9 May 2012

DSM - V drops 'dependency' forever!

Drugs and Society meeting at Columbia University. 7.30pm Tuesday 17th April 2012.

I have just had the privilege of attending a presentation of the newly proposed DSM-V criteria for substance use disorders (SUD) which is due for implementation in May 2013. The talk was to have been given by Charles 'Chuck' O'Brien who was apparently entwined in 'grants' and was replaced by Deborah Hasin who is also on the committee devising the new DSM standards.

Dr Hasin is an epidemiologist who has done work with adolescent drug use, HIV, alcohol, household surveys, natural history, etc. She was at home at Columbia University where the meeting was held at their Faculty House in Amsterdam Avenue near 110th Street in Manhattan (West Harlem). Deborah is one of about fifteen members of the DSM-V committee looking as substance use disorders, chaired by Dr O'Brien from U Penn. There is also international representation from Australia (John Saunders), Holland (Wim van der Brink) and elsewhere. We were told some details of the process being followed with consensus and unanimity being attempted rather than confrontation and disagreement. In fact, we were told that there was agreement on most of the issues, often after extensive reviews of the research and discussion.

The DSM-IV was implemented in 1994, replacing the DSM-III and “IIIR”. There was also a 'text review' to DSM IV in 2000. Dr Hasin told us that this very meeting was one of many in the review process and she assured us that our views would be reported back to her committee members.

Dr Hasin gave us a splendid talk about the process being undertaken by the DSM review committee and the brief they were given to redefine the diagnostic categories for drug use disorders.

The committee had discussed changing 'abuse' to 'misuse' but opted to remove any 'loaded' terminology, remaining completely scientific with 'substance use disorder' (SUD). Likewise, 'pathological' gambling was rejected since any diagnosis in the manual was obviously 'pathological' so it became a redundancy and will be called something like ‘gambling disorder’.

The essential change, now virtually concluded, is that the new classification will lose the distinction between abuse and dependency so that there will only be one diagnosis based on 11 criteria. The diagnosis will be moderate SUD if 2 or 3 are present and severe SUD if there are 4 or more. The old criterion of involvement in frequent legal issues has been removed while 'cravings' has been added this time. The time frame for such reports needs to be within 12 months apart from cravings which can last for many years after drug use has ceased, causing an immediate anomaly.

The concept of 'dependence' now only refers to the physiological states of tolerance and withdrawal, something which I predict will cause confusion in the 'dependency' literature for years to come. I worry that the entire process may end up like accreditation, forming an unproductive bureaucracy, language and series of steps to nowhere.

Shopping, sex, eating and internet/gaming disorders have been put into the too hard basket while gambling itself has been taken on board with the same criteria but with minor differences as above.

The criteria for inclusion for 'Substance use disorder' ('SUD') are (simplified):

1. Repeated use with negative consequences

2. Repeated use in hazardous situations

3. Repeated use despite interpersonal issues

4. Tolerance

5. Withdrawals

6. Repeated use for longer or in larger quantities than intended

7. Unsuccessful desire and/or attempts to cut down drug use

8. Long periods taken to obtain drugs or recover from the effects

9. Repeated use causes neglect of other important activities

10. Repeated use despite known continuing adverse consequences on health

11. Cravings

1 criterion = no DSM diagnosis

2-3 criteria positive = Moderate diagnosis of SUD

4 or more criteria positive = Severe diagnosis SUD

Under the existing DSM-IV the first three (plus repeated legal problems) were used to define substance "abuse" (one or more) while 'dependency' required three or more of the remaining criteria (excluding cravings which were not included until DSM-V).

In the ‘case’ to justify the changes Dr Hasin quoted numerous published papers which examined the ‘discrimination’ of individual criteria against an overall diagnostic measure. Various rather complex graphs were shown, each with a flattened ‘S’ curve purportedly showing the effect of up to 15 chosen criteria upon the "latent trait" for problem severity measured in some non-linear manner. Each tracing was coded with its criterion below and each formed a flattened 'S' curve starting from a flat take-off on the X axis, ending similarly on a possible maximum parallel above. I noted that Dr Hasin herself was co-author of some of these papers. She has done extensive public health research in Israel where we were told that American surveys had been translated into Russian and Hebrew (but apparently not Arabic).

We were told that the close approximation of these curves showed the degree of contribution concordance each had with the overall occurrence of problematic drug use in the various (population) samples (none were clinic or patient samples). While the overall impression was that each of the criteria had a similar contribution, the value of the process in population studies was questioned by some delegates so we were then shown some curves of clinic / dependency populations (oops, should not use the term ‘dependency’ any more!).

Dr Hasin's point seemed to be that the inclusion of 'legal issues' added little to the statistical 'mix' for diagnosis. Yet several people in the room pointed out that it was legal issues alone which originally brought some of their most needy patients into treatment. Furthermore, with 10 or more criteria, removing any one would likewise have had little effect on the diagnosis. In practice, the great majority of our patients by the time they get to treatment have not 2 or 3 of these criteria but most of them.

I was a little surprised that there was no patient representative on the committee. Perhaps I should not have been surprised that a majority of delegates contribution to a psychiatry manual were not MD’s or psychiatrists. This is not to question the superb qualifications and need for non-medical input … in fact one member even had two PhD degrees in her credentials (I had thought it was a ‘typo’!).

The new DSM-V definitions remind me of accreditation in a way. The supposed improvements will be of very limited value to my view. The definitions have hazy time-lines with most being 'in the past 12 months have you had …'. As an exception, ‘cravings’, a new criterion, can last for decades after any drugs have been consumed! There is a somewhat closer parallel with smoking, drinking and other medical diagnoses ... but to what end I am not sure. There is absolutely nothing about the quantities of drug used, we were told due to the illicit nature of most of the drugs (now no longer the case with so much prescription drug abuse). However this does not stop every clinician in the field taking such a history, albeit with the inherent difficulties. Hence under the new system $10 per day smoked heroin use on two days per week could be the same under DSM-V as $500 per day if the consequences and reported symptoms were the same. 'Remission' is another problem issue they have decided to avoid altogether. "A lack of symptoms" one delegate said of remission. But for how long? And what of ‘recovery’? Don't ask!

Gambling is ‘in’ the new DSM classification, partly, we were told, because about 20% of substance users have gambling problems and a substantial proportion of gamblers have alcohol/drug troubles too.

But shopperholics and sex addicts and internet habitues don't use enough substances to be included apparently, at least in the SUD section ‘and related disorders’ department. We were told that eating problems and sexual problems had lobby groups of their own and thus were left well alone by this committee. Internet/gaming victims likewise.

Denise Kandel had some most interesting stuff to tell about her mouse experiments ... I am getting the references ... also about adolescent drug use definitions.

Gross and Edwards’ definition of alcoholism in 1960s and is still the basis for all of these modern definitions.

Dr Hasin was thanked for her input and she promised to get feedback working in both directions. True to her word an email mooting a survey appeared only a week after the meeting calling for volunteers to become involved in the process.

Written by Andrew Byrne ..