President's Blog

When Will There Be Definitions and Terminology in Addiction Medicine?

by Stuart Gitlow | January 27, 2013

Each medical specialty has its own language. The specialty itself generally defines the terms. It wouldn't do, for instance, if a surgeon asked for a "Richardson" and was handed a "Kelly." But that could happen if surgeons defined "Richardson" one way and nursing staff defined it as something else. Unfortunately, in the field of addiction, we have terms that are defined by various factions. This has led to the oft-heard discussion regarding the differences among use, overuse, misuse, abuse, dependence, addiction, not to mention recovery, sobriety, and abstinence. One might think that the variety of understandings result from the wide range of healthcare staff involved with addiction treatment. And yet as other specialties of medicine become multidisciplinary much as addiction treatment has been for many years, we don't see the same difficulties arising. Diabetes counselors don't define DKA any differently than the endocrinologists, and they don't call diabetes itself by some other name.

One of the major difficulties here is that our own national organization has not yet published a broad manual of definitions for the field. Psychiatry, for example, publishes their Diagnostic and Statistical Manual, now about to see its seventh edition (and naturally named DSM-5). And just to throw a monkey wrench into the works, DSM includes a section that defines various terms in the field of addiction. But isn't that our field of expertise? Why would one specialty of medicine follow another's definition of its own field? Why, particularly, when we have the start of our own approach that is at odds with the one in the psychiatric manual? (Our definition of addiction broadly does not recognize the various substance use categories as representative of differing disease states).

I've been asked to comment on the new section in DSM-5 dealing with addiction. I have not done so since I haven't seen the new section. I've heard that it creates definitions for mild, moderate, and severe substance use disorders, something we've not had before and something I've never heard any of our members request. I can't see myself telling a patient that he has a "moderate alcohol use disorder." And I worry that an individual defined as having a "mild" substance use disorder would not be able to gain access to treatments that would be available if he simply had a substance use disorder. What I've learned from patients is that addiction is something you either do or do not have. There's little middle ground. I've also heard that DSM-5 fails to correct the oversight of earlier editions that separate alcohol use disorders from other sedative use disorders. This means that by definition, individuals' alcohol use disorders are gone once they've switched from Bud to Xanax. They now have another disease state. And that is simply wrong.

But we've never said that formally. Isn't it time to do so? Isn't it time, now that we have our own Board and our own residencies and our very well established specialty of more than 50 years, to have our own set of terms and definitions? 

4 Comments

  1. 4 Keith Harryhill 31 Jan

    Try to look at it from a different perspective. Social work for example took over 30 years to become recognized as a professional field ( to have their own set of values, ethics, terminology, and respect of other professions). Medicine had no interest in addiction. Can you blame them.The first success with addiction came from the grass roots 12 step movement.Gradually turning into a profession the AMA recognizes it. It gets assigned to the Mental health field (DSM) imagine that. Where else could you put it? Fundamentally, Addiction treatment and Medicine have opposing values. The fact that we have to put these words together just to form a legitimate discipline shows how far we still have to go. Give it another 10 years. 

  2. 3 Stuart Gitlow 29 Jan

    Rich, you raise another issue: do individuals who choose to engage in hazardous behavior because they believe the benefit outweighs the risk belong in a medical diagnostic schedule? Rock climbers, bungee jumpers, skydivers, and professional athletes (boxers, football players, etc.) may then belong here.

     

    And what about those who choose to engage in such behavior but who are not aware of the potential risks? Such individuals may choose differently if provided with education or counseling, but it would be questionable as to whether they require medical attention. 

     

    Mixing such individuals with those who have a biologic disease state muddies the water as to those who require medical attention by dramatically increasing the population size, and does so to such an extent that those who truly have addictive illness might be given fewer services because we're trying to meet the needs of the mean.

     

    Thanks for your comment!

  3. 2 Rich Saitz 29 Jan

    Agree that we need consistent terms. My view of DSM 5 is that the proposed criteria for a "disorder" will include what we would all recognize as "addiciton" but it also will include people who have had consequences of substance use but who do not have addiction (eg DSM IV abuse, for example).  Clearly there are people who drink to much and even have some consequences who are not addicted. Whether or not a diagnostic manual should include them is another discussion, but DSM 5 proposed "severe" disorder crosswalks to DSM IV dependence which is where you will find people with addiction.  "mild" or "moderate" are most likely to be people who are not addicted.  Frankly, addiction probably applies only to a subset who met DSM 4 dependence criteria (and of those who will meet DSM 5 severe disorder criteria)(evidence: most common pattern in population surveys for people with alcohol dependence is one self-limited episode. I suspect you would not define that as addiction).  So....true that one cannot be a little addicted. One has it or one doesnt. But many (who can benefit from our help) have important effects of substance use who are not addicted...Some of those were captured in DSM IV by abuse and dependence, and will be captured by mild/mod disorder in DSM V (assuming the proposed version is what was adopted).

  4. 1 Beth Ann Middlebrook 29 Jan

    Agreed. Additionally, the lack of consistent terminology has lead to confusion in the implementation and enforcement of the Mental Health Parity and Addiction Equity Act. What is meant by "residential" treatment? How can we reach consensus on what clinical components are covered under a plan if the definitions vary so vastly? 

     

    Please keep me included on any developments.

    Thank you.

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