Transcript Alcohol Use Disorders US - NCADD

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

Workgroups convened in 2008 to update the criteria for
different sections

Decisions and text finalized December 31, 2012

Due for publication May, 2013
Substance Related Disorders Workgroup
• Charles O’Brien, M.D., Chair • Thomas Crowley, M.D.
• Marc Auriacombe, Ph.D.
• Bridget Grant, Ph.D. , Ph.D.
• Guilherme Borges, Ph.D.
• Deborah S. Hasin , Ph.D.
• Kathleen Buchholz, Ph.D.
• Walter Ling, M.D.
• Alan J. Budney, Ph.D.
• Nancy M. Petry, Ph.D.
• Wilson M. Compton, M.D.
• Marc A. Schuckit M.D.
Substance Use Disorder Criteria: DSM-IV
Abuse
Dependence
Failure to fulfill major role obligations
X
--
Hazardous use
X
Substance-related legal problems
X
Social/interpersonal substance-related problems
X
--
Tolerance
--
X
Withdrawal
--
X
Persistent desire/unsuccessful efforts to cut down
--
X
Using more or over for longer than was intended
--
X
Neglect of important activities
--
X
Great deal of time spent in substance activities
--
X
Psychological/Physical use-related problems
--
X
1+ criteria
3+ criteria
Diagnostic Criteria
Diagnostic Threshold
1+
---
3+
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Text Revision. Washington, DC, American Psychiatric Association, 2000.
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?
Primary Studies contributing to DSM-5 decisions
Sample
# Studies
Ns
Locations
17
722 - 43,093
Australia, Israel, US
2
5,195
Argentina, Mexico,
Poland, US
Adult substance abuse
treatment
5
372 - 1,511
Australia, US
Adult genetic studies
4
496 - 9,313
US
Adolescent general
population
4
353 - 3,641
France, US
Adolescent substance
abuse treatment
2
279 - 472
US
Adolescent mixed
2
5,587
US
Adult general population
Adult emergency room
Columbia University
Deborah Hasin, Ph.D.
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
NESARC ICC
Current Cannabis Abuse, Dependence (N=1,603)
Compton, Saha, Grant et al., Drug and Alcohol Dependence 2009
NESARC ICC
Lifetime Cocaine Abuse, Dependence (N=2,528)
1.00
0.90
Probability of Symptom Endorsement
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
3.00
2.80
2.60
2.40
2.20
2.00
1.80
1.60
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
-0.20
-0.40
-0.60
-0.80
-1.00
-1.20
-1.40
-1.60
-1.80
-2.00
-2.20
-2.40
-2.60
-2.80
-3.00
0.00
Severity of Lifetime Drug Use Disorder- Cocaine/Crack (Latent Trait)
Tolerance
Withdrawal
Larger/longer
Quit/control
Time spent
Activities given up
Physical/psychological problems
Neglect roles
Hazardous use
Legal problems
Social/Interpersonal problems
Saha, Compton, Chou, Smith, Ruan, Huang, Pickering, Grant. Drug and Alcohol Dependence 2012
NESARC (2001-2002) ICC
Current Alcohol Abuse, Dependence (N=22,526)
Probability of Symptom Endorsement
1.00
0.90
0.80
0.70
0.60
0.50
0.40
Quit control
Hazardous use
0.30
Tolerance
Withdrawal
0.20
0.10
Severity of Alcohol Use Disorder (Latent Trait)
Tolerance
Withdrawal
Larger/longer
Quit/control
Time spent
Activities given up
Physical/psychological problems
Neglect roles
Hazardous use
Legal problems
Social/Interpersonal problems
Saha, Grant et al., Drug and Alcohol Dependence 2007
3.00
2.80
2.60
2.40
2.20
2.00
1.80
1.60
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
-0.20
-0.40
-0.60
-0.80
-1.00
-1.20
-1.40
-1.60
-1.80
-2.00
-2.20
-2.40
-2.60
-2.80
-3.00
0.00
Combine abuse and dependence
into one diagnosis?
Yes
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
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)
Prevalence of current DSM-IV criteria
in clinical sample (N=663)
Hasin et al., in press Drug and Alcohol Dependence
Columbia University
Deborah Hasin, Ph.D.
Factor loadings, clinical sample
Hasin et al., in press Drug and Alcohol
Columbia University
Deborah Hasin, Ph.D.
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
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)
Prevalence of current DSM-IV criteria and
craving in clinical sample (N=663)
Hasin et al., in press Drug and Alcohol Dependence
Columbia University
Deborah Hasin, Ph.D.
Factor loadings, clinical sample
Hasin et al., in press Drug and Alcohol
Columbia University
Deborah Hasin, Ph.D.
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.
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.
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
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
•
•
•
•
Israeli adult household residents
N = 1,349
AUDADIS interview translated to Hebrew and Russian
NIAAA and NIDA funding
DSM-IV ABUSE Items
Criterion
Social/Interpersonal
Hazardous Use
Neglect Roles
Prevalence
(%)
In your ENTIRE life, did you EVER…
41.3
Continue to smoke even though it made other
people like family members angry or unhappy?
36.3
Smoke in a situation that increased your
chances of getting hurt – like smoking in bed or
smoking around flammable chemicals?
07.7
Find that your smoking interfered with taking
care of your work, school work, or work at
home?
Shmulewitz…Hasin, 2011, Addiction
Columbia University
Deborah Hasin, Ph.D.
Israel ICC (N=732)
Lifetime nicotine abuse, dependence, craving
1
Probability of Criterion Endorsement
0.9
0.8
0.7
0.6
0.5
Tolerance
Withdrawal
0.4
Larger/Longer
Quit/Control
0.3
Time Spent
Activities Given Up
Physical/Psychological
0.2
Neglect Roles
Hazardous Use
0.1
Social/Interpersonal
4
3.6
3.2
2.4
2
1.6
1.2
0.8
0.4
0
-0.4
-0.8
-1.2
-1.6
-2
2.8
Unbearable/Strong Desire
0
Latent Trait Severity
Shmulewitz…Hasin, 2011, Addiction
Columbia University
Deborah Hasin, Ph.D.
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.
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
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
Examples of Naming in the
Alcohol and Drug Field
Abuse
Habituation
Addiction
Harmful Use
Alcoholism
Inebriety
Chemical
Misuse
Dependence
Narcomania
Dependence Syndrome Psychoactive Substance
Dipsomania
Pseudoaddiction
Drug
Substance
Kelly and Westerhoff: “Abuse” More
Stigmatizing Than “Use Disorder”
Vignette study of 516 clinicians
showed lower perpetratorpunishment responses when
faced with the substance use
disorder label compared to the
substance abuser label.
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)
Perpetrator-Punishment
Scale
3
2.9
2.8
2.7
2.6
2.5
2.4
2.3
2.2
2.1
2
p = .02
PerpetratorPunishment
Scale
Substance Substance
Use
Abuser
Disorder
Kelly JF, Westerhoff CM. International J Drug Policy 2009
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.
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.)
Workgroup Recommendations:
Chapter Heading
Substance-Related Disorders and Gambling
Disorders
(….but definite lack of consensus…)
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
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
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
SF-12 Mental/Psychological Functioning
by Alternate Severity Measures
SF-12 mental/psychological functioning
(NBMCS), by alternate severity measures
55.0
Number of criteria
Severity score
SF-12
50.0
45.0
40.0
0
1
2
3
4
5-6
Number of criteria/severity equivalent
Grant et al, in preparation
7-8
9+
Reliability of Self-Report Measures
of Consumtion
Test-Retest Reliability of Adult Self-Rated DSM-5 CrossCutting 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
Reliability of Self-Report Measures
of Consumption
Test-Retest Reliability of Child (11+ years) / Parent SelfRated 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
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).
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?
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
% Concordant among
individuals where DSM-IV
dependence is:
DSM-5 SUD threshold
for the number of
positive criteria
Kappa
Positive
(Sensitivity)
Negative
(Specificity)
% Concordant among
individuals where DSM-5 SUD
threshold is:
Positive
(PPV)
Negative
(NPV)
Opioids (n=264):
3+
.856 (.026)
100.0 (0.0)
97.1 (1.1)
77.1 (7.3)
100.0 (0.0)
4+
.835 (.029)
87.0 (7.6)
98.3 (0.9)
83.2 (7.1)
98.7 (0.8)
5+
.727 (.039)
64.5 (10.4)
99.2 (0.6)
88.9 (7.5)
96.6 (1.2)
6+
.724 (.040)
59.0 (10.7)
100.0 (0.0)
100.0 (0.0)
96.1 (1.2)
3+
.428 (.016)
100.0 (0.0)
88.9 (1.0)
30.6 (3.5)
100.0 (0.0)
4+
.614 (.018)
99.3 (0.7)
94.5 (0.7)
47.0 (4.5)
100.0 (0.0)
5+
.757 (.017)
95.6 (2.1)
97.4 (0.5)
64.6 (5.5)
99.8 (0.1)
6+
.781 (.018)
78.6 (5.2)
99.0 (0.3)
79.7 (5.4)
98.9 (0.3)
Cannabis (n=1,622):
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
DSM-5 SUD threshold
for the number of
positive criteria
Kappa
% Concordant among
individuals where DSM-IV
dependence is:
% Concordant among
individuals where DSM-5 SUD
threshold is:
Positive
(Sensitivity)
Positive (PPV) Negative (NPV)
Negative
(Specificity)
Cocaine (n=271):
3+
.734 (.022)
100.0 (0.0)
85.8 (2.9)
67.5 (5.8)
100.0 (0.0)
4+
.864 (.018)
96.2 (3.7)
94.6 (1.8)
84.1 (4.7)
98.8 (1.2)
5+
.852 (.019)
86.7 (5.5)
97.3 (1.4)
90.4 (4.7)
96.1 (1.7)
6+
.760 (.025)
69.8 (6.9)
99.0 (0.7)
95.3 (3.3)
91.7 (2.3)
3+
.802 (.003)
100.0 (0.0)
96.2 (0.2)
69.5 (1.1)
100.0 (0.0)
4+
.830 (.003)
82.6 (1.1)
98.8 (0.1)
86.0 (1.2)
98.5 (0.1)
5+
.720 (.005)
60.0 (1.4)
99.8 (0.1)
95.4 (1.2)
96.7 (0.2)
6+
.568 (.006)
41.8 (1.3)
100.0 (0.0)
99.6 (0.3)
95.3 (0.2)
Alcohol (n=23,013):
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
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.
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.
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.
Substance Use Disorder Criteria: DSM-IV and DSM-V
DSM-IV
DSM-5
Abuse
Dependence
Substance Use Disorder
Failure to fulfill obligations
X
--
X
Hazardous use
X
--
X
Substance-related legal problems
X
--
--
Social/interpersonal substance-related problems
X
--
X
Tolerance
--
X
X
Withdrawal
--
X
X
Persistent desire/unsuccessful efforts to cut down
--
X
X
Using more or over for longer than was intended
--
X
X
Neglect of important activities
--
X
X
Great deal of time spent in substance activities
--
X
X
Psychological/Physical use-related problems
--
X
X
Craving
--
--
X
1+ criteria
3+
Criteria
Mild: 2-3
Moderate: 4-5
Severe: >5
Diagnostic Criteria
Diagnostic Threshold
11
criteria