Alcohol

Correlates of Mild, Moderate, and Severe Alcohol Use Disorder (AUD) Among Adults with Problem Substance Use: Validity Implications for DSM-5

Citation

Mannes, Z. L., Shmulewitz, D., Livne, O., Stohl, M., & Hasin, D. S. (2021). Correlates of mild, moderate, and severe Alcohol Use Disorder among adults with problem substance use: Validity implications for DSM-5. Alcoholism: Clinical and Experimental Research, 45, 2118–2129. https://doi.org/10.1111/acer.14701

Abstract
  • Background: The DSM-5 definition of AUD is validated, but research on how alcohol use, comorbidity, and impairment relate to its severity levels (mild, moderate, severe) is scarce. This study investigates the clinical and functional characteristics that correlate with these severity levels.
  • Methods: A total of 588 adults aged 18+ with current substance use problems were studied between 2016 and 2019. Assessments included DSM-5 AUD and potential correlates such as craving, binge drinking frequency, problematic use, harmful drinking, psychiatric disorders, and functional impairment. Multinomial logistic regression was used to analyze associations between these variables and AUD severity compared to a no AUD reference group.
  • Results: All alcohol use correlates significantly linked to a higher likelihood of all AUD severity categories. However, psychiatric disorders specifically correlated with severe AUD. Certain measures of functional impairment also correlated exclusively with severe AUD. Findings support the criterion validity of the DSM-5 tri-categorical measure, emphasizing the utility of severity-specific interventions.
Introduction
  • Alcohol Consumption Rates: In the United States, 66% of adults consume alcohol, with 6% reporting heavy or high-risk drinking.
  • Consequences of Excessive Drinking: Heavy alcohol use is a principal cause of preventable morbidity and mortality, contributing significantly to substance-related fatalities.
  • Definition of Alcohol Use Disorder (AUD): Characterized by a harmful pattern of alcohol use leading to significant impairment and distress, with several comorbidities and increased mortality risk associated.
  • Diagnostic Evolution: The criteria for AUD have evolved from DSM-III to DSM-5, transitioning from a model of abuse/dependence to a single disorder classified by severity levels:
      - Mild: 2-3 criteria
      - Moderate: 4-5 criteria
      - Severe: 6+ criteria
  • Research Gaps: Limited empirical data on the relationship between clinical characteristics and AUD severity classifications. The purpose of the study is to explore these associations further.
Materials and Methods
Participants and Procedures
  • Participants aged 18 and older were recruited from a suburban inpatient addiction treatment program and urban medical center.
  • Recruitment occurred via flyers and advertisements, with eligibility tied to certain substance use criteria over the past 30 days.
  • Exclusion criteria: Non-English speakers, those with cognitive impairments, and individuals currently exhibiting psychosis or suicidality.
  • Informed consent was obtained, and participants were compensated for their time.
Measures
  1. Outcome (AUD Severity): Using the Psychiatric Research Interview for Substance and Mental Disorders-5 (PRISM-5), the 11 DSM-5 criteria for AUD were assessed among participants who used alcohol.
       - DSM-5 AUD criteria include withdrawal, tolerance, inability to reduce alcohol use, and craving.
  2. Validators:
       - Alcohol-Specific Validators:
         - Craving: Assessed via the Alcohol Urge Questionnaire (AUQ), measuring participants' thoughts and feelings about drinking on a scale from 1 (strongly disagree) to 7 (strongly agree).
         - Problematic Use: A binary measure from the Addiction Severity Index indicating perception of alcohol as a major problem.
         - Harmful Use: Assessed using the Alcohol Use Disorders Identification Test (AUDIT); scores ≥8 indicate significant alcohol-related issues.
         - Binge Drinking Frequency: Evaluated via AUDIT.
       - Psychiatric Validators: Included diagnoses such as Major Depressive Disorder, PTSD, BPD, and ASPD.
       - Functioning Validators:
         - Social Impairment: Measured by the Social Adjustment Scale Self-Report (SAS-SR).
         - Physical/Mental Impairment: Measured using the Medical Outcomes Study Short Form 12-Item (SF-12).
  3. Control Variables: Demographic factors like age, sex, education, and employment status.
Statistical Analysis
  • Conducted using Chi-square and ANOVA for categorical and continuous variables.
  • Multinomial logistic regression analyzed the relationship between validators and AUD severity, controlling for demographic factors.
Results
Sociodemographic Characteristics and Validators
  • Demographics: Predominantly male participants (69.7%), majorly Black (47.7%), 42.1% age 50 or older, high unemployment (74.1%).
  • AUD Prevalence: Prevalence rates were noted as follows:
       - Mild: 12.2%
       - Moderate: 13.4%
       - Severe: 40.3%.
  • Psychiatric Conditions: MDD (39.3%), BPD (37.9%), ASPD (26.0%).
Adjusted Associations
  • Alcohol Validators: All were positively correlated with increasing AUD severity; strongest associations were noted for harmful use.
  • Psychiatric Validators: Only severe AUD was associated with psychiatric disorders; significant odds for individuals with MDD, PTSD, BPD, or ASPD relative to the no AUD group.
  • Functioning Validators: Mental and physical health impairments positively correlated with severe AUD, indicating a delineation between severe and less severe groups.
Discussion
  • Findings underscore the validity of the DSM-5 AUD severity classification, emphasizing that while alcohol use variables correlate with all severity levels, psychiatric and functional impairments were primarily associated with severe AUD.
  • Clinical Implications: The necessity for severity-specific interventions, particularly those addressing comorbid psychiatric conditions and functional impairments, especially in severe AUD populations.
  • The study also highlights the need for effective treatment protocols for mild AUD and the potential benefit of preventive measures and brief interventions.