Some over the years have wanted to envision addiction as being represented on a pyramid where mere use falls at the base of the pyramid, abuse falls partway up, and dependence lives at the peak. This type of approach suggests a continuum in which an individual might go up and down on the pyramid depending upon the conditions at any given time. Yet no such continuum exists. Those with addictive disease generally recognize that they are using in a manner that differs from their peers from the time of their very first use. And it is only a very rare individual who does not have addictive disease, then develops the illness as a result of the impact of addictive substances on his or her brain.
DSM-5 has now arrived. It is critical to recognize that addictive disease itself has not changed with this new publication. The disease is what it was. We may use different terminology, as “abuse” is now gone, and “dependence” has returned to its pharmacologic roots where it will again refer to the development of tolerance and withdrawal. We applaud DSM-5 for using the term “addictive disorders” within its overall framework. DSM-5 does not, however, speak to addiction but rather to some of the markers seen with addictive illnesses.
Let’s use alcohol as an example. DSM-5 has “Alcohol Use Disorder,” which comes in mild, moderate and severe flavors, suggesting the inadequate pyramid approach. There are 11 possible symptoms of the “use disorder,” of which two are necessary to achieve a mild specifier, four for moderate and six for severe. “Alcohol use disorder is defined by a cluster of behavioral and physical symptoms,” the authors of DSM-5 state. I have no problem with that except that some may confuse “alcohol use disorder” with addictive disease or with alcoholism or with what the field in general has defined as being a specific abnormality of the brain’s reward system producing repetitive use despite negative consequences.
In DSM-5, mild alcohol use disorder is present if the patient has tolerance and withdrawal. Nothing else is necessary. Yet tolerance and withdrawal are measurable metabolic factors that are present for alcohol within just a few hours of use. How much tolerance and withdrawal are necessary to achieve this particular part of the diagnosis? In fact, anyone drinking a couple of glasses of wine with dinner each evening will have measurable and noticeable tolerance and withdrawal. It won’t be present to the extent of causing significant dysfunction, but it will be quite evident on exam. That person now has a mild alcohol use disorder. But that shouldn’t be confused with mild addiction or mild alcoholism, or even mild DSM-IV abuse. It isn’t any of those things.
As for moderate alcohol use disorder, let’s say that we have a patient who drinks in larger amounts or over longer periods than intended, persistently tries and fails to stop drinking, fails to fulfill major role obligations and recurrently uses alcohol in situations where such use is physically hazardous. If these are the only difficulties present, the patient has a moderate degree of severity of the illness. We’ll hypothesize that the patient drinks only in a binge-like manner so tolerance/withdrawal do not develop to the point that either is counted. If they were present, we’d have someone with a severe alcohol use disorder, yet the individual drinking in a binge-like manner may well have greater risk of morbidity/mortality than the individual utilizing a consistent amount on a daily basis. So the moderate and severe specifiers in this case may actually be the reverse of the actual case where we utilize such specifiers to indicate or suggest risk, danger and need for treatment.
DSM-5 failed again to put alcohol use disorders together with sedative use disorders, continuing the scientifically inaccurate suggestion that the two somehow differ from one another, and undoubtedly leading yet another generation of clinicians to the inevitable conclusion that there is no problem prescribing a benzodiazepine to an individual with an “alcohol use disorder.” Alcohol is simply a central nervous system depressant, like barbiturates and benzodiazepines, and the authors of DSM-5 seem to have overlooked the importance of grouping like substances together.
Ultimately, the definitions in DSM-5 are definitions for a new set of illnesses. They have different terminology and are accompanied by new defining structures. A patient who ends up in the ER only once each year due to a suicide attempt, car accident, slip/fall, barroom brawl, each time after imbibing considerable alcohol, does not meet criteria for even a mild alcohol use disorder. And a college student who is not an alcoholic does meet criteria for a mild alcohol use disorder if he has tolerance and hangovers.
Now it’s up to us to remember that addictive illness is still addictive illness; it remains unchanged despite the arrival of DSM-5.
Stuart Gitlow MD MPH MBA
Dr. Gitlow is President, American Society of Addiction Medicine (ASAM). His commentary reflects personal opinion and is not necessarily reflective of the official position of ASAM.