Presentation on theme: "DSM-5: Substance Related & Addictive Disorders Charles P. O’Brien, M.D., Ph.D. University of Pennsylvania Philadelphia, PA."— Presentation transcript:
DSM-5: Substance Related & Addictive Disorders Charles P. O’Brien, M.D., Ph.D. University of Pennsylvania Philadelphia, PA
Familiar to everyone Criteria first published in 1994 Text but not criteria updated in 2000 Used worldwide for diagnosis, education, research and reimbursement purposes
Columbia University Deborah Hasin, Ph.D. Wilson Compton, M.D. Bridget Grant, Ph.D., Ph.D. Deborah Hasin, Ph.D. Walter Ling, M.D. Nancy Petry, Ph.D. Marc Schuckit M.D. Charles O’Brien, M.D., chair Marc Auriacombe, M.D Guilherme Borges, Ph.D. Katherine Buchholz, Ph.D. Alan Budney, Ph.D. Thomas Crowley, M.D. DSM-5 Substance Disorder Workgroup members
AbuseDependence Diagnostic Criteria Failure to fulfill major role obligationsX-- Hazardous useX-- Substance-related legal problemsX-- Social/interpersonal substance-related problemsX-- Tolerance--X Withdrawal--X Persistent desire/unsuccessful efforts to cut down--X Using more or over for longer than was intended--X Neglect of important activities--X Great deal of time spent in substance activities--X Psychological/Physical use-related problems--X Diagnostic Threshold 1+ criteria3+ criteria American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000. 1+ 3+ Substance Use Disorder Criteria: DSM-IV Columbia University Deborah Hasin, Ph.D.
What should be done about abuse, specifically, should abuse be combined with dependence to create a single disorder? Should new criteria be added, e.g., craving or old criteria (legal problems) be removed? Can nicotine criteria be aligned with other substances? Can cannabis and caffiene withdrawal be included? What should be the diagnostic threshold, how should severity be indicated? International considerations Columbia University Deborah Hasin, Ph.D.
Confusion about relationship of abuse to dependence because abuse is assumed to be milder than dependence –Leads to thinking abuse is prodromal to dependence –Leads to thinking all cases of dependence meet criteria for abuse Reliability and validity of dependence is excellent Reliability and validity of abuse much lower, more variable than dependence ~50% with abuse dx’ed with only 1 criterion: hazardous use Diagnostic “orphans” (2 dependence criteria, no dx) Columbia University Deborah Hasin, Ph.D.
Many factor analyses showed abuse and dependence criteria formed 1 factor, or 2 highly correlated factors Item Response Theory analysis extends factor analysis, provideing more information Item characteristic curves (graphed) show relationship of abuse and dependence criteria to each other Total information curves (TOC) allow comparison of two or more sets of criteria Columbia University Deborah Hasin, Ph.D.
Sample# StudiesNsLocations Adult general population 17722 - 43,093Australia, Israel, US Adult emergency room 25,195 Argentina, Mexico, Poland, US Adult substance abuse treatment 5372 - 1,511Australia, US Adult genetic studies 4496 - 9,313US Adolescent general population 4353 - 3,641France, US Adolescent substance abuse treatment 2279 - 472US Adolescent mixed 25,587US Columbia University Deborah Hasin, Ph.D.
Saha, Grant et al., Drug and Alcohol Dependence 2007 NESARC (2001-2002) ICC Current Alcohol Abuse, Dependence (N=22,526) Columbia University Deborah Hasin, Ph.D.
Keyes KM…Hasin DS, Psychological Medicine 2010 Columbia University Deborah Hasin, Ph.D.
Compton, Saha, Grant et al., Drug and Alcohol Dependence 2009 NESARC ICC Current Cannabis Abuse, Dependence (N=1,603) Columbia University Deborah Hasin, Ph.D.
NESARC ICC Lifetime Cocaine Abuse, Dependence (N=2,528) Saha …Grant., Drug and Alcohol Dependence, 2012 Columbia University Deborah Hasin, Ph.D.
Tolerance Withdrawal More use than intended Unsuccessful efforts to cut down Spends excessive time in acquisition Activities given up because of use Uses despite negative effects DSM-III 1987 DSM-IV 1994
Maladaptive use within 12 month period (one or more) 1. Failure to fulfill major role obligations 2. Recurrent use in hazardous situations 3. Recurrent substance related legal problems 4. Continued use despite consistent social or interpersonal problems Never met dependence criteria DSM-IV
Use Use Use Use Abuse (declarative) Abuse Addiction (automatic) Abuse Addiction
Tolerance* Withdrawal* More use than intended Craving for the substance Unsuccessful efforts to cut down Spends excessive time in acquisition Activities given up because of use Uses despite negative effects Failure to fulfill major role obligations Recurrent use in hazardous situations Continued use despite consistent social or interpersonal problems *not counted if prescribed by a physician DSM-5
0 1 2 3 4 5 6 7 8 9 10 11 12 13 C BBAC ABCABCACBAACB Time (min) Alcohol (A) Beverage (B) Visual Control (C) Comparisons: Alcohol - Beverage Beverage - Vis Ctrl Comparisons: Alcohol - Beverage Beverage - Vis Ctrl Alcohol - Vis Ctrl Beverage - Rest Alcohol - Vis Ctrl Beverage - Rest Vis Ctrl - Rest Vis Ctrl - Rest RR R RRR Sip of Preferred Beverage Examples of the various visual cues from Normative Appetitive Picture System (NAPS) Rest (R) * Craving rated after each block Time Course of the Presentation of Stimuli During fMRI
Ventral Tegmental Area Cingulate Z=1.645 Ex.05, Myrick et al,2004 Alcohol - Beverage Condition Alcoholics (n=10)Controls (n=10)
1. No more abuse and dependence 2.Severity measured by number of symptoms, 2- 3 mild, 4-6 moderate, 7-11 severe 3.? Agonist maintenance (methadone, Suboxone) requires“Moderate to severe opioid use disorder”
1. 1. Neuroscience based diagnosis 2.150,000 diagnostic interviews 3.Bio markers not yet reliable 4.Heredity important, but no genetic impact on treatment 5.Relapse prevention meds show efficacy but rarely used 6.New findings if replicated > DSM 5.1 7.Potential pharmacogenetic indication, Genotype, then select medication
1. No intermediate state-abuse, dependence; only a single dimension, mild, moderate, severe 2. Two symptoms is diagnostic threshold for the combined disorder 3. “Dependence” only used for pharmacological dependence which is not a disorder 4. Delete legal symptom and add craving 5. Group gambling disorder with substance use disorders 6. Add cannabis withdrawal. 7. Add Internet gaming disorder to section 3 8. Add Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure to Section 3 9. Add caffeine use disorder to section 3
Impact of Changes in DSM-5 on SUDs Interviewed 7,543 subjects for genetic studies of substance dependence Modestly increased prevalence largely due to DSM-IV “diagnostic orphans” receiving DSM-5 diagnoses Vast majority of switches to DSM-5 due to reduced threshold and increased number of criteria Support for omission of the legal criterion due to limited diagnostic impact Little impact of the addition of craving Peer et al., Drug Alcohol Depend, 2013
Impact of Changes in DSM-5 on SUD Prevalence Peer et al., Drug Alcohol Depend, 2013
Why Classify Gambling Disorder with SUDs? Strong comorbidity of the two disorders Measurable phenotype with high heritability that underlies SUD and GD: Different manifestations of an underlying predisposition Evidence for shared neurobiology: Imbalance between motivation/reward systems and inhibitory systems Why Classify Gambling Disorder with SUDs? Strong comorbidity of the two disorders Measurable phenotype with high heritability that underlies SUD and GD: Different manifestations of an underlying predisposition Evidence for shared neurobiology: Imbalance between motivation/reward systems and inhibitory systems
DSM-IV Pathological Gambling (5 or more required for diagnosis) 1.Preoccupation with gambling 2.Need to gamble in increasing amounts 3.Unsuccessful efforts to control gambling 4.Restlessness or irritability when attempting to stop 5.Gambling as a way to escape problems
DSM-IV Pathological Gambling (5 or more required for diagnosis) 6.After losing, returns another day to get even (“chasing losses”) 7.Lies to conceal extent of gambling 8.Commits illegal acts to finance gambling 9.Jeopardized or lost relationship, job, education, or career because of gambling 10. Relies on others to relieve desperate financial situation caused by gambling
DSM-5 Gambling Disorder (GD) Included in Substance-Related and Addictive Disorders “Illegal Acts” criterion dropped, leaving a total of only 9 criteria Number of criteria required for the diagnosis reduced to 4
Impact of Changes in DSM-5 GD Interviewed 6,613 subjects from genetic studies of substance dependence 1,507 had ever gambled $10 at least monthly and were the focus of analyses Three subgroups: “No Diagnosis” (n=829, 55.0%), a “DSM-5-Only” (n=115, 7.6%), and a “Both-Diagnoses” (n=563, 37.4%) Rennert et al., Exp Clin Psychopharmacol, in press
Impact of Changes in DSM-5 GD Prevalence of DSM-5 GD was 20.4% higher than DSM-IV Pathological Gambling (PG) DSM-5-Only group was intermediate on the prevalence of comorbid substance use disorders, distribution of DSM-IV PG criteria endorsed, types of gambling reported, and acknowledgment of a gambling problem DSM-5 appears to identify problem gamblers who were not diagnosed under DSM-IV Rennert et al., Exp Clin Psychopharmacol, in press
Other Changes Eliminated Polysubstance Dependence Added Cannabis and Caffeine Withdrawal and include them as criteria for Cannabis Use and Caffeine Use Disorders Aligned criteria for Tobacco Use Disorder with criteria for other Substance Use Disorders
Summary of Major Changes Replaced Abuse/Dependence with SUD Increased criteria to 11 for SUD –Omitted legal criterion and added craving –Mild = 2-3, Moderate = 4-5, Severe = 6-11 Renamed and moved Gambling Disorder to Substance-Related and Addictive Disorders Reduced criteria to 9 for Gambling Disorder –Omitted illicit acts –Lowered threshold to 4 criteria required for diagnosis
Treatment of Alcoholism in USA <10% receive treatment Medications only for treatment of withdrawal Medications only for treatment of withdrawal Relapse prevention medication rare Relapse prevention medication rare CNN Special on addiction: Relapses CNN Special on addiction: Relapses Interviews with counselors at famous programs Interviews with counselors at famous programs
CNN Special Addiction: Life on the edge 5 patients followed for one year Different parts of country Admissions Admissions Graduations Graduations Relapses Relapses Interviews with counselors at famous programs Interviews with counselors at famous programs Interview with the one patient who did NOT Interview with the one patient who did NOT relapse relapse
This time he got counseling once a week and a daily pill, a medicine called naltrexone. About two months into it, Walter Kent suddenly noticed the world around him looked and felt different. GUPTA: And so he tried again. He checked himself into an experimental program run by Brown University. This time he got counseling once a week and a daily pill, a medicine called naltrexone. About two months into it, Walter Kent suddenly noticed the world around him looked and felt different. for the first time in my life that I never had this sensation where I didn’t want a drink KENT: And I had just turned around and I said, this is really something for the first time in my life that I never had this sensation where I didn’t want a drink. And this, to me, was like a godsend because of the fact that for someone who had to have a drink, now all of a sudden I don't need that -- I don't have that feeling anymore. He hasn’t had a drink in more than eight years. He’s healthy, back at work, fixing up carburetors. GUPTA: He hasn’t had a drink in more than eight years. Even after his doctor stopped the medication. He’s healthy, back at work, fixing up carburetors.. And now he's part of a running debate. Is addiction an illness you can treat with a pill or a character flaw to be tackled with therapy and self-help? Addiction: Life on the Edge – CNN Correspondent Dr. Sanjay Gupta aired April 19, 2009
Despite the evidence, most fancy rehab centers use medication only rarely, if at all. The focus is much more on therapy. GUPTA: Despite the evidence, most fancy rehab centers use medication only rarely, if at all. The focus is much more on therapy. With the health care professional staff here at Hazelden, our experience tells us having that network of support in recovery is what really makes the difference. Head Counselor Minnesota: With the health care professional staff here at Hazelden, our experience tells us having that network of support in recovery is what really makes the difference. GUPTA: More so than medication? CLARK: More so than just medication, exactly. GUPTA: And that's the conventional wisdom. Addiction: Life on the Edge – CNN Correspondent Dr. Sanjay Gupta aired April 19, 2009
California Program What about medications? GUPTA: What about medications? We do not use them at the Betty Ford Center. Head Counselor California Program: We do not use them at the Betty Ford Center. No comment from the interviewer, no follow up questions. Addiction: Life on the Edge – CNN Correspondent Dr. Sanjay Gupta aired April 19, 2009
Evidence-based treatments not often used in US programs Medication only for detoxification Few programs prescribe relapse prevention medication Affordable Care Act, 2014 will cover all FDA approved medications for substance use disorders.
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