The Use and Misuse of Language by Addiction Counselors, Part I
The language we use has the potential to have a significant effect, either positive or damaging, which is especially important in relationship to a disease marked by stigma and misunderstanding. Many people—including people with substance use disorders themselves, clinicians, payers, and policy makers—view substance use disorders as conditions that are self- inflicted, matters of criminal behavior, indications of immorality, and generally unworthy of our time and resources. We have the opportunity to effect attitudes and beliefs by the language we use. This column is the first in a three-part series that will address specific terms and their correct or incorrect use.
“Abstinence” vs. “Sobriety”
Abstinence connotes the state in which the individual with a substance use disorder no longer uses psychoactive substances excepting prescribed drugs taken as prescribed. In contrast, sobriety, which includes abstinence, is much more than mere abstinence, as it contains the concept of mental, emotional, and spiritual growth in a recovery process and stability in terms of the substance use disorder.
“Abstinence” as the Measure of Recovery
Abstinence is sometimes used as a representation for recovery. However, depending on the treatment outcomes desired, abstinence may not be a reliable indicator of recovery. For example, the patient referred to addiction treatment by child welfare because of child maltreatment, who no longer uses substances after treatment, but continues to neglect or abuse his or her children is not “in recovery” from a child welfare perspective. Similarly, a patient referred to addiction treatment from the criminal justice system because of having committed a crime while under the influence of alcohol or other drugs, who no longer uses substances but continues to engage in criminal behavior, is not “in recovery” from a criminal justice perspective. In fact, cessation of drinking and drug use may permit the criminal justice referral to more efficiently apply his or her criminal skills now that he or she is no longer impaired by the substances. This belief that “abstinence is everything” is what has caused the field to be historically so resistant to the appropriate use of psychiatric medication, and what currently causes much of the reluctance to use antiaddiction medications—both agonists like methadone and buprenorphine and antagonists such as oral and long-acting injectable naltrexone (Vivitrol).
This term reflects addiction treatment where the goal is total abstinence, in contrast to various harm-reduction strategies or moderation management. It becomes problematic because the approach may make no distinction between the phase or severity of substance use, such as someone who abused alcohol but never suffered from loss of control and returns to nonproblem drinking versus the individual who is addicted and has lost the ability to control use. It also tends to argue against the appropriate use of prescribed substances, particularly psychiatric or antiaddiction medications.
This term was a substance use disorder in the DSM-IV when one of four criteria for the diagnosis was met, but is not a diagnosis in the DSM-5 where it is most comparable to mild substance use disorder. The term “abuse” is often and incorrectly used to describe the entire range of substance use disorders (e.g., The National Institute for Drug Abuse). Since “abuse” connotes a willful or voluntary component, when it is used in this fashion, it demeans the model of disease.
“Addicted” vs. “Physiologically Dependent”
“Addiction” is defined as a primary, chronic, relapsing neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestation. It is characterized by impaired or loss of control over substance use, compulsive use, continued use in spite of adverse consequences, and craving. In contrast, “physiological dependence” is a state of cellular adaptation that is manifested by a drug-class-specific withdrawal syndrome that is produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug and/or administration of an antagonist (ASAM, 2001). The misuse of these terms is common when describing patients on an agonist drug for maintenance such as methadone or buprenorphine. Some clinicians use the two terms interchangeably as if they are the same or equivalent, which creates or justifies opposition to certain treatment modalities such as opioid maintenance treatment. The belief is that methadone maintenance is unacceptable as a treatment modality because patients are “still addicted” as evidenced by their continuing use of an opioid (methadone) rather than the individual remains physiologically dependent.
When first used, the term was usually restricted to physical dependence on a psychoactive substance, generally an opiate. Over time, the application broadened to include alcohol and other psychoactive substances, but then was again broadened to include a variety of compulsive and impulse control behaviors engaged in to the point of self-harm including gambling, shopping, running, exercising, Internet use, sexual behavior, eating, working, and relating to others, and has been extended to ingestion of certain foods such as sugar and chocolate. The only one of these addictive behaviors that became an addiction diagnosis in the DSM-5 was gambling disorder, which had previously been listed as an impulse control disorder in the DSM-IV. The reason that these others weren’t listed—although some were identified “for further study” in the DSM-5—is because the workgroup determined that there was insufficient credible research to justify addictive labels for them.
While any behavior can become compulsive and harmful, describing these behaviors as “addictive” diminishes the significance of the term when applied to dependence on psychoactive substances. I believe that we should use the appropriate diagnostic terminology instead of “such-and-such addiction” whenever possible. For example, using “compulsive sexual behavior” instead of “sexual addiction,” “compulsive internet use” instead of “internet addiction,” and “compulsive overeating” or “binge eating disorder” instead of “food addiction.”
The American Society of Addiction Medicine (ASAM) defines addiction as
a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission (ASAM, 2011).
“Administrative discharge” usually refers to a staff-initiated discharge for treatment noncompliance, rule infraction, patient lack of cooperation with treatment protocols or sometimes “just being difficult.” The specific reasons for the discharge are often the same reasons for the admission—drinking or illicit drug use during treatment. Since in this case, the drinking is symptomatic of the alcohol use disorder and the illicit drug use is symptomatic of the drug use disorder, the corollary in mental health treatment would be administratively discharging the patient with schizophrenia because of hallucinations or in medicine discharging the patients with tuberculosis for coughing. While drinking or drug use during treatment for substance use disorders is not acceptable, it is not uncommon and we should avoid the knee-jerk reaction of automatic discharge. Instead, we need to revisit and modify the treatment plan.
This usually applies to professionally or peer-directed treatment and support after primary treatment to solidify the gains made in treatment and reduce relapse potential. The problem with the term is that it begs the question of why a patient should continue in treatment after he or she has already been treated (see “continuing care”). Furthermore, in some cases aftercare is an afterthought on the part of addiction professionals during primary treatment. A more appropriate term is “continuing care.” Since length of time in a treatment system might be the best predictor of positive treatment outcome, continuing care may be as important as or even more important than the primary treatment.
“Alcohol misuse” refers to risky or harmful drinking behavior by individuals who are experiencing physical, social or psychological harm from alcohol, but who do not meet the criteria for an alcohol use disorder as outlined in the DSM-5. It often implies the lack of intention on the part of the misuser; for example, the older adult who doubles up on the dose of medication after missing a dose. There is little agreement on how this term should be operationalized. For example, the federal government warns against women having more than one drink a day because of the risk of breast cancer (American Cancer Society, 2013). At the same time, the Agency for Healthcare Research and Quality (AHRQ) describes risky or hazardous drinking for women as “more than seven drinks per week or more than three drinks per occasion” (2012). The term is also sometimes not clearly distinguished from diagnosable alcohol use disorders.
The importance of this term cannot be overstated when considering the value to an individual who stands up at an Alcoholics Anonymous (AA) meeting and says, “My name is Bob and I am an alcoholic.” The problem with the term stems from the fact that it is neither diagnostic nor precise. The term is used to describe an entire range of drinking behaviors, including the physician who thinks that an alcoholic is anyone who drinks more that he or she does. It may be applied to someone who is an alcohol abuser (DSM-IV) or has a mild alcohol use disorder (DSM-5). These are individuals who most of us would not consider “addicted” in the true sense of the term, meaning they exhibit loss of control, compulsion, continued use in spite of adverse consequences, and cravings. A good example of this kind of drinking would be college students who set out to get drunk. Its use in clinical or research applications is problematic because it does not discriminate between mild and severe forms of an alcohol use disorder. This muddling of the two diagnoses creates obstacles to applying the research findings to the real world of treatment. Some people who labeled “alcoholics” are able to return to nonproblem drinking because the term “alcoholism” in some cases is used to describe an alcohol abuser or someone with an alcohol use disorder. At the same time, the term may be used to describe those who are alcohol dependent (DSM-IV) or have a severe alcohol use disorder, thus leading some to believe that any alcoholic can return to social drinking. The recommendation is not that we stop using the term, but rather be precise and mindful of the context in which we are using it.
This is a psychological condition associated with diminished inspiration to participate in social situations and activities, with episodes of apathy caused by an external event, situation, substance (or lack of), relationship (or lack of), or other cause. It is very frequently associated with cannabis use, but interestingly it was not included as a diagnostic criterion for cannabis use disorder in the DSM-5.
The second part in this series will discuss the correct usage of terms such as “binge drinking,” “discharge vs. transfer,” and “graduation.”
Agency for Healthcare Research and Quality. (2012). Section 2. Recommendations for adults. Retrieved from http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/section2.html
American Cancer Society. (2013). What are the risk factors for breast cancer? Retrieved from http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-risk-factors
American Society of Addiction Medicine (ASAM). (2001). Definitions related to the use of opioids for the treatment of pain: Consensus statement of the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine. Retrieved from http://www.asam.org/docs/publicy-policy-statements/1opioid-definitions-consensus-2-011.pdf?sfvrsn=0
American Society of Addiction Medicine (ASAM). (2011). Public policy statement: Definition of addiction. Retrieved from http://www.asam.org/docs/publicy-policy-statements/1definition_of_addiction_long_4-11.pdf?sfvrsn=2