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Armed With a New Definition, Addiction Enters the Healthcare System - But Not Without Resistance

The DSM, a manual of mental disorders, will have the section "Addiction and Related Disorders," expanding what it means to be an addict and improving healthcare options.

The medical definitions of addiction are poised to undergo a massive makeover—an occurrence almost as rare as a meteor sighting—and the potential ramifications are likely to be enormous, ranging from the specific treatments your health insurance is obliged to cover to the moral, social and legal “meanings” of being an “addict.” Beginning in 2013, for the first time in history, the word addiction will be used as a category by the monolithic authority of mental health in America, the Diagnostic and Statistical Manual of Mental Disorders (DSM). And given other major changes, such as the first-ever addition of a behavioral disorder, there will undoubtedly be a massive increase in the number of addiction diagnoses nationwide. Predicting the many ramifications requires a crystal ball. 

The most recent version, the  DSM-IV, was published in 1994 and slightly revised in 2000. The mental-health field has undergone a revolution in diagnostic technology, such as brain imaging and genomics since then, and no specialty has advanced faster than the science of addiction.

The new edition, the DSM-5, is not scheduled to be published until May 2013, but the proposed changes, which are sweeping, reflect the current expert consensus informed by these advances. While you might think that the APA writes its bible in a high-security bunker, in fact the proposed draft revisions have been available  online for public comment since February 2010, and substantial revisions of the revisions have already been incorporated as a result. These draft diagnoses are now being “tested in the field”—in both large trials at universities and by individual clinicians.

The revisions under debate for substance addictions (alcoholism and drugs) are, predictably, already sparking controversy. The most fundamental change in the new edition will likely be the combination of the two distinct diagnoses of “substance abuse” and “substance dependence” into the single all-purpose label “substance use disorder."

Underscoring this controversy, in an attempt to pre-empt the DSM-V and reframe how the public understands addiction, last week the American Society of Addiction Medicine (ASAM) released its own definition—a more radical revision because it defines the disease almost entirely as a neurological dysfunction—a brain disorder.

“Abuse” and “Dependence” vs. “Addiction”

The DSM-5 will—after a review process already in its closing stages—do away with the long-established distinction between “abuse” and “dependence.” In the DSM-IV, abuse was the harmful or excessive use of a substance, dependence the habitual harmful use of a substance. All addicts were understood to move from abuse to dependence, although not all abusers became dependent (or addicted), so the two conditions were different problems with different diagnostic criteria that demanded a different treatment. Starting with the release of the DSM-5, abuse and dependence will be collapsed into a single diagnosis—“substance use disorder”—specified by 11 “criteria.” You will have to meet only two of these 11 criteria to merit a “moderate” diagnosis—a relatively low threshold that has raised the hackles of some addiction specialists. In the DSM-IV, patients had to meet three criteria out of seven to qualify for a diagnosis of “dependence.”

If this is likely to be the most controversial revision, the one that has so far garnered the most headlines is the introduction of the word addiction itself to describe these disorders. As baffling as it may seem, the word was effectively banned from previous version of the mental-health bible. So for the first time, the DSM-5 will feature a section titled “Addiction and Related Disorders,” which will include “substance-use disorders”—for example, “alcohol-use disorder” and “cannabis-use disorder.”

The change from the word dependence to addiction comes after long disagreement over the terminology. Dr. O’Brien said that “dependence was what went into DSM-IV, but only by one vote,” adding that subsequent research has shown that this decision was a “significant mistake” because dependence typically refers to physical dependence, which can exist even in drugs not normally abused—for example, people who are on opiate-based painkillers may develop a physical dependence, even though they are taking the drugs exactly as prescribed. (Even certain antidepressants can cause a physical dependence that results in symptoms of withdrawal when stopped abruptly.)