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Wilson M. Compton, M.D., M.P.E.

DSM-5: Conceptual and Practice-Relevant Changes for Addiction-Related Disorders. Wilson M. Compton, M.D., M.P.E. Aimed to incorporate scientific advances since 1994 Development conferences sponsored by NIH, WHO and APA 2003-2008

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Wilson M. Compton, M.D., M.P.E.

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  1. DSM-5: Conceptual and Practice-Relevant Changes for Addiction-Related Disorders • Wilson M. Compton, M.D., M.P.E.

  2. Aimed to incorporate scientific advances since 1994 • Development conferences sponsored by NIH, WHO and APA 2003-2008 • Workgroups convened in 2008 to update the criteria for different sections • Decisions and text finalized December 31, 2012 • Due for publication May, 2013

  3. Substance Related Disorders Workgroup • Charles O’Brien, M.D., Chair • Marc Auriacombe, Ph.D. • Guilherme Borges, Ph.D. • Kathleen Buchholz, Ph.D. • Alan J. Budney, Ph.D. • Wilson M. Compton, M.D. • Thomas Crowley, M.D. • Bridget Grant, Ph.D. , Ph.D. • Deborah S. Hasin , Ph.D. • Walter Ling, M.D. • Nancy M. Petry, Ph.D. • Marc A. Schuckit M.D.

  4. Substance Use Disorder Criteria: DSM-IV 1+ 3+ American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

  5. DSM-5 Substance-Related Issues • Should abuse be combined with dependence to create a single disorder? • Should new criteria be added (e.g., craving) or old criteria (legal problems) be removed? • Can tobacco/nicotine criteria be aligned with other substances? • What will the main disorders and chapter be named? • Will gambling disorders be incorporated into the chapter? • Is there adequate evidence to add Cannabis Withdrawal and Caffeine Withdrawal diagnoses? • How should remission and severity be classified? • How can treatment decisions based on a diagnosis of DSM-IV Dependence be applied in DSM-5?

  6. Primary Studies contributing to DSM-5 decisions Columbia University Deborah Hasin, Ph.D.

  7. Problems from Diagnosing Substance Dependence and Abuse as Separate Disorders • Confusion about relationship of abuse to dependence because abuse is assumed to be milder than dependence • Leads to thinking abuse is prodromal to dependence • Leads to thinking all cases of dependence meet criteria for abuse • When dx’ed hierarchically, reliability and validity of abuse much lower, more variable than dependence • ~50% with abuse dx’ed with only 1 criterion: hazardous use • Diagnostic “orphans” (no abuse, 1-2 dependence criteria) • Many factor analyses showed abuse and dependence criteria formed 1 factor, or 2 highly correlated factors

  8. NESARC ICCCurrent Cannabis Abuse, Dependence (N=1,603) Compton, Saha, Grant et al., Drug and Alcohol Dependence 2009

  9. NESARC ICCLifetime Cocaine Abuse, Dependence (N=2,528) Saha, Compton, Chou, Smith, Ruan, Huang, Pickering, Grant. Drug and Alcohol Dependence 2012

  10. NESARC (2001-2002) ICC Current Alcohol Abuse, Dependence (N=22,526) Saha, Grant et al., Drug and Alcohol Dependence 2007

  11. Combine abuse and dependence into one diagnosis? Yes

  12. Legal problems • A serious problem for some, but should it be a criterion for substance use disorders? • Using a socially constrained phenomenon to define a disorder may be problematic • Clinical concerns about dropping it • May be the criterion that allows for a diagnosis

  13. Legal problems: low loadings with other criteria in general population samples Alcohol: 1991-1992 U.S. national (Keyes et al., 2008) Alcohol: 2001-2002 U.S. national (Saha et al, 2006) Cannabis: 2001-2002 U.S. national (Compton et al., 2009) Amphetamine, cocaine, non-med prescription drugs: 2001-2002 U.S. national (Saha et al., 2012)

  14. Prevalence of currentDSM-IV criteriain clinical sample (N=663) Hasin et al., in press Drug and Alcohol Dependence Columbia University Deborah Hasin, Ph.D.

  15. Factor loadings, clinical sample Hasin et al., in press Drug and Alcohol Columbia University Deborah Hasin, Ph.D.

  16. Legal problems in clinical sample (N=663)Casting a wider “diagnostic net”? • With threshold of ≥2 criteria, keeping legal problems added no cases to those otherwise undiagnosed Conclusion regarding legal problems: drop from DSM-5 list of substance disorder criteria

  17. Craving • Craving is in ICD-10 • Craving seen as a promising target for pharmaceutical intervention (C. O’Brien, others) • May particularly arise in conjunction with stress and substance cues (R. Sinha, others) • Craving of interest due to neural basis, as shown in many brain imaging studies • Relationships and methodology are complex (S. Tiffany, others)

  18. Prevalence of currentDSM-IV criteria and craving in clinical sample (N=663) Hasin et al., in press Drug and Alcohol Dependence Columbia University Deborah Hasin, Ph.D.

  19. Factor loadings, clinical sample Hasin et al., in press Drug and Alcohol Columbia University Deborah Hasin, Ph.D.

  20. Clinical TOC (N=534)Current alcohol abuse, dependence, craving Dependence + craving – n.s. Dependence + abuse = p<.05 Dependence + abuse + craving = p<.05 Hasin et al., in press Drug and Alcohol Dependence Columbia University Deborah Hasin, Ph.D.

  21. Clinical TOC (N=364)Current heroin abuse, dependence, craving Dependence + craving – n.s. Dependence + abuse – n.s. Dependence + abuse + craving = p<.05 Hasin et al., in press Drug and Alcohol Dependence Columbia University Deborah Hasin, Ph.D.

  22. Craving: Cons and Pros Cons • Not included in all existing datasets • Somewhat sensitive to item wording • Adds to information sometimes but not consistently Pros • Unidimensional with existing criteria • SUD structure unimpaired when craving is added • Addition aligns DSM-5 with ICD-10 • Well received by clinicians Conclusion: Add craving to the diagnostic criteria

  23. Nicotine use disorders: Could DSM-5 criteria be aligned with the other substance use disorders? In DSM-IV, dependence only, not abuse Expert opinion 25 years ago: abuse criteria don’t apply to nicotine This picture may be different today Nicotine experts are interested in craving

  24. Israeli adult household residents • N = 1,349 • AUDADIS interview translated to Hebrew and Russian • NIAAA and NIDA funding • DSM-IV ABUSE Items Shmulewitz…Hasin, 2011, Addiction Columbia University Deborah Hasin, Ph.D.

  25. Israel ICC (N=732)Lifetime nicotine abuse, dependence, craving Shmulewitz…Hasin, 2011, Addiction Columbia University Deborah Hasin, Ph.D.

  26. Total information provided by the nicotine criteria Dependence + craving : n.s. Dependence + abuse: p<.05 Dep. + abuse + craving: p<.05 Dependence + abuse + craving vs. Dependence + abuse: n.s. Shmulewitz…Hasin, 2011, Addiction Columbia University Deborah Hasin, Ph.D.

  27. Nicotine abuse, dependence and craving Summary • Nicotine abuse, dependence and craving criteria unidimensional • Same structure as alcohol and drug criteria • Adding abuse and craving significantly increases information • Combined criteria relate more strongly to external correlates Conclusion: align nicotine disorder criteria with those for alcohol and drugs

  28. Terminology: Names for the Main Disorders and Chapter DSM III, III-R and IV Chapter Heading: Substance Use Disorders /Psychoactive Substance Use Disorders/ Substance Related Disorders Primary Disorders: Abuse and Dependence

  29. Examples of Naming in the Alcohol and Drug Field Abuse Addiction Alcoholism Chemical Dependence Dependence Syndrome Dipsomania Drug Habituation Harmful Use Inebriety Misuse Narcomania Psychoactive Substance Pseudoaddiction Substance

  30. Kelly and Westerhoff: “Abuse” More Stigmatizing Than “Use Disorder” Vignette study of 516 clinicians showed lower perpetrator-punishment responses when faced with the substance use disorder label compared to the substance abuser label. p = .02 e.g. “His problem is caused by a reckless lifestyle” (.69) “Mr. Williams is responsible for causing his problem” (.59) “He should be given some kind of jail sentence to serve as a wake-up call” (.53) “His problem is caused by poor choices that he made” (.51) Kelly JF, Westerhoff CM. International J Drug Policy 2009

  31. Comments Solicited from the Field February – April 2010 DSM-5 Development Website Comments on terminology: ~22* May – July 2011 DSM-5 Development Website Comments on terminology: ~57* * Comments primarily related to chapter and diagnostic nomenclature. Overlap was found with comments on pathological gambling, elimination of abuse/dependence dichotomy, and severity. Also, includes a few duplicates.

  32. Workgroup Recommendations: Disorder Name Substance Use Disorder (as in alcohol use disorder, amphetamine use disorder, etc.) Minimal support for : Addiction (i.e. alcohol addiction, amphetamine addiction, etc.) and Substance Dependence (i.e. alcohol dependence, amphetamine dependence, etc.)

  33. Workgroup Recommendations: Chapter Heading Substance-Related Disorders and Gambling Disorders (….but definite lack of consensus…)

  34. Final APA Decisions: Chapter and Disorder Names DISORDER: Substance Use Disorder (as in alcohol use disorder, amphetamine use disorder, etc.) CHAPTER: Substance-Related and Addictive Disorders

  35. DSM-5 threshold: ≥2 criteria • Findings from analysis (IRT, factor) and graphic inspection do not indicate threshold (continuous condition) • Basis for threshold using NESARC and clinical samples: • Diagnostic cut-off of 2+ providing best agreement between prevalence of DSM-5 substance use disorder and prevalence of DSM-IV abuse + dependence

  36. Severity indicator • Compared two measures of severity: • Criterion count of 11 abuse/dependence criteria • Criterion count of 11, weighted by IRT severity parameters • Assessed relationship of these two severity indicators and validating correlates of severity: • Consumption (volume, frequency, largest quantity, frequency of 5+) • Psychological functioning, family history of alcoholism, antisocial personality disorder, early onset of drinking

  37. SF-12 Mental/Psychological Functioning by Alternate Severity Measures Grant et al, in preparation

  38. Reliability of Self-Report Measures of Consumtion Test-Retest Reliability of Adult Self-Rated DSM-5 Cross-Cutting Symptom Measures Substance Intraclass Correlation Coefficient (95% CI) Alcohol 0.75 (0.73-0.77) Tobacco 0.97 (0.97-0.97) Other Drugs 0.75 (0.73-0.78) Narrow WE, Clarke DE, Kuramoto J, et al. American Journal of Psychiatry 2013;170:71-82

  39. Reliability of Self-Report Measures of Consumption Test-Retest Reliability of Child (11+ years) / Parent Self-Rated DSM-5 Cross-Cutting Symptom Measures Substance Parent ICC (95% CI) Child ICC (95% CI) Alcohol 0.84 (0.79-0.88) 0.89 (0.86-0.92) Tobacco 0.96 (0.94-0.97) 0.98 (0.97-0.98) Illegal Drugs 0.65 (0.52-0.75) 0.86 (0.83-0.89) Rx Drugs 0.52 (0.52-0.53) 0.51 (0.41-0.60) Narrow WE, Clarke DE, Kuramoto J, et al. American Journal of Psychiatry 2013;170:71-82

  40. Severity and Remission • Criterion Count for current disorder severity. • Self-report consumption for cross-cutting severity and measure of short-term change in clinical status. • Remission based on absence of criteria (except craving).

  41. Clinical Issue: How does DSM-IV Dependence Compare to DSM-5? • DSM-IV dependence diagnoses are used for decisions about use of medications for alcohol and opioid disorders. • How well to the DSM-IV Dependence Diagnoses compare to the new DSM-5? • What severity threshold produces the best agreement?

  42. Concordance of DSM-IV Dependence with DSM-5 Opioid, Cannabis, Cocaine and Alcohol Use Disorders Past Year Disorders in NLAES Adults: Compton, et al. In press. Drug and Alcohol Dependence

  43. Concordance of DSM-IV Dependence with DSM-5 Opioid, Cannabis, Cocaine and Alcohol Use Disorders Past Year Disorders in NLAES Adults: Compton, et al. In press. Drug and Alcohol Dependence

  44. Clinical Issue: How does DSMIV Dependence Compare to DSM-5? • Generally excellent agreement of DSM-IV Dependence and DSM-5 disorders. • Threshold varies by substance: • Opioids, Cocaine and Alcohol show best agreement at 4+ criteria • MJ shows best agreement at 6+ criteria

  45. DSM-5 Substance-Related Issues • Combine abuse with dependence as a single disorder? Yes. • Should new criteria be added (e.g., craving) or old criteria (legal problems) be removed? Yes. • Can tobacco be aligned with other substances? Yes.

  46. DSM-5 Substance-Related Issues • What will the main disorders be named? Substance Use Disorder (as in Alcohol Use Disorder, Cannabis Use Disorder, etc.) in the Substance-Related and Addictive Disorders Chapter of DSM-5 • Will gambling disorders be included in the chapter? Yes. (Internet Disorder as a disorder to be studied further) • Evidence to add Cannabis Withdrawal and Caffeine Withdrawal diagnoses? Yes.

  47. DSM-5 Substance-Related Issues • How should remission and severity be classified? Remission based on absence of all symptoms; disorder severity based on symptom counts. • How can treatment decisions based on a diagnosis of DSM-IV Dependence be applied in DSM-5? A threshold of 4+ criteria endorsed shows excellent overlap with DSM-IV Dependence for opioids, cocaine and alcohol. For marijuana a threshold of 6+ is needed.

  48. Substance Use Disorder Criteria: DSM-IV and DSM-V 11 criteria

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