Substance Use Disorder change gets mixed response

One DSM-5 change that has divided mental health experts is the new category of Substance Use Disorder, which combines the DSM-IV Substance Abuse and Substance Dependence categories into a single disorder measured on a continuum of severity.

Some say this change may improve early diagnoses/interventions, while others fear it could mislabel or stigmatize normal, transient behavior – for example, by lumping college binge drinkers in with those who have a hard-core dependence. According to one study, the new criteria could increase by more than 60 percent the number of people classified with alcohol problems.

According to the DSM-5 Task Force, each substance is addressed as a separate use disorder, with nearly all diagnosed based on the same overarching criteria; in this overarching disorder, the criteria have not only been combined, but strengthened. Whereas a diagnosis of Substance Abuse previously required only one symptom, mild Substance Use Disorder in DSM-5 requires two-to-three symptoms from a list of 11. Drug craving will be added to the list and problems with law enforcement will be eliminated because of cultural considerations that make the criteria difficult to apply internationally.

John F. Kelly, Ph.D., associate director of the MGH-Harvard Center for Addiction Medicine and program director of Addiction Recovery Management Service, says the overall prevalence of Substance Use Disorder may rise and more younger people may potentially fall in the category, even though they may have only two or three symptoms. “Even though there’s a mild, moderate, and severe subcategorization, it will still mean they will be ultimately classified as the same category,” Kelly says.

He says incorporating the abuse and dependence items into one dimension is “a bit like mixing apples and oranges.”

“Because now you’ve got the syndrome itself, what kind of happens with the addiction in the brain of the person, coupled with the consequences of addiction,” Kelly says. “It’s a bit like mixing cancer with unemployment and other psychosocial consequences of the cancer.”

“When you measure people who meet criteria for addiction, they also have a lot of the consequences, which have been the abuse criteria (in DSM-IV),” Kelly says. But while there may be an empirical basis to put these categories together, it’s not a good conceptualization, he adds. “You’re just combining apples and oranges together in one big long list. We are mixing them into one single dimension and now we’re going to have a lot more variability within this single dimension, and that has treatment implications.”

Also, Kelly says that while eliminating the “problems with law enforcement” criteria may remove a potential source of bias, there may be another consequence. “You have a large population of people, for example, who have multiple DUIs who would have had a diagnosis of alcohol abuse, but will no longer have a diagnosis,” Kelly says. “That has ramifications for reimbursements for those folks. For example, they may not be eligible for an intervention, because they no longer have that diagnosis.”

Rick Barnett, Psy.D., LADC, president of the Vermont Psychological Association, who has specialized training in treating addictive behaviors, says he believes it’s a good thing that the DSM-5 will no longer distinguish between abuse versus dependence.

“I think it takes away the stigma associated with using the term abuse – that’s a pejorative term,” Barnett says. “And saying ‘you’re dependent on a substance’ – that could be a pejorative term.”

Barnett says he doesn’t think the change will make the labeling of people with a condition more widespread or prompt a lot of false-positive diagnoses. “If you are trained in addiction you are going to know whether or not this college binge drinker has a problem or not by doing a thorough diagnostic interview.”

“I don’t think it’s going to change anything for me,” Barnett says. “The only thing I think it changes most significantly is those people who are not versed in addiction, it’s an opportunity for those of us who like to teach and disseminate information on the topic to clarify a lot of myths that have been promoted for years.”

Barnett says use of the word “dependence” in the past has falsely given people who aren’t trained in the field the idea that it’s only a biological disease.

“Getting rid of the dependence thing is going to clear up a lot of misconceptions of what constitutes a real substance use disorder. This change might help promote training and education in this topic, and that’s a big thing for me.”