Posted by Phillipa on December 16, 2010, at 19:59:10
The new DSM V will change addiction to tolerance a good thing for many on meds. Phillipa
American Academy of Addiction Psychiatry (AAAP) 21st Annual Meeting & Symposium
This coverage is not sanctioned by, nor a part of, the American Academy of Addiction Psychiatry.
From Medscape Medical News > Psychiatry
DSM-V, Healthcare Reform Will Fuel Major Changes in Addiction Psychiatry
Steven FoxAuthors and Disclosures
December 6, 2010 (Boca Raton, Florida) â Revision of the American Psychiatric Association's (APA's) Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-V) is inching its way toward completion, with the final version due in 2013. Healthcare reforms are also set to take effect in the next couple of years. The confluence of those major events is likely to produce significant changes in all areas of psychiatry, researchers announced here.
Changes in addiction psychiatry, in particular, are predicted, attendees at this year's annual meeting of the American Association of Addition Psychiatry 21st Annual Meeting & Symposium heard here in a detailed session this morning. One of the most important of those is the elimination of "substance abuse and dependence," to be replaced with "addictions and related disorders."
Dr. Charles O'Brien
Charles O'Brien, MD, who chairs the APA's DSM Substance-Related Disorders Work Group, provided an update on the expected impact of DSM-V and healthcare reform on addiction treatment to a crowded session at the meeting. "This is going to produce big changes for all of us. It's going to impact training programs, it's going to impact your practices, and it's going to impact patient reimbursement for the services we provide and the drugs we prescribe." Dr. O'Brien is professor of psychiatry and director of the Center for Studies of Addiction at the University of Pennsylvania in Philadelphia.One of the most important changes is the elimination of "substance abuse and dependence" as disease categories, replacing them with a new category, "addictions and related disorders," he noted.
Why the change? Dr. O'Brien said that cutting out dependence as a category will help highlight a crucial distinction: between compulsive drug-seeking behavior associated with addiction and normal physiologic and psychiatric responses of tolerance and withdrawal that some patients experience when they're taking prescribed drugs. "This has traditionally been an area of much misunderstanding," he said, "and we hope that making this distinction will help eliminate that misunderstanding and the problems that arise from it."
The introduction of the new category of addictions and related disorders includes, as a subgroup, several "substance-use disorders," categorized by drug â for example, "alcohol-use disorder" and "cannabis-use disorder." Dr. O'Brien said that although the language for DSM-V will be modified significantly from earlier editions of the manual, the diagnostic criteria for these types of disorders will remain essentially the same.
Another significant change in the fifth edition of DSM will be the recognition of "drug craving" as an added criteria for diagnosing addiction. "I think that adding these criteria is big news," he said, pointing to recent studies that have identified craving as a pervasive symptom of addiction, as well as other research that has demonstrated the efficacy of anticraving medications in treating various types of addiction, including comorbidities such as depression and alcoholism.
In previous editions, patients' encounters with law enforcement, as a result of their illness, have been criteria of diagnosis. That will be dropped in the new edition because of both the pejorative aspects associated with such encounters and the lack of uniformity of laws from state and country to country.
Added to DSM-V will be a new category of "behavioral addictions," for now containing only a single entity: gambling addiction. "We have a growing body of research that shows this is an identifiable and treatable disorder," O'Brien said.
Other types of behaviors were considered for inclusion â eating, shopping, sex, work, exercise â but were rejected for lack of reliable data. "We have insisted on their being hard science before we make changes," Dr. O'Brien said.
Internet addiction, though, nearly made the cut, Dr. O'Brien noted, adding that addictive behaviors associated with Internet use are an increasing problem, particularly in some parts of the world. "When I was in China some time ago, I visited a hospital that is one of several specifically focused on treating patients with Internet addiction," he said. For this edition of the DSM, Internet addiction will probably be included in an appendix, with hopes that giving it that recognition will spur further research, he said.
In an interview with Medscape Medical News, Dr. O'Brien noted there has long been significant disagreement about the use of the terms addiction vs dependence.
Dependence was the term used in the fourth edition, published in 1994, but the working group that put together that section of DSM was nearly evenly split on which word to use.
"Dependence was what went into DSM-IV, but only by 1 vote," said O'Brien, who was involved in the revision.
But he added that clinical experience and research studies since then have shown that the choice was a "significant mistake." Historically, dependence has been used in reference to physical dependence, he noted. And that can simply be an adaptation a patient experiences when drugs administered in the long term are withdrawn, even drugs not normally abused, such as β-blockers or various antidepressants.
Dr. George Woody
In contrast, he noted, addiction is associated with a distinct loss of control over the urge to take the drug, even when the user knows the consequences could be severe.Concluding, Dr. O'Brien said that what's vitally important about the evolution of DSM-V and impending healthcare reform is that "primary care physicians are going to be mandated to screen patients for these disorders." He acknowledged that more money will go for treating the disorders early but stressed that numerous studies have shown that early intervention saves money later on, for example, avoiding the cost of liver transplantations in alcoholic patients. "It means we're likely to catch these problems earlier, when they're more amenable to treatment," he said. "And that's really a wonderful step forward."
Commenting on Dr. O'Brien's presentation, George Woody, MD, also of the University of Pennsylvania and a principal investigator with the National Institute of Drug Abuse Clinical Trials Network, said he agrees that the combination of changes in DSM-V and healthcare reform are likely to have a big impact throughout the field of addiction psychiatry. "I especially think that drawing a line between tolerance associated with chronic use of medications and addiction will be an excellent change in the DSM," he said. "That's an important distinction and a real advance for our field."
Less certain, he said, is what the overall effect the changes in diagnostic criteria will have once clinicians and researchers start using them and the results find their way into the epidemiologic literature â literature that's been accumulated using different criteria. "It will be interesting to see how all this sorts out," he said, but added, "I think we're headed in the right direction."
Neither Dr. O'Brien nor Dr. Woody has disclosed any relevant financial relationship.
American Academy of Addiction Psychiatry (AAAP) 21st Annual Meeting & Symposium: Impact of DSM-V and Health Care Reform on Addiction Psychiatry. Presented December 3, 2010.
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