Battle Over 'Addiction' and 'Dependence'

The American Psychiatric Association's (APA) has finished the first draft of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). The DSM-IV is used all over the world to diagnose behavioral and mental disorders, and to help provide patients reimbursement for medical bills from insurance companies. There will be several changes, many of which involve the areas of the DSM that deal with addiction and dependence. There has been a battle over 'addiction' and 'dependence' and how those words should be properly used. The first draft of the DSM-V no longer has disease categories for substance abuse and dependence, "addictions and related disorders" is the desired new wording.

In a press release on Feb, 2010, the APA explained that: "eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system". "Substance-use disorders" will be classified by the particular substance type, i.e. "heroin-use disorder" or "cocaine-use disorder" will be the appropriate terminology when diagnosing. One difference in the new draft from the DSM-IV is the symptom of "drug craving"; the symptom would be added to the criteria; according to the APA "problems with law enforcement" would be eliminated from the criteria "because of cultural considerations that make the criteria difficult to apply internationally".


Gambling addiction looks like it will make the cut for the new DSM - finally. A new category of "behavioral addictions" would be created, but it will probably only contain one disorder (gambling) because other behavioral disorders have not had enough research. According to the APA, "Internet addiction was considered for this category, but work group members decided there was insufficient research data to do so, so they recommended it be included in the manual's appendix instead, with a goal of encouraging additional study". This is a big deal, for the first time, the term "addiction" would be tied to disorders other than drugs and alcohol. Charles O'Brien, M.D., Ph.D., chair of the APA's DSM Substance-Related Disorders Work Group, said, "There is substantive research that supports the position that pathological gambling and substance-use disorders are very similar in the way they affect the brain and neurological reward system". Although, in the DSM-V draft, sex and food disorders will still fall outside and not be included in the "behavioral addictions" category; instead, sex disorders will be included In the "hyper-sexuality" category and food problems will be classified as "binge eating" disorders.

The APA will be accepting comments on the proposed DSM-V revisions until April 20. The world has a much better understanding of the science of addiction, many breakthroughs in understanding have happened since the DSM-IV was released in 1994.

All of the proposed changes and information about submitting comments can be found on the DSM-V Website

Alcoholic Gary Reinbach Dead at 22 After Transplant Refused

So sad, the news that came my way this morning, a 22 year-old's plea for a transplant was refused. Alcoholic Gary Reinbach dead at 22 after transplant refused while at University College Hospital in London. This is a troubling story, which I read on Times Online, of the ethics in the health care system on a global level; unfortunately, this is not a new story, nor one that we will not hear again. How a 22 year kid could be refused a liver transplant, despite his alcoholism, has to make you wonder: Is the donor organ system flawed?

Gary Reinbach started drinking at a very young age, a product of a broken home in Essex, England. Nine years later he would be diagnosed and admitted to the hospital for an alcohol related illness for the first time. He was diagnosed with cirrhosis of the liver which is a fatal disorder that requires a liver transplant. The catch 22 is that in order for an alcoholic to receive a transplant they must demonstrate that the have been sober for 6 months; an impossible feat for a patient that does not have 6 months to live. Gary's doctors and his family went public making an appeal for the rules to be waived. But, despite their appeal Reinbach died less than 48 hours after it was issued; he died only 10 weeks after being admitted. This is unacceptable on multiple fronts for the fact is that people who suffer from the disease of alcoholism get less of an opportunity to receive proper health care than other diseases; do they make obese people swear they will stop overeating before they are given an insulin pump? Alcoholism is a disease that is far from understood by the masses of people who believe that alcoholics simply lack will power and that is why they continue to drink.

It is fair to say that if Gary were granted the transplant he would have had the opportunity to re-evaluate things and at least had one second chance to better his life. Sadly, this is not the case and the rules for donor organs do not leave room for exceptions; cutting people's lives short because people do not understand the disease concept of addiction. It is understandable that a repeat offender, someone in and out of hospitals for multiple years, does not receive a transplant; but, Gary was not one of those people, nor was he given the chance to prove that to be true.

My deepest sympathy and compassion goes out to Gary Reinbach's family. My greatest hope is that he did not die in vain and that his story will convince policy makers that a change needs to be made. Please share your thoughts with me on this subject as I will be glad to hear other's opinions. This story deeply pains my heart!