Introduction: The State of Addiction Psychiatry

[[{"type":"media","view_mode":"media_crop","fid":"34279","attributes":{"alt":"The State of Addiction Psychiatry","class":"media-image media-image-right","id":"media_crop_6629934968287","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3645","media_crop_rotate":"0","media_crop_scale_h":"125","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]Over the past 50 years, the addiction field has exploded, thanks to a convergence of neurobiological research, psychopharmacological advances, and an exponentially growing evidence base. Nevertheless, despite a deep-rooted foundation, addiction psychiatry faces an ongoing struggle to achieve acceptance among physicians-from general practitioners to primary care psychiatrists. All too often, true neuro-pathologies such as alcoholism and injection drug use are marginalized, ignored, and sidelined for comorbid medical-or psychiatric-diagnoses.

In 1952, DSM-I formally recognized addiction as a subset of “sociopathic personality disorder” (alongside dyssocial reaction and unspecified sexual deviation). Almost 3 decades later, DSM-III dedicated an entire chapter to substance use disorders, providing separate abuse and dependence criteria for alcohol, barbiturates and sedative/hypnotics, opioids, amphetamines and sympathomimetics, phencyclidine (PCP)/arylcyclohexylamines, hallucinogens, cannabis, and tobacco. DSM-IV famously incorporated polysubstance dependence, which was redacted in DSM-5 to allow better conceptualization of individualized patient care.

In addition to removing polysubstance use, DSM-5 features several salient changes in its approach to patients struggling with addiction. First, addictive disorders no longer exist as “abuse” or “dependence”; both criteria sets have been combined into “use disorders.” This change promotes diagnostic reliability, validity, and clarity while it proposes a unidimensional spectrum of severity informed by both abuse and dependence.

Next, “craving” now serves as a symptom of substance use disorders. This addition reflects recent strong correlations of subjective craving data and functional neuroimaging. Conversely, legal consequences are no longer included as a criterion for substance use disorders; compared with other diagnostic criteria, their diagnostic yield was negligible because of their relatively low prevalence and accuracy.

Several nonsubstance addictive behaviors have been reclassified. Pathological gambling now falls under addictive disorders (previously it was an impulse-control disorder), and addiction to online video games is considered a “condition for further study.” Both shifts echo an increasing prevalence and expanding evidence base.

The articles in this Special Report provide a broad, cross-cutting perspective on the current state of addiction psychiatry, insofar as it may pertain to your own clinical practice. We hope you enjoy this addiction “smorgasbord” featuring cannabis use disorder, psychosocial addictions, pathological gambling, opioid use disorder, club drugs, and Internet gaming disorder.

In this Special Report:

Introduction: The State of Addiction Psychiatry

An Update on Street and Club Drugs: What Clinicians Need to Know

Opioid Use Disorder: Update on Diagnosis and Treatment

Marijuana and Madness: Clinical Implications of Increased Availability and Potency

A Brief Review of Gambling Disorder and Five Related Case Vignettes

Video Games: Recreation or Addiction?

The Therapeutic Alliance and Psychosocial Interventions for Successful Treatment of Addiction

Disclosures:

Mr Mals is a fourth-year University of New Mexico medical student, currently awaiting Match results for general psychiatry. Dr Foster is Assistant Professor of Addiction Psychiatry at the University of New Mexico and Medical Director of the Services for Teen Addiction in Recovery in Albuquerque. They report no conflicts of interest concerning the subject matter of this Special Report.