What The DSM-5 Definition of "Substance Use Disorder" Doesn't Tell Us
All "Substance Use Disorders" Are Not Equivalent
The SAMHSA National Survey on Drug Use and Health reports place heavy emphasis on the label of “Substance Use Disorder.” The category is apparently intended to identify the proportion and number of Americans who have developed a dysfunctional relationship with their substance(s) of choice.
Substance Use Disorder is defined by the American Psychological Association’s Diagnostic Statistical Manual-5 (DSM-5) using the same basic set of 11 criteria for all substances. The website VeryWellMind quotes the APA DSM-5 criteria , below:
“Substance use disorders span a wide variety of problems arising from substance use, and cover 11 different criteria:
Taking the substance in larger amounts or for longer than you're 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 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 eleven criteria outlined in the DSM-5-TR can be grouped into four primary categories: physical dependence, risky use, social problems, and impaired control…”
The site also lists the substances for which the APA definition of SUD applies. (The SAMHSA NSDUH reports focus on a different selection of substances than the APA, and the NSDUH lists have changed over the years; I’ll have more to say about that in another post.)
To continue:
“The DSM-5-TR recognizes substance-related disorders resulting from the use of 10 separate classes of drugs:
Alcohol
Caffeine
Cannabis
Hallucinogens
Inhalants
Opioids
Sedatives
Hypnotics, or anxiolytics
Stimulants (including amphetamine-type substances, cocaine, and other stimulants)
Tobacco
The site also notes that“While some major groupings of psychoactive substances are specifically identified, the use of other or unknown substances can also form the basis of a substance-related or addictive disorder.”
The site also quotes the means used by the APA to determine the severity of SUD:
Severity of Substance Use Disorders
The DSM-5-TR allows clinicians to specify how severe or how much of a problem the substance use disorder is, depending on how many symptoms are identified.
Mild: Two or three symptoms indicate a mild substance use disorder.
Moderate: Four or five symptoms indicate a moderate substance use disorder.
Severe: Six or more symptoms indicate a severe substance use disorder.
Clinicians can also add “in early remission,” “in sustained remission,” “on maintenance therapy” for certain substances, and “in a controlled environment.” These further describe the current state of the substance use disorder.”
Ergo, the relative severity of Substance Use Disorder is diagnosed simply on the basis of the total number of symptoms drawn from that list of 11 criteria (or “symptoms.”)
This is misleading. To give an example of why I find this to be so, consider this entirely plausible hypothetical example of a person found with the following six symptoms of SUD:
(1)Taking the substance in larger amounts or for longer than you're meant to
(2)Wanting to cut down or stop using the substance but not managing to
(4)Cravings and urges to use the substance
(9)Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance
(10) Needing more of the substance to get the effect you want (tolerance)
(11) Development of withdrawal symptoms, which can be relieved by taking more of the substance
According to the explicitly stated APA symptom criteria, anyone answering “yes” to the six questions above is suffering from a Severe Substance Use Disorder- whether the substance being used is coffee or heroin. There’s no acknowledgement in the SUD criteria that there are profound differences in the severity of Substance Use Disorders, derived from the unique properties of the specific substances that might happen to be involved.
Seriously. Who is up for making the case that anyone checking 6 or more of the 11 symptoms on the SUD list in the throes of a Severe Substance Use Disorder- whether they’re a nurse stealing medications from their patients to feed their opioid addiction, or an office worker who drinks six cups of coffee a day and experiences chronic insomnia and occasional palpitations?
The same elision of the intensity of habituation and dysfunctionality is true for all of the other substance categories covered by the APA Substance Use Disorder definition, of course. The conflation of the array of substances covered by the SUD label allows for no differentiation between “yes” answers from respondents- whether prompted by the excessive use of cannabis, a glue huffing habit, a physical dependency on alcohol so severe that it leads to delirium tremens and convulsions, or the requirement of dire necessity to resort to the Russian roulette of the street fentanyl market. It’s all about how many perceived SUD “symptoms” elicit a “yes” answer. The actual amount of extant harm or hazard is absent from the measurement. It’s sufficient that it’s perceived to be present.
In that regard, it’s also noteworthy that in the case of criminalized substance use, a few of the criteria can just as plausibly manifest on account of the exclusions and denigrated social status attendant to user criminalization. Items #3, #5, #6, and #7, most notably.
The DSM-5 does make some effort to account for the profound differences between substances in terms of their widely varying potential to produce a threat to public health and safety, serious or long-lasting physical harm, grave behavioral toxicity, intractable physical dependency, and/or single-minded obsession with habitual use, but the manual supplies a different label to attach to such concerns: “Substance Induced Disorders”, or SID. SID is different from SUD. SID covers a set of behavioral phenomena that shares some overlap with the 11 criteria used for SUD, but there’s no checklist for it, only a set of three subcategories: substance-induced mental disorders, intoxication, and withdrawal.
Readers who are curious about the definitions used to determine the presence of those behavioral syndromes and the extent of dysfunctionality can refer to the summary found in the same VWM article that I’ve quoted above, down the page. I’m not going to quote it all here. I’m simply noting that the set of symptoms used to define Substance Use Disorder (SUD) and the dysfunctions labeled as Substance Induced Disorders (SID) comprise two separate sets of conditions, as far as the APA is concerned.
It appears to me that the DSM-5’s defined separation of the two Disorders has opened up the potential for an unfortunate amount of confusion, including exploitation for the purpose of pettifoggery and shell-game legerdemain that’s all too often the stock in trade of oppressive bureaucracies. I doubt that this was intended by the APA; conceivably, the the distinctions of the separation of SUD from SID provide some useful diagnostic benefit for clinicians and therapists. But it also has to be said that diagnoses of “dysfunctional drug abuse” and “addiction” that are based solely on the 11 symptoms listed to determine SUD are incorrectly inferred.
The confusion elicited by that unclarity would probably be a matter of only minor concern, if it weren’t for the fact that an agency of the Federal government, the Substance Abuse and Mental Health Services Administration, is currently relying on the DSM-5 definition of SUD as their baseline measure to estimate the extent of the US “illicit drug abuse” problem for the purpose of crafting decisions of Federal policy- including items like Federal funding for drug rehabilitation efforts, and decisions related to the Federal response to recent efforts by the States to legalize marijuana.