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As DSM-5 Launches, the Drama Ends and the Effects Begin

The newly revised, hotly contested book of psychiatric diagnoses is finally here. As the dust settles,The Fix reads the tea leaves for its real-world significance.

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By Michael Dhar

05/21/13

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The newest edition of psychiatry's "bible" of diagnosis, the DSM-5, made its long-awaited appearance on May 18 at the opening of the American Psychiatric Association’s (APA) national conference in San Francisco. This revision of the DSM-IV took the APA more than a decade to produce, and unprecedented criticism dogged it most of the way.

Because of the unique role the DSM-5 plays in the diagnosis of addiction—and, as a result, its influence on the allocation of billions of dollars for research, prevention and treatment—The Fix has devoted extensive coverage in recent months to the controversies. Now, with the book launched and the dust settling, we turn our attention to two questions about short- and long-term consequences, and what people with substance use problems stand to gain or lose:

• Will treatment for addiction become more accessible for more people? 

• Will research into addiction produce more effective diagnostics and drugs?

1. The Promises and Perils for Treatment

The DSM-5 arrives in the midst of an historic overhaul of the nation's healthcare system under Obamacare (aka the Patient Protection and Affordable Care Act, or ACA ). Together, the legislation and the diagnostics revision are likely to dramatically increase the number of Americans eligible for addiction treatment. But the noble goal of securing more care for substance users could have an unintended consequence, some experts warn: stretching an already-overwhelmed patchwork of services past their limits.

Once Obamacare kicks in, as many as 5 million people with substance use disorder will be newly eligible for insurance, according to an Associated Press analysis. The quandary: In most states, patients already fill treatment centers to the brim. The worst-hit states have only one rehab or hospital bed available for every 100 people in need of inpatient care. The new arrivals could double the existing wait-lists.

The DSM-5 revisions were based on the same healthcare research that shaped Obamacare, and will work in tandem with the legislation to encourage early intervention in substance use disorders, Charles O'Brien, MD, PhD, head of the University of Pennsylvania's Center for Studies in Addiction and chair of the DSM-5's Substance-Related Disorders Work Group, told The Fix. By defining substance use disorder across a spectrum from “mild” to “moderate” to “severe,” the revision could add as many as 20 million more substance use diagnoses, Keith Humphreys, PhD, a Stanford psychology professor who served as a senior advisor on drug policy under Obama, told The New York Times.

That jump in diagnoses, paired with the ACA's expansion of coverage, will present a formidable challenge to already-shrinking addiction services. And since the majority of new diagnoses will likely be people in the initial stage of disease, critics fear that the most severe cases most in need of treatment will lose out. “Our scarce [addiction] resources are already distributed in an irrational manner,” Allen Frances, MD, who headed the DSM-IV revision, wrote in Bloomberg News. “We badly shortchange those with clear disorders while overtreating essentially normal people.”

That alarm misrepresents the large-scale, long-term changes likely to result from the one-two punch of expanded insurance and diagnosis, Humphreys told The Fix. "I think that's a misplaced concern and an old way of looking at things," he said, because it fails to consider how Obamacare will transform the provision of addiction treatment. To be blunt, insured patients can pay medical bills, so the new healthcare law will make addiction profitable. That will move the bulk of substance use care from the realm of government funding to that of private enterprise.

Insured patients can pay medical bills, so Obamacare will make addiction profitable, encouraging private enterprise.

Hospitals and other private health centers will realize that the millions of newly insured addicts represent a source of customers, which could prompt their rapid expansion, Humphreys said. In another benefit, the provisions will likely shift services away from residential and stand-alone programs toward outpatient and integrated care systems.

But in the short term, Humphreys admits, there will be lag time before these “market adjustments” take effect. “While it's being figured out, some people will have a tougher time getting treatment,” he said.

The prospect of more accessible treatment for more people is based on two major changes in the ACA:

Medicaid: Obamacare’s main strategy to cover most of the 30 million uninsured Americans is by an enormous expansion of this government program for the poor. (Health exchanges will allow uninsured people who do not qualify for Medicaid to shop for competing private insurers.) In the past, Medicaid covered only half of mental health and substance use services. New rules have extended that to two-thirds, and come January 2014, it will reach 100%.

Parity: Under new "parity-plus" laws, health insurers will have to cover mental health and addiction care at the same rate as physical maladies.

But the Medicaid expansion may look better on paper than it works in reality. Why? Because the Supreme Court ruled last year that states have the right to restrict it. As a result, the effectiveness of the legislation will partly depend on whether or not states choose to implement the changes, said Susan Foster, MSW, vice president and director of policy research and analysis for the National Center on Addiction and Substance Abuse at Columbia University. Political agendas opposed to government spending appear to have shaped these choices, at least for the time being.

In additional changes, Obamacare relies heavily on cost-effectiveness—via prevention and early intervention—to bend the curve of runaway healthcare costs. And that's where the DSM-5 links arms most closely with the new Medicaid requirements, thanks to the manual's new “spectrum” approach to defining substance use disorder. The "mild" end of the DSM-5's substance-use spectrum will help healthcare providers identify patients at risk of, or in the first stages of, addictive behavior, O'Brien said. The DSM, in other words, will serve as a guide to help clinicians follow ACA mandates.

For example, a protocol called Screening, Brief Intervention and Referral to Treatment (SBIRT) has shown success at halting substance use disorder before it gains much momentum. Yet insurers have refused to cover SBIRT, limiting the program's actual use. Obamacare aims to change that, mandating that Medicaid and state-exchange insurance plans cover SBIRT as a prevention benefit provided by primary-care physicians and in hospital emergency rooms. 

“I think the DSM-5 and Obamacare should work well together, synergistically," Humphreys said.

Yet this spectrum definition of addiction prompts dire predictions of critics like Frances, who say the change will increase diagnoses by, for example, turning "normal" binge drinking into "substance use disorder" requiring treatment.

The research is mixed on whether or not that will happen. While an Australian study did, in fact, predict a shocking 62% increase in "alcohol use disorder" diagnoses under the DSM-5, two US studies estimated much smaller increases (of 11% and 5%). “I doubt that the increase in diagnoses is going to be significant,” Foster told The Fix.

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