DSM-5 Made A Mistake Eliminating Substance Abuse

DSM-5 made a mistake when it joined together into one big, heterogeneous category ('Substance Use Disorder') what in DSM IV had been two quite different diagnoses ('Substance Abuse' and 'Substance Dependence').

In DSM IV, Substance Abuse described someone who gets into recurrent, but intermittent, trouble as a consequence of recreational binges.

In sharp contrast, DSM IV Substance Dependence described a continuous and compulsive pattern of use, often with accompanying tolerance and withdrawal.

The two DSM IV diagnoses have radically different implications for treatment planning and for prognosis. Artificially lumping them together in DSM-5 forces inaccurate diagnosis, loses critical clinical information, and stigmatizes as addicts, people whose substance problem is often temporary and influenced by contextual and developmental factors.

A college kid who binges occasionally on weekends can get into serious trouble and often requires an immediate intervention, but is very different from someone whose life revolves around drugs and who can't get through a day without them. The majority of substance abusers are in a passing phase, never become addicted in any meaningful sense of that word, and require a very different treatment approach than those who really are addicted. And lumping abusers with the addicted creates unfortunate stereotypes that jeopardize future marital and job prospects, legal status, and insurance eligibility.

The DSM-5 workgroup based its rationale for dropping Substance Abuse on studies suggesting that there is no bright line boundary separating Abuse from Dependence. The results of these studies are certainly not definitive and their interpretation was flawed by a basic DSM-5 misunderstanding of the nature of psychiatric diagnosis. All DSM disorders overlap with other DSM disorders and also frequently with normality. Fuzzy boundaries among near neighbors are ubiquitous and inherent to the entire diagnostic system in psychiatry and are not sufficient excuse to collapse distinctions that are clinically valuable. There was no problem that needed fixing or matter of principle at stake. The change was radical, creates obvious harms, and provides no apparent benefit.

What to do? My suggestion to clinicians is simply to ignore the DSM-5 change. It is perfectly appropriate and clinically preferable to continue making the valuable distinction between Substance Dependence and Substance Abuse. In what follows, I will explain why and indicate how appropriate and easy it is to retain Substance Abuse within the rules of the ICD-10- CM coding system.

Substance Abuse vs Substance Dependence vs Normal Use

There are cases that straddle the boundary between Substance Abuse and Substance Dependence, but much more often they are easily distinguished by marked difference in behavior, treatment needs, and prognosis.

In contrast to Substance Dependence, Substance Abuse is defined by its absence of tolerance, withdrawal or compulsive use. The typical substance abuser gets into recurrent but intermittent (often weekend) trouble as a consequence of episodic recreational binges. He goes through periods when he can take or leave the substance, use it in a controlled way, or abstain altogether. Then comes a binge with bad outcome, then another peaceful period, then another binge, and so on. The label Substance Abuse implies an intervention directed to the harmful consequences of the binges, how to avoid them, and the substitution of other less dangerous recreational activities.

The label Substance Dependence alerts the clinician to the importance, but great difficulty, of achieving abstinence and the significant risk it will trigger severe physiological or psychological withdrawal unless done under close medical supervision. Treatment and rehabilitation services will need to be much more intense, continuous, and long-term.

There is also a considerable difference in prognosis between Substance Abuse and Substance Dependence -while some go on from an early history of substance abuse to later dependence, the majority do not and are much more likely to have an early and permanent remission.

The differential diagnosis of Substance Abuse must also distinguish it from normal, recreational substance use. Substance Abuse is a mental disorder- a label that should not be applied casually to everyone who experiences an occasional episode of substance excess. A few binges does not a mental disorder make or else almost all of us would qualify as mentally disordered at some point in our lives. Binging is always ill advised, risky, and unfortunate, but does not indicate mental disorder unless and until it becomes part of a repetitive pattern that causes significant distress, impairment and/or legal consequences. The person doesn't learn from the repeated painful experience that a couple of drinks (or snorts or pills or joints) can lead to a binge and that a binge can, and often does, have serious (and sometimes even catastrophic) consequences.

In DSM IV, the definition of Substance Abuse is "a maladaptive pattern of substance use manifested by significant adverse consequences" in at least one of four different domains of trouble: 1) driving under the influence; 2) other legal problems (e.g., disorderly conduct, assault, etc.); 3) reduced performance at work or school, and; 4) problems with interpersonal relations and family life.

Prognosis and Risks

For some, Substance Abuse is a stably unstable life pattern- but most people either outgrow it or go on to Substance Dependence. The threshold between the two is crossed when the periodic bingeing turns into continuous use and the motivation switches from pleasurable recreation to needing the substance on a regular basis just to get by.

The risks of Substance Abuse must not be missed or minimized. It can be one of the most dangerous disorders in all of psychiatry- sometimes leading to DUI's and car accidents; raping or being raped; shootings; fights; other crimes; getting fired for using on the job; marital discord; neglect of parental responsibility; and/or spending excessively. Substance Abuse is perhaps the strongest indication in psychiatry for early identification and active intervention- both to prevent the risk of later substance dependence and to avoid the catastrophic harms that can arise from any given binge.

How To Code Substance Abuse

It turns out that including Substance Abuse is much truer to the official coding system than dropping it. All of the official diagnostic codes, used in the US and around the world, are provided by the International Classification of Disease (ICD). DSM codes are merely a subset derived from ICD codes. The editors of DSMs simply pick the ICD codes they feel most resemble the categories they have chosen to include in DSM. There is nothing sacred or official about the DSM-5 choices -- I know because I made the choices for DSM-IV. The ICD coding system is official; the DSM codes are just one groups' fallible adaptation of them.
It is of great significance that the official coding in ICD-10-CM does not follow the DSM-5 decision to eliminate Substance Abuse. Instead, ICD-10-CM retains the DSM-IV terminology and continues to provide separate Substance Abuse and Substance Dependence codes for each of the major classes of substances. Thus, the code for Alcohol Abuse is F10.10; Opioid Abuse is F11.10; Cannabis Abuse is F12.10, etc. with the 3rd character in each case indicative of the specific class of substance.

Also telling is the position taken by the ICD-11 workgroup currently revising the labels and codes that will be used in the next version of the international coding system. They have flatly rejected the DSM-5 change and will continue to separate Substance Dependence and Harmful Substance Use- having 
concluded that these two separate categories are needed for both public health and clinical reasons. The DSM-5 mistake thus places it out of line with ICD-10, ICD-11, previous DSM's, and well established clinical practice.

Clinicians remain truer both to clinical reality and to ICD coding when they ignore the new DSM-5 lumping of substance use disorders and instead continue to distinguish Substance Abuse from Substance Dependence. DSM's are explicitly meant to be used only as guides, not worshiped as bibles. Clinicians are free to ignore DSM whenever it makes mistakes that go against clinical common sense and the International coding system.

This article was originally published on Recovery Brands' Pro Talk/Pro Corner

Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.