DSM-5 and Substance Use Disorders: Clinicolegal Implications – J Am Acad Psychiatry Law – December 2014
Presumed distinctions between substance dependence and substance abuse have been at the heart of the development and utilization of substance-based diversion from criminal prosecution to treatment for the past several decades, including its use in drug courts.
These distinctions have been promulgated by organized psychiatry since the publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) in 1980.
With the release of DSM-5 and the replacement of abuse and dependence categories with a single use disorder construct, the legal grounds for diversion in many states now stand at odds with organized psychiatry and its adoption of recent science.
This article reviews the scientific basis for the DSM’s new classification scheme, the dilemmas posed for states with statutes that rely on the abuse/dependence distinction, and potential remedies for legislatures wishing to keep pace with evolving research and clinical practice.
Many states have statutes that provide for the diversion to treatment of criminal defendants with substance abuse disorders. Most make a specific distinction between defendants who abuse substances and those who are physiologically or psychologically dependent on substances
Organized psychiatry’s early attempts at diagnostic classification suggested that addiction reflected an antisocial personality. In 1952, the first edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) identified Addiction (with subcategories of Alcoholism and Drug Addiction) as part of the Sociopathic Personality Disturbance
Iterations of the DSM from the third edition (DSM-III)3 through the fourth edition, revised (DSM-IV-TR),4 discriminated between “out-of-control use” (dependence) and “harmful use” (abuse).
For many years now, the law has relied on these DSM distinctions in determining whether defendants with substance abuse disorders are appropriate for diversion
In the second edition (DSM-II), addictions were placed alongside, rather than under, the personality disorders, and some definitions were added.
The elimination of these distinctions in the fifth edition (DSM-5) in favor of a combined substance use disorder construct may well prompt lawmakers and judges in many states to reconsider their substance use diversion standards
Dependence on alcohol was subclassified as alcohol addiction and was presumed in the patient who could not abstain for one day or who experienced withdrawal symptoms.
In this article, we review the literature on substance use disorders and the decision to eliminate the abuse/dependence dichotomy in the DSM
Substance Use Research and the DSM
In 1980, the DSM-III introduced the categories of “abuse” and “dependence,” requiring pathological patterns of use or negative consequences of use for a diagnosis of abuse and tolerance or withdrawal for a diagnosis of dependence (plus one of the abuse criteria in the case of alcohol or cannabis dependence)
In 2007, the DSM-5 Substance-Related Disorders Work Group (hereafter, Work Group) was established. A central question for the Work Group was whether to keep abuse and dependence as separate disorders.
The Work Group examined studies involving more than 200,000 subjects. In multiple studies, the dependence criteria were found to be valid and reliable, but the abuse criteria produced equivocal or weak results.
There were good reasons to retain the abuse criteria, however. Two of the three most clinically severe symptoms among both the DSM-IV abuse and dependence criteria were in the abuse category: neglected major roles to use and social/interpersonal problems related to use
The two factors, or axes, were always thought to be related…they co-occur in some proportion of cases.
The significant overlap between the two constructs can also be explained by a unidimensional understanding of substance use disorders
That is, they represent the same underlying condition, which is manifested in different individuals in different ways.
Further, the criteria of abuse and dependence are intermixed through the spectrum of symptom severity
Based on 39 articles describing this effect, the Work Group chose to eliminate the distinction between abuse and dependence and to combine the various criteria into a single diagnosis with 11 criteria (see Table 1).
The Work Group had to select a threshold for diagnosing a substance use disorder under the revised classification scheme, knowing that the decision had the potential to enlarge the pool of diagnosed individuals
The studies on which the Work Group relied suggested no natural threshold for diagnosis.
The Work Group wanted to select a value that would maintain the overall prevalence of abuse and dependence diagnoses at DSM-IV levels but that would identify even mild cases that warrant intervention.
At the threshold of 2 criteria (of the total 11), the prevalence remained steady and inter-rater agreement was high, so that threshold was chosen
Inter-rater agreement means only agreement within the Work Group. Since these were all addiction-focused individuals, their agreement does not constitute a knowledge of the various facets of drug use, like prescribed opioids for pain.
The breadth of this categorization raises concerns for criminal justice policy as well,
This played right into the coffers of the recovery industry. Their residential clinics, like the notorious Phoenix House, are extremely expensive and profitable.
The timing of the DSM-V, destroying the distinction between legitimate use and abuse/addiction, in the midst of the “opioid crisis” makes me wonder if these same people had their fingerprints on it.
Concerns have been raised that a threshold of two identifies a heterogeneous population spanning “from simple abuse to severe addiction [such] that it is no longer helpful in guiding understanding, communication, or treatment decisions”
This discussion is only about mild abuse versus destructive abuse and never even considers that some of the drugs being taken are legitimate prescriptions for pain medication.
The addiction field, which was so overrepresented in the Workgroup can only see drug abuse – never legitimate use.
A new criterion of “craving” was added to substance use disorders in DSM-5.
This item arguably does not contribute much to the diagnostic exercise and is thus not likely to have clinicolegal significance, but there was clinical support for adding it, perhaps in hopes of future biological treatments targeting craving.
The Work Group was focused on the scientific evidence concerning substance use, for clinical purposes
The Work Group debated the relative merits of each of these terms before deciding in the end to discard both in favor of the “more neutral label of ‘substance use disorder’”
Again, it’s clear that they never considered the prescribed use of a drug that also happens to be addictive.
In many states, diversion turns on a finding of substance dependence or addiction. Yet the dependence/addiction construct has fallen from favor recently, rejected by the research community and abandoned by the DSM-5
I look at an awful lot of pain and opioid research and never saw any signs of this. So it’s likely this only occurred among addiction researchers with zero input from pain specialists.
As the boundary separating those who merit diversion from those who do not changes in response to evolving research and professional opinion, the nexus between legal theory and science will be illuminated for further societal inspection.
Whatever criteria are established inevitably will be challenged by both defendants and prosecutors.
The unidimensional construct of substance use disorders in the DSM-5 seems to support an ideologically defensible expansion of diversion for all offenders with use disorders.
In light of contemporary scientific knowledge and clinical practice advancing the unidimensional construct of SUD, states may be hard pressed not to expand diversion eligibility to broader categories of persons with use disorders.
This is typical lawyer reasoning. They have no concern for the human costs of the law they defend and clearly take whatever the addiction industry tells them without further thought, using it as an excuse to defend the indefensible.