DSM5 "Addiction" Swallows Substance Abuse

By Allen Frances, MD | March 30, 2010

DSM-IV provides separate categories for Substance Abuse and Substance Dependence. The typical substance abuser is someone who gets into recurrent, but intermittent, trouble as a consequence of recreational binges. This is in contrast to the continuous and compulsive pattern of use that is typical of DSM-IV Substance Dependence.

At the extremes, the differences between abuse and dependence are clear-cut. The abuser goes through periods when he seems able to take it or leave it, using the substance in a controlled way or abstaining from it altogether. Then comes the bender with a bad outcome. Another peaceful period, then another destructive bender, and so on. The person doesn't learn from the repeated painful experience that a couple of drinks (or snorts or pills or joints) can lead to a binge and a binge can, and often does, have serious (and sometimes even catastrophic) consequences.

Substance Abuse also must be distinguished from run of the mill recreational bingeing, which is unfortunate but usually does not qualify as a mental disorder. The definition of Substance Abuse requires that there be "a maladaptive pattern of substance use manifested by significant adverse consequences" in at least 1 of 4 different domains of trouble:
1. Driving under the influence
2. Other legal problems (eg, disorderly conduct, assault,etc)
3. Reduced performance at work or school
4. Problems with interpersonal relations and family life

Substance Abuse can be the first step on a path that eventually leads to Substance Dependence. The threshold between the 2 is crossed when the periodic bingeing turns into continuous use and the motivation switches from pleasurable recreation to needing the substance on a regular basis just to get by. Substance Dependence requires some combination of tolerance, withdrawal, and a pattern of compulsive use. Tolerance means you have diminishing pleasurable returns--you need to take more and more of the substance to get the same buzz or any buzz at all. Withdrawal means that trying to reduce or stop the substance leads to unpleasant (and sometimes dangerous) symptoms that will drive you to start using again. Compulsive use means you feel driven to do whatever it takes to get the substance despite the fact that it no longer provides much, if any, pleasure.

The DSM5 draft suggests 2 radical changes:
1. Eliminating the separate categories of Substance Abuse and Substance Dependence and replacing them with 1 unified category Substance Use Disorder
2. Labeling the overall section "The Addiction and Related Disorders"
The combined result would be that someone now diagnosed with DSM-IV Substance Abuse would in DSM5 instead be diagnosed with Substance Use Disorder--and (given the title of the overall section) would be considered to have an addictive disorder.

The DSM5 rationale for lumping together what in DSM-IV are the separate categories of Substance Abuse and Substance Dependence comes from factor analytic and latent class analyses that suggest that there is no sharp boundary between them (although the results and their interpretation are far from definitive). The Work Group is impressed by analyses suggesting that abuse and dependence are unidimensional and lack of a point of rarity clearly demarcating a boundary between them.

This is a weak rationale and reflects a basic misunderstanding about the nature of all mental disorders--that none of them enjoys a clear boundary with near neighbors. All the DSM disorders overlap with one another and frequently also with normality. For example, there is no clear boundary between bipolar and unipolar mood disorder, between anxiety and depression, even between schizophrenic and psychotic mood disorders, and so on throughout all the sections.

There is thus no matter of principle at stake here. If substance abuse and dependence are to be joined, it must be because there is a clear practical benefit of doing so that outweighs whatever are the risks. The Work Group suggests no pressing practical problem that needs fixing with the DSM-IV definition Substance Abuse. I can see no benefit in its elimination, but there are 3 substantial risks:

o What is now Substance Abuse in DSM-IV would be subsumed in a section labelled "Addiction Disorder" in DSM5. I think it is unwise and unfair to pin the pejorative and stigmatizing label "addict" on someone whose substance problems are intermittent, may be temporary, and are often very influenced by contextual and developmental factors. Take the example of a college kid in a hard drinking fraternity who binges on weekends and gets into one fight and has one DUI. He is obviously already in serious trouble (and flirting with much worse). His situation certainly does require rigorous and immediate intervention. But what is gained by the stigmatizing label addiction that may jeopardize future insurance, marital and job prospects, and legal status? Most substance abusers are in a passing phase and never become "addicted" in any meaningful sense of that word.

The term "addiction" has never (in its entire history of loose usage) been used in so loose and indiscriminate a fashion. If there is some compelling reason to include it at all in DSM5 (a question to be addressed in another piece), "addiction" should replace only the term "substance dependence." Allowing the term "addiction" to also cover "substance abuse"seems unnecessary, misleading, and potentially harmful.

o Combining Substance Abuse and Dependence loses much valuable distinguishing information that would melt into the amalgam. There is a world of difference in behavior, treatment needs, and prognosis separating abuse and dependence. The label substance dependence clues the clinician that abstinence may trigger severe physiological or psychological withdrawal reactions requiring a special intensity of medical and rehabilitation response. The intervention with abusers will be more directed to the harmful consequences of the binges, how to avoid them, and the substitution of other less dangerous recreational activities. There is also a considerable difference in prognosis--while some go on from an early history of substance abuse to later dependence, most do not and are much more likely to have an early and permanent remission.

o The message to the abuser that he is "addicted" to the substance can cut both ways. It might benefit some who would heed this dire warning and take the opportunity to become abstinent. But many others may seize on the many unfortunate connotations associated with being "addicted" including that:
1. The substance has already gained a central and (difficult to end) role in the person's life
2. It will be terribly difficult to give up because of psychological and/or physical dependence and painful withdrawal symptoms
3. All this is somehow biological, fated in the genes, and outside his control or ability to change
4. The individual has reduced personal responsibility for substance use and its consequences. Being "addicted" can become a self-fulfilling prophecy and a great excuse for not meeting responsibilities to self, family, school, and the legal system.

This leads me to suggest 2 recommendations: retain the useful distinction between Substance Abuse and Substance Dependence; and if the term "addiction" is to be used at all in DSM5, it should be restricted to substance dependence.

by Eoin Stephens | April 07, 2010 4:59 AM EDT

Excellent article, a lot of good sense, needs to be said.

by Susan Haney | April 07, 2010 1:09 AM EDT

The reason that the DSM-IV is trying to lump substance abuse and substance dependence into a single category has to do with the reimbursement scheme of the addiction treatment industry as created by the American Society of Addiction Medicine (ASAM), which is simply a front organization for the coercive, prosthetlyzing religious cult known as Alcoholics Anonymous.

According to their official website (www.aa.org):

"The origins of Alcoholics Anonymous can be traced to the Oxford Group, a religious movement popular in the United States and Europe in the early 20th Century. Members of the Oxford Group practiced a formula of self-improvement by performing self-inventory, admitting wrongs, making amends, using prayer and meditation, and carrying the message to others."

(See http://www.aa.org/aatimeline/ for full history)

Alcoholics Anonymous (AA) was founded in 1935 by failed New York stockbroker Bill Wilson (a.k.a. "Bill W."), a severe alcoholic with a high school education who believed that alcoholism is a spiritual disease and that successful recovery from alcoholism requires a person to, among other things, admit that he or she is powerless over the addiction to alcohol and to believe that only God or a "higher power" can restore the person to sanity. Co-founder Robert Holbrook Smith, MD (a.k.a. "Dr. Bob"), a deeply religious Ohio surgeon and severe alcoholic for thirty years, said that AA's basic ideas came from their study of the Bible and their experiences with a popular contemporary evangelistic Christian movement known as the Oxford Group.

The American Society of Addiction Medicine (ASAM) was started by Dr.Ruth Fox (founding president) in the early 1950's to promote AAand its spiritually-based 12-step treatment of alcoholism to doctors. The Federation of State Medical Boards (FSMB) first identified alcoholism and drug addiction as a disciplinary problem in 1958 and called for a model probation and rehabilitation program to be adopted by state medical boards. ASAM used this opportunity to broaden its power and influence among medical professionals, despite the fact that the American Medical Association (AMA) had previously gone on record as strongly critical of the unscientific basis of the 12-step approach promoted in AA's so-called "Big Book" as being "a curious combination of organizing propaganda and religious exhortation" and generally having "no scientific merit or interest." [Book review of "Alcoholics Anonymous", Journal of the American Medical Association, 1939;113(16).]

In 1960 AA-funded alcohol researcher E.M. Jellinek coined the expression, "the disease concept of alcoholism". In the late 1960's the "disease concept" was gradually expanded to include other addictions as well. In the 1970's, as the "disease concept" of alcoholism promoted by AA and ASAM took root, health insurance companies began to cover the costs of alcoholism treatment.

In 1973, the Journal of the American Medical Association (JAMA) published a landmark policy paper on "The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence". [Journal of the American Medical Association, 1973;223(6):684-687.] By 1980, less than a decade after the AMA's policy paper, all but three of the 54 U.S. medical societies of all states and jurisdictions had authorized or implemented impaired physician programs -- the majority of which were simply state branches of ASAM with slightly modified AA programs designed to rehabilitate and monitor physicians with drug or alcohol addiction.

In 1988, "Addiction Medicine" was declard a specialty by the AMA, and in 1990 ASAM was given voting rights within the AMA House of Delegates. That same year, the Federation of State Physician Health Programs (FSPHP) was created as an association of individual ASAM-based state physician health programs.

In 1991 ASAM first published its "Patient Placement Criteria" (PPC), which was designed for programs offering addiction treatment services. By 2001 the revised ASAM PPC-2R had adopted the increasingly prevalent term "Co-Occurring Mental and Substance-Related Disorders" in formal descriptions of diagnostic criteria and treatment recommendations. Throughout the text of the ASAM-PPC-2R, however, the term "dual diagnosis" is also used because it still has the widest recognition nationally.

In May 1993, Federation of State Medical Boards (FSMB) President Hormoz Rassekh, MD, established a special Ad Hoc committee on "physician impairment" in order to develop medical board strategies for identifying, evaluating, regulating, and managing "impaired" licensees. According to a 1995 FSMB policy statement, "After discussion of several forms of physician impairment, the committee elected to focus primarily on chemical dependency, because of its prevalence."

Today, forty-six states now have physician health programs -- the majority of which are still simply chemical dependency treatment programs embellished and promoted ASAM. Forty-two of these programs are currently members of the FSPHP. Over the years, ASAM has continued to promote the AA position that alchoholism (and by inference, any other addiction or chemical dependency) "is an illness which only a spiritual experience will conquer". All addictions are believed by ASAM to be caused by a lifelong brain disorder ("chemical dependency") that can only be treated by complete abstinence from all mood-altering substances (except caffeine and nicotine, which for some strange reason are still permissible). The vast majority of ASAM fellows also still believe that the only effective treatment for addiction must include surrendering one's "will and life over to the care of God" and completely immersing the individual in some variation of AA's spiritually-based 12-step program.

ASAM is not recognized by the American Board of Medical Specialties (ABMS), which certifies all of the more than 130 conventionally recognized specialties and subspecialties in medicine (Internal Medicine, Psychiatry, Surgery, Anesthesiology, Pediatrics, Emergency Medicine, etc.). ASAM certification requires only a medical degree, a valid license to practice medicine, completion of a residency training program in ANY specialty, and one year's full time involvement plus 50 additional hours of medical education in the field of alcoholism and other drug dependencies. ASAM does not require any specific formal training or experience in the diagnosis and treatment of physical or mental illness.

Because of their limited training and education, ASAM fellows tend to view all physical and mental health problems as "co-occurring" and secondary in importance to addiction problems. They freely apply various psychiatric labels to their "dual diagnosis" patients despite the fact that most ASAM fellows are not formally trained in the diagnosis and treatment of "mental disorders", and despite the fact that most ASAM fellows do not recognize that many psychiatric diagnoses are subjective, imprecise, and subject to change over time. They apply their limited knowledge of the DSM-IV-TR in cookbook fashion in the same way they apply their black-and-white thinking about addiction diagnosis and treatment: if a patient has a "dual diagnosis", then they require formal treatment for "the disease" of addiction.

In most of today's state physician health programs, "Regardless of setting or duration, essentially all treatment provided to these physicians (95%) was 12-step oriented." [DuPont RL, McLellan AT, White WL, Merlo LJ, Gold MS. Setting the Standard for Recovery: Physicians' Health Programs, Journal of Substance Abuse Treatment. 2009;36:159-171.] In these programs, ASAM practitioners routinely impose their spiritually-based 12-step abstinence recovery program on licensees they have labeled with a "substance use disorder", "chemical dependency", or "dual diagnosis" regardless of whether or not there is clear evidence of addiction or even impairment. These programs forbid all access to medications ASAM considers to be potentially addictive -- even when appropriately prescribed by a physician or psychiatrist with more expertise in their given specialty, even when used safely and appropriately, and regardless of any other medical or psychological risks and benefits to the licensee. These programs also forbid any use of alcohol, even when consumed safely and appropriately, and regardless of any other medical or psychological risks and benefits to the licensee.

According to one widely read online publication known as the Orange Papers,

"There are no good studies or surveys that reveal what the suicide rate in A.A. really is, but there is quite a lot of anecdotal evidence that A.A. drives some people to suicide. A program that tells people that they are powerless over alcohol and hopeless and defective and sinful and full of moral shortcomings and cannot ever recover is just depressing enough to push some people over the edge into suicide. And then the crazy, dogmatic, true-believer sponsors telling people with mental problems to stop taking their doctor-prescribed medications has caused a lot of deaths." Orange Papers, on AA Effectiveness

Although the FSPHP was originally founded by ASAM in order to organize ASAM-based individual state physician diversion programs, over the years the FSPHP has gradually expanded its mission statement. According to a 2008 presentation on Physician Health Programs (PHP's) before the FSMB (Federation of State Medical Boards) at their 2008 annual meeting, given by 2009-2011 ASAM president Dr. Louis E. Baxter, Sr., MD (an addiction psychiatrist), PHP missions now include, "To provide a means to identify, evaluate, and treat physicians who have DISEASES OF IMPAIRMENT." (Physician Health Programs: How They Work, FSPHP Conference 2008) He goes on to define "diseases of impairment" as including alcohol and drug use disorders, psychiatric disorders, disruptive disorders, psychosexual disorders, metabolic disorders, and physical disorders (including diabetes, hypertension, and asthma). This expanded mission statement has not changed the fact that the majority of state PHP's are run by medical directors who are qualified only in "addiction medicine" (as defined by Bill Wilson in 1935 and as treated by the evangelistic 12 steps of Alcoholics Anonymous that Wilson and a friend invented in the 1930's) and have supervisory committees who are run by addiction specialists and people "in recovery" who need not be physicians at all.

ASAM is currently attempting to receive medical specialty recognition (and billions of health insurance dollars) for promoting AA's spiritually based 12-step recovery model to the American Board of Medical Specialties (ABMS), which certifies all of the traditionally recognized medical specialties and subspecialties (Internal Medicine, General Surgery, Psychiatry, Emergency Medicine, Anesthesiology, Pediatrics, Radiology, etc.). As part of its comprehensive long-term plan to obtain specialty recognition by the ABMS, in 2006 ASAM established the American Board of Addiction Medicine (ABAM). According to the official ASAM/ABAM website (http://www.asam.org/abam.html),

"Grandfathering is the pathway to acquire ABMS certification in a new specialty or subspecialty, without having to complete all of the training requirements that will eventually be established, such as completion of an ACGME-accredited residency program...For ASAM and ABAM certified physicians who are not already Diplomates of an ABMS member board, ABAM will facilitate and advocate for the establishment of non-onerous pathways for eligibility for an ABMS-recognized Addiction Medicine examination."

ASAM/ABAM and the 12-step addiction treatment industry were instrumental in lobbying for passage of the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, which requires health insurance companies to cover addiction treatment on an equal basis as physical illnesses. The idea of a federal mental health parity law had been promoted to Congress for many years, but had not been seriously considered for approval prior to the last-minute inclusion of the multi-billion-dollar addiction treatment industry. With no meaningful opportunity for debate or dissent, ultimate approval of the Wellstone-Dominici Parity Act was quietly tied to President George W. Bush's hastily passed $700 billion financial bailout in October of 2008. The parity law took effect on January 1, 2010. ASAM/ABAM are getting closer to ABMS recognition each day.

State physician health programs across the nation are currently under attack on numerous fronts: in the media, in state legislatures, in Congress, and in the courts (where they are being challenged for numerous constitutional and civil rights violations -- including free speech, freedom of religion, due process, privacy rights, medical malpractice, and ADA (Americans with Disabilities Act) violations.

For more information, go to www.orpag.org (The Oregon Physician Advocacy Group).

by Teresa Valliere | April 06, 2010 6:25 PM EDT

It strikes me that once again, words, tied to money, get in the way. If we work with people to understand the nature of their relationship to a substance or behavior along a continuum from - abstinence - use - misuse - abuse - dependence - addiction - with expected risks and benefits, it seems we can steer clear from stigmatizing labels overall. As long as we continue within a McDonaldized and fragmented system that breaks down health and illness into a la carte items of diagnoses to match a treatment, we're not going to move beyond stigmatizing labels.

by Michael Velardo | March 31, 2010 2:04 PM EDT

Excellent article pointing out the inconsistencies between DSM-IV and V regarding substance abuse and addiction. This is going to cause more harm than good.

Detroit Substance Abuse Examiner

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DSM5 "Addiction" Swallows Substance Abuse

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