The Diagnostic and Statistical Manual (DSM) – 5 describes substance use disorders (SUD) as “a problematic pattern of using alcohol or another substance that results in impairment in daily life or noticeable distress.” Published in 2013, it made major changes to the categorization of what had in the DSM-IV, been broken into two separate diagnoses of substance abuse and substance dependence. Changes to the DSM-5, combined these two diagnoses into one, to create a single diagnostic category of SUDs. We wonder if this has led to loss of understanding of addiction and an increased emphasis on moderation of use in respect to addiction.
Addiction is characterized by the inability to consistently abstain from use – so by definition moderation is not effective for addicted persons. As noted in the American Society of Addiction Medicine (ASAM) definition of addiction:
“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.” Link here: https://www.asam.org/resources/definition-of-addiction
So what is the issue?
There are a few, but on of the main ones is that this change in categorization has led to confusion of what used to be termed abuse. Abuse can be moderated by people who may be using problematically in response to a life situation or stressor and are not in an early stage of addiction. These are not the same things, additionally, we lack definitive ways to differentiate between a person in an early stage of addiction who is unable to moderate with a person who is not addicted and is abusing substances. An abuser under the old terminology may use more than intended but can moderate their use if their life circumstances change or they experience consequences from their use and then change their use patterns.
What are the problems we are seeing?
- Abstinence is essential to life for a person with a severe form of an SUD. People who would have met criteria under the DSM IV for abuse and not dependence who are able to moderate the use of one or more substances identifying themselves as in recovery due to the loss of distinction created by changes in the DSM-5 is creating additional confusion.
- A loss of understanding of the differences between abuse and addiction and the importance of recognizing that an individual may be on a trajectory that as ASAM notes “without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”
- Increased false sense that addiction can be moderated either fully or selectively by a person.
- Increased risk of minimization of the severity of the condition, both within the person and those around the person.
- An individual who is in an early stage of addiction or who is minimizing their consequences may well disregard the diagnosis of a mild or moderate substance use disorder e.g. “I am not that bad.”
- These categories may result in a false sense of safety for persons in an early stage of a severe SUD.
- Insurance entities have historically under-treated addiction, and the diagnosis of a mild or moderate SUD may result in a greater tendency to not treat or under-treat the condition.
What should be done?
- As has always been the case, good clinicians will remain cognizant to treat substance use disorders as a life-threatening condition and consider that what they are seeing as mild or moderate may be an early stage of a life threatening, severe SUD.
- Clinicians working with patients in care who are unsure if they have severe SUD should remain engaged with them and educate them on the differences between these categories in the event that moderation efforts fail.
- We should consider future changes to the DSM to better reflect the distinctions between these categories.
- We should concentrate more research to support identifying early stage severe SUDs to focus efforts on these cases and save lives.