Definitional Problems. The first two symptoms
of the DSM-IV’s substance dependence
diagnosis--tolerance and withdrawal-- reflect
physiological dependence on a substance as a
result of its regular use.^171 There has been
considerable confusion about the difference
between physiological dependence on a
substance and addiction involving that
substance. This is further confused by the use of
the same term “dependence” to apply to both
conditions.
According to the DSM-IV diagnostic criteria,
tolerance and withdrawal symptoms neither are
necessary nor sufficient for a diagnosis of
substance dependence^172 (e.g., an individual may
meet diagnostic criteria for addiction involving
cocaine or methamphetamine in the absence of
symptoms of tolerance and withdrawal).^173
There also are cases where an individual is
physically dependent on a substance but does
not meet clinical criteria for addiction.^174 This
occurs relatively frequently in relation to the use
of controlled prescription pain relievers.*
Prolonged use of these medications may result in
physical symptoms, including tolerance and
withdrawal as a result of the body’s adaptation
to taking the drug,^175 but may not include the
loss of control and other behavioral symptoms
associated with addiction.^176
Other symptoms of substance dependence also
can be observed in patients legitimately using
certain prescription medications.^177 For
example, if a patient’s pain is under-treated, he
or she may become preoccupied with finding a
pain medication or may take a pain medication
for a longer time than originally was
prescribed.^178 Mischaracterizing this behavior as
addiction may result in further withholding of
legitimate pain treatment.† 179
Issues have been raised with regard to the
reliability and validity of the nicotine
- Opioids.
† While the under-treatment of pain has been
acknowledged, there are emerging indications that
many physicians may now be overprescribing
addictive opioid medications for the treatment of
patients with non-malignant chronic pain.
dependence criteria as well: they have been
described as ambiguous, failing to address
important aspects of addiction involving nicotine
such as craving, too subjective and intertwined
with an individual’s social context (e.g., with
regard to assessing the “costs” of continued use)
and limited in their ability to predict key
outcomes such as extent of tobacco use,
withdrawal severity and likelihood of future
cessation.^180Proposed Modifications to the DSM Diagnostic
Criteria. Partially because of these definitional
problems, work is under way to redefine and
reorganize the DSM’s diagnostic criteria for
substance use disorders. These revisions are
proposed to be included in the upcoming DSM-
V version, which is estimated to be released in
May 2013.^181 Among the proposed revisions is
the suggestion to replace the two categories of
substance abuse and substance dependence with
a single diagnostic category of substance use
and addictive disorders.‡ 182 This modification
recognizes a broad category of addiction
including substance addiction and other
compulsive behaviors that reflect a common
neuropathology.^183 Separate disorders would be
identified for each type of addictive substance or
behavior and for multiple addictive disorders.
The addictive disorder diagnosis would contain
11 criteria; meeting two or three criteria would
result in a diagnosis of “moderate” severity,
while meeting four or more criteria would result
in a diagnosis of “severe.” The presence of
physical dependence (symptoms of tolerance or
withdrawal) also would be identified.§ 184‡ Initially, the Substance-Related Disorders Work
Group for the revisions to the DSM considering
renaming this category “Addiction and Related
Disorders.”
§ The proposed revised criteria clearly state that
tolerance and withdrawal are “not counted for those
taking medications under medical supervision such as
analgesics, antidepressants, anti-anxiety medications
or beta-blockers.” This stipulation is designed to
prevent a patient who becomes physically dependent
on a prescription drug received during the course of
medical care from being diagnosed with addiction
(i.e., a substance use disorder).