance use disorder, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's substance use disorder.

Note: terminal event is defined in the Schedule 1 – Dictionary.

8               Basis for determining the factors

The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that substance use disorder and death from substance use disorder can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA.

 Note: relevant service is defined in the Schedule 1 – Dictionary.

9               Factors that must exist

At least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting substance use disorder or death from substance use disorder with the circumstances of a person's relevant service:

(1)          having a clinically significant disorder of mental health as specified at the time of the clinical onset of substance use disorder;

Note: clinically significant disorder of mental health as specified is defined in the Schedule 1 - Dictionary.

(2)          experiencing a category 1A stressor within the five years  before the clinical onset of substance use disorder;

Note: category 1A stressor is defined in the Schedule 1 - Dictionary.

(3)          experiencing a category 1B stressor within the five years before the clinical onset of substance use disorder;

Note: category 1B stressor is defined in the Schedule 1 - Dictionary.

(4)          experiencing the death of a significant other within the five years before the clinical onset of substance use disorder;

Note: significant other is defined in the Schedule 1 - Dictionary.

(5)          having a medical or psychiatric condition for which a substance was medically prescribed, at the time of the clinical onset of substance use disorder, where the substance use disorder involves one or more agents from the same pharmacological class as the prescribed medication;

(6)          experiencing severe childhood abuse before the clinical onset of substance use disorder;

Note: severe childhood abuse is defined in the Schedule 1 - Dictionary.

(7)          having a medical illness or injury which is life-threatening or which results in serious physical or cognitive disability, within the five years before the clinical onset of substance use disorder;

(8)          experiencing a category 2 stressor within the one year before the clinical onset of substance use disorder;

Note: category 2 stressor is defined in the Schedule 1 - Dictionary.

(9)          having persistent pain of at least three months duration at the time of the clinical onset of substance use disorder;

Note:  persistent pain is defined in the Schedule 1 - Dictionary.

(10)      having a clinically significant disorder of mental health as specified at the time of the clinical worsening of substance use disorder;

Note: clinically significant disorder of mental health as specified is defined in the Schedule 1 - Dictionary.

(11)      experiencing a category 1A stressor within the five years  before the clinical worsening of substance use disorder;

Note: category 1A stressor is defined in the Schedule 1 - Dictionary.

(12)      experiencing a category 1B stressor within the five years  before the clinical worsening of substance use disorder;

Note: category 1B stressor is defined in the Schedule 1 - Dictionary.

(13)      experiencing the death of a significant other within the five years before the clinical worsening of substance use disorder;

Note: significant other is defined in the Schedule 1 - Dictionary.

(14)      experiencing severe childhood abuse before the clinical worsening of substance use disorder;

Note: severe childhood abuse is defined in the Schedule 1 - Dictionary.

(15)      having a medical illness or injury which is life-threatening or which results in serious physical or cognitive disability, within the five years before the clinical worsening of substance use disorder;

(16)      experiencing a category 2 stressor within the one year before the clinical worsening of substance use disorder;

Note: category 2 stressor is defined in the Schedule 1 - Dictionary.

(17)      having persistent pain of at least three months duration at the time of the clinical worsening of substance use disorder;

Note:  persistent pain is defined in the Schedule 1 - Dictionary.

(18)      inability to obtain appropriate clinical management for substance use disorder.

10           Relationship to service

(1)          The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.

(2)          The factors set out in subsections 9(10) to 9(18) apply only to material contribution to, or aggravation of, substance use disorder where the person's substance use disorder was suffered or contracted before or during (but did not arise out of) the person's relevant service.

11           Factors referring to an injury or disease covered by another Statement of Principles

In this Statement of Principles:

(1)          if a factor referred to in section 9 applies in relation to a person; and

(2)          that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(2) of the VEA;

then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

Schedule 1 - Dictionary  

Note:               See Section 6

1               Definitions

In this instrument:

                             category 1A stressor means one of the following severe traumatic events:

(a)          experiencing a life-threatening event;

(b)          being subject to a serious physical attack or assault including rape and sexual molestation; or

(c)          being threatened with a weapon, being held captive, being kidnapped or being tortured.

                             category 1B stressor means one of the following severe traumatic events:

(a)          being an eyewitness to a person being killed or critically injured;

(b)          viewing corpses or critically injured casualties as an eyewitness;

(c)          being an eyewitness to atrocities inflicted on another person or persons;

(d)          killing or maiming a person; or

(e)          being an eyewitness to or participating in, the clearance of critically injured casualties.

Note: eyewitness is also defined in the Schedule 1 - Dictionary.

                             category 2 stressor means one of the following negative life events, the effects of which are chronic in nature and cause the person to feel ongoing distress, concern or worry:

(a)          being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness;

(b)          experiencing a problem with a long-term relationship including the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation or divorce;

(c)          having concerns in the work or school environment including ongoing disharmony with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful workloads, or experiencing bullying in the workplace or school environment;

(d)          experiencing serious legal issues including being detained or held in custody, ongoing involvement with the police concerning violations of the law, or court appearances associated with personal legal problems;

(e)          having severe financial hardship including loss of employment, long periods of unemployment, foreclosure on a property or bankruptcy;

(f)           having a family member or significant other experience a major deterioration in their health; or

(g)          being a full-time caregiver to a family member or significant other with a severe physical, mental or developmental disability.

Note: significant other is also defined in the Schedule 1 - Dictionary.

                             clinically significant disorder of mental health as specified means one of the following conditions, which is of sufficient severity to warrant ongoing management:

(a)          acute stress disorder;

(b)          adjustment disorder;

(c)          agoraphobia;

(d)          alcohol use disorder;

(e)          Alzheimer-type dementia;

(f)           anxiety disorder;

(g)          attention-deficit/hyperactivity disorder;

(h)          bipolar disorder;

(i)            conduct disorder;

(j)            depressive disorder;

(k)          eating disorder;

(l)            gambling disorder;

(m)        gender dysphoria;

(n)          insomnia disorder;

(o)          obsessive-compulsive disorder;

(p)          panic disorder;

(q)          paraphilic disorder;

(r)           personality disorder;

(s)           posttraumatic stress disorder;

(t)            schizophrenia;

(u)          sexual dysfunction;

(v)          social anxiety disorder;

(w)        somatic symptom disorder;

(x)          specific phobia; or

(y)          vascular dementia.

 Note 1:               "                                                                                    Management" of the condition may involve regular visits (for example, at least monthly) to a psychiatrist, counsellor or general practitioner.

 Note 2: To "warrant ongoing management" does not require that any actual management was received or given for the condition.

                             DSM-5 means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.  Arlington, VA, American Psychiatric Association, 2013.

                             eyewitness means a person who experiences an incident first hand and can give direct evidence of it.  This excludes persons exposed only to public broadcasting or mass media coverage of the incident.

                             MRCA means the Military Rehabilitation and Compensation Act 2004.

                             persistent pain means:

(a)          continuous pain; or

(b)          almost continuous pain; or

(c)          frequent, severe, intermittent pain;

which is severe enough to interfere with usual work or leisure activities or activities of daily living.

                             relevant service means:

(a)          operational service under the VEA;

(b)          peacekeeping service under the VEA;

(c)          hazardous service under the VEA;

(d)          British nuclear test defence service under the VEA;

(e)          warlike service under the MRCA; or

(f)           non-warlike service under the MRCA.

Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary.

                             severe childhood abuse means:

(a)          serious physical, emotional, psychological or sexual harm whilst a child aged under 16 years; or

(b)          neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing whilst a child aged under 16 years;

where such serious harm or neglect has been perpetrated by a parent, a care provider, an adult who works with or around that child, or any other adult in contact with that child.

                             significant other means a person who has a close family bond or a close personal relationship and is important or influential in one's life.

                             substance means any of the following substances, alone or in combination:

(a)          amphetamine-type substances;

(b)          cannabis and cannabis derivatives;

(c)          cocaine;

(d)          hallucinogens, including phencyclidine and pharmacologically similar substances;

(e)          hydrocarbon-based inhalants;

(f)           opioids, and opioid derivatives and synthetic opioids with morphine-like effects;

(g)          sedatives, hypnotics and anxiolytics, including barbiturates, nonbarbiturate sedatives and benzodiazepines, and tranquillisers with similar effect; or

(h)          tobacco.

                             substance use disorder—see subsection 7(2).

                             terminal event means the proximate or ultimate cause of death and includes the following:

(a)           pneumonia;

(b)           respiratory failure;

(c)           cardiac arrest;

(d)           circulatory failure; or

(e)           cessation of brain function.

                             VEA means the Veterans' Entitlements Act 1986.