Friday, March 5, 2010

APA Finally Gets Opioid “Addiction” Sorted Out

Language MattersAfter years of confusion, a review draft of the American Psychiatric Association's (APA) latest Diagnostic and Statistical Manual of Mental Disorders (DSM-5) finally eliminates perplexing “Substance Abuse” and “Dependence” disease categories and suggests replacing them with a new "Addiction and Related Disorders" designation. Expectedly, the more appropriate language and definitions will help to dispel unfounded fears and accusations of addiction in patients taking opioid medications for pain.

As reported in Join Together Online [Curley 2010] and at a special APA website presenting the draft DSM-5 document [APA 2010], this is one of several major changes to the “psychiatry bible” widely used to diagnose (and get insurance reimbursement for) behavioral-health problems. The current edition — DSM-IV (Roman numeral designations for editions have been used until now) — was first published in 1994 and has been plagued by contention and controversy through the years. Many critics have claimed that the DSM series has “medicalized” many problems of everyday life into mental disorders, and it appears that this trend may continue to an extent in the new version. Work on the DSM-5 revision first began in 2000, has progressed most rapidly during the past few years, and the final document is expected in 2013.

Prior versions of the DSM have eschewed use of the term “addiction” in favor of “substance dependence,” plus a separate category for “substance abuse” as sort of a prodromal stage leading to substance dependence. This was a serious mistake because it created confusion with “physiological dependence” — eg, drug tolerance and withdrawal — which was considered a component of substance dependence but can naturally occur in persons taking prescribed opioid analgesics. Healthcare providers and their patients erroneously came to believe that signs of tolerance and withdrawal meant that patients were becoming dependent on or, in everyday language, addicted to opioid medications. Such confusion has been an important contributor to the undertreatment of pain [see, Leavitt 2006, p. 3]. The new approach will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system. Presumably, any future use of the term “dependence” would strictly refer to physiological dependence.

The new draft document has an omnibus category called “Substance-Related Disorders,” which is expected to be renamed “Addiction and Related Disorders.” And, within this addiction category would be a variety of substance-use disorders broken down by drug type, such as "Alcohol-Use disorder" and “Opioid-Use Disorder.” Diagnostic criteria for these disorders in DSM-5 would remain similar to those found in the current DSM-IV; however, the symptom of "drug craving" would be added, while a symptom referring to "problems with law enforcement" would be eliminated due to cultural considerations that make the criteria difficult to universally apply. Furthermore, there would no longer be a separate category for substance abuse.

Opioid-Use Disorder is defined in the draft DSM-5 as a maladaptive pattern of substance (ie, opioid) use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following 11 items, occurring within a 12-month period:
  1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.

  2. Recurrent substance use in situations in which it is physically hazardous (eg, driving an automobile or operating a machine when impaired by substance use).

  3. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (eg, arguments with spouse about substance use, physical fights).

  4. Tolerance, as defined by either: a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect, or b) markedly diminished effect with continued use of the same amount of the substance.

  5. Withdrawal, as manifested by either: a) the characteristic withdrawal syndrome for the substance, or b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.

    (Note: Tolerance and withdrawal are not counted for those taking prescribed medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)

  6. The substance is often taken in larger amounts or over a longer period than was intended.

  7. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

  8. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.

  9. Important social, occupational, or recreational activities are given up or reduced because of substance use.

  10. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

  11. Craving or a strong desire or urge to use a specific substance.
Apparently, there is no hierarchy of the above criteria, with top-listed items having greater weight; just how the numerical order was determined is somewhat of a mystery. Furthermore, and very importantly, opioid addiction would be considered to develop and exist along a continuum, with a patient fulfilling any 2 to 3 of the above criteria considered moderately addicted and 4 or more positive criteria designating a severe condition.

This would relieve practitioners of the burden of trying to assess whether a patient is merely abusing opioids or has become addicted; simply put, if at least 2 criteria are met (excluding tolerance and withdrawal) there are opioid-use problems that must be addressed if pain therapy is to be successful. Along with this, however, the new approach could mean that data from many past studies using older notions of opioid abuse versus dependence (addiction) would be invalidated. This is not necessarily bad, because much of the research and government survey data to date have used vague, inconsistent, or poorly defined terminology that has biased the outcomes.

ADDENDUM: The APA is accepting public comments on the DSM-5 revision until April 20, 2010. All of the proposed changes and information about submitting comments can be found on the DSM-5 Website at:

> APA (American Psychiatric Association). DSM-5: The Future of Psychiatric Diagnosis [online]. 2010 [
access website].
> Curley B. DSM-V draft includes major changes to addictive disease classifications. Join Together [online]. 2010(Feb 12) [
available here].
> Leavitt SB. Discard “Dependence”; Get Serious About “Addiction.” Pain Treatment Topics [e-Briefing newsletter online]. 2006;1(2):3-4 [
PDF available here].

## APA press release: APA Announces Draft Diagnostic Criteria for DSM-5: New Proposed Changes Posted for Leading Manual of Mental Disorders. 2010(Feb 10) [
PDF available here].
## Frances A. The first draft of DSM-V [editorial]. Br Med J. 2010;340:c1168 [
## Shorter E. Why psychiatry needs therapy: A manual’s draft reflects how diagnoses have grown foggier, drugs more ineffective. Wall Street Journal [online]. 2010(Feb 27/28) [
available here].