The latest issue of the Journal of Public Health Policy includes an interesting piece by Linda Richter and Susan E. Foster of the organization CASAColumbia about “changing the language of addiction.” (The journal is open access during the month of March; the home page is here.) They note that while the science of addiction has advanced, outdated public attitudes about it persist and interfere with effective treatment. Surveys have found adults, and even many physicians, to consider alcohol addiction to be at least partially a personal or moral weakness. Stigmatizing addiction can interfere with treatment, and updating the language we use to discuss diseases of addiction can allow for more effective responses. Richter and Foster summarize the current scientific understanding (references omitted):
Emerging scientific evidence supports an understanding of addiction as a primary disease rather than a symptom or sequela of another disease or condition. In the case of addiction involving nicotine, alcohol, or other drugs, it typically is triggered by the initiation of substance use during adolescence, a time of critical brain development. Addiction may involve a variety of compulsive behaviors in addition to those related to addictive substances. These include compulsive gambling and sex, for which there are accepted clinical diagnostic criteria, and may include other pathologically compulsive behaviors for which formal diagnostic criteria are under consideration but have yet to be established – behaviors related to food and Internet use, for example.
A growing body of research supports the notion that addiction may be a singular underlying disease with multiple manifestations that have common genetic antecedents, evince similar differences in brain structure and function, and co-occur at high rates; there also is a marked tendency for one manifestation of addiction, if addressed in isolation or inadequately, to be replaced by another. For example, some people with obesity who have bariatric surgery end up manifesting symptoms of risky substance use. While the bariatric surgery may address the symptom of addiction that is expressed through compulsive eating, it does not address adequately the underlying disease of addiction itself, increasing the likelihood of ‘addiction hopping’ where someone replaces one expression of addiction with another.
Richter and Foster emphasize that it is also important to distinguish between risky behaviors that may increase an individual’s risk of developing addiction but do not meet the clinical definition of addiction. Addiction, they note, is a chronic disease whose successful management is likely to require more than a single intervention or brief detoxification. For those with sub-clinical symptoms, however, less-intensive treatment can be most appropriate. For instance, Richter and Foster suggest, “placing an impressionable adolescent who engages in risky substance use but does not meet diagnostic criteria for addiction in an intensive addiction treatment program can increase rather than reduce the extent and severity of the young person’s substance use.”
Using terms like “risky behavior” and “addiction” can not only improve diagnosis and treatment, but can reduce the shame that can accompany descriptions of “drug abuse.” Feelings of shame can discourage patients from discussing concerns about tobacco, alcohol, and other drug use with their healthcare providers — even though such discussions could allow for earlier treatment. And, indeed, mental health professionals are moving in that direction, Richter and Foster explain:
Removing imprecise and pejorative terms from our clinical and popular lexicons and adopting language consistent with other health conditions is a necessary prologue to effectively preventing risky substance use and treating and managing the disease of addiction. Movement in this direction has begun with changes in the 2013 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM),in which the separate categories of substance ‘abuse’ and ‘dependence’ are replaced with one disease classification with different levels of severity. A stronger step toward clear and accurate language, however, would be a comprehensive definition of ‘addiction’ that encompasses these DSM revisions and that is distinguished clearly from the definition of ‘risky use’, which encompasses any use of nicotine or illicit drugs, misuse of controlled prescription drugs, or alcohol use in excess of the US dietary guidelines, which does not meet clinical criteria for addiction.
Read the whole article here.