Reply

We thank Dr. Samuel for continuing the conversation about the changes in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)¹ related to substance use disorders. Although he expressed his disagreement with our “assessments and conclusions” we first wish to point out that we agree with some of his subsequent comments, as we expressed in our paper.² For example, we described the same concern expressed by Dr. Samuel that the new criterion of craving “does not contribute much to the diagnostic exercise and is thus not likely to have clinicolegal significance,” but was added “in hopes of future biological treatments targeting craving” (Ref. 2, p 445). We also noted that concerns have been raised about the diagnostic threshold of two criteria for diagnosis of mild use disorder (Ref. 2, p 445) and, in fact, discussed at length the forensic significance of this choice by the DSM-5 Work Group. Hasin and colleagues (Ref. 3, pp 840–1) clearly noted this concern, but dismissed it in stating that the overall prevalence of the Fourth Edition (DSM-IV)⁴ abuse and dependence disorders matched very closely with the total prevalence of use disorders when the threshold of two or more criteria is used. The concern expressed by Dr. Samuel in his last paragraph does not describe a disagreement with any of our conclusions, but rather with the decisions reached by the DSM-5 Work Group, about which we remained agnostic and merely descriptive in our paper.

There is a major area of confusion, however, related to the correlation of the former abuse and dependence categories with the levels of severity in the new use disorders, which is germane to the second and final paragraphs of Dr. Samuel's letter. This confusion may stem from the research literature itself, in which the terminology used to describe the severity of use disorders at various criteria levels was transformed in 2013. Early papers described the presence of two to three criteria as a moderate use disorder and the presence of four or more criteria as a severe use disorder.^5,–,8 Subsequent papers used the terminology ultimately adopted in DSM-5: two to three criteria for mild disorder, four to five for moderate, and six or more for severe.^2,9 Thus, when Dr. Samuel writes that “what was formerly considered abuse would now be considered moderate substance use disorder and what was formerly considered substance dependence … would now be considered severe substance use disorder,” he is correct in regard to the terminology used in the earlier stages of the literature leading up to DSM-5. However, that was not the schema ultimately adopted by the Work Group. We noted that final decision, as described by the Vice Chair of the DSM-5 Task Force (Ref. 2, p 448). To add to that description, the DSM-5 code for mild alcohol use disorder is 305.00 (Ref. 1, p 491), the same code as was used in the Fourth Edition, Text Revision (DSM-IV-TR) for alcohol abuse (Ref. 10, p 214). The DSM-5 codes for moderate and severe alcohol abuse are both 303.90 (Ref. 1, p 491), the same code used for alcohol dependence in DSM-IV-TR (Ref. 10, p 213). Thus, in its final form, DSM-5 equates abuse to a mild use disorder and dependence to moderate and severe use disorders.

We agree with Dr. Samuels (and so noted in our paper; Ref. 2, p 445) that the decision to use a threshold of two criteria had a “public health purpose,” in the same way that Hasin et al. noted the “need to identify all cases meriting intervention, including milder cases” (Ref. 3, p 841). In fact, this public health purpose was precisely the basis for our discussion about the clinicolegal significance of this change. If the medical profession believes that clinical intervention is appropriate at these lower levels of criteria, we predicted that attorneys will use this same argument in court in requesting diversion to treatment for their clients whose conditions do not rise to the level of what was formerly described as dependence or addiction, the condition which is the current basis of many of the diversion statutes that we reviewed.

• © 2015 American Academy of Psychiatry and the Law