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The New DSM Criteria for Substance Use Disorder: What Does It Mean for TTSs?

I served as a consultant on nicotine to the DSM-V Workgroup on Substance Use Disorders and thought you might like to know about how The American Psychiatric Association has pretty much decided on the new criteria for substance use disorders ( DSM-IV had two categories “Substance Dependence” and “Substance Abuse.” The former included seven criteria indexing tolerance, withdrawal and loss of control criteria. The later included four criteria indexing harm from substance use. However, since these four all indexed harm from intoxication and illegal use and since nicotine use causes neither, DSM-IV did not include Nicotine Abuse

The DSM-V has subsumed both under one new category called “Substance-Use Disorders” (see below for a recent draft). The main rationale was that the abuse items were very similar to the loss of control items and seemed to predict the same outcomes as the dependence items. One of the abuse items “legal problems” was deleted and “craving” was added In addition, the term “dependence” was dropped because to many that term only indexed tolerance and withdrawal, not loss of control. Some wanted to use the term “addiction” but that was turned down.

Finally, the number of criteria for a diagnosis was changed from 3 of 7, to 2 of 11. Given this one would think the prevalence of a diagnosis would dramatically increase. The two studies that have tested this found the incidence of nicotine disorder increased from 60% to 86% for past year disorder among young adults who smoked in the last 30 days(Addiction 107:810) and from 72% to 87% lifetime disorder among lifetime smokers (Shmulewitz et al, Psychol Med 2013). Some might think this appropriate for nicotine dependence because population-based surveys have found only about half of current daily smokers meet DSM-IV criteria for current nicotine dependence (Drug Alcohol Dep 85:91).

However, the real problem is that neither the DSM-IV nor the DSM-V criteria robustly predict inability to quit or response to treatment (Addiction 101- suppl 1: 134; Addiction 107:263) whereas the Fagerstrom Test for Tobacco Dependence has done so. This is probably because many of the DSM criteria were developed for alcohol/opiate dependence and appear not to be readily applicable to nicotine and because DSM lacks validated criteria such as time to first use.

In summary, until the DSM criteria are shown to predict long term smoking cessation or who does better with certain treatments, I think best to use the Fagerstrom Test –or even just time to first cigarette (TTFC) as it is the main predictor in the Fagerstrom test. However, although the Fagerstrom test and TTFC predicts who needs higher doses, they do not predict response to buproprion or varenicline. So I think measures of nicotine dependence are best used to indicate that someone will likely need treatment in order to have a good likelihood of quitting. There are several other more lengthy measures of nicotine dependence that are being developed in a very systematic manner (NTR 8:339) and perhaps in the future these will prove more useful.

Draft of DSM-V criteria for Substance Use Disorder

Tolerance, as defined by either of the following:

  1. A need for markedly increased amounts to achieve intoxication or desired effect.
  2. Markedly diminished effect with continued use of the same amount.

Withdrawal, as manifested by either of the following:

  1. The characteristic withdrawal syndrome or
  2. Use of substance or a closely related substance to relieve or avoid withdrawal symptoms.

Often taken in larger amounts or over a longer period than was intended.

Persistent desire or unsuccessful efforts to cut down or control use.

A great deal of time is spent in activities necessary to obtain, use, or recover from its effects of substance.

Craving, or a strong desire or urge to use.

Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home.

Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

Important social, occupational, or recreational activities are given up or reduced because of use.

Recurrent use in situations in which it is physically hazardous.

Use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by substance