The DSM-5 Changes and Challenges in Diagnosing Substance-Related Disorders

• 6 • Taiwanese Journal of Psychiatry (Taipei) Vol. 30 No. 1 2016 Overview

The DSM-5 Changes and Challenges in Diagnosing Substance-related Disorders

Chang-Chih Tsou, M.D.1, San-Yuan Huang, M.D., Ph.D.1,2*

The DSM-5 that was released in May 2013, has incorporated scientifi c advances, and enhanced clinical utility with more concise, as well as been amenable in primary care. In this overview, the authors review the new classifi cation structure and changes in diagnosing substance related disorders from the DSM-IV to the DSM-5, and point out the new challenge with the new criteria. The major changes of the DSM-5 include (A) renaming the title of chapter; (B) substance reclassifi cation; (C) eliminating the terms of dependence and abuse, and merge the criteria of substance dependence and abuse together; (D) removing legal problem and adding craving in substance use disorder criteria; (E) course specifi er modifi cation; (F) modifying substance-specifi c disorders, such as separate substance-induced mood disorder into bipolar and depressive disorder, and separating substance-induced obsessive-compulsive disorders from anxiety disorders; (G) newly adding or removing each class diagnosis of substance related disorders; (H) adding non-substance-related disorders; and (I) adding other substance-related and addictive disorder for further study. Although the DSM-5 solves the problems of the DSM-IV, there are several challenges in diagnosing substance-related and addictive disorder: First, what behaviors could be considered as an addiction is still an ongoing debate. Second, there are some controversies on the new criterion “craving.” Third, the polysubstance is still an important issue to be discussed. In addition, this overview also covers the changes from the ICD-9-CM to the ICD-10-CM codes related to the substance-related disorder of the DSM-5, but present some discrepancies between the DSM-5 and the ICD-10-CM for more clinical conveniences and utility.

Key words: substance related and addictive disorders, neurobiological advances, DSM-5, ICD-10-CM (Taiwanese Journal of Psychiatry [Taipei] 2016; 30: 6-22)

1 Departments of Psychiatry, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan 2 Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan Received: March 3, 2016; accepted: March 8, 2016 *Corresponding author. No. 325, Section 2, Cheng-Kung Road, Taipei 114, Taiwan E-mail: San Yuan Huang Tsou CC, Huang SY • 7 •

amygdala composed of “stress neurotransmitter,” Introduction including corticotropin-releasing factor, norepi- nephrine, orexin, vasopressin, and dynorphin Substance use disorders are chronic, relaps- [10]. The overactive anti-reward systems give rise ing diseases with long-term functional impair- to negative emotional or stress-like states [5] and ment, and it is associated with a high impact on increases in reward thresholds to all the stimuli the health, social, and economic costs [1]. The during withdrawal from drugs of abuse, leading to global prevalence of substance use disorders is the urge of recurrent drug use [9]. This distinct about 3.8%, and that of men having higher rate framework of function of brain reward systems (7.5%) than that of woman (2.0%) [2]. Although and anti-reward systems in contrast form a cycle the prevalence is predicted to increase in coming that progressively worse, resulting in compulsive decades, most patients do not receive adequate use of drugs [11]. The preoccupation-anticipation treatment [3]. The early concept of drug addiction or craving stage associated with the positive and was illegal drug-seeking behavior and participa- negative reinforcement, and accompanied by tion in illegal activities, and needs the involve- functional changes in the prefrontal cortex regions ment of the criminal justice system [4]. But centu- due to down-regulating dopamine release [5]. The ries of efforts of punishing addictive behaviors disrupted prefrontal regulatory circuits impair ex- have failed to take effect [5], and punishment ecutive process [5], thus promoting the compul- alone cannot be a safety intervention for offenders sivity of drug-taking in addiction [12]. with drug-use related criminal behavior [4]. The transform of viewpoint from traditional Neurobiological advances have provided in- sanction-oriented public safety approaches for sight into the fundamental biological processes in criminal behavior to the therapeutic strategies drug or behavioral addiction [5]. Three major against addiction [4] was correlated with the stages of the addiction cycle exist, with different change in the American Psychiatric Association’s sources of reinforcement correspond to activating Diagnostic and Statistical Manual of the Mental different neurobiological circuit [6]. The binge- Disorders (DSM). The fi rst edition of the DSM intoxication stage is associated with positive rein- was published in 1952, and was the fi rst formal forcement accompanied by activating the meso- attempt to provide a nosology to guide the diagno- limbic dopaminergic pathway with increased sis of mental disorders, including substance use extracellular concentrations of dopamine (DA), disorders [13]. The DSM-I initially classifi ed ad- and triggers craving for drugs [5], instead of natu- diction as part of the sociopathic personality dis- ral reward satiation [7]. The withdrawal-negative turbance, and subsequent the DSM-II placed the affect stage is associated with negative reinforce- addiction within “personality disorders and cer- ment [6], with much less sensitive of reward sys- tain other non-psychotic mental disorders.” From tem to everyday stimuli and decreased release of the DSM-III to the DSM-IV-TR, the substance use dopamine [8], thus re-orientated to drugs and the disorders were on their distinctive chapter, with cues [5]. On the other hand, the “dark side” of ad- criteria and discrimination between dependence diction also involves persistent recruitment of an- and abuse. The law has gradually relied on these ti-reward systems that drive aversive states [9]. DSM distinctions between defendants abusing The anti-reward systems within the extended substance and those dependent on substance phys- • 8 • DSM-5 Substance-related Disorders

iologically and/or psychologically, and court or- Substance reclassifi cation ders for addicted persons to receive treatment be- In the DSM-IV, the substance-related disor- came relatively common since 1970s [14]. But der are grouped into 11 classes -- alcohol; amphet- some debates and controversies still exist, in sub- amine or similarly acting sympathomimetics; caf- stance abuse/ dependence [15], and the substance feine; cannabis; cocaine; hallucinogens; inhalants; use disorder is still questioned and challenged by nicotine; opioids; phencyclidine (PCP) or simi- public views for addiction as being a social prob- larly acting arylcyclohexylamines; and sedatives, lem rather than an actual disease [16]. hypnotics, or anxiolytics. While in the DSM-5, amphetamines and cocaine are grouped together Changes from the DSM-IV to into “stimulants,” and phencyclidine (PCP) is in- the DSM-5 corporated into “hallucinogens” [20]. Nicotine- related disorders are renamed as tobacco-related The Fifth Edition of the Diagnostic and disorders; nicotine dependence is recognized as a Statistical Manual of Mental Disorders (DSM-5) medical condition in the DSM of the APA. Tobacco was released at the American Psychiatric dependence is recognized in the International Association’s annual meeting in May 2013 and Classifi cation of Diseases (ICD) [21]. Those marked more than a decade’s efforts in revising changes may refl ect a desire to ensure a better the criteria for the diagnosis and classifi cation of alignment with the ICD, to facilitate DSM-ICD mental disorders [17]. The DSM-5 is expected to harmonization [22]. solve the problems in the DSM-IV, incorporate scientifi c advances, simplify the criteria without Elimination of distinction between depen- declined accuracy, and to enhance clinical use dence and abuse, in favor of a combined with more concise and amenable in primary care substance use disorder [18]. Here, we provide the major changes and To divide impulsive use and harmful use general concept in substance-related disorders from the DSM-III through the DSM-IV-TR, the from the DSM-IV to the DSM-5. term of dependence and abuse are made in substance use disorder [13]. The DSM-IV required 3 Renaming the title of chapter of 7 criteria to meet for dependence, and 1 of 4 for As with the changes from the DSM-IV to the abuse. Dependence forms one dimension of sub- DSM-5, the title was renamed from “substance- stance problem with physiologically or psycho- related disorder” in the DSM-IV, to “substance- logically dependent on substance, while abuse is related and addictive disorder” in the DSM-5. The formed for another only with social and interper- term addiction represents for the addition of be- sonal consequence [19]. In addition, through the havioral addiction to this chapter. Nonetheless, DSM-III-R to the DSM-IV-TR, the dependence di- there are still debates and lack of consistent agree- agnosis is hierarchically over abuse, such that any ment about the title change [19], and the word ad- lifetime dependence diagnosis precludes the diag- diction is not applied as disorder diagnostic termi- nosis for an abuse [23]. For many years, the law nology because of its uncertain defi nition and its has been relied on these distinctions in determin- potentially negative connotation. ing defendants with substance use disorders for diversion, for dependence has been thought to be Tsou CC, Huang SY • 9 •

less responsible and need for treatment, and abuse physiologic features [23]. Instead, they index anti- is considered as more responsible to their behav- sociality which is more common in men and lack ior and less deserving of treatment [14]. of gender invariance [27]. Those changes imply Three reasons exist to merge substance abuse that substance-related illegal behavior is a better and dependence together: fi t as a criterion for adolescent conduct disorder ‧The validity and reliability of the abuse criteria and adult antisocial personality disorder, but not are much lower and variable than the depen- as substance use disorder criteria [23]. Other rea- dence criteria [24]. sons for removing criterion of legal problem in- ‧The hierarchy between dependence and abuse clude low prevalence, low discrimination, poor fi t is not always obvious in every case [25]. with other criteria, and little added information in Besides, the criterion sets for abuse and depen- item response theory analysis [19]. dence symptom categories do not differ in their The criterion of craving has been added to prevalence [23]. The overlap between these DSM-5 substance use disorders. Craving is corre- two distinctions may represent the same under- lated positively to activity in brain regions includ- lying substance use disorders, with different ing the nucleus accumbens, inferior frontal/orbi- manifestations in different ways [14]. tofrontal gyrus, and anterior cingulate [28]. While ‧The hierarchy between dependence and abuse the equivocal benefi t in adding craving criterion leads to “diagnostic orphans,” that a person with for diagnostic information and clinical signifi - substance use problems can meet two criteria for cance, craving still plays a rôle in becoming a fu- dependence but none for abuse, thus left the pa- ture biological treatment target [14]. Craving is tient undiagnosed [26]. These fi ndings suggest also a dependence criterion in the ICD-10, so that the abuse and dependence criterion sets added craving criteria in the DSM-5 can increase should be combined to form a unidimensional the consistency between the DSM-5 and the ICD- structure that across the severity spectrum. 10 [19]. Table 1 summarizes the changes of sub- The DSM-5 Substance-related Disorders stance use disorder criteria from the DSM-IV to Work Group wants to select a threshold for DSM- the DSM-5. 5 substance use disorders under the revised criterion sets that wound maintain the overall preva- Specifi er modifi cation lence of DSM-IV substance abuse and dependence In the DSM-IV, four remission specifi ers diagnoses combined [14]. They fi nally chose the have been applied after the criteria for substance threshold of two or more criteria, for the more dependence or abuse have not been present for at similar and agreement with the prevalence com- least one month. There are early full remission (at pared with the other thresholds [19]. least 1 month but less than 12 months, without any criteria have been met), early partial remission (at Removing legal problem, but adding least 1 month but less than 12 months, with one or craving more criteria have been met), sustained full remis- The criterion of legal problem has been re- sion (without any criteria have been met for 12 moved from the fi nal criteria set in DSM-5 sub- months or longer), and sustained partial remission stance use disorders. Legal problems do not re- (with one or more criteria have been met for 12 fl ect either compulsive patterns of use or months or longer). But such a division for remis- • 10 • DSM-5 Substance-related Disorders

Table 1. The criteria of Substance use disorder from the DSM-IV to the DSM-5§ DSM-IV criteria DSM-5 criteria Abuse: Dependence: Substance use disorders: ≥ 1 criterion ≥ 3 criteria ≥ 2 criteria Neglect major roles to use □ □ The Severity Legal problems □ × according to criterion counts: Hazardous use □ □ Social/interpersonal problems related to use □ □ Mild: Tolerance □ □ The presence of 2 to 3 symptoms Withdrawal □ □ Used larger amounts/longer □ □ Moderate: Repeated attempts to quit/control use □ □ The presence of 4 to Much time spent using □ □ 5 symptoms Activities given up to use □ □ Severe: Physical/psychological/problems related to use □ □ The presence of 6 or Craving New criterion in DSM-5 □ more symptoms

§ Adapted from references [20], [23] and [26]

sion is complex and little used [19]. In the DSM-5, for the more appropriate description about the the remission specifi ers are simplifi ed into two treatment in the case of opioid and tobacco use categories according only to the time frame, and disorders, including agonist, partial agonist and the term of partial remission has been removed. antagonist therapy. The other course specifi er “in There are early remission (at least 3 months but a controlled environment” is retained and not been less than 12 months, with none of the criterion in changed through the DSM-IV to the DSM-5, indi- substance use disorder have been met except the cating that the person is in a restricted environ- criterion of craving) and sustained remission (for ment and the substance is unavailable. 12 months or longer, with none of the criterion in The DSM-IV also includes physiological substance use disorder have been met, except the specifi ers for tolerance and withdrawal which are criterion of craving). The time division of three associated with a higher risk for general medical months has been chosen for the better outcome if problems and relapse, and these specifi ers divide retained abstinence for three months or longer, patients into “with physiological dependence” and the criterion of craving is an exception for re- (with tolerance or withdrawal) or “without physi- mission specifi ers as it is the core symptom of de- ological dependence” (no evidence of tolerance or pendence and could persist for longer than other withdrawal). But due to inconsistent predictive symptoms [19]. value and poor clinical utility, these specifi ers Another course specifi er “on agonist thera- were eliminated fi nally in the DSM-5 [19]. py” in the DSM-IV has been replaced by the course As shown in Table 1, another issue is the se- specifi er “on maintenance therapy” in the DSM-5, verity indicators. Where available, severity speci- Tsou CC, Huang SY • 11 •

fi ers are given in the DSM-5 for the purposes of have been established the neurobiological basis guiding clinicians to rate the intensity, frequency, with the clinical reliability, validity, time course, duration, symptom count, or other severity indica- and the effect of various medications on cannabis tor of a disorder. Based on the number of symp- withdrawal [29]. Cannabis withdrawal is also re- tom criteria met, the work group uses a criteria ported as common among treatment-seeking pa- count as the severity indicators of substance use tients and is associated with relapse to dependence disorders, from mild (2 to 3 symptoms), moderate [30]. The DSM-5 fi nally adds cannabis withdraw- (4 to 5 symptoms), to severe (6 or more symp- al in cannabis-induced disorders. The DSM-IV in- toms) [19]. cludes the caffeine withdrawal as a research diagnosis in the Appendix B, “Criteria Sets and Axes Modifi cation of substance-specifi c disor- Provided for Further Study,” and there is only caf- ders feine intoxication in the caffeine-related disor- The DSM manual provides a table for diag- ders. Based on accumulated evidences supporting nosis associated with substance class. Table 2 the reliability, validity, and the clinical signifi - shows the changes of substance related disorders cance, the DSM-5 work group has modifi ed the and substance classifi cation form the DSM-IV to DSM-IV research criteria, elevating caffeine with- the DSM-5. In the DSM-IV, The assortment of drawal to an independent disorder of caffeine-re- substance induced disorders includes intoxication, lated disorders in the DSM-5 [19]. Other additions withdrawal, psychotic disorders, mood disorders, of the substance related disorders include canna- anxiety disorders, sleep disorders, sexual dysfunc- bis intoxication/withdrawal-induced sleep disor- tion, intoxication delirium, withdrawal delirium, ders, stimulant intoxication/withdrawal-induced dementia and amnestic disorders. As with the obsessive-compulsive and related-disorders, and classifi cation changes of mental disorders in the tobacco withdrawal-induced sleep disorders DSM-5, the substance-induced mood disorder has (Table 2). In the DSM-IV, the withdrawal syn- been separated into bipolar disorders and depres- dromes are not included in the hallucinogen/inhal- sive disorder, and the substance-induced dementia ant-related disorders, and those remain unchanged and amnestic disorders are merged into neurocog- in the DSM-5, for insuffi cient evidence and fur- nitive disorders. The intoxication delirium and ther studies being needed [19]. withdrawal delirium were merged into one, as de- The polysubstance dependence has been re- lirium. Obsessive-compulsive and related disor- moved from the DSM-5. The DSM-IV character- ders are separated from anxiety disorders in the izes the “polysubstance dependence” as who has DSM-5 (Table 2). been repeatedly using at least three groups of substance (not including caffeine and nicotine) dur- Which classes of diagnoses of substance ing the same 12-month period, but no single sub- related disorders have been added or stance predominated. Further, during the 12-month removed in the DSM-5? period, the dependence criteria are met for sub- The DSM-IV dos not include cannabis with- stances as a group but not for any specifi c sub- drawal, but cannabis has long been questioned stance when all the drugs of abuse are considered whether can really cause physiological depen- collectively. But few clinicians and researchers dence or withdrawal. In addition, recent studies have used this label in a manner consistent with • 12 • DSM-5 Substance-related Disorders al al Substance Substance withdraw- withdraw- X X (New) tion tion intoxica- intoxica- Substance Substance DSM-5 dence Depen- disorders Merged into Merged Substance use Abuse but deleted in the during withdrawal; P, the disorder is persisting; during withdrawal; P, DSM-IV disorders Amnestic I/P X X X I/W/P X X X I/W/P X X X → → → disorders Merged into Merged Neuro-cognitive dementia With- drawal delirium I/W X X X → Delirium Merged into Merged tion delirium Intoxica- DSM-5 to I/W I/W P I/W I I/W I/W P tion tion → → → Sexual Sexual dusfync- dusfync- DSM-IV I/W I/W I → Sleep Sleep disorders disorders (New) related OC and disorders

I/W (New) I/W I/W I X X X → I → deleted Anxiety Anxiety disorders disorders I/W sive → Depres- I disorders . DSM-5 Mood disorders Bipolar disorders and the

IIII I X X I I/W I/W I → ; I, With onset during intoxication; W , With onset during withdrawal, I/W, either with onset during intoxication or onset during withdrawal, I/W, With , W onset during intoxication; With ; I, to the DSM-5; “new”, disorder is new and added in DSM-5, “deleted”, presented I/W I/W I/W W I/W I I/W I/W I/W I/W I/W I/W I/W I/W I/W/P X X X I deleted disorders disorders Psychotic Psychotic DSM-5 DSM-IV-TR DSM-IV or ics into gens PCP to PCP deleted Merged Merged anxiolyt- Disease categories associated with substance class: changes form hypnotics unknown) Others (or Sedatives, Combined Hallucino- Stimulants or ics Substance class DSM-IV PCP gens amine stance Opioids Opioids Alcohol Alcohol I/W I/W I/W I/W I/W I Cocaine Cocaine Caffeine Caffeine I I Nicotine Tobacco (new) W X X polysub- DSM-IV DSM-5 DSM-5 Amphet- anxiolyt- Inhalants Inhalants I I I I P Cannabis Cannabis I I (New) I/W I X X X (New) hypnotics unknown) Others (or Sedatives, Hallucino- Table 2. Table The table was adapted from the The category is recognized in X, the arrow , change from Tsou CC, Huang SY • 13 •

the diagnostic manual [31]. The work group fi - Section II of the manual. But “conditions for fur- nally eliminates the polysubstance dependence in ther study” exists in the section III including dis- the DSM-5, not only for the poor utility, and also orders that require future research and more scien- for the often misunderstanding as co-dependence tifi c evidence but are not suffi ciently on different substances [19]. Besides, the opioid well-established to be a part of the offi cial classi- intoxication-induced psychotic disorders and the fi cation of mental disorders for clinical use; these opioid withdrawal-induced anxiety disorders have diagnostic criteria are included for the purpose of been removed in the DSM-5 (Table 2). encouraging further studies. Substance/non-substance-related disorders in the section III (condi- Adding non-substance-related disorders tions for further study) include caffeine use disor- An important distinction from the DSM-IV is der, internet gaming disorder, and neurobehavioral that the DSM-5 substance-related and addictive disorder associated with prenatal alcohol expo- disorders now include non-substance-related dis- sure [19]. orders. The DSM-IV characterizes pathological gambling as persistent and recurrent maladaptive Challenges in Substance- gambling behavior and listed in the “impulse-con- related and Addictive trol disorders not elsewhere classifi ed” [32]. There Disorders in the Future are growing evidences showing the similarities between pathological gambling and drugs of Non-substance-related addictive behav- abuse in many aspects, including the biochemistry ior [33], neurocircuitry [34], genetics [35], and the Non-substance-related behavioral addiction treatment modalities [36]. In the DSM-5, the path- has never been listed in the DSM until recently, as ological gambling has been renamed as gambling the DSM-5 fi rstly includes gambling disorder as disorder, and is reclassifi ed to the “substance-re- the only condition in non-substance-related disor- lated and addictive disorders.” This change re- ders in the chapter [38]. In the meanwhile, the fl ects that the gambling disorder shares many fea- DSM-5 also proposes internet gaming disorder as tures with substance-related disorders, supporting a condition needed for further study. their grouping together as addictions [37], and for Contrary to the common belief for addiction the purpose of improving further research efforts to be dependent on psychoactive drugs, behavior- directed to the addictive behavior [32]. DSM-5 al science experts believe that all entities can be gambling disorder has also changed the diagnosis considered as an addiction whenever a habit criteria by removing the criterion “illegal acts” in changes into an obligatory behavior despite ad- the DSM-IV, and its criteria count for the diagno- verse consequences [39]. These disorders have sis has also been reduced from 5 to 4. historically been considered as impulsive-compulsive problems or non-substance-related behav- Other substance-related and addictive ioral addictions, but growing evidence indicates disorder for further study in the section III that behavioral addictions resemble substance use of the DSM-5 disorders in many domains [40]. But impairment In the DSM-5, the offi cial mental disorders in social or occupational function should also be with accepted clinical applicability are located in present to diagnose a behavioral addiction [39]. • 14 • DSM-5 Substance-related Disorders

The gambling disorder is included for its be- ‧No consensus exists regarding the defi nition of ing most thoroughly studied of the behavioral ad- craving [46], despite the term being used regu- diction, providing further insight into the relation- larly by laboratory researchers and clinicians ship of behavioral addictions and substance use [47]. Craving has generally been regarded as a disorders [40]. In addition to the gambling disor- subjective experience of urgent and overpower- der, the internet gaming disorder has also been ing desire which motivates drug use, but other included in section III of the DSM-5 for the large defi nitions have been modifi ed by many au- literature available on internet gaming addiction thors and no unique defi nition exists at the pres- as a problematic condition, with mostly Asian ent time [48]. cases/series of young males [19]. But further re- ‧No single perfect measure of craving exists search is needed for reliability and validity of the across all settings with measurement selection diagnostic criteria, and for more evidence of bio- as a formidable challenge [49], and one key logical factors in this disorder [19]. question is whether the measurement should There are still other internet-related behav- comprise multiple response domains, including iors as addictive conditions, such as social net- emotional experiences, cognitive experiences, working and pornograph-viewing that are under overt behavior, and psychophysiological expe- scrutiny [38]. Non-internet-related technology riences [47]. (such as non-internet video/computer gaming or ‧We are still awaiting the development of bio- television viewing), may also be addictive that logical craving indicators for craving [45], al- warrant consideration [41]. Besides, other form of though the DSM-5 work group suggests a cav- behavioral addictions (including compulsive buying query. ing [42], sexual addiction [43], and love addiction Nonetheless, as more attention and emphasis [44]), have ever been presented. In a word, what on the new criterion for craving as a possible core behavior could be considered, or whether they symptom for addiction, further research may deal should be labelled as an addiction is still an ongo- with these unsolved problems, and better insight ing debate in the future [38]. into craving may contribute to the target treatment strategies and the development of more effi cient Debates on the new criterion “craving” relapse prevention [46]. As mentioned above, craving has been added to DSM-5 substance use disorder criteria for many Polysubstance reasons. The most important issues are to empha- The DSM-5 has abandoned the polysub- size craving as a core symptom and a treatment tar- stance dependence because of little utility and be- get, and to encourage further research on the rôle of ing often misunderstood as dependence on differ- craving for substance use disorder criteria [19]. But ent substances simultaneously [19]. The four issues about craving are still under debates: polysubstance use is defi ned as using many sub- ‧The new criterion does not contribute much to stances within a period of time, and it is prevalent the psychometric benefi t and thus not likely to in substance users, particularly among adolescents add much clinical signifi cance [14]. Some stud- [50]. In the U.S., between 15% and 39% of ado- ies have considered craving as redundancy of lescents in school have been estimated to be clas- the other criteria [45]. sifi ed as polysubstance users [50]. Polysubstance Tsou CC, Huang SY • 15 •

use is also associated with high comorbid psychi- preparing and publishing the revisions since 1946, atric/physical health problems [51], and early on- and subsequently published the ICD-6 in 1949, set polysubstance use is an important risk factor which was the fi rst to contain a section on mental for injection drug use in adulthood [52]. disorders [54]. Beginning from 1900 with the In our clinical practice, most of the patients ICD-1 to 1990 with the ICD-10, the ICD is nowa- with substance use is not only using one sub- days the most widely used classifi cation of dis- stance. They are often meeting the criteria of sub- eases in the world. The system of ICD is not only stance use disorder for more than one substance for classifying morbidity and mortality in statisti- class simultaneously, but this condition cannot cal purposes, and it is also useful for applications point out in the DSM-5 diagnostic system. In addi- in many fi elds such as reimbursement, administra- tion, research to prevent and to treat of polysub- tion, epidemiology, and health services research stance use is still under-explored, but benefi t may [55]. be obtained from the efforts of doing clinical research targeting specifi c polysubstance use and Clinical utility of the ICD-9-CM and the risk profi les [51]. Whether to include polysub- ICD-10-CM stance use disorder as a unique disease diagnosis As with the adopted trends over the world is an important issue to be discussed, not only for that WHO members agree to use as the basis for the high prevalence and important clinical profi le, reporting of health statistics and for consistency and also for promoting clinical understanding and [56], the U.S. and Taiwan transited from the ICD- further research. 9-CM to the ICD-10-CM since October 2015 and January 2016, respectively. Therefore, we should Using ICD-10-CM Codes for understand the ICD-9 and the ICD-10 in clinical Substance-related practice. Disorders of the DSM-5 The ICD-9 was designed in 1970s and was adopted thereafter by many countries around the In this overview on substance use disorders world [53]. To make the application of the ICD-9 in the DSM-5, a brief section covering on the ICD appropriate to the American healthcare settings, is appropriate and necessary because most, if not the U.S. National Center for Health Statistics and all, hospitals in Taiwan are adopting the ICD sys- the Council on Clinical Classifi cations modifi ed tem for the purpose of statistics and insurance re- the ICD-9 as the International Classifi cation of imbursement. Therefore, the authors here would Diseases, Ninth Revision, Clinical Modifi cation like to discuss the ICD-10-CM codes briefl y. (ICD-9-CM) [57]. This modifi ed version introduced a fi fth-digit numeric code for classifi cation A brief ICD history with increased specifi city, and contains more than The ICD system has a long history of devel- 12,000 diagnostic and 3,500 procedure codes opment and can be traced back to 1893, when the [55]. The ICD-9-CM has an alphabetic or numeric French physician J. Bertillon fi rst introduced the fi rst digit and the remaining digits are numeric, Bertillon Classifi cation of Causes of Death to the with minimum of three digits to a maximum of world [53]. After several decades of evolution, the fi ve digits [57]. The ICD-9-CM codes diseases World Health Organization took responsibility for with the fi rst 3 digits describing category, and • 16 • DSM-5 Substance-related Disorders

each character beyond the fi rst 3 providing more rizing the disease and the 4th to 6th digits describ- specifi city [54]. For substance-related disorder, ing cause, anatomical site, and severity; and the the substance use disorders and substance-induced 7th being an extension [57]. disorder have been considered to be different categories and received distinct fi rst-3-digit codes ICD-10-CM diagnostic code for sub- (Table 3). stance-related disorders Principally, the substance dependence has In the ICD-10-CM, each disorder is divided been coded as 304.x0 (expect for alcohol depen- into three sections, with the fi rst section consisting dence (303.90) and nicotine dependence (305.1), of the main clinical features, the second section and the substance abuse is coded as 305.x0. For the generally diagnostic guidelines, and the third substance induced disorders, intoxication section the differential diagnosis [56]. (292.89), withdrawal (292.0), delirium (292.81), The substance-related disorders in the ICD- persisting dementia (292.82), persisting amnestic 10-CM have been coded with the format F1X. disorders (292.83), psychotic disorders (292.1X), XXXX. As showed in Figure 1, the fi rst digit “F” mood disorders (292.84), other disorders (292.89, represents the “mental, behavioral and neurode- including anxiety disorders, sleep disorders, sexu- velopmental disorders” in the chapter 5, and the al dysfunction and persisting perceptional disor- second digit “1” represents the mental or behav- ders), and disorders not otherwise specifi ed ioral disorder due to psychoactive substance use. (292.9) all have been coded as 292.XX, except for The third digit represents the substance class, la- alcohol intoxication (303.00) and other alcohol- beled from 0 to 9. After the decimal point, the sub- induced disorders (291.xx). But the coding system sequent digits manifests more information about for substance use disorders is too complex and nature and severity, including abuse or depen- complicated to fi nd the consistency between the dence, uncomplicated or with intoxication, with codes and the representing disorders easily. induced mood disorders, psychotic disorders of The ICD-10 was released in 1990, and then other disorders. For example, for a patient diag- with modifi cation as the ICD-10-CM in 2003 [53]. nosed as alcohol abuse with alcohol-induced psy- Compared to the 3 to 5 numeric digit system of the chotic disorder with hallucinations, the ICD-10- ICD-9-CM, the ICD 10-CM introduces alphanu- CM code is F10.151. Table 3 reveals the substance meric codes, with the fi rst digit being an alphabet class and codes of related disorders, from the (any letter except “U”), second digit always nu- DSM-IV/ICD-9-CM to the DSM-5/ICD-10-CM. meric, and 3rd to 7th digits being alpha or numeric, with totally 3 to 7 digits consisting of more dif- Challenges in the ICD-10-CM code for ferent codes and permitting greater coding substance-related disorders of the DSM-5 specifi city [57]. The ICD-10 classifi cation system As with the DSM evolution, the ICD-10-CM also incorporates V codes (factors infl uencing provides new code system to apply in the sub- healthcare) and E codes (external causes of injury) stance use disorders. But two major inconsisten- into the main classifi cation and totally contains 21 cies exist between the DSM-5 and the ICD-10-CM chapters and other supplementary classifi cations classifi cation: [54]. The ICD-10-CM has the similar structure ‧The DSM-5 merges substance abuse and depen- with the ICD-9-CM, for the fi rst 3 digits catego- dence together as substance use disorders, with Tsou CC, Huang SY • 17 •

Table 3. Substance class and codes: from DSM-IV/ICD-9-CM to DSM-5/ICD-10-CM DSM-IV with ICD-9-CM code DSM-5 with ICD-10-CM Alcohol use disorders: (D) 303.90, (A) Alcohol-related disorders As F1a.bcx: Alcohol-related 305.00 (F10.bcx) disorders Alcohol induced disorders: (I) 303.00, The 1st digit must be F (mental (others) 291.xx disorders) Amphetamine use disorders: (D) 304.40, (A) Stimulant-related The 2rd digit must be 1 (substance Amphetamine- 305.70 disorders related disorders) related Amphetamine induced disorders: (I) 292.89, The 3rd digit (a) from 0-1 accord- disorders (W) 292.0, (ID) 292.81, (P) 292.1x, (M) 2 (Cocaine-related disor- ing to substance class 92.84, (others) 292.89, NOS (292.9) ders) (F14.bcx) a = 0: alcohol Cocaine use disorders: (D)304.20, (A)305.60 a = 1: opioids Cocaine-related Cocaine induced disorders: (I) 292.89, (W) (Amphetamine-related a = 2: cannabis disorders 292.0, (ID) 292.81, (P) 292.1x, (M) 292.84, disorders) (F15.bcx) a = 3: sedatives, hypnotics and (others) 292.89, NOS (292.9) anxiolytics a = 4: cocaine Caffeine use disorders:X Caffeine-related disorders Caffeine-relat- a = 5: other stimulants, including Caffeine induced disorders: (I) 305.90, (F15.bcx) ed disorders caffeine (others) 292.89, NOS (292.9) a = 6: hallucinogens Cannabis use disorders: (D) 304.30, (A) Cannabis-related a = 7: tobacco Cannabis- 305.20 disorders a = 8: inhalants related Cannabis induced disorders: (I) 292.89, (ID) (F12.bcx) a = 9: other psychoactive substanc- disorders 292.81, (P) 292.1x, (others) 292.89, NOS es and multiple drug use (292.9) b = 1: abuse (in ICD) and represent Hallucinogen use disorders: (D) 304.50, (A) Hallucinogen-related severity as mild (in DSM-5) 305.30 disorders (F16.bcx) b = 2: dependence (in ICD) and Hallucinogen- Hallucinogen induced disorders: (I) 292.89, represent severity as related (PPD) 292.89, (ID) 292.81, (P) 292.1x, (M) moderate or severe (in disorders 292.84, (others) 292.89, NOS (292.9) DSM-5) b = 9: Use, unspecified Phencyclidine use disorders: (D) 304.60, (A) (Phencyclidine-related The 4rd digit (b) manifests -use Phencyclidine- 305.90 disorders) disorder and could be 1, 2 or 9 related Phencyclidine induced disorders: (I) 292.89, The 5rd digit (c) manifests disorders (ID) 292.81, (P) 292.1x, (M) 292.84, (others) -induced disorder and could be 292.89, NOS (292.9) 0~9 Inhalant use disorders: (D) 304.60, (A) Inhalant-related disorders c = 0: Uncomplicated (without) 305.90 (F18.bcx) c = 1: In remission Inhalant-related Inhalant induced disorders: (I) 292.89, (ID) c = 2: With intoxication disorders 292.81, (PD) 292.82, (P) 292.1x, (M) 292.84, c = 3: With withdrawal (others) 292.89, NOS (292.9) c = 4: induced mood disorder c = 5: induced psychotic disorder Nicotine use disorders: (D) 305.1 Tobacco-related disorders c = 6: induced persisting amnestic Nicotine induced disorders: (W) 292.0, NOS (F17.bcx) disorder Nicotine-relat- (292.9) ed disorders c = 7: induced persisting dementia c = 8: other induced disorders c = 9: unspecified induced disorder (to be continued) • 18 • DSM-5 Substance-related Disorders

(continued from the previous page)

DSM-IV with ICD-9-CM code DSM-5 with ICD-10-CM Opioid use disorders: (D) 304.00, (A) 305.50 Opioid-related disorders (F11.bcx) Opioid-related Opioid induced disorders: (I) 292.89, (W) disorders 292.0, (ID) 292.81, (P) 292.1x, (M) 292.84, (others) 292.89, NOS (292.9) Sedative, hypnotic or anxiolytic use disor- Sedative, hypnotic or Sedative, ders: (D) 304.10, (A) 305.40 anxiolytic-related hypnotic or Sedative, hypnotic or anxiolytic induced disorders (F13.bcx) anxiolytic- disorders: (I) 292.89, (W) 292.0, (ID,WD) related 292.81, (PD) 292.82, (PAD) 292.83, (P) disorders 292.1x, (M) 292.84, (others) 292.89, NOS (292.9) Polysubstance- Polysubstance use disorders: (D) 304.80 Polysubstance-related related Polysubstance induced disorders: X disorders (deleted) disorders Other(or unknown) use disorders: (D) Other (or unknown)- Other (or 304.90, (A) 305.90 related disorders (F19. unknown)- Other (or unknown) induced disorders: (I) bcx) related 292.89, (W) 292.0, (ID) 292.81, (PD) disorders 292.82, (PAD) 292.83, (P) 292.1x, (M) 292.84, (others) 292.89, NOS (292.9)

The left side is the DSM-IV-TR categories for substance related disorders with accompanied ICD-9-CM code; the right side is the DSM-5 categories for substance related disorders with accompanied ICD-10-CM code.

severity discrimination. But the ICD-10-CM independent class. However, in the ICD-10- still distinguishes abuse and dependence, and it CM, cocaine is in an independent class, where- is similar to the DSM-IV. The ICD-10-CM code as amphetamine and caffeine are in the other for DSM-5 substance use disorders categories class (other stimulants, including caffeine). As accord to the severity, with F1x.10 (mild), more effort to the DSM-ICD harmonization F1x.20 (moderate and severe); but the ICD-10- there may be a solution to these inconsistencies CM code for ICD substance use disorders clas- in the future. siﬁ cations accord to abuse (F1x.10) or dependence (F1x.20). These codes imply that mild Conclusion substance use disorders correspond to the previous abuse categories, while the moderate to The concept of drug addiction has been severe disorders correspond to the previous de- transformed from illegal drug-seeking behavior to pendence categories, being similarty seen in the a chronic brain disease, and the transform of view- DSM-IV [14]. point has also correlated to the change in DSM ‧Some differences of substance classiﬁ cation diagnosing system. From the DSM-IV to the DSM- exist between those two nosologies. In the 5, the most remarkable change is merge substance DSM-5, stimulants include amphetamine and abuse and dependence together, and the replace- cocaine as same class, and caffeine is another ment of abuse and dependence categories with Tsou CC, Huang SY • 19 •

Figure 1. Code information for mental or behavioral disorder due to psychoactive substance use in the ICD-10-CM. Before the decimal point, the three digits represent the categories; for substance-related disorders, the fi rst and second digit must be “F” and “1,” respectively. The third digit represents the substance class. After the decimal point, the fourth digit represents the substance use disorder severity (abuse of dependence), and the fi fth and sixth digits represent the presentation of substance-induced disorders, with the seventh digit being an extension. unifi ed substance use disorder construct. Despite system, making them more suitable and perfect, the DSM-5 diagnosing system solves the prob- and to improve the DSM-ICD harmonization. lems of the DSM-IV and enhances the clinical utility and research advance, several challenges and Acknowledgement controversies still exist in the chapter of substance-related and addictive disorder, including The authors declare no potential confl icts of the debate on non-substance related disorders, interest in writing this invited overview. adding the new criterion “craving,” and eliminating polysubstance dependence. References The ICD is nowadays the most widely used classifi cation and coding systems for diseases. 1. Baingana F, al’Absi M, Becker AE, Pringle B: Global The ICD-10-CM provides a more principal and research challenges and opportunities for mental easier way to code substance use disorder, but the health and substance-use disorders. Nature 2015; ICD-10-CM remains some difference to the DSM- 527: S172-7. 5. Perhaps the future research and expert discus- 2. Steel Z, Marnane C, Iranpour C, et al.: The global prevalence of common mental disorders: a system- sion could improve these international diagnosing atic review and meta-analysis 1980-2013. Int J • 20 • DSM-5 Substance-related Disorders

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