Diagnostic Criteria for Identifying Individuals at High Risk of Progression From Mild or Moderate to Severe Alcohol Use Disorder

Abstract

Importance: Current Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) diagnoses of substance use disorders rely on criterion count-based approaches, disregarding severity grading indexed by individual criteria.

Objective: To examine correlates of alcohol use disorder (AUD) across count-based severity groups (ie, mild, moderate, mild-to-moderate, severe), identify specific diagnostic criteria indicative of greater severity, and evaluate whether specific criteria within mild-to-moderate AUD differentiate across relevant correlates and manifest in greater hazards of severe AUD development.

Design, setting, and participants: This cohort study involved 2 cohorts from the family-based Collaborative Study on the Genetics of Alcoholism (COGA) with 7 sites across the United States: cross-sectional (assessed 1991-2005) and longitudinal (assessed 2004-2019). Statistical analyses were conducted from December 2022 to June 2023.

Main outcomes and measures: Sociodemographic, alcohol-related, psychiatric comorbidity, brain electroencephalography (EEG), and AUD polygenic score measures as correlates of DSM-5 AUD levels (ie, mild, moderate, severe) and criterion severity-defined mild-to-moderate AUD diagnostic groups (ie, low-risk vs high-risk mild-to-moderate).

Results: A total of 13 110 individuals from the cross-sectional COGA cohort (mean [SD] age, 37.8 [14.2] years) and 2818 individuals from the longitudinal COGA cohort (mean baseline [SD] age, 16.1 [3.2] years) were included. Associations with alcohol-related, psychiatric, EEG, and AUD polygenic score measures reinforced the role of increasing criterion counts as indexing severity. Yet within mild-to-moderate AUD (2-5 criteria), the presence of specific high-risk criteria (eg, 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 1 high-risk criterion was associated with more accelerated progression to severe AUD (adjusted hazard ratio [aHR], 11.62; 95% CI, 7.54-17.92) compared with 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 relevance: In this cohort study of a combined 15 928 individuals, findings suggested that simple count-based AUD diagnostic approaches to estimating severe AUD vulnerability, which ignore heterogeneity among criteria, may be improved by emphasizing specific high-risk criteria. Such emphasis may allow better focus on individuals at the greatest risk and improve understanding of the development of AUD.

Figure 1.. Cross-Sectional Collaborative Study on the Genetics of Alcoholism (COGA) Cohort (N = 13 110) Endorsement Rates and Item Response Theory (IRT) Response Curves for 11 Lifetime Alcohol Use Disorder (AUD) Criteria

B, The probability of endorsement of each AUD criteria, P(θ) (y-axis), is plotted as a function of increasing severity of the underlying AUD latent trait, θ (x-axis). The horizontal dotted line represents a 50% probability of endorsing criteria; the vertical dotted line represents 2 SD above the mean of AUD latent severity. Criteria with difficulty parameters of 2 or above (ie, to the right of intersection of vertical and horizontal lines: Failure to fulfill, Physical/psychological, Craving, Withdrawal, Given up/reduced, and Time spent) were identified as high-risk diagnostic criteria. Hazardous use refers to recurrent alcohol use (≥3 times) in situations in which it is physically hazardous; Larger/longer = drinking in larger amounts or over longer periods than intended; Tolerance = need for markedly increased amounts of alcohol to achieve intoxication or desired effect or a markedly diminished effect with continued use of the same amount of alcohol; Cut down = persistent desire or 3 or more unsuccessful efforts to stop, cut down, or control drinking; Social/interpersonal = continued alcohol use despite having persistent or recurrent (≥3 times) social or interpersonal problems caused or exacerbated by the effects of alcohol; Failure to fulfill = recurrent use of alcohol resulting in a failure to fulfill major role obligations at work, school, or home; Physical/psychological = continued drinking despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to be caused or exacerbated by drinking; Craving = craving or a strong desire or urge to use alcohol; Given up/reduced = important social, occupational, or recreational activities given up or reduced because of drinking; Withdrawal = the characteristic withdrawal syndrome for alcohol or drinking (or using a closely related substance) to relieve or avoid withdrawal symptoms; Time spent = a great deal of time spent in activities necessary to obtain, use, or recover from the effects of drinking.

Figure 2.. Longitudinal Collaborative Study on the Genetics of Alcoholism (COGA) Cohort (N = 2818) Survival Curves and 95% Confidence Intervals for Progression to Severe Alcohol Use Disorder (AUD)

All survival curves include no prior mild-to-moderate AUD as comparison and are adjusted for sex, race and ethnicity, and mild-to-moderate AUD criterion count. A, Survival curves additionally adjusted for endorsement of prior mild-to-moderate AUD. B, Survival curves additionally adjusted for mild vs moderate AUD. C, Survival curves additionally adjusted for low-risk vs high-risk mild-to-moderate AUD. Dotted lines represent point estimates of median survival ages (not accounting for 95% CIs): A, prior mild-to-moderate AUD = 34 years; B, mild AUD = undefined, moderate AUD = 31 years; C, low-risk mild-to-moderate AUD = undefined, high-risk mild-to-moderate AUD = 32 years.