will replace this classification to reflect the recent scientific literature. A catch-all diagnosis of “substance use disorder” will replace the “abuse” and “dependence” diagnoses, and its severity will be rated according to the number of symptoms of compulsive drug-seeking behavior. Thus, alcoholism will become “alcohol use disorder,” and services based on the diagnosis of “dependence” versus “abuse” will have to be redefined. The symptoms as described in DSM-IV will remain the same except that “legal problems” has been eliminated as a symptom, and “craving” has been added as a symptom (APA, 2011). Several papers have analyzed the proposed criterion changes and demonstrate support for the new classification in DSM-5 (Hasin, 2012). The prevalence of SUDs will not be significantly affected by this change.

The modern approach to SUDs begins with prevention that involves educating the population in the avoidance of risky behaviors and establishing and enforcing policies to discourage such behaviors. One such behavior is binge drinking, defined as five or more standard drinks on a single occasion for a male or four or more for a female (NIAAA, 2005). This is a common behavior among young adults, whether in the military or not, and it increases the likelihood of developing alcohol use disorders. Weekly volume of alcohol consumption also has been used as an early indicator of the risk of developing an alcohol use disorder. For men the danger level is 14 standard drinks per week and for women 7 drinks per week. Early detection of problem drinking should lead to further evaluation and specific intervention according to the needs of the individual. Environmental strategies that have been effective in preventing alcohol problems include such approaches as raising the minimum legal drinking age to 21, enforcing minimum purchase age laws, increasing alcohol taxes and reducing discount drink specials, and holding retailers liable for damage inflicted on others by intoxicated and underage patrons. These strategies are reviewed in greater detail in Chapter 5.

The dimensional approach of DSM-5, in contrast to previous categorical diagnoses, mirrors research findings that SUDs occur along a continuum. While some patients with milder, recent onset may be managed with outpatient therapy, those with more severe disorders may require inpatient care followed by a long period of aftercare. The tradition of 30 days of inpatient or residential care with uncertain follow-up is no longer considered the optimal approach. Clinical research also supports medication-assisted treatment using an array of Food and Drug Administration–approved medications, as discussed later in this report.

The past three decades have seen enormous advances in our understanding of the neurobiology of addiction. Until the 1940s, addiction was regarded as a moral failure that could happen only to people with “bad character.” As recently as 1988, the Supreme Court declared that the



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