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Discussion in Am. J. Psychiatry in Letters to Editor about the term "addiction" in DSM ---------- http://ajp.psychiatryonline.org/content/vol163/issue11/ Whatâ??s in a Word? Addiction Versus Dependence in DSM-V ROBIN L. FAINSINGER, M.D., VINCENT THAI, M.B.B.S., M.Med., M.R.C.P., C.C.F.P., A.B.P.H.M., GARY FRANK, B.A., B.Ed., R.N. and JEAN FERGUSSON, B.Sc., R.N. Edmonton, Alberta, Canada To the Editor: We agree with the call made by Charles Oâ??Brien, M.D., Ph.D., et al. for a clarification of terminology in discussions of opioid use (1). We also agree that the DSM Committeesâ?? choice of terminology to date is problematic. The use of the term "dependence" as a euphemism for addiction originated as a well-intentioned attempt to counter negative effects of the social stigmatization of addicted patients. Unfortunately, it has resulted in creating significant confusion in discussions of pain management by clouding the important distinction between physical dependence and uncontrolled psychological craving (addiction). Examples of this confusion are replete in the literature (2â??4). One of the most important requirements for successful pain management is a rigorous, multidimensional assessment of the patient, including a clear description and classification of the pain syndrome. Recognition of addiction, and distinguishing addiction from physical dependence, is an important part of such an assessment. The experience of cancer pain specialists around the world has confirmed this time and again. The Edmonton Classification System for Cancer Pain (5, 6) has shown that, among other factors, clear recognition and management of addiction is required for effective pain control in a subset of cancer patients. At the same time, clear distinction between physical dependence and addiction is an important tool in the prevention of "opioid-phobia" and the unwarranted fear of addiction that can impede effective pain management in any patient population. Unfortunately, the DSM Committee has not provided such clarity to date. Fortunately, other groups have done so. The American Pain Society, The American Academy of Pain Medicine, and the American Society of Addiction Medicine, for example, have developed a consensus document with clear and useful definitions of opioid-related phenomena: Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Physical dependence is a state of adaptation that is manifested by a drug-class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist (7). In the interest of patientsâ??addicted or notâ??we urge that the DSM-V Committee should pursue the same degree of clarity. References 1. Oâ??Brien C, Volkow N, Li T: Whatâ??s in a word? addiction versus dependence in DSM-V. Am J Psychiatry 2006; 163:764â??765[Free Full Text] 2. Streltzer J, Johansen L: Prescription drug dependence and evolving beliefs about chronic pain management. Am J Psychiatry 2006; 163:594â??598[Free Full Text] 3. Comer S, Sullivan M, Yu E, Rothenberg J, Kleber H, Kampman K, Dackis C, Oâ??Brien C: Injectable, sustained-release naltrexone for the treatment of opioid dependence. Arch Gen Psychiatry 2006; 63:210â??218[Abstract/Free Full Text] 4. Johnson R, Jaffe J, Fudala P: A controlled trial of buprenorphine treatment for opioid dependence. JAMA 1992; 267: 2750-2755 5. Fainsinger R, Nekolaichuk C, Lawlor P, Neumann C, Hanson J, Vigano A: A multicenter study of the revised Edmonton Staging System for Classifying Cancer Pain in advanced cancer patients. JPSM 2005; 29:224â??237 6. Nekolaichuk C, Fainsinger R, Lawlor P: A validation study of a pain classification system for advanced cancer patients using content experts: The Edmonton classification system for cancer pain. Palliative Medicine 2005; 19:466â??476[Abstract/Free Full Text] 7. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine: Definitions Related to the Use of Opioids for the Treatment of Pain. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine, 2006 (www.ampainsoc.org/advocacy/opiods2.htm, accessed July 5, 2006) --------------------- Language and Addiction SHANNON C. MILLER, M.D., F.A.S.A.M., F.A.P.A., C.M.R.O. Cincinnati, Ohio To the Editor: I wish to support the editorial published by Dr. O"Brien et al. Clearly, our field of addiction medicine has been plagued by problematic language (1). As the authors point out in their editorial, this affects the interaction between patient and clinician when dealing with pain and prescribing. However, the impact of such language on the practice of addiction medicine extends to two larger, and arguably more pervasive, issues in clinical practice. In my experience, the use of the term "dependence" when working with patients with addiction disorders is highly problematic to the earliest stages of developing a therapeutic alliance and helping the patient gain insight into her/his disease. When patients hear this term applied to them, they often have difficulty internalizing this term as an accurate descriptor of their substance use. When asked how they themselves would define the clinical appearance of someone who is "substance dependent," they often focus more on physical manifestations of the illness (tolerance and withdrawal). Not surprisingly then, they describe an individual who daily uses or needs the drug regularly in order to display adaptive psychosocial functioning. This observation appears most pronounced for patients in the precontemplation or contemplation stages of change. Moreover, when asked to describe someone who is "addicted" to a substance, more accurate descriptions are given, including discussions about the behavioral and psychological manifestations of the illness. A second additional problem this term creates is that its use automatically excludes nonsubstance-related behaviors from future consideration for a diagnosis of addiction; the best example being pathological gambling disorder. The categorization of pathological gambling has been previously debated in DSM planning meetings: Is it an impulse control disorder or in the same diagnostic cluster as substance use disorders (2)? Pathological gambling disorder has been increasingly defined by scientific and biological findings akin to substance use disorders, arguing for its diagnostic reclassification. Moreover, it has been recognized as perhaps one of the best sources of study for addiction disorders in humans because it is devoid of drug (of abuse) effects which may confound biological research findings (3). I support the authorsâ?? timely discussion toward re-assessing the DSMâ??s language prior to its next revision. Replacing "substance use disorders" with "addiction disorders" could benefit not only the care of patients with pain, but could also enhance the patientâ??s understanding and acceptance of their newly diagnosed disease as well as open future options with respect to potential nondrug addictions and their classification. References 1. Miller SC, Salsitz EA: Perspectives: the language of addiction. Am Soc Addict Med New 2002; 17:13 2. First MB: Diagnostic issues in substance use disordersâ??a summary. Psychiatr Res Report 2005; 21:6â??8 3. Sumitra L, Miller SC. Pathologic gambling disorder. Postgrad Med 2005; 118:31â??37[Medline] ----------------- Please, Not "Addiction" in DSM-V CARLTON K. ERICKSON, PH.D. and RICHARD E. WILCOX, PH.D. Austin, Tex. To the Editor: In the May 2006 issue of the Journal, Drs. Oâ??Brien, Volkow, and Li touch on a very serious issue regarding the proper labeling of a drug-induced brain disease known as either "addiction" or "dependence." We agree with the authorsâ?? concerns and with the need to have a better word than "dependence" in the DSM-V. However, "addiction" is not the word. "Addiction" is unscientific, overused, misunderstood (e.g., addicted to my cell-phone), and clinically inaccurate (e.g., addicting antidepressants). What we have found in working with people in recovery is that the word is incredibly stigmatizing. The popular press is flooded with stories of crack-addicted babies and heroin addicts being thrown in jail. Sadly, in everyday use, "addiction" fails to differentiate between the medical (brain) disease associated with drug use by at-risk people and over-involvement with drugs (abuse) or activities. Stigma-driven discrimination is seen when those with "addiction" cannot use our newest scientific advances in treatment because of insurance problems. Stigmatization is one reason we have insufficient research dollars for the study of drug actions on the brain. We fear that continued use of the term "addiction" would forever prevent society from destigmatizing this chronic medical illness. Our Center faculty believes that the answer lies in proper education regarding the now-diagnosable differences between pathological chemical dependence and "bad-choice" drug abuse. We indicate that the old (1950) World Health Organization terms "psychological dependence" and "physical dependence" are outmoded and are being phased out. We teach that the term "dependence" is a specific descriptor of the adapted brain state studied so intensively by neuroscientists (1). Our publications on neuroscience-based workshops clearly show that these professionals "get it" (2). We believe the field terminology is changing (e.g., gambling "addiction" has been replaced in many treatment centers with "pathological gambling disorder"). To reduce confusion about "dependence," the use of a qualifier such as "chemical dependence" could be used. It is only through such diagnosable (and clearly articulated) distinctions that we can hope to convince policy makers and the public that a major drug-overuse problem we are treating is truly a chronic medical illness (called "chemical dependence"), for which we need more treatment and research funds. References 1. Erickson CK, Wilcox RE, Littlefield JH, Hendricson WD: Education of nonscientists about new alcohol research: results of two types of presentations plus 6-month follow-up. Alc Clin Exptl Res 1998; 22:1890â??1897 2. Lawson KA, Wilcox RE, Littlefield JG, Pituch KA, Erickson CK: Educating treatment professionals about addiction science research: demographics of knowledge and belief changes. Subst Use Misuse 2004; 39:1235â??1258[CrossRef][Medline] ---------------- Addiction Versus Dependence in Pain Management JON STRELTZER, M.D. Honolulu, Hawaii, C.R. SULLIVAN, M.D. Morgantown, W.Va. and BRIAN JOHNSON, M.D. Newton, Mass. To the Editor: The editorial by O"Brien, et al. argues that classification of substance use disorders should use the term "addiction" instead of "dependence," which involves normal physiological adaptations. They argue that confusing "dependence" with "addiction" prevents pain patients from getting needed "additional pain medication" (p. 764). A problem with this argument is the implicit underlying assumption that sustained opioid pain medication is continuously effective for chronic pain, and more opioid medication is more effective. The evidence, however, is to the contrary. Chronic opioid intake results in multiple, overlapping physiological adaptations that counteract the analgesic effects of opioids and even enhance pain sensitivity (1, 2). A recent review of the effects of sustained opioid intake concluded that opioids given chronically, at least in high doses, are neither safe nor effective (3). Differentiating addiction from dependence has been promulgated as a way to determine which chronic pain patients may safely be prescribed opioids. This belief corresponds with the marked increase in prescription of strong opioids in recent years and a simultaneous increase in morbidity and mortality from prescription drug dependence (4, 5). Psychiatrists are receiving more and more referrals of chronic pain patients dependent on opioids. In our experience, whether or not they have been behaviorally compliant, they usually do better when detoxified and treated with nonopioid analgesics and psychiatric support (6, 7). In contrast, increasing the opioid dose will provide no more than temporary benefit. We are aware that many patients can function satisfactorily while maintained on steady doses of opioids, such as methadone maintenance patients. When chronic pain patients are managed in this fashion, it may not be pain that is being treated, but rather this may be a form of office-based opioid maintenance. Whatever the terminology that is used for substance use disorders, the assumption that if a patient is not an addict they can be treated freely with opioids will not diminish suffering and will often increase it (8). References 1. King T, Gardell LR, Wang R, Vardanyan A, Ossipov MH, Malan TP Jr, Vanderah TW, Hunt SP, Hruby VJ, Lai J, Porreca F: Role of NK-1 neurotransmission in opioid-induced hyperalgesia. Pain 2005; 116:276â??288[CrossRef][Medline] 2. Mollereau C, Roumy M, Zajac JM: Opioid-modulating peptides: mechanisms of action. Curr Top Med Chem. 2005; 5:341-355 3. Ballantyne JC, Mao J: Opioid therapy for chronic pain. N Engl J Med 2003; 349:1943â??1953[Free Full Text] 4. Franklin GM, Mai J, Wickizer T, Turner JA, Fulton-Kehoe D, Grant L: Opioid dosing trends and mortality in Washington State workers" compensation, 1996-2002. Am J Ind Med. 2005; 48:91-99 5. Compton WM, Volkow ND: Major increases in opioid analgesic abuse in the United States: concerns and strategies. Drug Alcohol Depend 2006; 81:103[CrossRef][Medline] 6. Anooshian J, Streltzer J, Goebert D: Effectiveness of a psychiatric pain clinic. Psychosomatics 1999; 40:226â??223[Abstract/Free Full Text] 7. Streltzer J: Pain management in the opioid-dependent patient. Curr Psychiatry Rep 2001; 3:489â??496[Medline] 8. Streltzer J, Johansen L: Prescription drug dependence and evolving beliefs about chronic pain management. Am J Psychiatry 2006; 163:594â??598[Free Full Text] -------------- Dr. Oâ??Brien Replies CHARLES P. Oâ??BRIEN, M.D., Ph.D., NORA VOLKOW, M.D. and T-K Li, M.D. Philadelphia, Pa. To the Editor: We thank the authors of the letters published here as well as the authors of the many more that were sent to us directly. Most of the letters that we received directly were heartfelt expressions of gratitude from clinicians, including nurses who care for chronic pain patients in hospices or who treat chronic pain with opiates and opioids. Along similar lines and in agreement with the letter by Dr. Miller, there have also been supportive letters from organizations of physicians who treat pain (American Pain Society, American Academy of Pain Medicine) and from the American Society of Addiction Medicine. We have read carefully the only two dissenting letters that we have seen. Drs. Erickson and Wilcox seem to agree with our statement of the problem but find the word "addiction" to be distasteful. They are entitled to that position, but they should also feel the responsibility to come up with a better alternative. "Chemical dependence" would retain the same problems as the current version. We do find it a bit odd, however, that the title of Dr. Ericksonâ??s own office contains the term "addiction science." The word is also used without apparent prejudice as the name of one of the most venerable journals in the field as well as in the names of scientific societies and in the name of an official subspecialty of psychiatry. Drs. Streltzer, Sullivan, and Johnson focus on the issues involved in long-term prescription of opioids. This is a controversial subject and was not addressed in our editorial. The reality is that many patients do receive opioids from their physicians, and both tolerance and "physical" dependence occur to some degree very rapidly. This normal response must be distinguished from compulsive drug-seeking behavior commonly known as "addiction." Quite frankly, the current classification is an unintentional violation of the Hippocratic Oath: "First, do no harm." We have created a situation with our terminology that not only confuses physicians, but also results in needless suffering and mislabeling of patients. |
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