Miriam Komaromy, MD Associate Director, Project ECHO Associate Professor, Internal Medicine, UNM...
19
DSM-5 Approach to Substance Use Disorder (SUD) Miriam Komaromy, MD Associate Director, Project ECHO Associate Professor, Internal Medicine, UNM 10/2013
-
Upload
aldous-strickland -
Category
Documents
-
view
222 -
download
1
Transcript of Miriam Komaromy, MD Associate Director, Project ECHO Associate Professor, Internal Medicine, UNM...
DSM-5 Approach to Substance Use Disorder (SUD)
Miriam Komaromy, MDAssociate Director, Project ECHOAssociate Professor, Internal Medicine, UNM10/2013
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 © 2013. 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 accurateSame criteria for substances that cause
physical dependence and those that don’tDSM 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 Disordersa 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):834-851
DSM-IV and DSM-5 Criteria for Substance Use Disordersa 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):834-851
Example of DSM V Mild SUD (2-3)
DSM-IV and DSM-5 Criteria for Substance Use Disordersa 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):834-851
Example of DSM V Moderate SUD (4-5)
DSM-IV and DSM-5 Criteria for Substance Use Disordersa 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):834-851
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):834-851
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 © 2013. 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 © 2013. American Psychiatric Association.
Additional Specifiers
In early remissionIn sustained remissionOn maintenance therapyIn a controlled environmentDiagnosis 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, [email protected]
