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SUBSTANCE USE DISORDERS (SUD)

SUBSTANCE USE DISORDERS (SUD) . Allen Zweben, Ph.D. DSM-5 Conference Columbia School of Social Work December 6, 2013. What has changed? . What has changed? . Substance use disorders (SUD) Combined substance abuse and dependence items from DSM-IV into one disorder (SUD)

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SUBSTANCE USE DISORDERS (SUD)

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  1. SUBSTANCE USE DISORDERS (SUD) Allen Zweben, Ph.D. DSM-5 Conference Columbia School of Social Work December 6, 2013

  2. What has changed?

  3. What has changed? Substance use disorders (SUD) • Combined substance abuse and dependence items from DSM-IV into one disorder (SUD) • Three abuse items from DSM-IV now included in the new SUD (omitting legal problems) criteria making it 10 symptoms • Craving added to the criteria making it 11 symptoms

  4. What has changed? • Due to elimination of substance abuse and dependence categories, a new threshold has been established for SUD - now set at 2 or more criteria • Severity indicator: mild=2-3 criteria; moderate= 4-6 criteria; and severe=6 or more • Early remission= >3 months but less <12 months without meeting SUD criteria (except craving) • Sustained remission = >12 months without meeting DSM-5 criteria of SUD(except craving)

  5. What has changed? New categories: • Added gambling to the list of disorder • Cannabis withdrawal disorder - (as specified in the DSM-V protocol) 3 or more of the following symptoms within 1 week after cessation of use: irritability, anger or aggression, nervousness or anxiety, sleep difficulty, decreased appetite of weight loss, depressed mood, physical symptoms - e.g., tremors, fever, chills • Caffeine withdrawal disorder – (as specified in the DSM-V protocol) 3 or more of the following: headache, fatigue or drowsiness, dysphonic mood or irritability, difficulty concentrating and nausea, vomiting, or muscle pain/stiffness

  6. What has changed? New DSM-5 Specifiers: • Controlled environment – substance-free settings (e.g., jails, therapeutic communities, and locked hospital units • Maintenance therapy - ongoing use of substance use medications (e.g., agonists such as buprenorphine, antagonists such as naltrexone, and tobacco cessation products such as varenicline– Chantix) • The DSM- V omitted physiological categories i.e., manifesting tolerance or withdrawal as is the diagnosis of polysubstance dependence

  7. What has changed? • DSM-IV did not have a category for tobacco abuse, so the criteria for SUD (tobacco) in DSM-5 are the same as DSM-IV’s category for tobacco dependence • Substance/medication induced mental disorders - changed from substance induced mental disorders; specifies that the substance must be pharmacologically capable of producing the same set of symptoms and criteria of the particular mental disorder  

  8. What has changed? Other issues: • Eliminating the use of the terms “dependence” and “addiction” • May cause stigmatization of patients in general medical practice. • Medicalization not moralization

  9. What has stayed the same?

  10. What has stayed the same? • SUD criteria essentially the same as criteria included in dependence and abuse criteria in DSM-IV except for the deletion of legal problems and the addition of craving

  11. What is the significance of this revision to clinical practice?

  12. What is the significance of this revision to clinical practice? • Addition of the gambling disorder category will expand coverage for this disorder, which in turn may facilitate early detection, intervention and/or referral for individuals afflicted with this disorder • Tobacco use disorder is now on a par with other substances – confirms the biopsychosocial perspective of this disorder  

  13. What is the significance of this revision to clinical practice? • The term substance use disorder is more neutral than the term “addiction” or “dependence and may be more acceptable to persons with SUD but are not seeking help for these problems • Such may be case for individuals with SUD seen in medical settings where these problems are initially detected • May eventually improve access to treatment for individuals with SUD seen in nonspecialty settings

  14. What is the significance of this revision to clinical practice? • The DSM-5 diagnoses of SUD provides a more accurate depiction of the various subgroups included in this category. • It provides a better understanding of the heterogeneity of the patient population. • Providers often view SUD as a dichotomous – i.e., “alcoholic or not”

  15. What is the significance of this revision to clinical practice? • Having knowledge of patient diversity may help the field move away a dichotomous view of the problem (e.g., “alcoholic” or not). • It may raise awareness that patients have different individual and social coping resources and may need a variety of approaches (i.e., behavioral and pharmacological interventions) to address substance use problems.

  16. What is the significance of this revision to clinical practice? • At the same time, concerns have been raised that the expansion of categories and specifiers may pose more difficulties in guiding decision-making about treatment particularly in nonspecialty settings. • Will insurance companies support coverage for different treatment options based upon such factors as the individual’s SUD severity level?

  17. Case Illustration

  18. Case Illustration Dave is a 38 year old factory worker who came into the treatment center after being arrested for drinking and driving. After his first arrest for a DUI, he paid a fine and went to a DUI education program for six weeks. Dave found the program a “waste of time”. Dave has been married for ten years with two children. He has had numerous arguments with his wife, Melissa over the drinking. He gets angry and defensive when Melissa confronts him about his heavy drinking especially when she calls him an “alcoholic”. Both Dave and Melissa have had a history of excessive drinking in their respective (Dave’s and Melissa’s fathers) families. Dave states that his father was an alcoholic who frequently was abusive toward his mother and children. He detests the thought that he could be like this father. Dave has numerous “buddies” at work who attend sport events with him where they “gulp” down too many beers. However, he does not consider any of them to be “alcoholic”.

  19. Case Illustration Dave has a good work history. He rarely misses a day of work even putting in overtime during the week and Saturdays. He is well regarded by this supervisors and peers at work. Dave smokes “pot” several times a week and drinks about 6-8 beers daily. On week-ends he often drinks a 12 pack a day. Since his DUI arrest, he has remained abstinent. Consequently he has stayed at home after work for the past two months. He has trouble getting to sleep at night, lying awake for an hour or two each night, then awakening in the early morning. He wants to drink so he can sleep. He feels that he is getting “jumpy” and “closed-in” at home on week days and that week-ends are very long. .

  20. Case Illustration Dave’s wife accuses of “having to get high in order to have sex”. He finds her comments unsettling and wonders whether “ I overdo it”. Dave has tried to cut back on the amount he drinks on several occasions but has never achieved a meaningful reduction in this drinking Dave feels that he has basically a good marriage. He met his wife at the factory and dated for a year before they were married. The marriage was solid for the first five years but has gone “downhill” since his drinking has steadily increased. Melissa will no longer “sleep” with him while he is an intoxicated state which occurs regularly. She complains about the house being a “wreck” because Dave does not keep up with the chores. Dave feels that the marriage could become solid again if he stops drinking. At the same time, he complains about Melissa hassling him about quitting drinking.

  21. Case Illustration Dave is not close with his family. His older brother Jerry lives in the same town but he sees him infrequently due to his excessive drinking. Dad died of congestive heart failure about five years. Mom lives nearby and is very religious. She hopes that Dave will come back to the church to help him with the drinking and strengthen his marriage. Dave rarely attend church services although his wife goes regularly with the children.

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