Stuart Gitlow, MD
| 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?