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DSM-5 reduces substance abuse diagnosis to unidimensional condition

PHILADELPHIA — Two levels of diagnosis relating to substance use — abuse and dependence — will be absent from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, according Charles O’Brien, MD, PhD, of the University of Pennsylvania.

Instead, substance abuse will be categorized “as a unidimensional condition known as ‘substance abuse disorder,’” O’Brien said. The disorder will be diagnosed as mild, moderate or severe depending on the number of symptoms.

“Data indicate that there is no evidence to support the existence of an intermediate level that was formerly called ‘abuse,’” O’Brien said. “Also, we no longer use the term ‘dependence’ when we really mean ‘addiction.’”

The updated iteration will include the addition of the symptom of “craving” and the deletion of “legal problems” as a symptom of substance abuse.

Marijuana and caffeine withdrawal were recognized by the group, and nicotine was defined similarly to other drugs, according to O’Brien. “We also listed gambling with other addictions.”

Internet use was considered, and the group ultimately included it in the appendix. “We also considered sexual disorder,” O’Brien said. “But we determined that it was not a scientific disorder. All this does is make a lot of money for sex addiction treatment centers.”

Rationale and opinion

According to O’Brien, building tolerance is a natural physical reaction to increased use of a substance, but it should not be termed as a problem. “We shouldn’t call our patients addicts if they develop this physical dependence,” he said. “Tolerance is a normal thing that we all have, withdrawal is normal if you become tolerant to [a substance].”

Craving, however, is a change in the brain that can remain for extended periods after use of the substance has ceased. “Craving is important because in large population interview studies, it tends to be a more severe symptom and may continue long after detoxification, thus increasing risk of relapse,” O’Brien said. “It is also a symptom that is associated with dopamine release. The greater the dopamine, the more severe the craving reported by the patient. Craving is also associated with cues that activate brain reward structures in drug-free former addicts.”

Nicotine is an example of a drug that yields cravings long after cessation, which is one of the reasons it was added to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), according to O’Brien.

“Internet game use varied with a lot of cultures,” O’Brien said. “So maybe this is genetic. It was much more common among Asians, predominantly in males. But there are no good hard data on this, so it warrants further investigation.”

Policy issue

“The coming of health care reform in 2014 will demand that all primary care patients be evaluated for substance abuse problems, and if such a problem is detected, referred for early treatment,” O’Brien said. “Cost-benefit studies have shown that early treatment prevents later complications and, thus, reduces costs to the health care system.”

Those who develop serious addictions may require liver transplantation or other costly surgeries. Detection and prevention efforts may mitigate most of those costs, according to O’Brien.

He said much of the discussion focused on the word “addiction” itself.

“Some people have a kind of an allergy to the word addiction,” he said. “But we feel it has lost a lot of its pejorative tone. For example, when the president says we’re addicted to oil, it takes away some of the stigma associated with substance users.”

With this in mind, and because of the cost issues, O’Brien said adding addiction to health insurance profiles may not be met with as strong opposition as it once was.

“Also, it turns out that genetics plays a very large role in addiction,” he said. “There is quite a lot of drug use, but few develop problems with it, and still fewer develop addiction. It is the luck of the draw of the genes whether you’ll be predisposed to addiction or not. This can also alleviate the stigma of the word.”

For more information:
O’Brien C. Symposium S044-3. Presented at: the 2012 Annual Meeting of the American Psychiatric Association; May 5-9, 2012. Philadelphia.

Disclosure: Dr. O’Brien reports being a consultant to Alkermes, Embera and Reckitt Benckiser.