Armed With a New Definition, Addiction Enters the Healthcare System - But Not Without Resistance
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.)
This change is also based on statistical studies showing that essential difference between abuse and dependence is one of degree rather than kind. The old AA truism that “You can’t be partly alcoholic any more than you can be partly pregnant” will no longer hold. Under the DSM-5 diagnosis for “alcohol use disorder,” you can be “moderately” or “severely” addicted.
An Increase in Addicts
Taken together, the introduction of the word addiction with both the increase from seven to 11 of the possible criteria and the decrease from three to two in the required number to meet a diagnosis will have one already-certain result: More of us will be “addicts” than ever before. The implications of this fact, however, are anything but certain.
Thomas Babor, an expert in psychiatric epidemiology at the University of Connecticut and an editor of the international journal Addiction, told The Fix, “If [the DSM-5] is published as currently proposed, you’re likely to see an explosion or an epidemic of addiction in the United States which is attributable to the fact that instead of three symptoms out of the current seven, you how have to have two symptoms out of eleven. The chances of getting a diagnosis are going to be much greater, which is artificially going to inflate the statistics even further. It could be an embarrassment.”
Moreover, by redefining substance abuse as addiction, the “mild” substance abuser will become the “mild” addict. Babor worries that this will make it harder to screen for people who might have harmful use of alcohol or drugs but who are not yet addicts. “If we take away that category,” he says, “we may lose our ability to bill for [alcohol screening], it may reverse a lot of the progress we’ve made in identifying risky drinking.”
Psychiatrists vs. Addictionists
Prof. Babor pointed out to The Fix that there does not seem to be any underlying theoretical continuity to the eleven proposed criteria for addiction, only statistical correlations. The DSM-IV worked on a theoretical model of dependence that the new version will fold into the new category of addiction. But critics like Babor fear that without a solid theoretical unity for the revisions in the DSM-5, treatment professionals will be less able to diagnose addiction and explain that diagnosis.
Last week’s announcement of the ASAM definition of addiction provided a stark contrast to this supposed DSM deficiency. The ASAM definition defines all addiction as fundamentally the same, regardless of the behavior or substance one is addicted to. Moreover, the ASAM clearly outlined the neurological “circuits” that produce addiction.
However, the DSM committee has resisted this strictly biological approach, partly because they need to create a standardized set of criteria to diagnose addiction that can be used by all treatment professionals in their practice—symptoms observable without using a brain scan.
The DSM functions as the bible not only for the mental health establishment—the manual is written by the American Psychiatric Association (APA)—but for the insurance and pharmaceutical industries. Although this bible does not have a monopoly on the idea of addiction—the Twelve-Step disease model retains tremendous influence—the redefinition is certain to have a significant, if hard to predict, impact on addicts, recovering or otherwise. It defines every psychiatric clinical condition or disease, laying out the criteria by which a diagnosis is made and treatment is recommended by doctors, covered by insurance companies and even developed and marketed by drug companies. The FDA relies on the DSM to decide what new drugs will be approved, and what conditions they will be approved for. The legal system relies on the DSM to determine what constitutes admissible mental disorders, and when treatment is preferable to incarceration.
For addiction to get the official DSM stamp of “disorder” means that entire realms of human behavior will be newly medicalized—or at least newly diagnosed—which will undoubtedly result in more diagnoses, and therefore more business for psychiatrists themselves. In theory, the changes will promote earlier intervention and better outcomes with the national health care system paying out more in the short term but saving in the long run because of fewer serious complications and expensive hospitalizations. Again in theory, former, current and future addicts should benefit, too, but only if they have access to affordable treatment and care.
The DSM-5 Substance-Related Disorders Work Group is chaired by Dr. Charles O’Brien, widely viewed as one of the most respected and innovative addiction researchers in the world. A professor of psychiatry at the University of Pennsylvania and the director of its Charles O’Brien Center for Studies of Addiction, O’Brien has, since the 1970s, focused on developing evidence-based diagnostic tools that scientists, drug developers and doctors can use to measure the effectiveness of treatments. Of the upcoming DSM revisions, O’Brien told Medscape, “This is going to produce big changes for all of us. It’s going to impact training programs, it’s going to impact your practices, and it’s going to impact patient reimbursement for the services we provide and the drugs we prescribe.”
This comes at the cost of separating the DSM from the most current scientific understanding of addiction. Dr. Raju Hajela, the chair of the ASAM’s committee and former president of the Canadian Society for Addiction Medicine, toldThe Fix, “Our frustration is that APA and DSM have been very behavioral [in their focus.] We have been trying to engage them, but we have agreed to disagree. We want to be more neuroscience-based and to encourage people to realize that this is not about bad behaviors but about brain circuitry and where people lose their choice.”
In fact, the ASAM definition turns traditional notions of the addict’s free will and moral responsibility on their head. Burdened with an impaired reward system in the brain, a person cannot choose not to be an addict, although he or she can choose how to live with this disease (whether to use or to abstain, etc.).
Another first-ever in the DSM-5’s addiction category the proposed inclusion of behavioral disorders, most notably gambling disorder. Other obsessive or compulsive behaviors have been considered, from sex to the Internet to shopping, but so far only gambling has made the cut—mainly, according to Dr. O’Brien, because it’s the only behavioral addiction that has been adequately studied. This expands the notion of addiction even further, beyond substances to behaviors. “The inclusion of behavioral addictions can obviously produce whole new populations of addicts,” Keane said.
Yet it seems obvious that behavioral addictions exist in a gray area that the Work Group has yet to resolve. On the one hand, they say they want to push the definition toward a more science-based, biological understanding of addiction. On the other, large numbers of people are already appearing in the offices of doctors and therapists saying that their lives are being ruined by addiction to sex, gambling, shopping, and other behaviors.
Including only gambling into the addiction club smacks of groupthink and reveals the fundamentally conservative, ultracautious bias of the Work Group. Yet however illogical this gambling-only bent may seem, the message being transmitted is: Do more studies of behavioral studies! Just because Dr. Phil has a TV show about it doesn’t make it medical.
By contrast with the APA, the ASAM has given the behavioral addictions the same status as the substance addictions. Dr. Haleja told The Fix that he would support the inclusion of any addictive behaviors, “because it’s what we see in our offices.”
The DSM-5 will call sex addiction “hypersexual disorder” and classify it under “obsessive-compulsive and related disorders.”
Addiction and Stigma
One reason the ASAM defines addiction exclusively on the brain science is to help free their patients from the stigma of addiction. The DSM committee, on the other hand, seems to assume that this stigma no longer exists. The DSM-5 committee will likely adopt the word “addiction disorders” into the name of their section for the first time ever, identifying everyone in that category with the word addiction. Dr. O’Brien claims that the word has been destigmatized outside the medical community, citing the common usage among recovering addicts.
However, Babor argues that the expansion of the addiction category “may result in the term being applied to millions of people who will be given a label which they don’t really agree with and that they may feel is pejorative.”
Helen Keane, author of What’s Wrong With Addiction? and a professor of medical ethics at Australian National University, criticizes the new addiction category as way too broad. “because none of the criteria are required to be present or are weighted more heavily than any other, the category becomes a rather sprawling entity with no identifiable core,” Keane told The Fix, adding that under the new definition, “You can easily imagine a ‘normal’ teenager or university student meeting these criteria because of heavy weekend drinking.” Keane also points out that “for the already marginalized, the label can be used to justify coercion, punishment and discrimination, and works to maintain a stigmatized and devalued identity.”
Here is a brief overview of some of the changes the DSM-5 workgroup are seriously considering:
Legal Criteria Dropped
Part of the effort to both destigmatize and medicalize addiction is to sever it from any reference to the law. In previous editions, legal trouble was seen as a criterion for an addiction diagnosis. This will likely be dropped in view of the pejorative associations of police encounters and the lack of legal uniformity from state to state and country to country.
The new DSM will likely include a new diagnosis for marijuana withdrawal, supported by new studies showing that stopping cannabis can cause marijuana irritability, anxiety, insomnia and decreased appetite.
Biological markers for addiction are favored by the DSM because they are objective rather than subjective symptoms. There are two main physiological flags of addiction included in the criteria: tolerance and withdrawal. That these remain while dependence, which is defined by tolerance and withdrawal, has been dropped presents an apparent contradiction that Dr. O’Brien and his experts will no doubt be asked to explain.
Dependence and Rx Painkillers
The issue of tolerance leading to dependence “has traditionally been an area of much misunderstanding,” said Dr. O’Brien. One of his criticisms of the DSM-IV is that by favoring the word dependence over addiction, “doctors have become afraid to prescribe legitimate medicine like painkillers for fear that their patients will become ‘dependent’ on it simply because the medicine creates increasing levels of tolerance.” The DSM-5’s use of addiction is partly an attempt to end that confusion and destigmatize patients using opiate painkillers—they may be physically dependent but they will not be addicted.
But critics like Keane worry that this distinction may backfire, reinforcing stigma. “The solution should not be a further division of drug users into good and bad, normal and addicted,” she says.
The problems related to prescription painkillers are unlikely to be resolved by word games. On the one hand, chronic pain remains widely undertreated; on the other hand, the availability of opiate-based painkillers and other prescription narcotics has spawned its own epidemic of addiction.
The Addition of Drug Craving
The new DSM-5 proposes to give cravings their due. “Drug craving” will become a new criterion for diagnosing addiction in most or all of the substance use disorders. New studies have identified craving as a pervasive symptom of addiction with a neurochemical—not behavioral—cause. This will open the door for the more widespread acceptance of new medications, such as naltrexone, acamprosate, and topiramate (off-label), that help to blunt cravings.
Going forward, the decisions of the DSM Work Group will factor into an upcoming revision of theInternational Classification of Diseases by the World Health Organization, which has global authority with special influence in poor nations the developing world. According to Babor, WHO experts would ideally seek compatibility between the DSM and their own classification, but he fears that “they may go off in a different direction” in disagreement with the APA because they have a stronger mandate to generate criteria not susceptible to cultural bias. This could result in a divergence of American addiction treatment from the rest of the world.
Still, ready or not, the US health care system is about to experience a sea-change in the very meaning of “addiction.” In the future, the label is likely to be applied to a much larger group of people than it is now, with a much larger range of problems and behaviors. The diagnosis will, for the first time, be applied to patients by the medical establishment. The ripples and waves triggered by this sea-change remain a mystery, but one thing is certain: they should be followed closely, especially by the addiction and recovery community because it is our health that is at stake.