Concerns that the threshold of two or more criteria is too low have been expressed in the professional (93, 94) and lay press (95), at presentations, and on the DSM-5 web site (e.g., that it produces an overly heterogeneous group or that those at low severity levels are not “true” cases). These understandable concerns were weighed against the competing need to identify all cases meriting intervention, including milder cases, for example, those presenting in primary care. Table 3 shows that a concern that “millions more” would be diagnosed with the DSM-5 threshold (95) is unfounded if DSM-5 substance use disorder criteria are assessed and decision rules are followed (rather than assigning a substance use disorder diagnosis to any substance user). Additional concerns about the threshold should be addressed by indicators of severity, which clearly indicate that cases vary in severity.
