Compatibility of current DSM-IV and proposed DSM-5 diagnostic criteria for cocaine use disorders

Addictive Behaviors 37 (2012) 722–728

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Addictive Behaviors

Compatibility of current DSM-IV and proposed DSM-5 diagnostic criteria for cocaine use disorders Steven L. Proctor a,⁎, Albert M. Kopak b, Norman G. Hoffmann c a b c

Department of Psychology, 236 Audubon Hall, Louisiana State University, Baton Rouge, LA 70803, USA Department of Criminology and Criminal Justice, 413-A Belk Building, Western Carolina University, Cullowhee, NC 28723, USA Department of Psychology, 301 Killian Building, Western Carolina University, Cullowhee, NC 28723, USA

a r t i c l e Keywords: DSM-5 Cocaine Cocaine use disorders State prison Inmates

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a b s t r a c t Objectives: The present study examined the compatibility of the current DSM-IV and proposed DSM-5 diagnostic criteria for cocaine use disorders (CUD) among state prison inmates, and evaluated the diagnostic utility of the proposed criteria in accounting for DSM-IV “diagnostic orphans” (i.e., individuals who meet one or two of the diagnostic criteria for substance dependence yet fail to report indications of substance abuse). Method: Data were derived from routine clinical assessments of adult male inmates (N = 6871) recently admitted to the Minnesota Department of Corrections state prison system from 2000 to 2003. An automated (i.e., computer-prompted) version of the Substance Use Disorder Diagnostic Schedule-IV (SUDDS-IV; Hoffmann & Harrison, 1995) was administered to all inmates as part of routine assessments. DSM-IV and DSM-5 criteria were coded using proposed guidelines. Results: The past 12-month prevalence of DSM-IV CUDs was 12.7% (Abuse, 3.8%, Dependence, 8.9%), while 11.0% met past 12-month DSM-5 criteria for a CUD (Moderate [MCUD], 1.7%; Severe [SCUD], 9.3%). When DSM-5 criteria were applied, 11.8% of the DSM-IV diagnostic orphans received a MCUD diagnosis. The vast majority of those with no diagnosis (99.6%) continued to have no diagnosis, and a similar proportion who met dependence criteria (98.4%) met SCUD criteria of the proposed DSM-5. Most of the variation in diagnostic classifications was accounted for by those with a current abuse diagnosis. Conclusions: The proposed DSM-5 criteria perform similarly to DSM-IV criteria in terms of the observed past 12-month CUD prevalence and diagnostic classifications. The proposed criteria appear to account for diagnostic orphans that may warrant a diagnosis. DSM-IV abuse cases were most affected when DSM-5 criteria were applied. Additional criteria, beyond those included in the proposed DSM-5 changes, concerning use to relieve emotional stress and preoccupation with use were frequently endorsed by those with a proposed DSM-5 diagnosis. © 2012 Elsevier Ltd. All rights reserved.

1. Introduction Cocaine use and cocaine use disorders (CUD) are a serious public health concern. Estimates from the 2008 National Survey on Drug Use and Health (NSDUH; Substance Abuse and Mental Health Services Administration [SAMHSA], 2009) found that 1.4 million persons aged 12 or older in the U.S. general population met Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association [APA], 1994) criteria for a CUD. Cocaine had the third highest rate of past year drug dependence or abuse, behind only marijuana and pain relievers (SAMHSA, 2009). Prevalence rates of cocaine use and CUDs among correctional populations, however, are considerably higher than those found among the general adult population (e.g., Lo & Stephens, 2000; Peters, Greenbaum, Edens, Carter, & ⁎ Corresponding author. Tel.: +1 757 570 5557; fax: +1 225 578 4125. E-mail addresses: [email protected] (S.L. Proctor), [email protected] (A.M. Kopak), [email protected] (N.G. Hoffmann). 0306-4603/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2012.02.010

Ortiz, 1998; Stewart, 2009). Thus, we examined the compatibility of the DSM-5 CUD criteria among prison inmates given substance use and use-related problems are particularly prevalent among this population (e.g., James & Glaze, 2006; Karberg & James, 2005). Among the many negative outcomes that have been linked with cocaine use, recent-onset cocaine users appear to be at an increased vulnerability to develop cocaine dependence more abruptly than other substance users. Epidemiological findings have shown that there is a rapid onset of cocaine dependence within the first 1–2 years after initiation of first use, with 5–6% of users manifesting the cocaine dependence syndrome during this initial interval of cocaine use (Wagner & Anthony, 2002). This rapid progression from first use to dependence for cocaine is in marked contrast to the development of other substance dependence syndromes among first onset cannabis and alcohol users, with risk estimates of approximately 1–4% during the first two years after initial use of these substances (Wagner & Anthony, 2002). More recent evidence from the National Household Survey on Drug Abuse (NHSDA; O'Brien & Anthony, 2005) suggests that 5–6% of recent-

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onset cocaine users develop DSM-IV cocaine dependence within the first two years following onset of cocaine use. Further research employing latent class analysis has also found support for this abrupt onset of a cocaine dependence syndrome shortly following initial cocaine use (Reboussin & Anthony, 2006). Findings revealed that 4% of recentonset cocaine users were members of a class that resembled DSM-IV cocaine dependence while 16% of recent-onset users were members of a class that reported a mean of 2.4 clinical indications of cocaine dependence and 80% reported few or no clinical indications of cocaine dependence. Thus, cocaine use and CUDs are a serious public health concern. What is unclear, however, is how the proposed DSM-5 criteria will affect diagnostic classification for individuals with a DSM-IV CUD. The DSM-IV (APA, 1994) is the most widely accepted nomenclature used by clinicians and researchers for the classification of mental disorders. A historical overview of the DSM criteria for substance use disorders (SUD) or a comprehensive discussion of the validity and performance data for the DSM-IV in the classification of SUDs, as described by Martin, Chung, and Langenbucher (2008), is beyond the scope of the present report. Rather, we will broadly discuss the current DSM-IV and proposed DSM-5 criteria for SUDs in an effort to provide a general context for the present investigation. The DSM-IV classifies SUDs into two mutually exclusive categories; substance abuse and substance dependence. According to the DSM-IV (APA, 1994), substance abuse is defined by a maladaptive pattern of substance use manifested by recurrent negative consequences related to use and requires the presence of at least one of the four stated criteria. Substance dependence, on the other hand, requires a minimum of three of seven criteria and is characterized by impaired control over use, desire or attempts to restrict use, continued use despite harm, tolerance, withdrawal, spending excessive time related to use, and sacrificing activities to use. Another important issue associated with the DSM-IV division between abuse and dependence is that of “diagnostic orphans.” Diagnostic orphans refer to those individuals who meet one or two of the diagnostic criteria for substance dependence yet fail to report indications of substance abuse, thus warranting a no diagnosis classification. Many authors argue that these individuals may manifest severe substance-related problems similar in severity level to those with a qualified substance dependence diagnosis. In fact, considerable prospective studies have amassed to support the contention that some diagnostic orphans may be at increased risk for developing subsequent SUDs and use-related problems relative to individuals who do not report positive diagnostic findings at baseline (Degenhardt, Coffey, Carlin, Swift, & Patton, 2008; Harford, Yi, & Grant, 2010; McBride & Adamson, 2010). Considering the negative clinical and prognostic implications of diagnostic orphans failing to receive a formal DSM-IV SUD diagnosis, it seems appropriate to consider whether these cases will be identified by the proposed DSM-5 revision of the diagnostic criteria. Despite the widespread utilization of the DSM-IV criteria and its reliance on a categorical system to SUD classification, many authors propose that conditions such as substance dependence are dimensional. For instance, results from numerous factor and latent class analyses indicate that substance-related problems may be arrayed along a single dimension rather than as separate abuse and dependence factors (Krueger et al., 2004; Muthen, 2006). Similarly, recent evidence from a substance use treatment sample suggests that the proposed DSM-5 criteria form a unidimensional latent trait for cocaine (Hasin, Fenton, Beseler, Park, & Wall, 2011). Moreover, findings from a clinical sample of adult substance users, using the item response theory measure of item threshold, did not support the validity of DSM-IV cocaine dependence criteria as distinct from and more severe than the milder abuse criteria (Langenbucher et al., 2004). Still, others argue that the DSM-IV categorical structure to SUD classification should not be abandoned and that dependence is a distinct condition from abuse (e.g., Hasin, Van Rossem, McCloud, & Endicott, 1997;

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Hoffmann & Hoffmann, 2003), and that abuse is also more distinct from dependence than from those with no diagnosis (Hasin et al., 1997). Hoffmann and Hoffmann (2003) documented that alcohol dependence and abuse present as distinct disorders, and that clinical profiles are quite pronounced for dependence cases, thus supporting a discrete and clearly identifiable syndrome for substance dependence. Results using exploratory factor analysis have also supported a two-factor solution of DSM-IV lifetime criteria for CUDs, similar to DSM-IV cocaine abuse and dependence (Blanco, Harford, Nunes, Grant, & Hasin, 2007). Given the conceptual and empirical problems noted for the DSMIV criteria, as well as the issue of diagnostic orphans often going undiagnosed when applying traditional classification standards, the DSM-5 SUD Work Group has announced changes that include introducing a dimensional classification scheme and modifying the symptom threshold (APA, 2010). The DSM-5 conceptualization of SUD classification involves a shift from the traditional categorical approach to a dimensional approach. The proposed changes to the DSM-5 include collapsing the four abuse and seven dependence criteria into a single unified SUD category of graded clinical severity, with two criteria required to assign a diagnosis. Specifically, the new SUD category will include two severity specifiers based on the total number of positive criteria; Moderate (2–3 positive criteria), and Severe (4 or more positive criteria). The proposed changes also include the removal of the legal problems criterion (DSM-IV abuse criterion 3), and the addition of a criterion representing craving or compulsive use. The empirical rationale for the removal of the legal problems criterion is based on epidemiological data indicating that this criterion has consistently shown low discrimination values and factor loadings as well as an extremely low prevalence relative to the other diagnostic criteria (e.g., Mewton, Slade, McBride, Grove, & Teesson, 2011; Proudfoot, Baillie, & Teesson, 2006). From a conceptual perspective, whether or not one has legal problems, such as being arrested for drug possession, is likely to involve serendipity as much as a diagnostic indication. Historically, the research literature dealing with the prevalence of SUDs among inmates has offered limited insight into substancespecific prevalence rates. For instance, research in this area is limited due to various methodological limitations, including the tendency of many studies to consider all non-alcohol SUDs (e.g., CUDs) as a single drug use disorder category, and/or the failure to definitively distinguish between diagnoses of dependence vs. abuse (e.g., Binswanger et al., 2010; Compton, Dawson, Duffy, & Grant, 2010; Draine, Blank, Kottsieper, & Solomon, 2005; Fazel, Bains, & Doll, 2006; RoundsBryant & Baker, 2007; Smith, Sawyer, & Way, 2002; Young, 2003). Given that substance-dependent individuals tend to experience poorer prognosis and treatment outcomes relative to individuals with a substance abuse diagnosis (Hasin et al., 1997; Schuckit et al., 2008, 2001), the need to clearly differentiate between diagnoses of dependence vs. abuse remains an important issue if authorities aspire to meet the unique SUD treatment needs of state prison inmates. The question is whether the severe SUD designation of the proposed DSM5 revision will result in effectively classifying those with a more pronounced clinical profile and also identify those with a more chronic course. In sum, given the many public health concerns associated with cocaine use and CUDs, coupled with the issue of DSM-IV diagnostic orphans often going undiagnosed, accurately identifying and classifying individuals with CUD indications remains of paramount importance. While a body of knowledge regarding SUD prevalence among inmates is accumulating, to date there remains limited published research examining specific CUD prevalence among male state prison inmates. Further, although previous studies have evaluated the compatibility of DSM-5 criteria for alcohol and opioid use disorders (Agrawal, Heath, & Lynskey, 2011; Boscarino et al., 2011; Mewton et al., 2011), there remains no published research, to our knowledge, investigating the appropriateness of the proposed DSM-5 diagnostic

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criteria in relation to identifying individuals with a current DSM-IV CUD. Finally, to date, there exist no studies evaluating the clinical utility of the proposed DSM-5 criteria in accounting for diagnostic orphans. Thus, the present study sought to fill the apparent gaps in the research literature and provide a comparison of the DSM-IV vs. DSM-5 diagnostic criteria for CUDs through the use of the Substance Use Disorder Diagnostic Schedule-IV (SUDDS-IV; Hoffmann & Harrison, 1995), a structured diagnostic assessment interview compatible with DSM-IV criteria, which provides substance abuse and dependence diagnoses for a variety of specific substances, using data from a large state prison sample of adult male inmates. The comparison with the DSM-5 was possible because the SUDDS-IV contains additional items of interest that are not formally DSM-IV criteria, but one of which covers the new DSM-5 criterion of craving or compulsive use. The present study has three aims. First, we examined the compatibility of the current DSM-IV and proposed DSM-5 diagnostic criteria for CUDs. We tested this in two ways: (1) by determining the prevalence of past 12-month DSM-IV and DSM-5 CUDs, and (2) by examining the distribution of the current DSM-IV diagnostic cases among the proposed DSM-5 CUD categories (i.e., no diagnosis, moderate cocaine use disorder [MCUD], and severe cocaine use disorder [SCUD]). Second, we evaluated the clinical utility of the proposed DSM-5 criteria in accounting for diagnostic orphans by breaking the DSM-IV diagnostic cases into subgroups to incorporate inmates positive for diagnostic orphan criteria and examining the distribution of cases among the proposed DSM-5 CUD categories. A tertiary, exploratory focus of the present study was to consider additional criteria in addition to the craving or compulsive use criterion proposed for DSM-5 to examine the frequency of positive findings for these criteria among the MCUD and SCUD designations.

2. Method Data for the present study were derived from routine clinical assessments of 6871 male inmates between the ages of 18 and 65 years (M = 30.8, SD = 9.28) recently admitted to the Minnesota Department of Corrections (MnDOC) state prison system from 2000 to 2003. All inmates were assessed for SUD indications by certified addictions counselors subsequent to admission to the MnDOC to identify potential treatment needs. Typically the interviews were conducted after the inmate had settled into the respective institution in the correctional system. Interviews were conducted in 35 to 45 min depending on the range of positive responses provided by the inmates. The automated version of the SUDDS-IV, adapted for correctional applications, was used as a computer-prompted interview whereby the clinical staff asked the questions as they appeared on the screen and recorded the inmates' responses on laptop computers. Since being in a controlled environment precludes a definitive SUD diagnosis, the questions were phrased to cover the 12-month period prior to incarceration for a current diagnostic indication. The computer program exported a tab-delimited text file that was imported into SPSS (Statistical Package for the Social Sciences) to facilitate the generation of quarterly and annual statistical summaries for the MnDOC. The clinical interview data from the SUDDS-IV were originally utilized by one of the authors to provide the MnDOC with periodic reports on relevant problem areas relating to SUD prevalence rates and various substance-related public health and safety concerns (e.g., health care utilization, personal health, motor vehicle accidents, driving while intoxicated charges). Thus, the present study utilized archival data, with all personal identifiers removed by the MnDOC. Release of the de-identified dataset was approved by the MnDOC for use in secondary analyses and permission to use the dataset was approved by the appropriate human subjects committee of the university with which the authors were affiliated at the time of the investigation.

2.1. Participants Demographic characteristics for the total sample are detailed in Table 1. Ethnic composition was predominately Caucasian (50.9%), while African Americans (31.5%) and Native Americans (7.7%) constituted the largest racial-minority groups. Over four-fifths had never been married (68.8%) or were divorced (14.4%) and only 12.3% of the inmates were currently married at the time of incarceration. In terms of educational attainment, slightly more than half (52.9%) of the total sample graduated from high school or received their GED. Approximately half (50.5%) of the inmates were employed full-time and 14.9% were employed part-time prior to incarceration. Specifically, over one-third (34.5%) of the inmates reported that they worked as a laborer/temporary worker prior to incarceration with skilled blue collar (24.0%) or white collar worker (9.2%) being the next largest job designations. Personal income tended to be rather low in that 57.5% reported earning a range of less than $10,000 in the year prior to incarceration and only 9.1% reported earning more than $30,000. 2.2. Measures The SUDDS-IV is a diagnostic assessment interview, compatible with DSM-IV criteria, designed to provide detailed and thorough coverage of lifetime and current SUDs with multiple items for most of the individual criteria. The SUDDS-IV has been used to assess SUDs among correctional populations (e.g., Hoffmann, DeHart, & Campbell, 2002; Hoffmann & Hoffmann, 2003; Jones & Hoffmann, 2006), and has evidenced adequate construct validity. Internal consistency reliability estimates of the items comprising the various substance-specific scales yielded Cronbach's alphas ranging from over .90 for the various

Table 1 Demographic characteristics of the total sample. Variable Age (years) 18–24 25–34 35–44 45 + Ethnicity Caucasian African American Native American Hispanic Asian Other/Multiracial Marital status Never married Married Divorced Separated Widowed Education Some high school or less High school graduate/GED Vocational/technical Associate degree Bachelors degree or more Employment status Unemployed Full-time Part-time Not working by choice Personal income $10,000 or less $10,001–$20.000 $20,001–$30,000 $30,001–$40,000 $40,001 + Note. Percentages may not total 100% due to rounding.

% (n) 32.8 34.2 24.3 8.7

(2255) (2348) (1681) (597)

50.9 31.5 7.7 6.8 1.6 1.6

(3495) (2163) (531) (464) (110) (108)

68.8 12.3 14.4 4.0 0.5

(4730) (844) (991) (273) (33)

35.6 52.9 7.4 2.8 1.2

(2447) (3635) (511) (189) (89)

15.6 50.5 14.9 18.9

(1075) (3470) (1025) (1301)

57.5 22.2 11.3 5.0 4.1

(3951) (1525) (776) (341) (178)

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dependence scales to above .85 for the various abuse scales (Hoffmann & Hoffmann, 2003). The automated version of the SUDDS-IV, adapted for correctional applications, considers the 12 months prior to incarceration for the timeframe utilized in arriving at current SUD diagnoses. This timeframe takes into account that being in a restrictive environment precludes assigning a formal diagnosis following incarceration. The SUDDS-IV also contains several supplemental items that address additional concepts in addition to the items covering the seven dependence and four abuse criteria specified in the DSM-IV. For example, one item addresses the issue of craving or compulsive use (Has the desire to use alcohol or drugs ever been so strong that you could not resist using?), which is consistent with the new criterion for the proposed DSM-5 SUD criteria (APA, 2010). Another item addresses preoccupation with use (Have you ever found yourself preoccupied with wanting to use alcohol or drugs?). The last item covers use to relieve emotional discomfort (Have you ever used alcohol or drugs to relieve emotional discomfort, such as sadness, anger, or boredom?). Positive responses to the general questions are then followed up with clarifications as to whether the positive response refers to alcohol and/or the other specified substances covered by the SUDDS-IV. Although the SUDDS-IV provides relevant indications for determining diagnoses for all of the SUD categories specified in the DSM-IV, only the positive responses specific to cocaine use were considered for the present study. 2.3. Data analyses De-identified data obtained from the SUDDS-IV were analyzed using SPSS (Version 18.0) to assess study aims. DSM-IV and DSM-5 diagnostic determinations were made from algorithms corresponding to the respective diagnostic formulations. Crosstabulations were utilized to consider the distribution of current DSM-IV diagnostic cases among the proposed DSM-5 categories of no diagnosis, MCUD, and SCUD. In addition, algorithms were utilized to place inmates into one of six a priori defined DSM-IV diagnostic categories: no diagnosis, diagnostic orphan, abuse only, abuse with one or two diagnostic orphan findings, dependence based on only three positive criteria, and dependence based on four or more positive criteria. A more detailed crosstabulation involved these six categories. Finally, the frequencies of positive findings for the various individual criteria were examined among the current DSM-IV and proposed DSM-5 diagnostic groupings. This allowed for the opportunity to explore whether some criteria provided stronger indications of a more severe CUD at the individual item level. 3. Results 3.1. Cocaine use disorder prevalence A comparison of the DSM-IV vs. DSM-5 CUD criteria revealed similar prevalence rates. In terms of the past 12-month prevalence of DSM-IV CUDs, 12.7% of the inmates reported indications of a CUD. A more detailed breakdown of the various DSM-IV diagnostic categories is as follows: abuse, 3.8%; and dependence, 8.9%. When the proposed DSM-5 criteria for CUDs were applied, 11.0% of the inmates met past 12-month criteria for a CUD (MCUD, 1.7%; SCUD, 9.3%). 3.2. Compatibility of DSM-5 diagnostic criteria We next examined the distribution of the three DSM-IV CUD categories (no diagnosis, abuse, dependence) among the three DSM-5 CUD categories (no diagnosis, MCUD, SCUD) when the proposed criteria are considered. Overall, 99.6% of the inmates who failed to meet DSM-IV criteria for a CUD remained in the no diagnosis category when DSM-5 criteria were applied and nearly all of the DSM-IV dependence cases (98.4%) received a DSM-5 SCUD diagnosis. In contrast, over half of the DSM-IV abuse cases (53.8%) did not meet criteria for

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a DSM-5 CUD. The balance of the DSM-IV abuse cases received a DSM-5 diagnosis of MCUD (33.5%) and SCUD (12.7%). Thus, while the DSM-IV no diagnosis and dependence cases remained largely unaffected when applying DSM-5 criteria, the DSM-IV abuse cases appeared most influenced by the proposed criteria with over half failing to meet criteria for a DSM-5 CUD. 3.3. Diagnostic orphan and additional DSM-IV diagnostic category classification Next, the question arises as to where the diagnostic orphan cases are classified according to the proposed DSM-5 criteria. When DSM5 criteria were applied, 11.8% of the diagnostic orphans received a MCUD diagnosis and none received a SCUD diagnosis. We then examined the crosstabulation for the remaining five a priori defined groups. Nearly all (95.0%) of the inmates who met DSM-IV criteria for cocaine abuse yet failed to report any DSM-IV cocaine dependence symptoms (i.e., the “pure” abuse group) did not meet DSM-5 criteria for a CUD, with 4.5% receiving a MCUD diagnosis. Of those inmates who met criteria for DSM-IV abuse and reported some dependence indications (i.e., the abuse + diagnostic orphan group), 64.3% received a MCUD diagnosis and 26.2% received a SCUD diagnosis. In terms of those inmates who met DSM-IV criteria for cocaine dependence, 83.6% of the inmates who met the minimum criteria for dependence (i.e., three dependence symptoms) received a DSM-5 SCUD diagnosis attributed to having positive findings on one or more of the abuse criteria, and 16.4% received a MCUD diagnosis. Finally, all inmates who exceeded the minimum DSM-IV criteria for cocaine dependence (i.e., four or more dependence symptoms) received a DSM-5 SCUD diagnosis and all of the inmates who failed to report DSM-IV CUD indications did not receive a DSM-5 diagnosis. 3.4. Frequency of individual criteria by diagnostic category Examination of the frequencies for the individual criteria endorsed by inmates in the various CUD diagnostic categories (DSM-IV vs. DSM-5) revealed several notable findings (Table 2). Regarding inmates who met criteria for a DSM-5 CUD, the most frequently endorsed criterion involved continued cocaine use despite knowledge of having a persistent or recurrent physical or psychological problem that was likely to have been caused or exacerbated by cocaine (DSMIV dependence criterion 7), with 90.6% and 42.2% of inmates with a SCUD and MCUD diagnosis providing a positive response to the item assessing this criterion, respectively. Additional criteria reported by 85% or more of the inmates with a SCUD diagnosis included: continued cocaine use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cocaine (DSM-IV abuse criterion 4); a great deal of time is spent in activities necessary to obtain cocaine, use cocaine, or recover from its effects (DSM-IV dependence criterion 5); and recurrent cocaine use resulting in a failure to fulfill major role obligations at work, school, or home (DSM-IV abuse criterion 1). Only three criteria were endorsed by more than one-third of the MCUD inmates: continued cocaine use despite having persistent or recurrent social or interpersonal problems related to cocaine use (DSM-IV abuse criterion 4); recurrent cocaine-related legal problems (DSM-IV abuse criterion 3); and recurrent cocaine use in situations in which it is physically hazardous (DSM-IV abuse criterion 2). The frequencies for the various criteria endorsed by those inmates with a DSM-IV CUD were fairly comparable to those observed for the DSM-5 diagnostic categories. Similar to the DSM-5 SCUD group, the most frequently endorsed criterion by inmates meeting DSM-IV criteria for cocaine dependence involved medical or psychological contraindications to cocaine use (92.0%; DSM-IV dependence criterion 7). Overall, consistent findings were noted between the DSM-IV dependence and DSM-5 SCUD categories in terms of the various

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3.6. Criteria predominately found among the DSM-5 severe designation

Table 2 Frequency of endorsed criteria by DSM cocaine use disorder category. Criterion

Role fulfillment Hazardous use Legal problems Interpersonal conflict Tolerance Withdrawal Unplanned use Cut down Time spent using Sacrifice activities Contraindications Compulsive use Relieve emotions Preoccupation

DSM-IV n (%)

DSM-5 n (%)

Abuse

Dependence

Dx orphana

Moderate

Severe

41 (15.8) 75 (28.8) 170 (65.4) 93 (35.8)

523 486 340 546

(85.3) (79.3) (55.5) (89.1)

– – – –

15 39 42 42

(12.7) (33.1) (35.6) (35.6)

546 509 351 574

(85.8) (80.0) (55.2) (90.3)

21 (8.1) 6 (2.3) 31 (11.9) 21 (8.1) 31 (11.9) 18 (6.9) 56 (21.5) 4 (1.5) 33 (12.7) 13 (5.0)

459 337 528 544 563 508 564 364 399 437

(74.9) (55.0) (86.1) (88.7) (91.8) (82.9) (92.0) (59.4) (65.1) (71.3)

76 (42.7) 0 (0.0) 12 (6.7) 5 (2.8) 89 (50.0) 2 (1.1) 15 (8.4) 0 (0.0) 3 (1.7) 5 (2.8)

30 5 32 23 36 7 50 2 24 11

(25.4) (4.2) (27.1) (19.5) (30.5) (5.9) (42.4) (1.7) (20.3) (9.3)

457 338 532 516 566 521 576 366 406 441

(71.9) (53.1) (83.6) (81.1) (89.0) (81.9) (90.6) (57.5) (63.8) (69.3)

Note. Dx Orphan = diagnostic orphan. Percentages in parentheses indicate proportion of inmates within each respective diagnostic category with a positive indication for each corresponding individual criterion. a Dashes are provided for the four DSM-IV abuse criteria given composition of the Dx orphan category excluded cases positive on one or more of these criteria.

individual criteria endorsed by over 85% of their respective category with the exception of two additional criteria. Specifically, unplanned cocaine use (86.1%; DSM-IV dependence criterion 3) and a persistent desire or unsuccessful efforts to cut down or control cocaine use (88.7%; DSM-IV dependence criterion 4) were reported by a majority of inmates with a DSM-IV dependence diagnosis. Regarding those inmates who met DSM-IV criteria for cocaine abuse, the most frequently endorsed criterion involved recurrent cocaine-related legal problems (65.4%; DSM-IV abuse criterion 3), followed by persistent or recurrent interpersonal problems related to cocaine use (35.8%; DSM-IV abuse criterion 4), and hazardous cocaine use (28.8%; DSMIV abuse criterion 2). Finally, for the DSM-IV diagnostic orphan group, the most frequently endorsed criteria involved those representing the presence of tolerance (42.7%; DSM-IV dependence criterion 1) and a great deal of time devoted to cocaine-related activities (50.0%; DSM-IV dependence criterion 5). No other individual criterion was endorsed by more than 9.0% of the diagnostic orphan cases.

3.5. Frequency of additional criteria by diagnostic category The frequency estimates for three additional criteria not considered by the proposed DSM-5 changes are also presented in Table 2. Overall, 63.8% of inmates with a DSM-5 SCUD diagnosis reported using cocaine to relieve emotions, and 20.3% of the MCUD group endorsed this criterion. In regard to the criterion representing preoccupation with cocaine use, 69.3% of the SCUD group and 9.3% of the MCUD group endorsed this criterion. Over half (55.2%) of the SCUD group and 35.6% of the MCUD group reported experiencing legal problems related to cocaine use (DSM-IV abuse criterion 3). In terms of those inmates who met DSM-IV criteria for cocaine abuse, 12.7% reported using cocaine to relieve emotions, 5.0% reported preoccupation with cocaine use, and 65.4% reported recurrent cocaine-related legal problems. Of those inmates who met DSM-IV criteria for cocaine dependence, 65.1% reported using cocaine to relieve emotions, 71.3% reported preoccupation with cocaine use, and 55.5% reported recurrent cocaine-related legal problems. Thus, it appears that some symptoms not currently considered in the proposed DSM-5 changes are highly indicative of a more severe CUD (i.e., DSM-5 SCUD, DSM-IV cocaine dependence), particularly the behaviors related to the use of cocaine to relieve emotions and preoccupation with use.

Positive findings for five of the criteria in the proposed DSM-5 revision were almost exclusively found among those receiving a SCUD diagnosis. Of those inmates with positive findings relating to a failure to fulfill major role obligations (DSM-IV abuse criterion 1), withdrawal (DSM-IV dependence criterion 2), persistent or unsuccessful efforts to cut down or control cocaine use (DSM-IV dependence criterion 4), sacrificing activities because of cocaine use (DSM-IV dependence criterion 6), and craving or compulsive cocaine use (proposed DSM-5 criterion), more than 95% were found among those with a SCUD diagnosis. This was also true for the additional criterion covered by the SUDDS-IV relating to preoccupation with cocaine use. The remaining criteria had greater prevalences among the MCUD cases. A similar pattern was noted for the abuse and dependence diagnoses of the DSM-IV. 4. Discussion The findings from the present study suggest that the proposed DSM-5 SUD criteria, with respect to CUDs, appear quite compatible with the DSM-IV criteria. In fact, a comparison of past 12-month CUD prevalence using both classification systems revealed similar rates, with 12.7% and 11.0% of inmates meeting DSM-IV and DSM-5 diagnostic criteria, respectively. For those in the no diagnosis and dependence designations, the vast majority fell into the no diagnosis and SCUD designations of the proposed DSM-5 criteria. Although these findings would at first appear surprising given the extent of changes proposed for DSM-5, similar results have been found in studies examining the compatibility of DSM-5 criteria for alcohol and opioid use disorders in terms of observed prevalence estimates (Agrawal et al., 2011; Boscarino et al., 2011; Mewton et al., 2011). Based on the results from a more detailed crosstabulation involving a consideration of the six a priori defined DSM-IV categories by DSM-5 diagnostic status, several noteworthy findings require discussion. First, it appears that adoption of the proposed DSM-5 CUD criteria may provide at least a partial solution in accounting for DSM-IV diagnostic orphans as 11.8% of the diagnostic orphans received a MCUD diagnosis when DSM-5 criteria were applied — that is they were positive on two dependence criteria. Second, many of the inmates remained largely unaffected when the DSM-5 criteria were adopted. For instance, nearly all of the inmates in both the no diagnosis group and the DSM-IV cocaine dependence group were unaffected by the proposed changes in that those currently without a diagnosis remained so and those meeting dependence criteria now met the proposed DSM-5 criteria for SCUD. However, the DSM-IV diagnostic categories most affected were those comprised of inmates who received an abuse diagnosis. In fact, over half (53.8%) of the inmates in the abuse group (i.e., abuse + diagnostic orphans) and nearly all (95.0%) of the inmates in the pure abuse group (i.e., met DSM-IV criteria for abuse yet failed to report indications of dependence) failed to receive a DSM-5 diagnosis. This appears to be due in large part to the proposed DSM-5 changes involving the removal of the criterion representing recurrent substance-related legal problems (DSM-IV abuse criterion 3) and requiring at least two positive criteria instead of just one for a DSM-IV abuse designation. Together, the resemblance between the observed prevalence rates (DSM-IV vs. DSM-5) and the findings from the crosstabulations raise an important issue regarding the implications of adopting the proposed DSM-5 revisions. While the current categories of no diagnosis and dependence seem to be highly compatible with the respective proposed DSM-5 designations, greater variability is seen in those currently diagnosed as having cocaine abuse and the diagnostic orphans. That is, it appears that the proposed DSM-5 changes relating to the removal of the DSM-IV legal problems criterion and requiring two criteria to be positive has dropped many of the abuse cases from

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receiving a diagnosis. This change would eliminate many cases whose diagnosis involved legal problems (e.g., arrested for possession) with only one other positive criteria. This may be a defensible change as such arrests may not be a rationally defensible criterion. Conversely, diagnostic orphans with two indications of dependence are now included in those receiving a MCUD diagnosis. Given the rationale for the proposed DSM-5 revisions as well as the negative clinical and prognostic implications of diagnostic orphans going undiagnosed, the changes seem appropriate. However, for the milder form of CUD, there appears to be a substantial shifting in who received a formal diagnosis. Further discussion is necessary regarding the implications of adopting the proposed changes to the DSM-5 SUD symptom threshold. Of particular interest was the finding that nearly all of the abuse only cases failed to qualify for a DSM-5 CUD diagnosis; a finding that appears consistent with the rationale for modifying the symptom threshold for DSM-5 (APA, 2010). It is important to note, however, that nearly one-third of the abuse category endorsed the criterion relating to hazardous use and two-thirds reported recurrent legal problems related to use. If one considers this finding from the perspective of the DSM-5 SUD Work Group, from which one of the goals in the proposed changes was to ensure that individuals who endorse a single symptom not receive a SUD diagnosis, this objective may be deemed a success. On the other hand, if one considers this finding from a public safety perspective, an individual who repeatedly drives while under the influence (DSM-5 hazardous use criterion) and receives multiple Driving While Intoxicated charges (DSM-IV legal problems criterion), yet fails to receive a DSM-5 SUD diagnosis, the success of the proposed threshold changes seems moot. Thus, depending on the perspective and ultimate objective in mind, the implications of this finding may not be as well-received. This raises the question as to whether two thresholds with three designations (i.e., no diagnosis, MCUD, and SCUD) is an optimal solution. The observed frequencies of the endorsed criteria among the various diagnostic groups also warrant additional comment. Overall, findings between the DSM-IV dependence vs. DSM-5 SCUD and DSM-IV abuse vs. DSM-5 MCUD diagnostic categories were relatively convergent with respect to the level of endorsement for the various criterion frequencies. Conversely, although several individual criteria were endorsed by over 85% of inmates with a cocaine dependence or SCUD diagnosis, only three criteria were reported by more than one-third of the DSM-5 MCUD group and only two criteria were reported by as many for the DSM-IV abuse group. Viewed from another perspective, five of the proposed criteria were found almost exclusively among the SCUD group. In other words, as the findings pertain to the proposed DSM-5 criteria, some of the diagnostic criteria appear to be more cardinal indicators of a SCUD diagnosis while others appear to be fairly evenly distributed among the three proposed DSM-5 designations (i.e., no diagnosis, MCUD, and SCUD) and are not as regularly endorsed. Thus, it appears that all individual criteria are not created equal. Findings from exploratory analyses at the item level revealed that inmates meeting both DSM-IV and DSM-5 criteria for a CUD reported positive findings for additional criteria not currently considered in the proposed DSM-5 criteria set. In fact, nearly 7 in 10 inmates who met DSM-5 criteria for SCUD reported using cocaine to relieve emotional stress and preoccupation with cocaine use, and over half reported experiencing recurrent legal problems related to cocaine use. These findings suggest that inmates meeting DSM-5 criteria for a CUD are likely to have experienced additional cocaine-related problems, beyond those covered in the proposed criteria. Noteworthy in this regard was the finding that preoccupation with cocaine use appeared to be a cardinal indicator of SCUD as were five of the criteria in the proposed DSM-5. Thus, this appears particularly salient for inmates presenting with more severe cocaine-related problems (i.e., those meeting criteria for SCUD). These findings have important research and clinical

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implications and suggest the need for additional investigation to determine the clinical utility of including some additional criteria either as part of the new diagnostic criteria set, or at the very least, supplemental survey items when assessing inmates for CUDs.

4.1. Limitations The findings from the present study should be considered in light of several limitations, which suggest the need for additional work in this area. First, the sample was comprised exclusively of male inmates, which warrants caution in the interpretation of the findings for female inmates or populations not comprised of incarcerated individuals. Second, the demographic composition of the MnDOC male state prison population is not entirely representative of other state prison systems. In particular, the ethnic composition of the current sample appeared to over-represent inmates of Caucasian ethnicity, and the level of educational attainment for the current sample was slightly higher than that of nationally representative samples (Harlow, 2003; West & Sabol, 2010). Thus, one would need to be cautious in extrapolating the findings for urban state prison settings with predominantly racial-minority populations or those prisons comprised of inmates with lower levels of educational attainment. Regarding the supplemental criteria assessed by the SUDDS-IV, the results are based on single items rather than a more comprehensive scale or multiple item set found for the DSM-IV criteria. Finally, as with other clinical interview data, the SUDDS-IV relies largely on self-report. Future research would benefit from a multi-method, multi-informant approach.

4.2. Conclusions To our knowledge, this is the first investigation to compare the compatibility of the current DSM-IV and proposed DSM-5 diagnostic criteria for CUDs and examine the clinical utility of the DSM-5 in accounting for diagnostic orphans. Despite the limitations, the findings suggest that the DSM-5 criteria perform similarly to DSM-IV criteria in terms of the observed 12-month CUD prevalence estimates and appear to be sufficient in regard to incorporating diagnostic orphans into the diagnostic realm. Variability between the two criteria appears largely confined to the abuse cases as the preponderance of those with no diagnosis still receive no diagnosis and the dependence cases tend to receive the severe designation. As a final point, from the perspective of advocates for the proposed DSM-5 changes, the proposed criteria eliminate inmates diagnosed previously with DSM-IV cocaine abuse due primarily to recurrent cocaine-related legal problems alone, but do account for diagnostic orphans with multiple problem indications. Given the present sample was comprised entirely from a state prison population, further work is necessary to replicate these findings with individuals not currently incarcerated. However, consideration of how the proposed criteria perform with high-risk populations is equally important. The findings do raise two issues regarding the proposed criteria. One is whether the two diagnostic categories and their respective thresholds are optimal. It is not clear that the designations of two categories based on two and four or more positive findings are optimal. Thus, the question remains of whether there should be some allowance of a risk category for those with only one indication, or should there be a more severe designation beyond four positive findings. The other issue is that the different criteria appear to differ in their indication of serious problem constellations. The question there is whether there should be some weighting of criteria that appear to be more cardinal indicators of a serious problem.

Role of funding sources There were no funding sources for this project.

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Contributors Hoffmann contributed to the study design and wrote the protocol. Proctor conducted background literature research and all authors conducted the statistical analysis and interpreted the results. Proctor wrote the first draft of the manuscript and the remaining authors all contributed revision and approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest.

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