Specific diagnostic criteria identify those at high risk for progression from ‘preaddiction’ to severe alcohol use disorder
Authors: Miller Alex P. , Kuo Sally I-Chun , Johnson Emma C. , Tillman Rebecca , Brislin Sarah J. , Dick Danielle M. , Kamarajan Chella , Kinreich Sivan , Kramer John , McCutcheon Vivia V. , Plawecki Martin H. , Porjesz Bernice , Schuckit Marc A. , Salvatore Jessica E. , Edenberg Howard J. , Bucholz Kathleen K. , Meyers Jaquelyn L. , Agrawal Arpana 
Published: June 2023

AbstractImportanceBoth current DSM-5 diagnoses of substance use disorders (SUDs) and the recent “preaddiction” conceptual proposal (i.e., mild-to-moderate SUD) rely on criterion count-based approaches, without consideration of evidence regarding varying severity grading indexed by individual criteria.ObjectiveTo examine correlates of alcohol use disorder (AUD) across count-based severity groups (i.e., mild, moderate, mild-to-moderate, severe), identify specific diagnostic criteria indicative of greater severity, and evaluate whether the presence of specific criteria within mild-to-moderate AUD differentiates across relevant correlates and manifests in greater hazards of severe AUD development.DesignCross-sectional and longitudinal cohort study.SettingFamily-based study of individuals from seven sites across the United States.ParticipantsCross-sectional (N=13,110; mean [SD] age, 37.8 [14.2] years) and longitudinal cohorts (N=2,818; mean baseline [SD] age, 16.1 [3.2] years) from the Collaborative Study on the Genetics of Alcoholism (COGA).ExposureN/AMain Outcomes and MeasuresSociodemographic, alcohol-related, psychiatric comorbidity (major depressive disorder, antisocial personality disorder, and other SUDs), brain electroencephalography (EEG), and AUD polygenic score measures as correlates of DSM-5 AUD levels (i.e., mild, moderate, severe) and criterion severity-defined “preaddiction” (i.e., low-riskvs.high-risk mild-to-moderate) AUD diagnostic groups.ResultsAssociations with alcohol-related, psychiatric, EEG, and AUD polygenic score measures reinforced the role of increasing criterion counts as indexing severity. Yet even within those meeting criteria for mild-to-moderate AUD (2-5 criteria), the presence of specific “high-risk” criteria (e.g., withdrawal) identified a group reporting heavier drinking and greater psychiatric comorbidity even after accounting for criterion count differences. In longitudinal analyses, prior mild-to-moderate AUD characterized by endorsement of at least one “high-risk” criterion outperformed other adolescent and young adult correlates of AUD progression (i.e., comorbid psychiatric diagnoses, alcohol involvement milestones) and was associated with more accelerated progression to severe AUD (adjusted hazard ratio [aHR], 11.62; 95% CI, 7.54-17.92) compared to prior mild-to-moderate AUD without endorsement of “high-risk” criteria (aHR, 5.64; 95% CI, 3.28-9.70), independent of criterion count.Conclusions and RelevanceCurrent count-based AUD diagnostic approaches and the “preaddiction” concept both ignore heterogeneity among criteria. Estimating addiction vulnerability by emphasizing specific “high-risk” criteria may improve our understanding of its development and focus attention on those at greatest risk.Key PointsQuestionDoes emphasis on specific alcohol use disorder (AUD) criteria improve identification of individuals at risk for developing more severe AUD?FindingsIndividuals meeting criteria for mild-to-moderate AUD are two-fold more likely to progress to severe AUD if they endorse criteria for drinking despite physical/psychological problems, giving up important activities, spending a great deal of time drinking, failure to fulfill major role obligations, withdrawal, and craving, even after accounting for total criterion count.MeaningEmphasis on especially severe criteria as indicators of addiction vulnerability in current diagnostic approaches may increase detection of individuals with greater likelihood for disorder progression.