Defining Multiple Substance Use Diagnostic Approaches

Changes in Diagnostic Criteria from DSM-III to DSM-IV-TR

"Polysubstance dependence" originated in the DSM nomenclature only in 1987, with the introduction of the third revised edition of the Diagnostic Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987). Prior to this, in DSM-III (American Psychiatric Association, 1980, p. 179), there was the diagnostic category of "mixed substance abuse," in which criteria for diagnosing substance abuse were met, but either the substances could not be identified or the abuse involved "so many substances that the clinician prefers" to treat them as a combination rather than define a specific disorder for each substance" (italics added). In addition, in DSM-III, there was an attempt to create clinically meaningful diagnostic categories with respect to dependence on multiple substances, hence the diagnoses "dependence on a combination of opioid and other non-alcoholic substances," an early nod to the high prevalence of use of multiple substances among heroin users, and "dependence on a combination of substances, excluding opioids and alcohol." In parallel with the DSM-III diagnosis for multiple substance abuse, each of these multiple dependence criteria was made only if the substances could not be identified, or the dependence involved so many substances that the clinician preferred to treat them as a combination rather than define a specific disorder for each substance.

This concept is what underlies the typical, non-DSM use of the term "polysub-stance dependence." In DSM-III-R, the concept of polysubstance dependence was formally introduced: The imprecise DSM-III concept of "so many" substances was dropped in favor of a threshold number of substances, and clinician "preference" was eliminated as an option to making such diagnoses. DSM-III-R polysubstance dependence stipulates that the person meets criteria due to repeated use of at least three categories of substances as a group over 6 months, excluding caffeine and nicotine, but does not fulfill dependence criteria for any specific substance (American Psychiatric Association, 1987, p. 185).

In DSM-IV, the concept of polysubstance dependence is more specific (American Psychiatric Association, 1994). However, the DSM-IV versions allow for two different ways to interpret the diagnosis. The first diagnostic concept of polysubstance dependence in DSM-IV is: at least 3 groups of substances repeatedly used by the patient during 12 months that, as a group, meet criteria for dependence, but in which there is no specific drug that independently qualifies for substance dependence. As in all recent versions of the DSM, any substance for which the patient satisfies criteria for dependence should be given that diagnosis independently of other substances used. A second, more exclusive DSM-IV concept of polysubstance dependence is: three or more classes of drugs used by the patient without dependence on any one drug, but the sum of the criteria met for all drugs used is three or more. The definition of "polysubstance dependence" has been clarified somewhat in DSM-IV-TR (American Psychiatric Association, 2000). However, there are still two interpretations possible with the DSM-IV-TR related to polysubstance dependence. One schema focuses on episodes of indiscriminate use of a variety of substances that each meet one criterion, but when added together meet three or more dependence criteria; the other is that full dependence criteria are only met when the drug classes used are grouped together as a whole (First & Pincus, 2002). That stated, as defined by DSM-IV, polysubstance dependence is a relatively rare disorder, and the formal diagnosis is used infrequently by clinicians and researchers (Schuckit et al., 2001).

Clinicians and researchers use the term "polysubstance dependence" more frequently as shorthand for patients for whom the DSM-IV criteria would suggest that the patient fulfills independent dependence criteria for several different substances. Conway, Kane, Ball, Poling, and Rounsaville (2003) call this construct "polysubstance involvement." According to DSM-IV (American Psychiatric Association, 1994, 2000), a patient should have a diagnosis of substance dependence for each substance for which the person meets criteria. Because there is room for misinterpretation between the formal DSM-IV concept of polysubstance dependence and the more frequently used broad concept of use of multiple substances that is also described as "polysubstance dependence," in this chapter we use the convention "multiple substance use disorders" (SUDs) to denote the latter, broad concept, reserving the former for cases in which a formal DSM-based diagnosis has been made. "Multiple SUD" here denotes that the identified subject or sample has two or more formal SUD diagnoses, at least meeting criteria for substance abuse, or meets it by reasonable proxy, such as seeking treatment. "Multiple substance dependence" means that the identified subject or sample meets formal or reasonable proxy criteria for two or more substance dependence disorders.

"Polysubstance Abuse"

Although there was a diagnostic category of "mixed substance abuse" in DSM-III (American Psychiatric Association, 1980, p. 179), there is no diagnosis of polysubstance abuse in DSM-IV-TR (American Psychiatric Association, 2000). There may not be many people who abuse multiple substances over time with clinically significant impact, for whom no one substance is sufficient to make formal abuse criteria. This is because one needs only to satisfy one of the four DSM-IV criteria to pass the threshold for a substance abuse diagnosis related to that particular substance. However, it is conceivable that one could meet a criterion for substance abuse based on use of multiple substances, but not on one in particular. For example, a person could have two arrests for driving under the influence, one for alcohol and the other for cannabis, in the same year.

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