Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

246 IV. SPECIAL POPULATIONSThis concept is what underlies the typical, non-DSM use of the term “polysubstancedependence.” In DSM-III-R, the concept of polysubstance dependencewas formally introduced: The imprecise DSM-III concept of “so many” substanceswas dropped in favor of a threshold number of substances, and clinician“preference” was eliminated as an option to making such diagnoses. DSM-III-Rpolysubstance dependence stipulates that the person meets criteria due torepeated 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 anyspecific 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 versionsallow for two different ways to interpret the diagnosis. The first diagnostic conceptof polysubstance dependence in DSM-IV is: at least 3 groups of substancesrepeatedly used by the patient during 12 months that, as a group, meet criteriafor dependence, but in which there is no specific drug that independently qualifiesfor substance dependence. As in all recent versions of the DSM, any substancefor which the patient satisfies criteria for dependence should be giventhat diagnosis independently of other substances used. A second, more exclusiveDSM-IV concept of polysubstance dependence is: three or more classes ofdrugs used by the patient without dependence on any one drug, but the sum ofthe criteria met for all drugs used is three or more. The definition of “polysubstancedependence” has been clarified somewhat in DSM-IV-TR (AmericanPsychiatric Association, 2000). However, there are still two interpretationspossible with the DSM-IV-TR related to polysubstance dependence. Oneschema focuses on episodes of indiscriminate use of a variety of substances thateach meet one criterion, but when added together meet three or more dependencecriteria; the other is that full dependence criteria are only met when thedrug classes used are grouped together as a whole (First & Pincus, 2002). Thatstated, 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” morefrequently as shorthand for patients for whom the DSM-IV criteria would suggestthat the patient fulfills independent dependence criteria for several differentsubstances. Conway, Kane, Ball, Poling, and Rounsaville (2003) call thisconstruct “polysubstance involvement.” According to DSM-IV (American PsychiatricAssociation, 1994, 2000), a patient should have a diagnosis of substancedependence for each substance for which the person meets criteria.Because there is room for misinterpretation between the formal DSM-IV conceptof polysubstance dependence and the more frequently used broad conceptof 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 inwhich a formal DSM-based diagnosis has been made. “Multiple SUD” here