Tuesday, January 29, 2013

DSM5 Substance Use Disorders Part 2

Yesterday, I posted about the changes in diagnosis of substance use disorders (SUDs) in DSM5 by addressing a key point about whether addiction is a disease, and what that actually means. This is second post that derives from a conversation that Maia Szalavitz and I have been having on this topic. You can read her post on this topic here.

2. What about DSM5 and the changes from DMS4? This is mostly a technical question relating to cut points. How many substance-related symptoms or criteria does one have to have before calling it a disease, meaning a focus of treatment interventions? As it turns out, there is no clear cut-point. Essentially, the more symptoms one has, the more likely they are to be associated with distress and dysfunction. Earlier in the course of the disorder (and most cases don't progress beyond mild to moderate disorder), most symptoms are "internal" meaning that the individual struggles with control of ingestion, especially once ingestion starts. (Going over self-limposed limits, persistent desire to quit/cut down, continued use despite internal problems such as heartburn, hangover, nausea.) The only "external" one is driving while intoxicated (no DUI). About 3/4 of people meeting DSM4 criteria for alcohol dependence only have these symptoms, and the problem is resolved after about 3-4 years on average and does not recur. 20 years after onset 40% report low risk non problem drinking. Proportions differ by drug of course, especially in the proportion of ever-users who become dependent (highest for smoking, lowest for cannabis/hallucinogens, intermediate for alcohol.) 

We have been studying people in rehab, hospitals and AA for the past 60 years, and then generalizing to people with the disorder in the community who are not in those places. It turns out that people in rehab are those with the most severe, treatment-refractory disease, the most co-morbidity, and the least social support. In terms of the spectrum of severity, the folks in rehab are the equivalent to people with depression or asthma who are hospitalized: a small proportion with the most severe, treatment-refractory illness. The problem is, we've made the mistake of generalizing from that sample to community dwellers, thinking everyone has exactly the same disease. Of course, this is absurd. This mistake has cost us dearly. For example, there are no treatment options for people with milder forms of the disorder, since no one goes to rehab who doesn't have to, usually with significant overt coercion such as a DUI. In SUDs, we are now where depression was 60 years ago. Then the only options you had were the state hospital, where you'd get committed for 6-12 months and get thorazine and ECT, or psychoanalysis which didn't work and was available only to a few. Prozac, in 1988, changed all that. Now, most people with depression go to their family physician and get a prescription for an antidepressant. Obviously this is much less stigmatizing and traumatic that the state hospital. Rehab is essential the state hospital at this point. This is all going to change soon, especially for alcohol. 

Another consequence of the peculiar development of ideas about addiction in the US (because of AA, as you (Maia) have pointed out) is that it is all or none, and inevitably severe and progressive. The new (really old and backward looking) definition of addiction by ASAM is an example of that kind of thinking. In your (Maia's) post, you use the word "alcoholic." This term needs to be retired for several reasons. First, it suggests black/white thinking, although the reality is infinite shades of grey when discussing SUDs. Second, it is strongly associated with images of severe, end-stage drunks (another stigmatizing term.) Third, it has no scientific or clinical meaning and is imprecise, being defined by the writer and readers in whatever way this wish.

But rather than only two or three discreet versions of "problem drinking" (another imprecise term), there are instead infinite shades of grey. Furthermore, severity or even presence of a problem usually waxes and wanes over the years. Again, contrary to popular belief, SUDs are not always progressive. For alcohol use disorder most are not. 

3. What else could the committee have done? There was and is no scientific basis for creating two distinct categories. Well, they could have made the cut point higher, such as 5 criteria rather than 2 for a diagnosis. But then that would simply be enshrining the AA ideology into medical diagnosis: you either have it or you don't, it's always severe or it isn't addiction, it's something else. And there would be no impetus to provide treatment for the much larger group of people who have milder forms of the illness and who desire help. They don't go to rehab because who would? It's an obnoxious often toxic treatment with enormous stigma that is terribly inconvenient and expensive. Other alternatives are needed. I believe that over time, people with come to understand that mild SUD is very common, and often self limited, or at least not chronic. In my opinion this will reduce stigma.

4. Finally, the new criteria at least technically will not increase diagnosis of an SUD, especially when it comes to drinking, since almost all cases of alcohol abuse w/o dependence are due to one criterion: admitting to drinking and driving (no DUI.) All other abuse criteria only occur among people with severe chronic addiction. How this is used in practice will become clear over time. My guess is that there will not be a significant increase in clinicians making diagnoses, although there should be. There should be because mild alcohol dependence is unrecognized and not diagnosed or addressed. So I think the same severely addicted people who are are now clinical diagnosed will continue to be.*

*A new study was published online 1/24/13 that shows very little change in overall prevalence of alcohol use disorder between DSM-IV and DSM5 diagnoses. I'll have more on that article later.



  1. Interesting 2 posts that certainly stimulate discussion and thought, which is always good. I am also currently pondering the implications of the DSM-V, although in South Africa we are not beholden to it as you are in the States. I am not convinced that to lump the orders together is either helpful or accurate. While I certainly believe that there is a spectrum of substance related disorders, I do believe that at some point the addiction "switch" is "switched". I believe that at some time in the future we will find biological markers for this. Having said that, I do believe that we need to offer a range of services and scaled interventions for those with substance use disorders, should they choose to avail themselves of these services. Although the markers I suggest are not currently there, to simply lump substance users, or those with potentially addictive traits, in the same category as the long-term addict and serial relapser may cause more problems than it solves. Either way, I think we are far from finding definitive answers in this extremely challenging field and I think that by neatly labeling addiction as simply a disease may make us blind to certain aspects of this condition and the required interventions.

  2. I totally agree with you, Mark, and think that what we need is education of health care professionals and consumers and to stop arguing about what's wrong with the new DSM. It's great to finally have more useful terminology for less serious substance use disorders - now we need more places and ways for people who have "mild" and "moderate" problems to get help. (I know you're working on that!)We also need to assure that people who fall into these less-serious categories stop getting sent to traditional treatment programs, as they often do, where they may receive "help" that does them a disservice. For instance, people like this typically do not belong in 12-step meetings and can wind up demoralized when told that they're not getting with the program.
    Author, Inside Rehab.

    1. Anne, great post. I agree AA is not a one size fits all kind of self-help/social organization that professionals should refer every client struggling with any substance use issue. Even though the 12 step process is a wonderful way of life that can be helpful to anyone there is a culture that pervades within the rooms that has nothing to do with what is stated in the book Alcoholics Anonymous (perhaps we could refer to this as the culture of treatment AA). The book is written rather humbly keeping the door wide open for individuals to make their own decisions about what they want to do regarding problematic or alcoholic drinking (12 steps are stated as "mere suggestions," also stated "we do not have a monopoly on addiction," and the list goes on and on). The book speaks of "the true alcoholic" as I stated in my post below, and I believe this is what you may be referring to in what kind of individuals can be best served by referrals to AA. With individuals who start using substances before the age of 15 drastic effects can be observed that result in lack of appropriate peers relations, limited sense of self, emotional dysregulation, co-occurrence of mental health disorders, etc, etc.. We could say they need habilitation instead of rehabilitation since there is nothing to "re." Within the context of individuals who fit within this group we can see a pattern of thoughts and behaviors that appear to fit with the underlying dis-ease that "The Big Book" is attempting to treat. I'm just trying to shoot from the hip here as I do not have time to review the research for complete accuracy and am also speculating a bit, but I want to make a point that AA has a very important place in ongoing care of SUDs while also completely agreeing with your thoughts.

    2. Well put Matthew. Clinically I am seeing what you are describing in terms of the Re(habilitation) aspect. In the population in which I work most are initiating drug use around 12, with some heroin users as young as 9. When they do come into treatment they have never learned "normal" behaviour, and are usually heavily influenced by prison-gang culture.

      I find it fairly strange the level of criticism towards 12-step programs in the states, but as you pointed out elsewhere, I think that this has been heavily influenced by the "cure all" adoption of the Minnesota Model. Personally I feel that 12-step facilitation in a professional setting is like feeding people with pneumonia oranges in hospital. 12-step programs are a free resource, and should not be professionalized. I believe that there is a lot of science and neuroscience that supports NA, but as professionals we need to measure and define what exactly we are offering; distill the process and "concentrate" the active ingredients while discarding the chaff.

    3. The scapegoating of AA is rather silly as it is not a political organization, is not affiliated with the MN model of addiction treatment, has no opinion on outside issues, etc etc... It is unfortunate that many professionals/experts miss the boat when discussing AA.

      Another issue that bugs me is some of the research utilizing 12 step processes. I was reading a study by Marsha Linehan the other day and had to laugh. She used 12 step meeting attendance as defined below:
      "CVT /12S clients attended a 120-min women’s Narcotics Anonymous (NA) meeting that was conducted in accordance with NA policy for ‘12 and 12’ meetings. These meetings were advertised as open to the public, but functionally, very few non-research participants ever attended. They were held in our research facility and the CVT /12S therapists attended the meetings, but did not serve as group leader or facilitate the meeting. In short, the majority of meetings included only our CVT /12S clients and therapists. In addition, all CVT /12S clients were strongly encouraged to meet weekly with a 12-Step sponsor of their choice, and to attend as many AA
      meetings as possible."
      Drug and Alcohol Dependence 67 (2002) 13 /26

      I am not attempting to say meeting attendance has no therapeutic value, but as I wrote in the email I sent her the therapeutic value of meeting attendance without the actual 12 step program is comparable to the outcomes seen if she measures DBT skills group attendance without compliance to weekly one on one DBT coach meetings and lack of compliance with diary cards and practicing in group skills in the real world (outcomes of positive change will be drastically limited).

      I believe much of what is contained in the book Alcoholics Anonymous is a layman's interpretation of what modern research has shown to be of high therapeutic value. The main sticking point I see in AA is the value of tradition keeping the program from growing into something way more valuable than it currently is.

      If I were to design a study to compare 12 step process with an alternative therapeutic intervention I would incorporate "Sponsors" that were trained or had comparable characteristics in their interpretation/application of the 12 step process, have study participants meet with sponsors weekly to do step work at the same rate as all participants, have participants attend the same 3 12 step groups weekly, etc..etc... In essence, I would follow the directions contained in the book in order to gain an actual measurement of the therapeutic value of the 12 step process.

    4. You make an excellent point here: The 12 step process is not the meeting. The process is what happens at home while working the steps. There are few people I know that have worked steps 4-9 and not been changed for the better by the process. There is certainly no abdication of responsibility in these steps!

      Another thing is that most rehabs in the short form (21-28days) usually only facilitate steps 1-3, which has limited value and certainly has led to the very confrontational approach that goes contrary to the principles of MI as described by Miller.

      You have given me some ideas for research in this area and certainly I shall be posting about this in the near future!

  3. Mark,great read, but I am having some issues with your comments about AA. First off, I think it is very important to distinguish the difference between AA, early research done on alcohol use disorders, and the MN model. The book Alcoholic Anonymous does a wonderful job of describing various kinds of alcohol use along a continuum, especially for a book written in 1939 by a layman. "Moderate drinkers have little trouble in giving up liquor entirely if they have good reason for it. They can take it or leave it alone. Then we have a certain type of hard drinker. He may have the habit badly enough to gradually impair him physically and mentally. It may cause him to die a few years before his time. If a sufficiently strong reason—ill health, falling in love, change of environment, or the warning of a doctor—becomes operative, this
    man can also stop or moderate, although he may find it difficult and troublesome and may even need medical attention.
    But what about the real alcoholic? He may start off as a moderate drinker; he may or may not become a continuous hard drinker; but at some stage of his drinking career he begins to lose all control of his liquor consumption, once he starts to drink (pgs. 20-21, Alcoholics Anonymous)." Also, once can easily separate AA from the MN model of treatment by reading pg. 31, "We do not like to pronounce any individual as alcoholic, but you can quickly diagnose yourself." The MN model has taken AA beyond what it is meant to be and is a very different beast. AA is not to blame for what has happened in the US regarding treatment of SUD. I'm not into the blame game so will avoid commenting further, but with this blog being about moving addiction treatment into the future and being the most helpful to individuals struggling with SUDs I believe we need to be very careful about what we state as misinformation is a very large part of the problem.

    1. Matthew, you raise some excellent points that I have never heard raised before and will go and do some research on this. Thanks for the insight!

  4. Matt, thanks for pointing out the difference between AA and 12-step treatment programs. Jung once said, "God save me from the Jungians" and we all know what kinds of things are done in the name of Jesus or Mohammed. I completely agree that the spectrum idea is consistent with the original vision of the founders of AA, as reflected in the Big Book. I would say, however, that the passage you quote essentially defines "an alcoholic" as someone who "loses all control of his liquor consumption, once he starts to drink," reinforcing the notion that "real alcoholics/addicts" have severe disorders. That just doesn't fit with the science though.
    Shaun, also excellent comment. I would like to clarify that there is a difference between at-risk drinking (heavy drinking w/o any symptoms) and mild alcohol dependence, and I think the same is true for most other drugs. So the spectrum dosen't start with alcohol use disorder diagnosis. In my view, there is nothing inconsistent with seeing addiction as a disease that can be mild and self-limiting. How many kids "grow out of" asthma?

  5. Mark, thanks for your response! I love being able to get a dialogue going as it moves goals forward. I have a counter point, well more of a speculation regarding you statement about loss of control. I have some concerns about the 60 plus studies we discussed in school regarding "loss of control." The research seemed more reactive than anything else, and I felt that through the reactivity important insights were not made. Within the research it is evident there is no such thing as an inability to control consumption once alcohol is ingested; however, the studies from what I remember did not use alcoholics that in my mind are comparably to the first 100 men and women used to write the anecdotal observations documented in the book Alcoholics Anonymous. I mean to say length of disorder, severity of disorder, physical complications due to disorder, etc did not seem to be adequately adjusted for. Also, the co-occurrence of mental health disorders were not subject to the studies if I recall correctly. Bill Wilson was most likely Bipolar type II as is evident through his recurrent major depressive episodes and at least one documented hypomanic episode as described in Not God by Ernest Kurtz. In 1941 Bill Wilson decided to go travel the country promoting AA, many members were extremely upset with Bill due to his complete lack of ability to abide by "Attraction not Promotion" organizational structure of AA. Many commented that Bill was going to drink soon. In reflecting on this extravagant adventure Bill termed his behavior "Alcoholic Grandiosity." I may be off in my assumption which then leads into MDD, recurrent. My personal belief is the book is addressing co-occurring disorders more than "Alcoholism." Anyways, I am attempting to argue for the existence of a sub-type of alcoholics that do not have the inability to control their drinking, but instead have strong co-occurrence of mental health disorders, struggle with negative affective states or the impulsivity of above baseline mood, are under incredible strain/stress due to the losses that occur with SUDs, which results in what appears to be an inability to stop drinking once started. Also, perhaps it can be argued that there is an actual subgroup of Alcohol Use disorders that do have an inability to stop drinking once started and the research has failed to use a proper sample to find the subgroup. Another issue I find interesting is the way culture affects substance use. I wonder if the cultural and temporal influences of the time (to be an alcoholic is to be committed for alcoholic insanity or to die of the disorder) somehow interplayed to create an actual inability to stop drinking once started. I'm just speculating of course, and fully acknowledge I may be completely overlooking important findings. I think thinking outside the box can lead us into doing better work and being more helpful to those in need.

  6. Matt, I think that impaired control over alcohol or other substance use exists along a continuum, from mild to severe. That is, some people struggle a little bit, others more, and still others can't control it at all! This is no different from other health behaviors. For example, some people can eat a few potato chips or a half-cup of ice cream, other have more than intended but not that much, and others eat the whole bag or carton. Culture is very important in determining the specific substance most likely to become addicted to. In the USA, alcohol is freely available while cannabis and opioids are not. In the middle east, it's the opposite. I think the important points on which we agree is that 1) there are large differences across people in terms of substance preference, use, and addiction, and 2) there are substantial cultural differences that affect choice of substance and acceptability of use.

  7. How can we even have the DSM portion of this discussion? APA has not shared the actual DSM-5 text on substance use disorders and it remains firmly locked behind a curtain of nondisclosure. Until we see what's actually in the text, there is no way for the field to discuss anything other than the material that was originally discussed on the APA's DSM website, much of which may have changed significantly.

    I also take strong issue with Mark's statement on alcoholism, which has been very well defined by the field as a consensus (most recently in a very well done JAMA article). I've taught extensively on the differences between "alcoholism," as defined in this statement and "alcohol dependence" as defined in DSM-IV. I imagine DSM-V will have still another definition, but alcoholism will continue to have the same definition that it has had until the field comes together again to address it.