A Fresh Look at “The Big 5” Substance Use Disorder Criteria

January 27, 2022
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Recently here on Recovery Review Jason Schwartz has been posting some fairly interesting new material, as well as re-posting older material, about the idea of addiction as a disease

The material he has shared has grown interesting enough and produced enough thoughtful conversation on various platforms, that I wanted to share a version of my very first post on Recovery Review (from 10/21/2019). It pertains to the topic.  Over the next few days I might post one or two more that are relevant to this topic Jason has highlighted.  

Earlier today, Bill Stauffer posted important and interesting content about the elimination of the classic diagnostic categories separating problematic use and addiction, their replacement with a simple list of criteria, and the relative uncertainties associated with the meaning (if any) concerning the number of criteria for SUD that may be met.  That post can be found here.

That post reminded me of conversations I have had over the years with Norman Hoffmann concerning what Norm calls “The Big 5”.

“The Big 5”

Norm has both published, and presented at national conferences, his work concerning what he calls “The Big 5” substance use disorder (SUD) criteria from the DSM-5.

In short, Norm has examined the relative weight of each of the 11 DSM-5 SUD criteria, separately, as applied to the probability of having any one or more additional positive criteria for SUD (from data collected on thousands of consecutively incarcerated individuals).

The empirical questions and answers on The Big 5 as Norm has presented them are summarized here:

  1. Question: Which of the 11 DSM criteria for SUD are commonly found among individuals with no SUD diagnosis?
    • Answer: Tolerance, and Use in dangerous situations.
    • That is to say, in his sample, the presence of tolerance as a single factor did not make it more likely than not that any additional criteria were present – and the same was true of use in dangerous situations as a single factor.
  2. Question: Which of the 11 DSM criteria for SUD are commonly found among those with mild to moderate SUD?
    • Answer: Unplanned use, Time spent, Interpersonal conflicts, and Use in spite of medical/psychological conditions.
  3. Question: Which DSM criteria for SUD are found primarily in severe SUD’s?
    • Answer: Efforts to control/cut down but unable (rule setting), Craving with compulsion to use, Failure to fulfill role obligations, Activities given up or reduced, Withdrawal.
    • That is to say, in his sample, the presence of any one of these 5 criteria, separately, was more likely than not to be present among 6 or more total positive SUD criteria for any one individual.

In presenting these results from his research, Norm has asked if perhaps the total constellation of The Big 5 is what is commonly called the disease of addiction.   Interestingly, Norm has also noted the individual may fit mild or severe characteristics (aside from DSM scaling), based on The Big 5, and as a result he has expressed the following questions:

  • Are those with mild to moderate DSM ratings without any of the Big 5 able to moderate use with less intense and briefer services?
  • What are the implications of The Big 5 for etiology and course of illness of the individual?
  • Specifically, do those that are positive on 2 or more of Big 5 in fact require initial residential placement and/or more intense and longer care, and require abstinence – even when not numerically “Severe” according to DSM-5?

Overall, Norm encourages the clinician to consider the pattern of positive criteria, in addition to the mere total number of criteria present.

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