WORDS MATTER: Evolving Definitions of Substance Use Disorder

Subtitle:  Series on Substance Use Disorder (Part I)

Case study:  A 45 year old woman with chronic obstructive pulmonary disease and peripheral neuropathy arrives to seek care in your office or facility.  She smokes a half pack of cigarettes per day, drinks one 750 ml bottle of white wine daily, smokes marijuana once daily and uses prescription long acting Morphine for “chronic pain,” lorazepam twice a day for “anxiety”, and prescription short acting amphetamine salts for “attention deficit disorder”.  She states that she would like to stop smoking, because of her lung problem, but thinks of her alcohol and marijuana use as “recreational” and her prescription drug use as treatment of medical conditions.  She emphatically states that she is only “addicted” to tobacco.

Question:  Is she addicted to something else?

Answer:  Maybe?

The words drug abuse and drug addiction carry a significant stigma in our society, which results in individuals who are using substances in dysfunctional ways strongly denying that they are addicted or abuse drugs.  This led the American Psychiatric Association to create a new terminology in 2013, as part of the newly released Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, affectionately known as DSM-5.

Substance use has a spectrum of labels, as currently standardized by DSM 5.  Of note, the terms addiction and abuse, which were widely misinterpreted and carried significant stigma, are no longer standard.

The spectrum is:

  • Substance use
  • Substance mis-use
  • Substance use disorder (SUD), further subcategorized as mild, moderate and severe

In DSM 5, Substance Use Disorders include:

  • Alcohol Use Disorder
  • Tobacco Use Disorder
  • Cannabis Use Disorder
  • Stimulant Use Disorder (includes methamphetamines, cocaine, crack, medications used for ADHD)
  • Opioid Use Disorder: (Includes heroin, injecting other opioids, taking prescription opioids orally)
  • Others: Hallucinogens, Sedatives, Inhalants

These different substances are grouped together in the overarching category of all SUDs, they all share a similar common pathway in disruptions in the stimulus/response, reward, habit centers of the brain (shared also with compulsive gambling, and eating disorders).  In spite of the final common pathway, different SUDs have critically different underlying biochemical, sociological, legal, psychological and sociological etiologies and pathways, such that they are often addressed by different staff, in different, separate settings.

In DSM-5, the diagnosis of SUD is based on the presence of at least 2 of 11 criteria; these can be divided into four clusters or groups, as follows:

Group 1:  Impaired Control

  1. Substance use in larger amounts or over a longer period of time than was originally intended.
  2. Persistent desire to cut down on use or multiple unsuccessful attempts at cutting down or stopping use
  3. Great deal of time spent using substance or recovering from its effects
  4. Intense desire to use or craving for the substance

Group 2:  Social Impairment

  1. Substance use resulting in failure to fulfill obligations at work, school or home
  2. Substance use causing or exacerbating interpersonal problems
  3. Important social, occupational, or recreational activities given up or reduced due to substance use

Group 3:  Risky use

  1. Recurrent use of substance in physically hazardous situations
  2. Continued use despite negative physical or psychological consequences

Group 4:  Pharmacologic Dependence

  1. Tolerance to the effects of the substance
  2. Withdrawal symptoms with cessation of substance use

The number of criteria determine the severity of the SUD:

2-3:  Mild SUD

4-5:  Moderate SUD

6 or more:  Severe SUD

This categorization system seems complicated, at first, but it is the bedrock for diagnosis of all the individual Substance Use Disorders.

All of us in the medical profession need to be aware of our use of language and educate out patients on this use of language.  It is not as easy as it seems.  For example, the American Society of Addiction Medicine (ASAM) has not changed its name (would it change to ASSUDM?), and their reference book  is Addition Medicine, published in 2016.  In fact, they have their own standard “short” definition of addiction which is different from the DSM-5 terminology, which starts out as follows:

“Addiction is 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.”  (See ASAM website for full definition.)

If ASAM hasn’t changed their language yet, we in the non-SUD world can be forgiven, perhaps, taking a few years to become facile with the new words and their uses.

Next in series:  Part II:  Alternative Facts on Alcohol Detox

Author: Robert Moore, MD, Chief Medical Officer, Partnership HealthPlan of California

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