Clinical Implications for Four Drugs of the DSM-IV Distinction Between Substance Dependence With and Without a Physiological Component

Department of Psychiatry, University of California, San Diego, VA Medical Center, 92161-2002, USA.
American Journal of Psychiatry (Impact Factor: 12.3). 02/1999; 156(1):41-9. DOI: 10.1176/ajp.156.1.41
Source: PubMed


The DSM-IV work group asked researchers and clinicians to subtype substance dependent individuals according to the presence or absence of physiological symptoms. A recent report from the Collaborative Study on the Genetics of Alcoholism demonstrated that among alcohol-dependent men and women, a history of tolerance or withdrawal was associated with a more severe clinical course, especially for individuals with histories of alcohol withdrawal. This article evaluates similar distinctions among subjects in the collaborative study who were dependent on marijuana, cocaine, amphetamines, or opiates.
Structured interviews gathered information from 1,457 individuals with a lifetime diagnosis of marijuana dependence, 1,262 with histories of cocaine dependence, 647 with amphetamine dependence, and 368 subjects with opiate dependence. For each drug, the clinical course was compared for subjects whose dependence included a history of withdrawal (group 1), those dependent on each drug who denied withdrawal but reported tolerance (group 2), and those who denied both tolerance and withdrawal (group 3).
The proportion of dependent individuals who denied tolerance or withdrawal (group 3) ranged from 30% for marijuana to 4% for opiates. For each substance, individuals in groups 1 and 2 evidenced more severe substance-related problems and at least a trend for greater intensities of exposure to the drug; those reporting withdrawal (group 1) showed the greatest intensity of problems.
The designation of dependence in the context of tolerance or withdrawal identifies individuals with more severe clinical histories. These results support the importance of the designation of a physiological component to dependence, especially for people who have experienced a withdrawal syndrome.

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    • "The proportion of subjects experiencing cannabis withdrawal is somewhat greater than that in most other studies of nontreatment-seeking adults with frequent lifetime or current cannabis use (range 15.6–40.9%) (Cottler et al., 1995; Schuckit et al., 1999; Swift et al., 1998, 2000; Wiesbeck et al., 1996) and smaller than that in two Australian studies of cannabis-dependent adults (95.5%, 88.8%) (Copeland et al., 2001; Swift et al., 2001). Differences in prevalence of true cannabis dependence and in substance abuse and psychiatric comorbidity among the various study populations may explain the discrepancy. "
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    ABSTRACT: Cannabis withdrawal is not recognized in DSM-IV because of doubts about its clinical significance. Assess the phenomenon of cannabis withdrawal and its relationship to relapse in non-treatment-seeking adults. Convenience sample of 469 adult cannabis smokers who had made a quit attempt while not in a controlled environment. Subjects completed a 176-item Marijuana Quit Questionnaire collecting information on sociodemographic characteristics, cannabis use history, and their "most difficult" cannabis quit attempt. 42.4% of subjects had experienced a lifetime withdrawal syndrome, of whom 70.4% reported using cannabis in response to withdrawal. During the index quit attempt, 95.5% of subjects reported > or =1 individual withdrawal symptom (mean [SD] 9.5 [6.1], median 9.0); 43.1% reported > or =10. Number of withdrawal symptoms was significantly associated with greater frequency and amount of cannabis use, but symptoms occurred even in those using less than weekly. Symptoms were usually of > or = moderate intensity and often prompted actions to relieve them. Alcohol (41.5%) and tobacco (48.2%) were used more often than cannabis (33.3%) for this purpose. There was little change during withdrawal in use of other legal or illegal substances. Cannabis withdrawal is a common syndrome among adults not seeking treatment. The intention to relieve withdrawal symptoms can drive relapse during quit attempts, giving cannabis withdrawal clinical significance as a target of treatment.
    Drug and alcohol dependence 09/2010; 111(1-2):120-7. DOI:10.1016/j.drugalcdep.2010.04.010 · 3.42 Impact Factor
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    • "The findings of previous studies also are limited in some ways. Schuckit et al. (1999) examined stimulant dependence symptoms as defined in DSM-III-R that occurred sporadically over the course of participants' lives. Because lifetime diagnoses are not specifically defined in DSM- IV, 1 it is unclear whether and to what extent results from lifetime symptoms apply to a current (past year) DSM-IV Drug Dependence that requires the occurrence of at least three criteria within a continuous 12-month period. 1 In addition, there are presently no known studies of subtypes of Amphetamine Dependence using DSM-IV criteria of current Dependence. "
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    ABSTRACT: We investigated the presence of DSM-IV subtyping for dependence on cocaine and amphetamines (with versus without physical dependence) among outpatient stimulant users enrolled in a multisite study of the Clinical Trials Network (CTN). Three mutually exclusive groups were identified: primary cocaine users (n = 287), primary amphetamine users (n = 99), and dual users (cocaine and amphetamines; n = 29). Distinct subtypes were examined with latent class and logistic regression procedures. Cocaine users were distinct from amphetamine users in age and race/ethnicity. There were four distinct classes of primary cocaine users: non-dependence (15%), compulsive use (14%), tolerance and compulsive use (15%), and physiological dependence (tolerance, withdrawal, and compulsive use; 56%). Three distinct classes of primary amphetamine users were identified: non-dependence (11%), intermediate physiological dependence (31%), and physiological dependence (58%). Regardless of stimulants used, most female users were in the most severe or the physiological dependence group. These results lend support for subtyping dependence in the emerging DSM-V.
    American Journal on Addictions 05/2009; 18(3):206-18. DOI:10.1080/10550490902787031 · 1.74 Impact Factor
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    • "As an example, the use of hallucinogens or binge drinking of alcohol may not lead to tolerance or withdrawal, but the presence of any other three out of seven criteria establishes the diagnosis of substance dependence. Nevertheless, the presence of tolerance and withdrawal should alert the clinician that the patient may have a DSM–IV–TR substance dependence diagnosis, in which case the disorder is associated with greater severity (Schuckit et al. 1999). "
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    ABSTRACT: Alcohol and other drug (AOD) use disorders (i.e., AOD abuse and dependence) commonly co-occur. This co-morbidity has important social, psychiatric, and medical consequences. Although making an accurate diagnosis can be challenging, especially in the context of multiple disorders, clinicians can adopt practices to improve their diagnostic accuracy. These practices include an empathic, accepting, and nonjudgmental stance that encourages patients to be honest and forthcoming in their self-report of alcohol use; being sensitive to the prevalence of substance use disorders in all patient populations and settings; and being familiar with diagnostic criteria.
    Alcohol research & health: the journal of the National Institute on Alcohol Abuse and Alcoholism 09/2008; 31(2):148-154. · 0.58 Impact Factor
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