BOCA RATON, Fla. – Pharmacologic strategies are underused for alcohol use disorders, Dr. Charles P. O’Brien said, despite backing from evidence-based medicine. "This is terrible that we have such a divorce in this field between evidence-based medicine and treatment."
However, use of medication is expected to get a big boost from the recent health care reform legislation. "There is an understanding they [insurers] will pay for medication, including monthly depot injections," Dr. O’Brien, chair of the DSM-5 Substance Use Disorders Committee, said at the meeting.
Overall treatment of substance use is mandated in the legislation, including coverage for screening and brief interventions done in primary care settings.
"We need to identify these patients, treat them earlier, and intervene before they need really expensive [interventions] like liver transplants, said Dr. O’Brien, director of the Center for the Study of Addiction at the University of Pennsylvania in Philadelphia. "This is big news, [and is] going to impact your practice and the training programs."
Treatment of all addictions is going to be an integral part of health care reform, Dr. O’Brien said. "Economists in the Obama administration agree that treating addiction saves money. Doctors will be mandated to look for problems. Most of the people involved in substance abuse are not at the level that they [initially] come to the attention of the primary care provider. The health care system is going to have to look for the early signs of substance use problems and treat that."
Meanwhile, Dr. O’Brien confirmed that the next revision of the Diagnostic and Statistical Manual on Mental Disorders (the DSM-5) probably will feature several important changes in terminology for alcohol and other substance use disorders.
"’Dependence’ is no longer there in DSM-5," Dr. O’Brien said to a round of applause at the meeting. "We got rid of it ... everyone agrees dependence is not addiction."
He explained that physical dependence might be normal with a whole range of prescription pain medications, Dr. O’Brien said. Some patients become tolerant after a few days and "we don’t want it to count if that is the only symptom, because it’s normal."
"I insisted in the DSM-5 that they don’t count this as a symptom of addiction as it has [been] in the past. So we are excluding physical dependence from DSM-5 criteria for substance use disorder," Dr. O’Brien said.
In contrast, compulsive, out-of-control drug seeking is distinct and will most likely be part of the definition for a moderate or severe substance use disorder.
The abuse category will be eliminated as well from the DSM-5. A meeting attendee commented that he liked the word "abuse." Dr. O’Brien replied, "The proposal is that they would have a substance use disorder; for example, a patient could have a cocaine use disorder. It is not that the word abuse cannot be used; it’s just not part of the definition."
The legal components of substance use in DSM-IV-TR will be removed as well. The definitions vary worldwide, depending on the country in which you practice, Dr. O’Brien explained.
It remains unclear whether the term "addiction" will appear in the DSM-5 despite its widespread use in the English language. "It was avoided in DSM IIIR and DSM-IV," Dr. O’Brien said. "Addiction is a perfectly good word, and it’s useless to oppose it. It’s everywhere. We cannot change the language." However, some resistance to its inclusion exists among other members of his DSM-5 committee.
What is clear is that "craving" will be added to the next manual. "Craving is not in DSM-IV, but it will be in DSM-5, and that is a good thing," Dr. O’Brien said.
Diagnosis of craving might be based on a question such as: Have you ever in your life had such severe craving for a drug that you could not think of anything else?
Craving is useful because clinical trial researchers have measured it as an outcome for years, Dr. O’Brien said. In addition, a reduction in craving often reflects the efficacy of pharmacologic treatment. "The evidence about medications that reduce craving is very interesting. It turned out to be pretty consistent. In the latest studies out of Russia with depot naltrexone [Vivitrol, Alkermes] the biggest change they see is reduction in craving versus placebo [Curr. Opin. Psychiatry 2010 (Epub ahead of print)].
In addition to depot naltrexone, the Food and Drug Administration has cleared oral naltrexone (generic), disulfiram (Antabuse, Odyssey Pharmaceuticals), and acamprosate (Campral, Forest Labs) for treatment of alcohol use disorders in the United States.
Dr. O’Brien disclosed that he is a consultant and researcher for Embera NeuroTherapeutics and a consultant for Alkermes, Gilead, and Reckitt Benckiser