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—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—which could produce excessive increases in diagnoses beyond the already troubling rise in prescriptions for these drugs that carry serious cardiovascular and other 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 theDSM, 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.