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The Debate on Defining Substance Use Disorders

The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association (APA) was created in 1952 to help clinicians standardize diagnoses of mental disorders. The DSM contains descriptions and symptoms related to a variety of mental disorders. According to the APA website, the DSM does not provide recommendations for treatment of mental disorders, but by facilitating accurate diagnosis it enables the delivery of appropriate treatments.   The DSM provides diagnostic codes that are listed in the International Classification of Diseases (ICD).  These codes are used to report diagnoses for purposes such as insurance reimbursement and to track causes of illness and death.


Since its creation fifty-nine years ago the DSM has been updated periodically to integrate new research findings from the behavioral sciences, genetics and neurology. The latest edition of the DSM, to be called DSM-5 includes significant changes for clinical professionals. These include the elimination of the categories "dependence" and "abuse" to be replaced by one new category "substance use and addictive disorders".   In addition, a new item, "cravings", will be introduced as one of the criteria for substance use and addictive disorders.  

In the May 23 edition of Alcoholism & Drug Abuse Weekly (ADAW) these changes to the DSM are explained and debated.  Those who support the changes think that doing away with "dependence" as a category for a mental disorder is logical because people who take maintenance medications such as Methadone and Buprenorphine (both used to treat opioid addiction) or who use opioid medication for chronic pain are dependent on these drugs for their treatment, however, they are not considered to have a substance use disorder. 

According to NIDAMED, "physical dependence in and of itself does not constitute addiction, but often accompanies addiction. This distinction can be difficult to discern . . . As used in maintenance treatment, buprenorphine and methadone are not heroin/opioid substitutes. They are prescribed or administered under monitored, controlled conditions and are safe and effective for treating opioid addiction when used as directed. . . . The cycle of euphoria, crash, and craving—sometimes repeated several times a day—is a hallmark of addiction. . . In contrast, methadone and buprenorphine have gradual onsets of action and produce stable levels of the drug in the brain; as a result, patients maintained on these medications do not experience a rush, while they also markedly reduce their desire to use opioids." (NIDA, Principles of Drug Addiction Treatment: A Research Based Guide, http://www.nida.nih.gov/podat/faqs3.html, accessed 8-1-2011)

Another upcoming change was designed to achieve more comprehensive diagnosis and treatment approaches.  The current version of DSM organizes disorders by categories, with a specific list of symptoms for each mental illness.  The categories of symptoms, however, do not always fit the actual range of symptoms that the patient experiences.  For instance, patients with Schizophrenia often have other problems such as insomnia that are not included as symptom criteria to diagnose Schizophrenia.  The new version, DSM-5 will enable clinicians to evaluate patients for an expanded range of symptoms they may be experiencing.  Those in favor of these changes feel that broader assessments of patients’ (referred to by APA as dimensional assessments) will help doctors and clinicians better understand the severity and range of symptoms and furthermore, may be used to gauge patients’ treatment progress.    Moreover, this approach may be helpful in treating people who have not been diagnosable using the categories in the current edition, the DSM-IV-R.

The addition of "cravings "as a criterion has met with resistance; some feel "cravings" is too undefined to be included as an item while others argue that "cravings" will increase the possible number of patients, which is not a bad thing if it means more people will receive treatment.

For others, the central issue is whether or not the APA should have a monopoly on defining substance use disorders. Some substance abuse treatment providers feel that psychiatrists may not fully understand addiction issues in the same way that they do. The APA accepted and encouraged comments about the proposed changes on their website until 5/13/11. The new edition of the DSM-5 will be published in 2013.


Alcoholism & Drug Abuse Weekly, News for policy and program decision makers. Volume 23, Number 20. May 23, 2011.

American Psychiatric Association (APA). Retrieved from http://www.dsm5.org/about/pages/faq.aspx

National Institute on Drug Abuse (NIDAMED). Retrieved from http://www.nida.nih.gov/podat/faqs3.html

By Courtney Stewart,   8/1/2011