In May of 2013 the DSM IV was published, and both the conditions and the criteria for diagnosing substance abuse/dependence were change. These changes are not necessarily for the better. That is to say, they do not, in my view, make diagnosis or treatment easier or more accurate, and they tend to leave forensic issues, which are those issues that most concern my clients, my referral sources, and myself, out of the equation.
American Psychiatric Publishing issued the following statement regarding the changes:
"Substance Use Disorder in the DSM-5 combines the DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum from mild to severe. Each specific substance (other than caffeine, which cannot be diagnosed as a substance use disorder) is addressed as a separate use disorder (e.g., alcohol use disorder, stimulant use disorder, etc.), but nearly all substances are diagnosed based on the same overarching criteria...Drug craving will be added to the list, and problems with law enforcement will be eliminated (emphasis mine) because of cultural considerations that make the criteria difficult to apply internationally...the diagnosis of dependence caused much confusion. Most people link dependence with 'addiction' when in fact dependence can be a normal body response to a substance."
The diagnosis of Substance Use Disorders spans a wide variety of problems arising from substance use, and covers 11 different criteria:
Taking the substance in larger amounts or for longer than the you meant to
Wanting to cut down or stop using the substance but not managing to
Spending a lot of time getting, using, or recovering from use of the substance
Cravings and urges to use the substance
Not managing to do what you should at work, home or school, because of substance use
Continuing to use, even when it causes problems in relationships
Giving up important social, occupational or recreational activities because of substance use
Using substances again and again, even when it puts you in danger
Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance
Needing more of the substance to get the effect you want (tolerance)
Development of withdrawal symptoms, which can be relieved by taking more of the substance.
The DSM 5 allows clinicians to specify how severe the substance use disorder is, depending on how many symptoms are identified. Two or three symptoms indicate a mild substance use disorder, four or five symptoms indicate a moderate substance use disorder, and six or more symptoms indicate a severe substance use disorder. Clinicians can also add “in early remission,” “in sustained remission,” “on maintenance therapy,” and “in a controlled environment.”
The problems these diagnostic criteria present to the clinician doing either treatment or a forensic evaluation are numerous. By removing the barrier between substance abuse and substance dependence, the writers of the new diagnostic manual have blurred an important distinction that treatment professionals use to determine what kind of therapy is appropriate, and, indeed, whether therapy is appropriate at all. From a forensic perspective this is particularly problematic because any degree of loss of control is a serious concern for someone operating an automobile. Yet a person can have three DUIs and not have a problem with substances, or have a mild problem because they may arguably experience only one or two symptoms on the list.
The line one "crosses" between substance abuse and dependence may be nebulous and impossible to define, but the definition of alcoholism offered by Alcoholics Anonymous, that "an alcoholic is a person who can't guarantee his behavior after the first drink" is still the most practical explanation of what constitutes a serious problem.
Colleagues of mine have sometimes debated with me about whether our clients are truly "alcohol dependent" as opposed to "alcohol abusers," and I must admit that it doesn't take as much abuse of alcohol as it used to for a person to have serious alcohol related problems. When I first started as a substance abuse counselor in the seventies, the typical treatment client was a middle aged man with an enlarged liver, pancreatitis or esophageal varices who drank a fifth a day and had a few DUIs, but still had a license. These days his life would be disrupted by legal problems before the condition ever progressed to serious health issues.
But the argument that "I'm not that bad" from someone with enough DUIs to constitute a felony is a hollow argument, regardless of whether they have actually been convicted of a felony. To explain this to my clients, I often use the following example: if a person drinks everyday, and only drinks to excess 1% of the time, but every time he drinks to excess he gets behind the wheel and gets arrested, how many DUIs does he have at the end of a year? The answer, of course, is 3.65 DUIs. Now, a person is probably not going to get arrested every time he drinks and drives, but if he got pulled over one of every ten times he drove drunk, he would still have three DUIs within a ten year period. For this particular type of drinker, the only way to guarantee that he will not be a problem for himself or others behind the wheel is to quit drinking. It is also the only way that he will get his license back and keep it.
So why quibble over the word dependence? Every treatment professional knows that physical addiction is the least problematic part of addiction to any substance. Anyone can be detoxed relatively painlessly. The problem is not how to sober someone up; it is how to keep them sober. Einstein's definition of insanity is to continue to repeat the same behavior while expecting a different result. This is the kind of insanity the alcohol and drug addict exhibits. Moreover, anyone but an addict will have success with a method of behavior and will want to continue to repeat the successful behavior. Not so with an alcoholic or an addict. Often, as soon as they are out of the woods they will drop the behavior that has been working and go back to the environment, the people, and the substance of choice that got them into trouble to begin with.
What needs to be treated is the thought process that will tell an otherwise intelligent person that he needs to go to the liquor store to buy a loaf of bread. If I didn't believe in the subconscious mind before I began treating addiction, I would surely have understood it soon enough. The need to bring the decision making process into the conscious mind and keep it there is the essence of all effective substance abuse treatment (including AA), and that process must be black and white. Gray areas that give the addict's mind room to maneuver will be used to his disadvantage. This is an important distinction between dealing with addiction and other conditions for which a person might present for counseling. The goals and methods of therapy have to be kept clear and simple. It is also important for the forensic client, who will not be able to give "clear and convincing" testimony to hearing officer if he rambles about vague abstractions.
As for the DSM V symptoms themselves, these have long been among the criteria for diagnosing substance abuse and have been available for decades as questions included in the Michigan Alcohol Screening Test (or in my variation, the Michigan Substance Abuse Screening Test). It is worth the time to examine them one by one to understand how they fit into a diagnosis:
Taking the substance in larger amounts or for longer than you meant to--This is perhaps the single most meaningful indicator of loss of control. Often, when I ask the two questions on the MSAST that deal with loss of control (Can you always stop without a struggle after you have begun to drink or use? and, Can you always stop using when you want to?) clients respond with a yes without too much thought. But then I ask them if they ever drank or used more than they intended to when they started out, and the answer is invariably yes. This shows the truth of the Japanese saying, "The man takes a drink; then the drink takes a drink; then the drink takes the man."
Wanting to cut down or stop using the substance but not managing to--This is another indicator of loss of control, but it is a deceptive measure. People who are addicted or on the path of addiction sometimes are able to control their substance abuse for long periods between abusive use--no one starts off sleeping under a bridge. One of the questions I typically ask people to get at this information is what their maximum intake of a substance they abuse is. They typically answer with what their average use is (or what they'd like to believe it is), which demonstrates a selective way of listening, and thinking. Moreover, I often know that their maximum is not, for example "five beers" because they weigh 175 lbs, and it would take a man that size 15 drinks over 3 hours to get to the .30 blood alcohol level he registered on his last DUI. This begs another question, which is, "Who is providing the information upon which you are basing your diagnosis?" Substance abusers are rarely honest with themselves or anyone else regarding either the amount of their abuse or the impact it has themselves or others. What do you think when a smoker tells you he has "cut down?"
Spending a lot of time getting, using, or recovering from use of the substance--Some drugs are a full time job, but even time intensive drugs like heroin or alcohol are not as time intensive if the addict has a lot of money or suppliers who deliver, or if they can mix their drinking or drugging with the job. If you are a rock star, it might be accepted as a given that you have to do a line of coke to give you an edge before you go out before an audience. Whereas, if you are poor and female you might have to sell your body to get enough money to get your fix or even a sufficient quantity of alcohol to get numb. Businessmen and politicians used to consider it normal and acceptable to oil the machinery with large quantities of alcohol, though that may no longer be the case, especially among the new, young high-tech entrepreneurs. How much time you spend using or recovering is also a function of which drugs you use and whether you are taking the drugs legally or illegally. Legal opiates kill more people every year than cocaine and heroin according to the CDC, but how long does it take to fill a script? Do you ever have to recover from doctor induced addiction? Why? Do you want your doctor to go broke? Even potheads can stay high all the time with very little effort. This is a time and cost effective addiction.
Cravings and urges to use the substance--This is another very subjective criterion for a symptom of clinical condition. One of the tricks alcoholics learn is the "hair of the dog that bit you"--the morning drink. Many drinkers learn that if they keep a blood alcohol going all day they never experience withdrawal. But they wouldn't necessarily see that as a reaction to withdrawal unless they had sobered up and acquired a little honesty. Then they might say, "Yea, if I didn't have a martini waiting when I walked in the door, I would be pretty irritable," and recognize that as a withdrawal craving, and an urge rather than a freely made decision to have a drink. Again, who is providing the information?
Not managing to do what you should at work, home or school, because of substance use--Addicts can cover up for a long time, or have others cover up for them, before they ever have to pay the piper. At some level they may know they are not getting the work done, but an important consideration is that the most important jobs--like attending the children's events, or even interacting with them at home--are the first affected. The most common complaint you hear from the children of addicts are not that they were abused, but that their parents was absent; and that "even when he's there, he's not there." Back in the days when I started doing substance abuse treatment, the alcoholics typically did not seek treatment to save the marriage, they came in when the job was on the line. These days, the first indication of a problem is likely to be an arrest, but this is not considered to be a symptom even though it is objective and clearly affects the person's ability to fulfill their home, school and work functions.
Continuing to use, even when it causes problems in relationships--The typical response I get from addicts in these situations is that the relationship problems are not caused by the drinking, but are unrelated. They may even be so bold as to claim the drinking is a response to the marital or other relationship issues. One certainly has to talk to the significant others to make a reasonably accurate assessment of whether the substance abuse is a problem for them. Like the previously discussed symptoms, this information, if given by the client, is highly subjective opinion in a condition that is characterized by denial. Without looking at some objective information it is likely to be missed in a diagnosis.
Giving up important social, occupational or recreational activities because of substance use--It is highly probable that the addict has built his social and recreational activities around the use of his substance of choice, so the most objective way of assessing this symptom is occupational. However, this can be tricky. The addict who lost a job is likely to blame the boss that didn't like him. Moreover, they are also very unlikely to acknowledge underperformance or the failure to advance as being a result of their substance abuse issues. Recovered substance abusers are, however, quick to point out improvements in job performance and status, and increased interest in active pursuits like working out or learning an instrument, instead of "hanging out."
Using substances again and again, even when it puts you in danger--Some drugs are clearly more dangerous than others. Any IV drug user is taking his life into his hands every time he shoots up. A coke addict can seize from snorting, and a tobacco addict is committing slow suicide. However, anyone who gets behind the wheel after having a drink is endangering himself or others. This includes almost everyone who drinks, and is probably too broad a criterion. But I did have one client (and know of another person) who went to prison for a fatal accident in which she had a BAC of .05. It makes one wonder about the wisdom of even legal substances at what most people presume to be legal amounts.
Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance--The cause is often seen by the addict to be the cure, but clearly anyone with a mental health diagnosis does not need any alcohol or any other non-prescribed substance. They also don't need a lot prescribed substances, but it doesn't keep doctors from prescribing benzodiazepines and opiates for people who regularly abuse these and other substances. The physical/medical complications of substance abuse are numerous and well documented, but the dangers of substance interaction perhaps more dangerous and less well known.
Needing more of the substance to get the effect you want (tolerance)--This is typically the first symptoms of an emerging problem and, as such, aught to be the first symptom listed. It sets up the early symptoms of withdrawal mentioned previously, the craving to use, and the loss of control over the frequency and amount of use. It is virtually impossible to have a substance abuse problem without some degree of tolerance. It should be noted that every habitual drinker or user of an addictive substance exhibits some degree of tolerance long before they exhibit other symptoms; i.e., if you can drink six beers in an evening, you have a tolerance to alcohol. Importantly, particularly with sedative drugs, the amount an addict needs to get high keeps increasing, but the amount necessary to kill him doesn't.
Development of withdrawal symptoms, which can be relieved by taking more of the substance--Withdrawal can be as mild as irritation, or as serious as delirium tremens, which can prove fatal. Psychological withdrawal will manifest in most addicts before they experience physical withdrawal, and psychological craving for the substance of choice will continue long after the person has recovered from physical addiction. I have heard a lot of attempts to explain this physiologically, but I am not sure I buy it. Behavior wears grooves, and any habitual behavior is easy to fall back into, especially if that behavior is remembered as being pleasurable. 12-step members condition themselves to "play the tape all the way through," that is, to remember the consequences of substance abuse, not just to entertain the pleasurable fantasy of abusing the desired substance. To stay clean and sober the addict has to be able to convince himself that he likes being abstinent better than he enjoyed his substance. He has to believe that everyday, because the day he doesn't he is back on the merry-go-round. This takes a lot of work, and an understanding of both the psychological and physical aspects of addiction.
…Well you don't have to go to off-Broadway
To see something plain absurd
Everybody's crying mercy
When they don't know the meaning of the word…