In the growing public debate over the revision of psychiatry’s Diagnostic and Statistical Manual—the DSM V, which categorizes mental illness and is used to determine insurance coverage and research agendas—addiction has been given little attention. But the upcoming update—a decade in the making and due out in May 2013—will significantly change the way addiction is medically defined: in one way that I believe will advance addiction science and pain treatment and another that could wrongly pathologize a whole new group of people.
Autistic people and parents of autistic children, who fear that the removal of Asperger’s Syndrome from the manual will result in denial of needed services and widespread underdiagnosis of autism, are raising a huge ruckus. From the opposite direction, those concerned with the overuse of antipsychotic medication oppose the proposed addition of a new diagnosis, or “prediagnosis,” for people identified as at high risk of developing schizophrenia. This could produce excessive increases in diagnoses beyond the already-troubling rise in prescriptions for these drugs, which can carry serious health risks. The changes slated to be made in the diagnosis of addictive disorders will cut both ways. In this article, I want to recognize the positive changes. These stem from the fact that the DSM V will no longer use the labels “substance dependence” and “substance abuse” but will instead classify addiction problems under the heading “Substance Use and Addictive Disorders.”
To both “abuse” and “dependence,” I say, “Good riddance.” Substance abuse—which was used to characterize drug problems that fall short of outright addiction, like college binge drinking—is a highly stigmatizing and misleading term. If “child abuse” means harming a child, does “drug abuse” mean harming a drug? It never made any sense linguistically and only served to associate drug users with abusive people in the public mind. Indeed, one randomized controlled trial showed that healthcare professionals who read vignettes about patients described as “substance abusers” supported more punishment and less therapy than those who read about the same patients identified as having “substance use disorders.”
Even worse is “substance dependence.” The term was placed into a revision of the third edition of the DSM, DSM III-R, in the ’80s as a euphemism for addiction with the intention of using a “medical sounding,” or nonstigmatizing, phrase.
Dr. Charles O’Brien, a professor of psychiatry at the University of Pennsylvania whose addiction expertise is so renowned that Penn even named it treatment center after him, described the events in a 2006 article co-written with NIDA director Nora Volkow:
There was good agreement among committee members as to the definition of addiction, but there was disagreement as to the label that should be used. The proponents of the term “addiction” believed that this word would convey the appropriate meaning of the compulsive drug-taking condition and would distinguish it from “physical” dependence, which is normal and can occur in anyone who takes medications that affect the [brain]. Those who favored the term “dependence” felt that this was a more neutral term that could easily apply to all drugs, including alcohol and nicotine. The committee members argued that the word “addiction” was a pejorative term that would add to the stigmatization of people with substance use disorders.
A vote was taken at one of the last meetings of the committee, and the word “dependence” won over “addiction” by a single vote. Experience over the past two decades has demonstrated that this decision was a serious mistake.
With “substance dependence” the “official” term for addiction, many lay people incorrectly concluded that addiction means simply needing a substance to function.
This idea implies that pain patients prescribed opioids long term, people who need antidepressants and medical users of anti-anxiety drugs are all addicts. (Even some members of Alcoholics Anonymous hold this view.) And it helped support undertreatment of pain and anxiety while increasing stigma for those suffering from these conditions. Indeed, since the federal law that regulates drugs makes “supplying an addict” a crime except for use of methadone and buprenorphine in treatment, this definition helped put doctors treating pain in addicts (or pain patients who were wrongly labeled as such) at risk of prosecution.
The focus on dependence also implied that cocaine—which does not produce physical dependence—isn’t “really” addictive. That lulled many people in the ’80s—including yours truly—to think that cocaine wasn’t likely to be hard to kick. We all know better now.
Moreover, with the term “dependence” in the medical definition of addiction itself, it became very difficult to teach people that needing a drug to function isn’t the essence of addiction. The misdefinition encapsulated the idea that suffering withdrawal—rather than compulsive use despite negative consequences—was fundamental to the problem. That meant that the drive to take drugs—now demoted to being called merely “psychological dependence”—was less important than getting sick if you couldn’t get the drug.
In reality, this desire—and related repetitive drug-taking—matters far more than how sick you get when you try to stop. In fact, with heroin withdrawal, the severity of symptoms like vomiting and diarrhea isn’t particularly linked to relapse risk, which is far more associated with how much the person wants the drug. With cocaine, which doesn’t make you sick at all if you quit abruptly, the entire addiction is “in your head” or “psychological”—but that obviously doesn’t make crack not addictive!
There was also another, more subtle problem with calling addiction dependence. That is, in America, which prizes independence, designating a stigmatized condition as “drug dependence” led to further denigration of dependence itself.
Never mind that dependence on other people is actually a critical part of human social life. In self-help groups, even normal, everyday caring was rapidly pathologized as “codependence.” Feeling a deep need to connect or nurture—especially if the other party was an addict—was seen as a sign of “relationship addiction,” not normal love.
And wanting to help when an addicted loved one was in pain was reframed as “enabling” the addiction, despite the fact that cutting addicted people out of one’s life is just as likely to harm them as it is to spur recovery.
Indeed, ever since the ’80s, some psychologists claim that healthy human function doesn’t require relationships at all—and that one can be entirely happy without depending on a lover, family or friends. These folks argue, in fact, that one should be able to get to this independent place of needing no one by working on yourself in therapy before even seeking relationships. Depending on others, in this context, means that you aren’t “emotionally mature.”
The entire history of human evolution argues against this, of course; not surprisingly, research shows overwhelmingly that interdependence is essential to physical and psychological health for members of a social species. We are all utterly dependent on one another—but this doesn’t make us sick or addicted, just human. Losing the idea of addiction as fundamentally due to dependence should help discredit these pernicious and dehumanizing ideas.
So, kudos to the authors of DSM-V for getting rid of those two problematic and, to my mind, loathsome terms.
Unfortunately, while losing these terms that can wrongly place people on antidepressants, anxiety or pain treatment in the “addicted” category and pathologize love itself, DSM V appears set to be overinclusive in a way that will hurt a whole different set of people.
What’s worse, that group is especially vulnerable: teens and college students. I’ll explain why next week.
- Canada: Mass-withdrawal disaster feared as OxyContin funding pulled (talesfromthelou.wordpress.com)
- Brains of addicts are inherently abnormal: study (talesfromthelou.wordpress.com)