ASSESSMENT IS THE KEY
Heated debates about abstinence vs harm minimisation could be coolly eliminated if… satisfactory, appropriate assessment identifies whether someone is dependent/ addicted or merely a misuser/abuser, states Norman Hoffmann.
This article was first published in Addiction Today journal in 2002. It remains topical.
Debate has raged for decades about the question of whether alcohol dependence and other substance dependencies are or are not diseases.
This unproductive discourse has tended to ignore the basic definition of what constitutes a disease. By definition, a disease involves an impairment of the normal state of a living animal or any of its components due to genetic, pathogenic, or environmental factors or any combination of these. Logically a disease, or disorder, should be identifiable by a unique constellation of symptoms. Indisputably, alcohol can be considered an environmental agent.
A brief review of the recent literature and accumulating data will present the case that alcohol dependence – as defined by the DSM-IV/DSM-IV-TR Diagnostic & Statistical Manual – meets the criteria of involving genetic factors and presents as a unique constellation of symptoms.
Dependencies concerning other substances such as cocaine also appear to involve genetic predispositions. And, as for alcohol, dependence for a given substance typically presents clear and distinct syndromes. This supports the distinction between dependence and abuse, and the criterion that a diagnosis of dependence should supersede a diagnosis of abuse.
WHY IS THIS IMPORTANT?
The issue of dependencies being unique clinical disorders from abuse is more than a semantic exercise: it has relevance to clinical practices.
The extent to which dependent people have different biological and/or psychological reactions to a given substance should influence the type and extent of treatment required, as compared to those who are misusers or abusers.
Likewise, the goals of treatment and the long-term prognosis can differ for the dependent client as compared to the abuser.
GENETICS AND BIOLOGY.
The Collaborative Study on the Genetics of Alcoholism has identified five chromosomes that might cause someone to be predisposed to developing alcohol dependence. These findings are consistent with the expectation that multiple genes influence the risk for alcohol dependence in addition to previously identified gene plumbing such as those for ADH (alcohol dehydrogenase) related to risk for dependence.
An intriguing study of Japanese men has found that ALDH (aldehyde dehydrogenase) alleles, related to facial flushing, are also related to drinking behaviour. But the ADH alleles are related to the level of alcohol intake among non-flushers.
Taken together, the genetic and biological studies point to variable susceptibility for not only alcohol dependence, but also to genetic influences on the behaviours which might predispose someone to become dependent.
The importance of genetic factors on the development of dependence for other substances is also being explored. Studies of twins suggest that heritabilities for cocaine dependence among women might be 0.65 as indicated by the concordance rates for MZ (monozygotic) and DZ (dizygotic) twins. The concordance rates for cocaine dependence for MZ and DZ twins were 35% vs 0%. And use concordance rates were 54% and 42% respectively.
A large study of males is consistent with substance-specific heritability. It shows that individuals who had alcohol dependence before developing stimulant dependence had the most severe clinical patterns.
Other studies further illustrate possible predispositions to dependence and relapse. For example, alcohol-dependent people have greater sensitivity to painful stimulation, but alcohol appears to have a normalising effect on pain and discomfort for them. And animal studies indicate that certain dopamine receptors have a time-dependent influence on relapse to cocaine and heroin seeking.
ADDICTION/DEPENDENCE IS TREATABLE.
Even with the overwhelming evidence that alcohol dependence and probably other substance dependence have a genetic and biological component, we must keep in mind several facts. First, just because a condition has a genetic or biological component, does not mean that it is not treatable
Second, behavioural interventions are critical to proper management and normalising of functioning for a variety of chronic conditions such as hypertension, diabetes and asthma.
Finally, if any dependence is to be properly recognised and treated, diagnostic approaches must use behavioural measures because no adequate or practical biological diagnostic procedures exist.
CLINICAL DIFFERENTIATION OF DEPENDENCE FROM ABUSE/MISUSE.
The literature and the data presented here indicate that dependence can be differentiated from abuse or misuse. This is of practical importance in the identification and proper treatment of both dependence and abuse. Dependence can be considered the more serious and chronic condition. Abuse typically is less serious and is more likely to resolve with or without treatment.
Studies using different assessment instruments with different populations find that dependence emerges as distinct from abuse or misuse.
Comprehensive studies of alcohol have shown convincing evidence of a clear distinction between dependence and abuse. This distinction extends to prognosis, in that dependent individuals are less likely to be trouble-free during a five-year period.
Other studies also have found that prognosis is linked to baseline severity for substances such as cocaine. Previous studies using the Sudds-IV structured interview and similar instruments have shown dependence to emerge as distinct from abuse for a variety of substances.
This article draws on a sample of 4,892 individuals who are Minnesota state prison inmates. The sample includes 547 women and 4,338 men between 18 and 65 years of age. Just over half (51%) are caucasian; 31% are african-american; 9% are native americans; and 6% are hispanics. The remainder are of asian or mixed ethnicity. 55% of the inmates were dependent on at least one substance, and another 20% met abuse criteria. Of the total sample, 32% were dependent on only one substance, and 23% dependent on two or more substances.
Since a dependence diagnosis for a given substances supersedes the abuse diagnosis, the term “abuse” will refer only to those people who do not also meet dependence criteria. But, as will be seen, the vast majority of dependent people qualified for the abuse criteria as well.
Figures are here: Download assessment_is_keytable.pdf . The explanations are below.
Alcohol dependence was the most prevalent diagnostic category with 31% of the cases, followed by marijuana dependence with 19%. The prevalence rates for cocaine and other stimulants were equal at 12%. Heroin dependence was only 3% in this population. Abuse prevalence rates for all substances were lower than for the respective rate of dependence.
Abuse diagnosis prevalences were 16%, 12%, 4%, 3% and under 1% for alcohol, marijuana, cocaine, other stimulants, and heroin respectively. As can be seen in the table, abuse was less prevalent than dependence for each substance in this population of inmates not seeking treatment. And the symptom profiles with respect to DSM-IV criteria differ dramatically, as shown by the number of positive abuse criteria. For all substances, the majority of each abuse diagnostic group is positive for only one of the four criteria, and less than 5% are positive for all four.
In contrast, about 80% of the cases in the typical dependence group are positive for three or more of the abuse criteria. The only exception is marijuana where 55% of dependent cases are positive for three or more criteria.
By definition, the abuse cases cannot be positive for more than two of the dependence criteria. But again, the typical abuse case either reports no dependence indications or at most one. The typical dependent case for a substance typically endorses at least five of the seven dependence criteria.
Again, the marijuana dependence group appears to have the lowest indications of severity while the heroine dependence group appears to manifest the greatest level of severity, as shown by the number of positive dependence criteria. Alcohol, cocaine and other stimulants present relatively similar prevalences for the number of positive dependence criteria.
The prevalences of dependence vary among some of the ethnic and gender subgroups. But for those who met criteria for dependence, caucasian females were the only subgroup to show significantly greater severity levels than their male counterparts in a given ethnic group. In other words, once the DSM-IV threshold of dependence is met, the typical individuals in the gender by ethnic subgroups tend to present similar severity profiles.
DO YOUNGSTERS SHOW THIS DIFFERENTIATION?
The dependence vs abuse distinction might extend to at least that portion of adolescents who have sufficient use histories to develop positive DSM-IV criteria for the disorders.
A sample of 251 adolescents in community and juvenile-justice treatment facilities were interviewed with the ‘Paddi’ Practical Adolescent Dual Diagnostic Interview. The typical adolescent in this sample was between 15 and 17 years of age. Of the 203 cases which met criteria for substance dependence, 88% were positive on five or more of the seven dependence criteria.
The clinical profiles of these youngsters was comparable to that found in the adults.
The accumulating genetic and biological evidence suggests that alcohol and other substance dependencies have a number of biological underpinnings. In addition, careful examination of the events and behaviours that define dependence and abuse according to DSM-IV criteria reveals that, for most people, dependence can be clearly distinguished from abuse or misuse.
Outcome studies provide evidence that the prognoses for abuse and dependence differ, thus adding further weight to the argument that clinical practice should distinguish between dependence and abuse in treatment planning and establishing therapeutic goals. Advocates of all methodologies can use this research to collaborate more closely.
NORMAN G HOFFMANN PhD is adjunct professor of Western Carolina University and director of Evince Clinical Assessments; he was clinical associate professor of community health at Brown University.
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