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No More Addict "Abuse"

The new DSM-5 is the object of an ongoing smackdown by critics for everything from its minor changes to its very existence. But there is one major change that addiction treatment providers can applaud.

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DSM-5: no joke book photo

By Dr. Richard Juman

05/08/13

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The DSM-5—the revision of the Diagnostic and Statistical Manual of Mental Disorders due out May 22—has already sparked a firestorm of criticism in the mental health community. On Monday the National Institutes of Mental Health (NIMH) made the stunning announcement that the manual displays "a lack of validity" and that the organization will stop funding research that uses DSM symptoms and diagnoses in favor of research focused on the biological underpinnings of psychiatric disorders. “As long as the research community takes the DSM to be a bible, we’ll never make progress,” NIMH director Thomas R. Insel told The New York Times. “People think that everything has to match DSM criteria, but you know what? Biology never read that book.” This brain-biology vs. clinical-symptom struggle will, no doubt, play out in fascinating fashion in the coming years.

As for addictive disorders, not much will change, despite the fact that since 1994's DSM-IV there has been an incredible amount of scientific research and practice devoted to addiction and addiction treatment resulting in a rich debate about the nature and meaning of addiction. Consider these questions:

• How is addiction, which involves the repetition of maladaptive patterns, different from other forms of compulsive behavior? 

• Which of several competing and compelling theoretical frameworks best defines addiction? As the use of a substance (alcohol, heroin, etc.)? Or as a “a primary, chronic disease of brain reward, motivation, memory and related circuitry,” the position of the American Society of Addiction Medicine? Or as a disease that is the result of a “hijacked brain,” as Nora Volkow, MD, the director of the National Institute on Drug Abuse, is fond of saying? Or as a maladaptive remedy for dealing with other overwhelming psychological conditions and early traumatic experiences?

• Is abstinence the best approach for most people in recovery? Or are more recent evidence-based treatment approaches like harm reduction and gradualism?

Don’t expect to find answers to these questions relating to the “grand unified theory” of addiction in the DSM-5

Instead the bible of psychiatry offers the same diagnostic criteria in use for the last two decades, albeit slightly reworked—for example, the addition of “cravings” and the deletion of legal problems. Yet if these specifics are not especially controversial, the more general changes in the “substance use disorder” diagnosis already strike many mental health providers as problematic. (Some of these changes are described in recent articles in the Professional Voices series here, here and here.) One change is that for the first time a “behavioral addiction”—gambling—is included as an addictive disorder. But in my opinion, none of the changes are so dramatic as to have a major impact on practice.  

Amidst all the criticism, there is one change worth celebrating because it is of great importance to the treatment community and, more important, to all those who have suffered from addiction: It eliminates any rationale for diagnoses containing the word “abuse” (for example, “alcohol abuse,” “substance abuse,” etc.) or for any psychiatric term at all that describes a person with a substance use disorder as an “abuser.” Let’s make sure that with the DSM-5’s stamp of approval we finally get “abuse” out of the lexicon!

This opportunity has presented itself because the DSM-5 redefines psychiatric illnesses as operating on a continuum as opposed to the previous binary categories of “abuse” and “dependence.” An example of this trend outside of the addictive disorders that has received much media attention is the DSM-5’s elimination of Asperger’s Syndrome as a diagnosis, replacing it with a "mild" version of "autism spectrum disorder." 

Similarly, substance use disorders are no longer diagnosed as either, on the one hand, “substance abuse” or, on the other, “substance dependence”—terms that have often been applied clinically as differences of degree rather than kind (as intended). Instead, a diagnosis of substance use disorder will be made on a spectrum of “mild,” “moderate” and “severe.” For example, a person previously diagnosed with “cocaine abuse” will now have a diagnosis of “cocaine use disorder, mild”; a person previously diagnosed with “alcohol dependence” will now get “alcohol use disorder, severe.”

Let’s make sure that with the DSM-5’s stamp of approval we finally get “abuse” out of the lexicon!

The term “dependence” has, in practice, been misunderstood and misused: Rather than indicating severity, it has been linked to the physiological processes of “dependence,” “withdrawal” and “tolerance.” These biomarkers of addiction make a great deal of sense in diagnosing certain substances such as opioids, alcohol and benzodiazepines, which do in fact result in a user becoming physically dependent. But the term causes much confusion because not only do people who are misusing, say, opiate-based painkillers, and who become addicts, develop dependence; so do patients who take these medications exactly as prescribed. So equating “dependence” with “addiction” is inaccurate. The inaccuracy and confusion are magnified when “dependence” is applied to substances such as cocaine or marijuana, where tolerance and withdrawal symptoms are rare. “Tolerance” and “withdrawal”—clearly defined physical responses to addictive substances—remain diagnostic criteria, but “dependence” is gone.  

In my view, “substance abuse” has never been a useful concept with which to discuss addiction or its diagnosis. Physical, sexual, child and domestic abuse all describe situations in which one person is victimized by another; that dynamic does not pertain to “substance abuse,” where, if anything, the “abuser” and the “abused” are the same person. Instead, describing addiction as “abuse” flows from our long history of stigmatizing and blaming those who suffer from addiction. The words we use to describe a person are inextricably bound up with the way that person is perceived and treated, and people with substance use disorders are still largely described and treated as criminal or morally defective.

The shame and stigma attached to the label “substance abuser”—a term that allows no distance between the person and his behavior—can make people reluctant to seek treatment, thereby causing worse outcomes, including death. “Substance abusers” also experience isolation, discrimination and other social and economic barriers; they are often denied medical services, government benefits and employment opportunities. Eliminating the word “abuse” alone will not right these wrongs, but it can help redefine addiction for the general public as a clinical disorder rather than a moral failing.

Now that “dependence” and “abuse” are no longer in the DSM, we treatment professionals should lead the way in ridding the word "abuse" from our terminology and talk. Stop using it with patients, colleagues or family members. Get the word out of the marketing materials of your facility or practice. And when you hear others use the term, point out that it’s time to let it go, and why.

Let's also insist that the powers-that-be at the national agencies that provide research and treatment leadership consider the affect that these changes in the DSM-5 will likely have on their agencies. Now that “abuse” is leaving the building, maybe it’s time for the word to be removed, literally, from the front of real brick-and-mortal buildings, like the National Institute on Drug Abuse (NIDA), the Center for Substance Abuse Treatment (CSAT), the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Substance Abuse and Mental Health Services Administration. Hint: The word “addiction” also starts with the letter “A.”

Richard Juman is the coordinator of "Professional Voices," a weekly feature on The Fix designed to provide a forum for addiction professionals to discuss critical issues in addiction theory, treatment, policy and research. He is also a former president of the New York State Psychological Association and a longstanding member of its Addiction Division Executive Committee. His email is dr.richard.juman@gmail.com; he tweets at twitter:@richardjuman.

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