Substance Use Disorders
DSM-IV-TR versus DSM-5 Issues and Controversies with Regards to Substance Use Disorder Diagnosis
When addressing workplace substance use disorder issues the DSM-IV-TR distinction between abuse and dependence is preferred for work-related administrative purposes including jurisprudence issues relating to treatment disposition.11 The DSM-IV-TR definitions are clinically useful for disposition regarding amount of time required for abstinence and stability before return to work with weapons and other law enforcement officer (LEO) safety critical job demands. Specifically, The DSM-IV-TR notes that compared to Substance Dependence, “the criteria for substance abuse do not include tolerance, withdrawal, or a pattern of compulsive use and instead only the harmful consequences of repeated use” This distinction may be helpful in assisting the police physician to decide whether or not the individual is more likely to have a degree of control over his substance use as notably the ASAM definition of addiction includes compulsivity. If the assessing addiction specialist physician or other clinician knowledgeable in substance use disorders chooses to provide a DSM-5 diagnosis however, they must also provide DSM-IV-TR diagnosis as return to work disposition decisions of employees will still be based on DSM-IV-TR abuse and dependence criteria.
- Reasons for this include the fact that jurisprudence issues e.g. in the Americans with Disabilities Act (ADA), can be still based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), Fourth Edition, text revised (DSM-IV-TR) criteria. In addition, many clinicians and institutions have not yet adopted the DSM-5.*
Administratively, the medical guides from the U.S. Federal Aviation Administration (last updated in July 2016), the U.S. Coast Guard (April 2016), the Canadian Nuclear Workers, the Veterans Affairs Canada (modified November 2015), the Canadian Council of Motor Transport Administrators Medical Standards for Drivers, and the Railway Association of Canada’s Canadian Railway Medical Rules Handbook (February 2016), still use the terms “abuse” and “dependence”. Others, such as U.S. Department of Veteran Affairs, have adopted the DSM-5 criteria.
- Despite the perceived strengths of the DSM-IV-TR diagnostic approach to substance use disorders there is an attempt with the DSM-5 to improve diagnostic shortcomings. For instance, although it is commonly assumed that abuse is a milder disorder than dependence, abuse criteria include severe consequences such as failure to fulfill major responsibilities. There was also an issue labelled “diagnostic orphans.” Here, in the case of an individual meeting only two dependence criteria (3 were needed for a diagnosis) and no abuse criteria, they were technically ineligible for a diagnosis despite two identified clinical concerns.12 In addition, criticism of the DSM-5 “spectrum of disease” approach includes concerns about the validity of diagnostic thresholds (i.e., mild, moderate, severe) and the arbitrariness of diagnostic cut-offs among SUD diagnoses.13
- A diagnosis of a substance use disorder in the DSM-5 has 11 criteria and can vary from mild to severe depending on the number of criteria meet. Notably, 10 of these 11 criteria are consistent with prior DSM-IV-TR substance abuse and substance dependence diagnostic criteria.
- The one new DSM-5 criteria is “craving or strong desire or urge to use…[substance].”1
- The one DSM-IV-TR substance abuse criterion which is not included is “recurrent alcohol-related legal problems – i.e., arrests for alcohol-related disorderly conduct.”2
- Therefore, 10 of the 11 DSM-5 criteria are identical to prior DSM-IV-TR criteria. The majority Substance Use Disorders cases diagnosed with of DSM-5 criteria can use the DSM-5 criteria to create a match for DSM-IV-TR criteria of substance abuse or substance dependence.12
- On the uncommon occasion that an employee meets DSM-5 criteria for mild substance use disorder (presence of at least 2 diagnostic criteria) and this does not align with the past DSM-IV-TR criteria for abuse, then both therapeutic and return to work disposition will be evaluated on an individual basis. A comprehensive personalized assessment should take into account any current psychological impairment, risk of relapse and any psychiatric comorbidities.
- Following a comprehensive substance use disorder evaluation, either the assessing clinician or the police physician may have a strong clinical suspicion of substance dependence (see Appendix C-3 regarding denial) but only the DSM-IV-TR criteria for substance abuse may have been formally met. Then, they may adjust the treatment to the dependence level and request additional evaluation in the future. With individuals working in law enforcement, as in other safety sensitive positions, if there is doubt with respect to the diagnosis, it may be considered appropriate to err on the side of safety at least during a defined period of further ongoing evaluation. Notably, individuals with substance dependence may not be fully aware of the magnitude of their problem because of denial or alternatively may simply under-report symptoms and substance use-related adverse consequences.
*Note: A 2014 poll of 6,000 clinicians by Medscape, 1 year after release of DSM-5 shows only 59% of psychiatrists, 60% of psychologists, and 44% of primary care physicians had incorporated DSM-5 into their practice (see www.medscape.com/viewarticle/830099)