By Mark Willenbring
Sometime this month, the DSM-5 will replace the DSM-IV as the coin of the realm for diagnosis of mental illnesses, including substance use disorders. Despite the unprecedented criticism that has accompanied the process, the final product’s changes are based on very solid epidemiological research, and they are likely to reduce ambiguity and confusion. But there may be some surprise, too, as received wisdom about the diagnosis and treatment of addiction is turned on its head. Let’s hope that this development will result in a more rational and nuanced approach to addiction.
When the DSM-IV was developed, it appeared that abuse and dependence were two distinct disorders. Substance abuse was defined according to four criteria; dependence, according to seven criteria. In practice, “abuse” was often used to denote a milder form of Substance Use Disorder (SUD); “dependence,” a more severe SUD.
In the case of opioids, “dependence” was confusing because almost anyone on opioid-based painkillers for any length of time develops physiological dependence (they will have withdrawal if they stop suddenly), whereas in the DSM-IV, “dependence” meant “addiction” (pathological, compulsive, harmful use). So pain patients prescribed opioids were mislabeled as opioid “dependent” even though they took their medication as prescribed.
Since then, a considerable body of research has shown that there are not two distinct types of substance misuse, but only one. More important, most DSM-IV “abuse” symptoms develop only in people with severe addiction, while “dependence” symptoms are among the earliest to develop. In the DSM-5, “abuse” and “dependence” are gone. In their place is the single “Substance Use Disorder.”
With alcohol, for example, the earliest and most common problems are “internal” problems, such as going over limits, persistent desire to quit or cut down, and use despite hangover or nausea. The only “abuse” criterion that develops early is drinking and driving, but without a DUI. In the largest study of its kind, the NIAAA Epidemiological Study of Alcohol and Related Conditions (NESARC), 90 percent of people who met criteria for DSM-IV alcohol abuse—but not dependence—did so because of admitting drinking and driving. All other abuse criteria only occurred in people with the most severe and chronic addiction, and then late in the game.
In fact, legal problems occur so infrequently that this criterion was dropped from theDSM-5. This may come as a surprise to people working in the treatment industry because legal problems are the most common reason people seek treatment in rehab. But only about 12 percent of people with DSM-IV alcohol dependence ever seek specialty treatment, which suggests that the rest—who are not in treatment—have less severe disorders. People in rehab or AA are to alcohol use disorder what asthmatics on a ventilator in the ICU are to people with asthma: the most severe, treatment-refractory disorders as well as the most co-morbid psychiatric and medical problems. We’ve made a large error by assuming that everyone in the community who meets the criteria for a substance disorder has exactly the same disease as people in rehab or AA.