Miriam Komaromy, MD Associate Director, Project ECHO Associate Professor, Internal Medicine, UNM 10/2013

DSM IV approach to SUDs was problematic Use of the term “dependence” to mean “addiction” Distinction between “abuse” and “dependence” as two separate entities of increasing severity Lack of reference to Craving in the criteria Inclusion of Legal Consequences as a criterion

Substance Use Disorder (SUD) (Substance-Related and Addictive Disorders) Consolidate substance abuse with substance dependence into a single disorder called substance use disorder Rationale: Dependence is a misunderstood term that has negative connotations when in fact it refers to normal patterns of withdrawal that can occur from the proper use of medications. Copyright © American Psychiatric Association.

Medical providers and patients often confuse physical dependence with addiction Medical providers who confuse these two may make poor medical decisions Patients may experience guilt and anxiety because of symptoms of withdrawal or tolerance

Abuse vs. Dependence in DSM IV Intended to represent less severe and severe SUD Not always accurate Same criteria for substances that cause physical dependence and those that don’t DSM V solution: SUD is a single category, of graded severity

DSM V approach to variations in severity Rather than using the presence or absence of dependence to indicate increased severity, DSM V uses # of criteria to indicate severity

DSM-IV and DSM-5 Criteria for Substance Use Disorders a One or more abuse criteria within a 12-month period and no dependence diagnosis; applicable to all substances except nicotine, for which DSM-IV abuse criteria were not given. b Three or more dependence criteria within a 12-month period. c Two or more substance use disorder criteria within a 12-month period. d Withdrawal not included for cannabis, inhalant, and hallucinogen disorders in DSM-IV. Cannabis withdrawal added in DSM-5. Hasan, D. Am J Psychiatry. 2013;170(8):

DSM-IV and DSM-5 Criteria for Substance Use Disorders a One or more abuse criteria within a 12-month period and no dependence diagnosis; applicable to all substances except nicotine, for which DSM-IV abuse criteria were not given. b Three or more dependence criteria within a 12-month period. c Two or more substance use disorder criteria within a 12-month period. d Withdrawal not included for cannabis, inhalant, and hallucinogen disorders in DSM-IV. Cannabis withdrawal added in DSM-5. Hasan, D. Am J Psychiatry. 2013;170(8): Example of DSM V Mild SUD (2-3)

DSM-IV and DSM-5 Criteria for Substance Use Disorders a One or more abuse criteria within a 12-month period and no dependence diagnosis; applicable to all substances except nicotine, for which DSM-IV abuse criteria were not given. b Three or more dependence criteria within a 12-month period. c Two or more substance use disorder criteria within a 12-month period. d Withdrawal not included for cannabis, inhalant, and hallucinogen disorders in DSM-IV. Cannabis withdrawal added in DSM-5. Hasan, D. Am J Psychiatry. 2013;170(8): Example of DSM V Moderate SUD (4-5)

DSM-IV and DSM-5 Criteria for Substance Use Disorders a One or more abuse criteria within a 12-month period and no dependence diagnosis; applicable to all substances except nicotine, for which DSM-IV abuse criteria were not given. b Three or more dependence criteria within a 12-month period. c Two or more substance use disorder criteria within a 12-month period. d Withdrawal not included for cannabis, inhalant, and hallucinogen disorders in DSM-IV. Cannabis withdrawal added in DSM-5. Hasan, D. Am J Psychiatry. 2013;170(8): Example of DSM V Severe SUD (> 6)

“An important exception to making a diagnosis of DSM-5 substance use disorder with two criteria pertains to the supervised use of psychoactive substances for medical purposes, including stimulants, cocaine, opioids, nitrous oxide, sedative-hypnotic/anxiolytic drugs, and cannabis in some jurisdictions” Hasan, D. Am J Psychiatry. 2013;170(8): For prescribed medications, the presence of tolerance and withdrawal alone do not signify a Substance Use Disorder

Substance Use Disorder (cont’d) Rationale continued: Further, studies from clinical and general populations indicate DSM-IV substance abuse and dependence criteria represent a singular phenomenon but encompassing different levels of severity. Mild SUD (2-3/11 criteria) will be coded with the DSM-IV substance abuse code to reflect the intent but not reality of considering substance abuse less severe than substance dependence. Moderate (4-5/11 criteria) and severe (6+/11 criteria) SUD will be coded with DSM-IV substance dependence codes. Copyright © American Psychiatric Association.

Substance Use Disorder (cont’d) Removal of one of the DSM-IV abuse criteria (legal consequences), and addition of a new criterion for SUD diagnosis (craving or strong desire or urge to use the substance) Rationales: The legal criterion had poor clinical utility and its relevance to patients varied based on local laws and enforcement of those laws. Addition of craving as a symptom is highly validated, based on clinical trials and brain imaging data, and may hold potential as a future biomarker for the diagnosis of SUD. Copyright © American Psychiatric Association.

Additional Specifiers In early remission In sustained remission On maintenance therapy In a controlled environment Diagnosis should contain specific substance, e.g. “Alprazolam use disorder’ List each dx separately (no poly-substance)

Other changes

Caffeine withdrawal added Caffeine Use Disorder is a “condition needing further study”

Cannabis withdrawal added

Miriam Komaromy, MD