Substance-Related And Addictive Conditions In DSM-5

The issue of psychiatric diagnosis has always aroused controversy. The publication last year of the standard reference book, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), brought its fair of controversy, but not so much in the addictions field. As DSM-5 moves into general use, questions do come up about the details of the transition from the prior edition. I can think of no one more qualified to speak about these details than our guest blogger this month, Dr. Roger Peele.

Currently the Chief Psychiatrist for Montgomery County, Maryland, Roger has been a leader within the American Psychiatric Association for many years and was intimately involved in the multi-year effort that culminated in the publication of DSM-5. I have worked with him closely on a number of issues, including the successful effort to increase the number of patients to whom a physician may prescribe buprenorphine. When emotional issues begin to intrude into professional disagreements, I have always looked toward Roger as a steady voice of reason.

By Roger Peele

DSM-5 [2013] has many changes from DSM-IV-TR [2000], but remains within the shadows of DSM-III [1980], so clinicians will be able to quickly grasp the changes.

First, DSM-5 combines DSM-IV-TR’s four abuse symptoms and seven dependence symptoms into one entity, “Use Disorders,” which has those eleven symptoms, much like those of DSM-IV-TR with one exception.  The DSM-IV-TR symptom related to legal difficulties has been replaced with the symptom craving the substance.  While craving does not have the quantification that legal troubles had, there were concerns that legal difficulties tilted these disorders as to gender and race. Before you can code the disorder, however, you must count up the number of symptoms to determine severity, as severity decides the code as follows:

• Less than four symptoms, use “mild.”
• Four or five symptoms, use “moderate.”
• More than five symptoms, use “severe.”

Second, the codes we used in DSM-IV-TR for abuse are now used for mild and those we used in DSM-IV-TR for dependent are now used for moderate or severe.  Moderate and severe have the same code, so when you switch from DSM-IV-TR to DSM-5, you will switch to “use,” but usually find no switch in the code, e.g.:

• 305.50 = opioid use disorder, mild
• 304.00 = either opioid use disorder moderate or opioid use disorder severe

Third, you can specify the following information about the duration of symptoms and occurrence of cravings in your notes, but there are no codes for such:

• “In early remission” [Without symptoms 3 – 12 months. May still crave but patient does not have other symptoms],
• “In sustained remission” [> 12 months. May still crave, but  patient does not have others symptoms
  • Can add “in a controlled environment.”
  • Can add “on maintenance therapy”

For example, a patient at Perkins might have DSM-5 diagnosis: Heroin use disorder, severe, in sustained remission, in a controlled environment, 304.00

The medical classification for the United States, ICD-9-CM, does have codes for the following three, but these are not in either DSM-IV-TR or DSM-5:

1. Continuous [xxx.x1
2. Episodic [xxx.x2]
3. In remission [xxx.x3]

Fourth, DSM-5’s chapter on addictive disorders incorporates changes in terms used to refer to specific substances.

DSM-5’s text combines cocaine and amphetamine-like substances as “stimulants,” but we are still expected to be specific, e.g. “Cocaine withdrawal,” not “Stimulant withdrawal.”

DSM-5 replaces “nicotine” with “tobacco.”

Steroid use is coded under “other,” 292.9

Also, DSM-5 added to this chapter on addictive disorders, and the following were added:

• Caffeine withdrawal [Was in Appendix of DSM-IV-TR]
• Cannabis withdrawal
• Gambling disorder [Was in Impulse-control disorders chapter in DSM-IV-TR]

Fifth, DSM-5 removed polysubstance dependence. Instead, we are to give each substance that is abused its own diagnosis.

Finally, a major change in DSM-5 that pertains throughout is the removal of the Multiaxial System. Disorders are simply listed the way they are in the rest of medicine.

A common question: What about ICD-10-CM?  We do not have a start date, but it will not be before October 1, 2015.