How Psychiatrists Make Drugs More Addictive

The next edition of the Diagnostic and Statistical Manual of Mental Disorders, scheduled to be published a year from now, is expected to include a looser definition of addiction that will qualify millions more drinkers, illegal drug users, and participants in other pleasurable activities for psychiatric diagnoses. The upshot will be a lot more spending by taxpayers and private insurers on rarely effective "treatment" for these putative diseases, along with expanded excuses for depriving people of their freedom and relieving them of their responsibility.

Neither the current edition (DSM-IV-TR) nor the new one (DSM-V) has a listing for addiction per se. Instead DSM-IV speaks of "substance dependence"  (of which "alcohol dependence" is one variety) and the less severe "substance abuse" (along with "alcohol abuse"). The proposed language for DSM-V collapses "dependence" and "abuse" into one category: "use disorder," broken down by type of substance (alcohol, cannabis, hallucinogen, inhalant, opioid, sedative/hypnotic, tobacco, or unknown). It tosses in "gambling disorder" for good measure while suggesting "caffeine use disorder" and "Internet use disorder" for "further study."

Both the current critera for "substance dependence" and the proposed criteria for "substance use disorder" refer to a "maladaptive" (DSM-IV) or "problematic" (DSM-V) "pattern of substance use leading to clinically signficiant impairment or distress." But while the current definition requires three or more out of seven "symptoms" during a 12-month period, the proposed definition settles for two out of 11. If you "crave" alcohol and end up consuming more than planned, for instance, you may be suffering from "alcohol use disorder," depending on a mental health professional's assessment of your "impairment or distress." If you spend a lot of time obtaining, using, or recovering from cannabis, plus you find that over time you need more to achieve the same effect, you could get a "cannabis use disorder" diagnosis.

"Many scholars believe that the new manual will increase addiction rates," The New York Times reports. Isn't that the whole point? "Unlike many other fields," notes lead DSM-IV editor Allen J. Frances, "psychiatric illnesses have no clear biological gold standard for diagnosing them." In other words, they are whatever psychiatrists say they are.

Although many people are apt to roll their eyes at "gambling disorder," the criteria for this new diagnosis are actually stricter than the criteria for substance use disorder: at least four out of nine gambling-related problems during a 12-month period. It seems fair to say that anyone who meets these criteria has a gambling problem. Whether he has an illness suitable for treatment by medical doctors is another question.   

Likewise for the various "substance use disorders." No doubt many of the people who would qualify for these labels (though definitely not all) have serious drug problems. That fact alone does not tell us how to deal with them: with talk therapy or psychiatric drugs, with social pressure or prison, with assistance for those who request it or with coercive treatment for everyone, whether or not he agrees he has a problem and whether or not he wants help with it. Already users of arbitrarily proscribed substances are more apt to receive a diagnosis (partly because the illicitness of their preferred intoxicant magnifies its hazards) and more apt to be forced into treatment (as an alternative to jail, for example). Lowering the diagnostic threshold will only magnify that problem, pushing recreational pot smokers into the same category as broken-down alcoholics. Furthermore, the "addiction rates" for illegal drugs will increase overnight, giving prohibitionists another reason to argue that talk of legalization is "irresponsible." Once we expand the definition of addiction so that every regular pot smoker qualifies, it will be obvious that we cannot tolerate a legal market in this highly addictive substance.

The Times summarizes the concerns of critics:

While the [American Psychiatric Association] says that the addiction definition changes would lead to health care savings in the long run, some economists say that 20 million substance abusers could be newly categorized as addicts, costing hundreds of millions of dollars in additional expenses.

"The chances of getting a diagnosis are going to be much greater, and this will artificially inflate the statistics considerably," said Thomas F. Babor, a psychiatric epidemiologist at the University of Connecticut who is an editor of the international journal Addiction. Many of those who get addiction diagnoses under the new guidelines would have only a mild problem, he said, and scarce resources for drug treatment in schools, prisons and health care settings would be misdirected.

"These sorts of diagnoses could be a real embarrassment," Dr. Babor added.

I am less concerned about the potential for embarrassing psychiatrists (which seems like a plus to me) than the potential for oppressing people in the name of helping them.

More on the DSM here.