Americans Spending $100 Billion on Illegal Drugs Annually

The U.S. White House Office of National Drug Control Policy (ONDCP) commissioned the RAND Corporation to investigate how much Americans were spending on the four most common illegal drugs from 2000-2010. The study, published recently on the whitehouse.gov website, uses a variety of sources to develop an estimate in yearly spending by consumers of cannabis, heroin, cocaine (including crack), and methamphetamine. Their conclusion: over $100 billion is spent on just these four drugs, every year. Interestingly, this number has stayed relatively constant throughout the past decade, despite the $25.2 billion that was spent "to reduce drug use and its consequences" in the US in fiscal year 2014 alone (!).

Since 2002, spending on cocaine and marijuana has flipped. Researchers note that cocaine consumption has dropped by about half, while marijuana consumption has increased by around 40%. Heroin consumption has remained stable throughout the decade, with a small increase detected in the later years. Methamphetamine consumption, the authors note, has been harder to track, as "national datasets do not do a good job of capturing its use." Across the board, heavy users are the main drivers of spending and consumption, and are defined as folks who use at least 21 days/month.

The authors culled data from a variety of sources, including the National Survey on Drug Use and Health, the Arrestee Drug Abuse Monitoring Program, various law enforcement and seizure databases, and more. Despite the apparent rigor involved in the creation of these estimates, the authors caution about the inherent uncertainty in this type of data analysis - especially considering that the bulk of the data came from self-report surveys.

Nevertheless, the fact remains that despite the increasing public investments in the so-called War on Drugs, demand-side consumption and expenditures are constant or rising throughout the country. Could this be one reason the Attorney General has agreed to endorse changes to Federal drug sentencing? What do readers think about the current state of availability and expense?

You can read the full report here:

http://www.whitehouse.gov/ondcp/research-and-data/estimation-drug-expenditures-consumption-supply

Computerized Vs In-Person Brief Intervention for Drug Misuse: RCT

We have written much about the challenges of widespread implementation of SBIRT in the US. Well, authors of a new study, published online this month in the journal, Addiction, have suggested a novel tool which they believe could help ensure that scores of additional patients are being screened: computerized brief intervention. And according to their study, it works as well and the in-person version:

Abstract

Background and aims

Several studies have found that brief interventions (BIs) for drug misuse have superior effectiveness to no-treatment controls. However, many health centers do not provide BIs for drug use consistently due to insufficient behavioral health staff capacity. Computerized BIs for drug use are a promising approach, but their effectiveness compared with in-person BIs has not been established. This study compared the effectiveness of a computerized brief intervention (CBI) to an in-person brief intervention (IBI) delivered by a behavioral health counselor.

Methods

Two-arm randomized clinical trial, conducted in two health centers in New Mexico, USA. Participants were 360 adult primary care patients with moderate-risk drug scores on the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) who were randomly assigned on a 1:1 basis to a computerized brief intervention (CBI) or to an in-person brief intervention (IBI) delivered by a behavioral health counselor. Assessments were conducted at baseline and 3-month follow-up, and included the ASSIST and drug testing on hair samples.

Results

The IBI and CBI conditions did not differ at 3 months on global ASSIST drug scores (b=-1.79; 95% CI=-4.37,-0.80) or drug-positive hair tests (OR=.97; 95% CI= 0.47,1.94). There was a statistically significant advantage of CBI over IBI in substance-specific ASSIST scores for marijuana (b=-1.73; 95% CI= -2.91,-0.55; Cohen's d=.26; p=.004) and cocaine (b= -4.48; 95% CI= -8.26,-0.71; Cohen's d=.50; p=.037) at 3 months.

Conclusions

Computerized brief intervention can be an effective alternative to in-person brief intervention for addressing moderate drug use in primary care.

What do you think - could computerized brief interventions be the key to widespread SBIRT implementation?

Source: http://onlinelibrary.wiley.com/doi/10.1111/add.12502/abstract 

Study: Healthcare Utilization Rates After Treatment Are Equivalent Among Abstinent and Low-Risk Drinkers

A fascinating new study will add to the small, but growing, treatment literature suggesting that low-risk drinking is a viable option for people receiving treatment for alcohol-use disorders. The paper, published this month in Alcoholism: Clinical and Experimental Research, measured healthcare utilization rates and associated costs over a 5-year period among clients receiving treatment in a large Northern California healthcare system. The results show that outcomes for abstainers and lower-risk drinkers were equivalent (and far better than the high-risk drinkers), despite the fact that the abstinence-based treatment received by all groups was the same.

According to the authors, "The finding that lower-risk drinkers did not differ from those of abstinent individuals, in inpatient use in particular, even when controlling for patient characteristics, suggests that a health policy perspective may consider benefits of lower-risk drinking."

Here's the abstract via Wiley:

Background

Lower-risk drinking is increasingly being examined as a treatment outcome for some patients following addiction treatment. However, few studies have examined the relationship between drinking status (lower-risk drinking in particular) and healthcare utilization and cost, which has important policy implications.

Methods

Participants were adults with alcohol dependence and/or abuse diagnoses who received outpatient alcohol and other drug treatment in a private, nonprofit integrated healthcare delivery system and had a follow-up interview 6 months after treatment entry (N = 995). Associations between past 30-day drinking status at 6 months (abstinence, lower-risk drinking defined as nonabstinence and no days of 5+ drinking, and heavy drinking defined as 1 or more days of 5+ drinking) and repeated measures of at least 1 emergency department (ED), inpatient or primary care visit, and their costs over 5 years were examined using mixed-effects models. We modeled an interaction between time and drinking status to examine trends in utilization and costs over time by drinking group.

Results

Heavy drinkers and lower-risk drinkers were not significantly different from the abstainers in their cost or utilization at time 0 (i.e., 6 months postintake). Heavy drinkers had increasing odds of inpatient (p < 0.01) and ED (p < 0.05) utilization over 5 years compared with abstainers. Lower-risk drinkers and abstainers did not significantly differ in their service use in any category over time. No differences were found in changes in primary care use among the 3 groups over time. The cost analyses paralleled the utilization results. Heavy drinkers had increasing ED (p < 0.05) and inpatient (p < 0.001) costs compared with the abstainers; primary care costs did not significantly differ. Lower-risk drinkers did not have significantly different medical costs compared with those who were abstinent over 5 years. However, post hoc analyses found lower-risk drinkers and heavy drinkers to not significantly differ in their ED use or costs over time.

Conclusions

Performance measures for treatment settings that consider treatment outcomes may need to take into account both abstinence and reduction to nonheavy drinking. Future research should examine whether results are replicated in harm reduction treatment, or whether such outcomes are found only in abstinence-based treatment.

Figure 1 shows Adjusted odds ratios of utilization by 6-month drinking group over time:

Figure 2 shows Adjusted average costs per member month by 6-month drinking group over time:

                                               






As mentioned above, these are the results from patients who attended abstinence-based treatment. It will be
interesting to see if these results are replicated among patients who are instructed on low-risk drinking. What experience do readers have with this issue? Do results like these make those directing abstinence-based programs think twice about the policy? It would be great to hear from you.

Hat tip: Thanks, Dr Reid Hester, for bringing this study to our attention.

Source: Kline‐Simon, A. H., Weisner, C. M., Parthasarathy, S., Falk, D. E., Litten, R. Z., & Mertens, J. R. (2013). Five‐Year Healthcare Utilization and Costs Among Lower‐Risk Drinkers Following Alcohol Treatment. Alcoholism: Clinical and Experimental Research.
http://onlinelibrary.wiley.com/doi/10.1111/acer.12273/abstract

SAMHSA Releases State and National Behavioral Health Barometer

The federal Substance Abuse and Mental Health Services Administration recently released its yearly report on the general state of behavioral health needs and services in the US. Based on population and treatment-facility data sets from state to state, the Behavioral Health Barometer is a sweeping, in-depth look into adolescent and adult drug use, treatment and mental health service utilization.

Among the highlights:
- Nationally, youth and young adult use of nonmedical pain relievers is declining in general.
- Past-month cigarette use among teens nationally and locally is declining, although Minnesota saw a small increase in 2011-2012
-Over 50% of Minnesota adolescents, and over 60% of adolescents nationally, did not receive treatment for their past-year depressive episode.
-In Minnesota, only 6.6% of people with past-year alcohol dependence received treatment. For illicit drugs, the number is 14.6%
-In Minnesota, while the number of people receiving methadone treatment has increased by nearly 1000 people since 2008, the number of people receiving buprenorphine has actually decreased in that time (owing to a sharp drop from 2008-2009.

The national report is here:
http://www.samhsa.gov/data/StatesInBrief/2K14/National_BHBarometer.pdf

Read the MN report here:
http://store.samhsa.gov/shin/content/SMA13-4796/SMA13-4796MN.pdf

And find your state here:
http://store.samhsa.gov/product/Behavioral-Health-Barometer-2013/SMA13-4796

New Report Sheds Light on Global Epidemiology of Stimulant-Use Disorders

A brand new study by researchers at the Australia National Health and Medical Research Council estimates the global burden of disease due to cocaine and amphetamine. Based on large systematic reviews of epidemiological data, disease models and global prevalence estimates, the authors present comorbidity-adjusted years of life lost to disability (YDL), years of life lost (YLL) and disability-adjusted life years (DALY) estimates. The authors note that their estimates include only the disease burdens attributable directly to amphetamine- and cocaine-use disorders, leaving out the likely considerable HIV- and HCV-attributable costs and burden.

via ScienceDirect:

Abstract

Aims

To estimate the global prevalence of cocaine and amphetamine dependence and the burden of disease attributable to these disorders.

Methods

An epidemiological model was developed using DisMod-MR, a Bayesian meta-regression tool, using epidemiological data (prevalence, incidence, remission and mortality) sourced from a multi-stage systematic review of data. Age, sex and region-specific prevalence was estimated for and multiplied by comorbidity-adjusted disability weightings to estimate years of life lost to disability (YLDs) from these disorders. Years of life lost (YLL) were estimated from cross-national vital registry data. Disability-adjusted life years DALYs) were estimated by summing YLDs and YLLs in 21 regions, by sex and age, in 1990 and 2010.

Results

In 2010, there were an estimated 24.1 million psychostimulant dependent people: 6.9 million cocaine and 17.2 million amphetamines, equating to a point prevalence of 0.10% (0.09-0.11%) for cocaine, and 0.25% (0.22-0.28%) for amphetamines. There were 37.6 amphetamine dependence DALYs (21.3-59.3) per 100,000 population in 2010 and 15.9 per 100,000 (9.3-25.0) cocaine dependence DALYs. There were clear differences between amphetamines and cocaine in the geographic distribution of crude DALYs. Over half of amphetamine dependence DALYs was in Asian regions (52%), whereas almost half of cocaine dependence DALYs was in the Americas (44%, with 23% in North America High Income).

Conclusion

Dependence upon psychostimulants is a substantial contributor to global disease burden; the contribution of cocaine and amphetamines to this burden varies dramatically by geographic region. There is a need to scale up evidence-based interventions to reduce this burden.

Figure 1 compares the DALYs of amphetamines and cocaine between genders:

Fig. 2 shows the distribution of "crude estimated DALYs" due to either substance:

And Fig. 3 shows "Country-level DALYs per 100,000 population due to amphetamine dependence, age-standardized, for persons in 2010":

Source:
http://www.sciencedirect.com/science/article/pii/S0376871614000234

Study: Burden of Disease Associated with Alcohol-use Disorders Higher Than Previously Thought

In a paper published online last week in the journal, Alcoholism: Clinical and Experimental Research, a group of international researchers have brought fresh eyes to a familiar data set: the NIAAA's NESARC. Whereas past studies have estimated the alcohol-attributable global burden of disease, or rates of alcohol-attributable deaths and years of life lost, no study has focused specifically on the burden of disease in the United States associated with alcohol-use disorders (AUD). This is important, the authors note, because alcohol-use disorders (including "abuse" and "dependence" from DSM or "the harmful use of alcohol" from ICD) "were identified as the largest disease category contributing to the alcohol-attributable global burden of disease for the year 2004, making up approximately one-third of this burden." By using US-specific data, including population and death statistics as well as Waves 1 and 2 of the NESARC, the authors were able to estimate the burden of disease from AUD in the US in 2005.


Results

"In the United States in 2005, 65,000 deaths, 1,152,000 years of life lost due to premature mortality (YLL), 2,443,000 years of life lost due to disability (YLD), and 3,595,000 disability-adjusted life years (DALYs) lost were associated with AUD. For individuals 18 years of age and older, AUD were associated with 3% of all deaths (5% for men and 1% for women), and 5% of all YLL (7% for men and 2% for women). The majority of the burden of disease associated with AUD stemmed from YLD, which accounted for 68% of DALYs associated with AUD (66% for men and 74% for women). The youngest age group had the largest proportion of DALYs associated with AUD stemming from YLD."

Some figures from the article:

Prevalence of alcohol use disorders by category, sex, and age in 2005. 

And:

Proportion of all deaths associated with alcohol use disorders in 2005, by sex and age


You can read the abstract of the paper by Rehm, et al. here:

http://onlinelibrary.wiley.com/doi/10.1111/acer.12331/abstract

Would love to hear readers reactions to these numbers. 

Illicit Online Retailers Expand In Response to Silk Road Closure

In an editorial published last week in the journal, Addiction, researchers from the University of New South Wales, Australia, sought to quantify the movement of illicit online drug retailers to alternative marketplaces on the so-called "dark web". On October 3, 2013, the FBI shut down the Silk Road, the largest of these marketplaces for illicit substances, and often referred to in mainstream media as the eBay of illegal drugs. Since then, consumers and sellers have simply moved to other sites, which themselves have seen an explosion in the number active retailers since October 3rd.

Two sites in particular have seen dramatic increases: "Black Market Reloaded" has experienced a two-fold increase in active retailers, and "Sheep Marketplace" a five-fold increase. A new version of the Silk Road, "Silk Road 2.0", opened in November and had 92 vendors by their second day of operation.

Here's the graph from the editorial:

Via:
http://onlinelibrary.wiley.com/doi/10.1111/add.12422/full

New Report Outlines Global Strategy to Reduce Harmful Drinking

New Report Recommends Public Health Focus on Harmful Drinking vs. Eliminating Consumption

Tuesday, February 26, 2013

International Center for Alcohol Policies (ICAP)  

Findings Run Counter to Current Public Health Approach, Discredit Traditional Perspectives

WASHINGTON, DC--(Marketwire) - The traditional public health perspective on alcohol and noncommunicable diseases is indicted in a new report from the International Center for Alcohol Policies (ICAP). "Alcohol misuse and global health: The case for an inclusive approach to harmful drinking" discredits the traditional public health perspective that focuses on a narrow group of stakeholders and ignores individual factors and social norms.

"Unfortunately, some widely-held public policy perspectives on reducing harmful drinking are based on questionable and misleading data," said ICAP President Marcus Grant. "This report draws on a wide pool of research to clarify misconceptions and propose a more effective model that involves a broader group of stakeholders and resources, including alcohol producers."

In the past decade, there is greater recognition of the impact of noncommunicable diseases (NCDs) in both developed and developing countries. Harmful alcohol consumption is a contributing lifestyle factor for several of the most widespread and harmful of these diseases, with alcohol misuse accounting for four percent of global disease burden.

The report notes that a reduction in heavy-drinking patterns will have a more significant impact on public health than limiting alcohol's physical and economic availability. Unlike tobacco use, which is harmful at any level, light to moderate drinking can have healthful benefits for some groups. There is little to be gained from stigmatizing what is, for many people, a normal behavior.

The WHO Global Strategy to Reduce the Harmful Use of Alcohol recognizes this distinction, and that including a wider array of stakeholders than historically have been engaged contributes to a more effective public health response. In an era of shrinking economies, the fight against such a critical public health issue cannot afford to exclude key influencers, such as alcohol producers, or the unique resources they can provide.

The focus of the public health community, policymakers, non-governmental organizations and yes, even producers, should be on mitigating the risk of unhealthy consumption patterns, rather than eliminating consumption altogether.

"Alcohol misuse and global health: The case for an inclusive approach to harmful drinking" is available:

http://icap.org/LinkClick.aspx?fileticket=C35rkfX54Mk%3d&tabid=159

The International Center for Alcohol Policies (ICAP; www.icap.org) is a not-for-profit organization supported by major international producers of beverage alcohol. Established in 1995, ICAP's mission is to promote understanding of the role of alcohol in society and to help reduce harmful drinking worldwide. ICAP's efforts to foster dialogue and partnerships in the alcohol policy field are shaped by its commitment to pragmatic and feasible solutions to reducing harm that can be tailored to local and cultural considerations and needs. ICAP has been recognized by the United Nations Economic and Social Council (UN ECOSOC) as a non-governmental organization in Special Consultative Status.

Smoke Free Laws Reduce Hospitalizations & Deaths

In a recent meta-analysis, Tan and Glanz compared rates of hospitalization and death due to cardiovascular disease, stroke and respiratory across communities with different levels of smoke-free laws (Tan, C. E., & Glantz, S. A. (2012). Association between smoke-free legislation and hospitalizations for cardiac, cerebrovascular, and respiratory diseases. Circulation, 126(18), 2177-2183.) They combined the results of 43 studies that examined rates a median of 30 months before enactment of the laws and then compared them to rates over a median of 24 months after enactment. The results are shown in the graph below. Relative risk refers to the likelihood of an event. A RR < 1 indicates that an event is less likely compared to baseline (before enactment.) As is evident from the graph, there is a consistent and significant reduction in hospitalization and death rates for these diseases as a result of smoke free laws, and the more extensive the restrictions (restaurants and bars as well as other workplaces) the larger the effect. 

Source: BASIS, Feb 2013. 

Why SBIRT Is Dead in the Water

In the latest issue of Health Affairs, Grace Lin et al. describe an effort to introduce decision-making aids to facilitate shared decision-making regarding back pain and colo-rectal cancer screening. Essentially, nothing changed, in spite of making the aids easily accessible, conducting training sessions, and so on. What's important is the authors' conclusion that "The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy."

Their experience mirrors my own in trying for over 20 years to get substance use addressed in primary care. Most recently, I have two separate but relate experiences here in Minnesota where I essentially ran up against a brick wall. Why? First, primary care doctors are besieged by quality improvement initiatives aimed at reducing variability of practice and improving outcomes for depression, diabetes, heart failure, back pain, asthma, hypertension and many others. These are typically mandated from the top of health care organizations (remember that most primary care physicians are now employees of a large health care organization (HCO.) By attempting to implement not only SBIRT but treatment of alcohol dependence in primary care (I call it Screening, Evaluation and Treatment, or SET, but another term could be SBIRT+) by asking physicians to voluntarily take it on was a non-starter. Typical comments were "It's a good idea but we can't take on anything more right now," or "We're having enough trouble trying to get this clinic's operations running smoothly, and until we do, it wouldn't work." 

A second factor is one of priorities. I have argued for years that universal SBIRT is not cost-effective, but should be more targeted. Related to this is a crucial question: since visit length is not going to increase, what do you want the doctor to stop doing so they can do these new things, like shared decision-making and SBIRT+?  In other words, in a typical visit, the patient has certain expectations about why they are there and what they want, and most patients have multiple chronic diseases like obesity, arthritis, hypertension and diabetes. Oh, and of course they smoke. So, do you want the doctor to not address the patient's presenting complaint (e.g., arthritis pain, insomnia), or not address their hypertensive control so they have the time to spend on shared decision-making for back pain, or to conduct SBIRT+? How do you think patients would feel about this? This applies especially to SBIRT, because it is attempting to identify a problem they patient is unaware of and not concerned about. "Doctor, I came here because my right knee is all swollen and painful, and you want to take 2 out of the 8 minutes you spend with me asking me about drinking!?"

So have come to a similar conclusion: until the medical home concept is fully implemented, with team care that includes a focus on health behaviors of all types, SBIRT or SET are DOA. My most recent attempt has been to start with something that has the attention of every primary care doctor: pain management. I'm providing training to all the primary care doctors in Allina Health in management of chronic pain, and the response so far has been overwhelmingly positive. I'm hoping that by getting to know so many primary care physicians in this HCO, they will be more receptive to introducing SET. However, it has also become clear that the only way this will occur is if the top leadership of the organization decides that SET is important enough to get it into the queue of quality improvement projects, and thus mandate its implementation. 

Primary care, even with the medical home, is not going to be all things to all people, and choices are going to have to be made about what is important enough to include and what might ideally be included but which doesn't make the cut because it is not cost-effective or clinically significant enough.

Besides, if we were serious about addressing the heavy disease burden associated with heavy drinking, we would triple the taxes on alcoholic beverages. That would have a greater public health impact than implementing SBIRT in every primary care practice in the country. 

MW

Here's the abstract:

An Effort To Spread Decision Aids In Five California Primary Care Practices Yielded Low Distribution, Highlighting Hurdles

1. Grace A. Lin1, 
2. Meghan Halley2, 
3. Katharine A.S. Rendle3,
4. Caroline Tietbohl4, 
5. Suepattra G. May5, 
6. Laurel Trujillo6 and
7. Dominick L. Frosch7,*

+Author Affiliations

1. ¹Grace A. Lin is an assistant professor in the Division of General Internal Medicine and at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco.
2. ²Meghan Halley is an assistant research anthropologist in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute, in California.
3. ³Katharine A.S. Rendle is a research associate in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
4. ⁴Caroline Tietbohl is a research assistant in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
5. ⁵Suepattra G. May is an assistant research anthropologist in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
6. ⁶Laurel Trujillo is medical director of quality at the Palo Alto Foundation Medical Group and chair of the Quality Improvement Steering Committee, both at the Palo Alto Medical Foundation, in Los Altos, California.
7. ⁷Dominick L. Frosch (dominick.frosch@moore.org) is an associate adjunct professor in the Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles.

1. ↵*Corresponding author

Abstract

Despite the proven efficacy of decision aids as interventions for increasing patient engagement and facilitating shared decision making, they are not used routinely in clinical care. Findings from a project designed to achieve such integration, conducted at five primary care practices in 2010–12, document low rates of distribution of decision aids to eligible patients due for colorectal cancer screening (9.3 percent) and experiencing back pain (10.7 percent). There were also no lasting increases in distribution rates in response to training sessions and other promotional activities for physicians and clinic staff. The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy. Among these changes are ongoing incentives for use, physician training, and a team-based practice model in which all care team members bear formal responsibility for the use of decision aids in routine primary care.

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.

MW