What’s wrong with Our View of Substance Use Disorders?

A problem that exists in both substance use and mental health disorders is that there is no direct measurement of the disorders. We identify them indirectly by self-report, observing behaviors, employing screening and assessment instruments, and obtaining reports from collaterals. This stands in stark contrast to most medical illnesses.

If there is a concern that I might have diabetes, I would be instructed to have nothing by mouth after midnight and the following day I would have lab work in which blood is drawn to determine my blood sugar level. This is direct measurement. If there is concern that I am hypertensive, my blood pressure would be directly measured with a sphygmomanometer (blood pressure meter), possibly in both arms and possibly at a number of different points in time. This number (or average) is then compared to a standard for desired blood pressure, which is generally 120/80 for adults. This is also direct measurement. There is nothing comparable to this in the behavioral health field. The best example of this deficiency is the DSM, which is a consensus document—a group of experts providing their best beliefs about what constitutes a diagnosis—but lost in this process is validity. Does this measure what it purports to measure?

While left unsaid, whether talking to researchers, clinicians or individuals in recovery support groups, it appears that substance use disorders are viewed as a unidimensional phenomenon. We speak of “alcoholism,” “substance abuse” or “addiction” as if the term describes the disorder. In fact, it does not, any more than “cancer” describes that disease. 

Cancer denotes a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body, just as addiction is a state characterized by compulsion, loss of control, continued use despite adverse consequences, and craving. But like cancer, the term denotes a series of different related disorders or diseases. There are a variety of different types of cancer that affect different parts of the body (e.g., breast, brain, blood) just as there are different types of substance use disorders (e.g., alcohol. opioid, cannabis). Even these distinctions are insufficiently precise.

Cancers are further designated by the degree of severity—a process known as “staging.” Staging cancers may help determine what treatments are likely to be most beneficial and in the most severe cases, provide estimates of time remaining. Returning to our hypertensive analogy, blood pressure can be categorized as prehypertension, or stage one or two hypertension or a hypertensive emergency, depending on the systolic and diastolic blood pressure numbers. In contrast, many treatment programs employ a “one size fits all” approach, as if addiction was in fact a unidimensional phenomenon.

There is some movement toward the goal of more precise measurement in substance use disorders. There are stages of Readiness to Change in Prochaska and DiClemente’s Transtheoretical Stages of Change model, but identifying the stage of readiness to change still cannot be done by precise measurement (Prochaska, DiClimente, & Norcross, 1992). The DSM-5 has, in my opinion, made a step forward for substance use and all of the other mental health disorders. It has moved from a categorical approach (e.g., substance abuse or substance dependence) where you either exhibited sufficient signs and symptoms or you did not; where you either met criteria or you did not; where you either met the diagnosis or you did not, to a continuum approach (APA, 2013). Each diagnosis in the DSM-5 now has severity scales: mild, moderate or severe. Although, interestingly, some different severity levels for some diagnoses carry the same CPT codes (APA, 2013).

Another step forward is the introduction of “crossing cutting symptoms” for all the DSM-5 diagnoses. There are symptoms that are not part of the criteria for diagnosis, but may still exert a significant effect on the patient. They include such things as insomnia, depression, and anxiety and might provide us with a more comprehensive picture of the patient.

However, this severity system is further flawed for substance use and the other mental health disorders because it assumes—as did the DSM-IV—that all the criteria carry the same weight in making the diagnosis, while in fact they do not. One exception in the DSM is found in the diagnostic criteria for major depressive disorder, which requires meeting five of the nine criteria. However, at least one of the five criteria must be depressed mood for most of day, nearly every day or loss of interest or pleasure, demonstrating that all nine criteria are not weighted equally.

Returning to substance use disorders, Dr. Norman Hoffmann through his research has determined that some of the substance use disorder criteria are found only in the mild to moderate category, some in the severe category, and some are associated with no diagnosis at all such as tolerance, which is a function of practice (if an individual stops drinking for a period of time and then resumes drinking, the same level of intake will have a greater effect). Those criteria generally associated with the severe designation, which he describes as the “Big Five,” are (Kopak, Proctor, & Hoffmann, 2012; Kopak, Metze, & Hoffmann, 2014; Proctor, Kopak, & Hoffmann, 2012):

1. Wanting to cut down, but unable to do so
2. Craving with compulsion to use
3. Sacrificing activities to use
4. Failure at role fulfillment due to use
5. Withdrawal symptoms

He hypothesizes that patients who meet none of the Big Five may be able to benefit from psychoeducation; low intensities of treatment, such as outpatient care; and can have harm reduction as a goal, such as not drinking and driving rather than abstinence. On the other hand, individuals who meet at least three of the Big Five are going to have a more difficult time recovering, will experience more relapse, will require higher intensities of treatment, and should have abstinence as the only goal.

Additional research has demonstrated that there are four demographic variables that lend more weight to outcome than the treatment itself: 

1. Under twenty-five years of age
2. Never married or having lived as married
3. Unemployed
4. No high school diploma or GED

In fact, adding one point to each variable predicts relapse and recidivism in a criminal justice population at one year (Kopak, Hoffmann, & Proctor, in press; Zywiak, Hoffmann, & Floyd, 1999). 

In conclusion, we are moving toward more precise and direct measurement, but that goal will be more likely to be achieved as a result of brain imaging and genetic research rather than future editions of consensus documents.

American Psychiatric Association (APA). (2013). The diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Press. 

Kopak, A. M., Hoffmann, N. G., & Proctor, S. L. (in press). Key risk factors for relapse and rearrest among substance use treatment clients involved in the criminal justice system. American Journal of Criminal Justice.

Kopak, A. M., Metze, A. V., & Hoffmann, N. G. (2014). Alcohol use disorder diagnoses in the criminal justice system: An analysis of the compatibility of current DSM-IV, proposed DSM-5.0, and DSM-5.1 diagnostic criteria in a correctional sample. International Journal of Offender Therapy and Comparative Criminology, 58(6), 638–54.

Kopak, A. M., Proctor, S. L., & Hoffmann, N. G. (2012). An assessment of the compatibility of DSM-IV and proposed DSM-5 criteria in the diagnosis of cannabis use disorders. Journal of Substance Use and Misuse, 47(12), 1328–38. 

Prochaska, J. O., DiClimente, C. C., & Norcross, J. S. (1992). In search of how people change application of addictive behaviors. The American Psychologist, 47(9), 1102–14

Proctor, S. L., Kopak, A. M., & Hoffmann, N. G. (2012). Compatibility of current DSM-IV and proposed DSM-5 diagnostic criteria for cocaine use disorders. Addictive Behaviors, 37(6), 722–8. 

Zywiak, W. H., Hoffmann, N. G., & Floyd, A. S. (1999). Enhancing alcohol treatment outcomes through aftercare and self-help groups. Medicine & Health/Rhode Island, 82(3), 87–90.