In my experience as a clinical psychologist and, dare I facetiously say, a Twitter addict, the most important and commonly confused distinction is between “addiction” and “dependence.”
And it is no wonder.
This deadly (to pain patients) confusion is due to the psychiatric “bible” which either unintentionally or intentionally erased the difference between the two.
The latest version, the DSM-5, now hides “addiction” as a category of “dependence”, even though these are two very distinct issues.
In the midst of this “opioid crisis”, the psychiatrists making this decision must have been aware of the difference between patients taking opioids for legitimate purposes and people using street drugs. I’m shocked at the ignorance of these highly educated people.
A Contentious History
One of the main medical texts used by mental health professionals to diagnose addiction is called the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is currently in its fifth edition.
In the 1980s a committee of experts met to revise what was, at the time, the DSM-III. And after much debate over whether to use the term “addiction” or “dependence,” the word “dependence” was chosen by a margin of a single vote, mainly because some of the committee members believed the word “addiction” was pejorative.
God forbid we should say anything “bad” about people with addiction, or make them feel bad about being addicted.
On the other hand, pain patients are fair game to be called “sissies” and “drug-seeking” and “liars” and “fakers” and even “addicts” (as long as that word doesn’t really refer to someone addicted, but just a pain patient who needs opioids for pain).
As a consequence, the diagnostic category of “substance dependence” stayed with us through the DSM-IV, until it was dropped in 2013 in the DSM-5, along with the diagnostic category of “substance abuse.”
The solution in the DSM-5 was to combine the categories of “substance dependence” and “substance abuse” into one category called “substance use disorder,” under a chapter heading called “Substance-Related and Addictive Disorders.”
The purposeful use of the phrase “addictive disorders” in the naming of this chapter was primarily because of the addition of gambling disorder to the DSM. And here, too, committee members grappled over and disagreed on whether to introduce the term “addictive” into the DSM-5.
The Biggest Source of Confusion
If that history lesson sounds confusing, that’s because it is and there’s no way to simplify what happened.
But the biggest source of confusion concerns the word “dependence.”
Prior to the DSM-III, the term “dependence” simply meant physiological dependence, as indicated by tolerance and withdrawal symptoms.
Unfortunately, the DSM-III committee expanded the definition of “substance dependence” to not only include physiological symptoms of tolerance and withdrawal but also other psychological and social symptoms, such as uncontrolled use and negative psychological and social consequences as a result of drug use.
Thus, the medical world was left with two very different definitions of dependence:
- one that signified physical dependence and
- one that signified a more complicated kind of biopsychosocial dependence, which, in reality, was used as a proxy to diagnose “addiction.”
How Do We Define Addiction and Dependence Today?
With the removal of the category “substance dependence” from the DSM-5, the definition of “dependence” should be clearer: Dependence means physical or physiological dependence, as indicated by tolerance and withdrawal symptoms. It is a state of neuroadaptation that can occur after repeated substance use, whereby continued substance use is needed to prevent withdrawal symptoms.
Dependence does not equal addiction, though it can be one feature of addiction.
It seems most doctors are not intelligent enough to understand this. Instead of wrangling with the psychological problems leading to and brought on by addiction, they can see physical evidence of withdrawal and are allowed to write the patient off as “addicted”.
The term “addiction” is much more complicated, and there still remains considerable debate in the medical community about exactly how to define it—for example, whether it’s best conceptualized within a disease model, a learning model or somewhere in between.
In fact, the American Psychiatric Association, which developed the DSM, nonchalantly uses the terms “substance use disorder” and “addiction” interchangeably on its Web site.
Here is the root of all evil directed at pain patients. This intellectual bubble of ignorant psychiatric “experts” casually threw pain patients under the bus in order not to offend people with addiction.
In medical practice, to get a diagnosis of substance use disorder, a mental health professional must first conduct a careful diagnostic interview.
The interviewer assesses whether there is a problematic pattern of substance use or behaviors causing a person distress and impairment in his or her functioning in a clinically significant way.
This leaves the term wide open to practitioner bias. Especially with all the PROPaganda about opioids, few individuals still understand what real addiction is.
Additionally, it’s much easier to determine a physical dependence than to determine whether a behavior is “problematic”.
“Clinically significant” can mean whatever the doctor believes it is. If they’ve never suffered chronic pain themselves, doctors have not a clue as to how difficult and unpleasant life becomes when every day starts and ends in pain.
They can’t understand why we would so vehemently insist we need opioids for our pain. For them, it’s easy to write us off as “drug-seeking” and “addicted” so they don’t have to wrestle with the destructive “symptom” of intractable pain.
In addition, a person needs to meet at least two of these 11 symptoms:
- repeated use resulting in a failure to fulfill major role obligations
- repeated use in hazardous situations
- continued use despite social/interpersonal problems
- use for longer periods or in larger amounts than intended
- persistent desire or unsuccessful attempts to control use
- a great deal of time spent in activities related to use
- reduced important social, occupational or recreational activities
- continued use despite physical or psychological problems
Who came up with such nonsense? By listing 2 signs of medication dependence and requiring only 2 signs for a diagnosis of addiction, they’ve created a false diagnosis of addiction when there is only physical dependence.
Can Someone Be Dependent without Being Addicted?
Absolutely. Physiological dependence is common and can occur with many different kinds of substances, including those considered medications.
Can Someone Be Addicted without Being Dependent?
This is a much tougher debate, but the short is answer is yes. According to the DSM-5, it is possible to meet diagnostic criteria for a substance use disorder without having tolerance and withdrawal symptoms.
Why Does it Matter?
Even the Centers for Disease Control and Prevention is confused, as evidenced by the terminology page on its Web site, which states that for “drug addiction,” the “preferred term is substance abuse disorder.” This is false. To reiterate, the DSM-5 dropped the categories of “substance dependence” and “substance abuse.”
the distinction between these two concepts—addiction and dependence—is not trivial.
This is incredibly important for pain patients because, once wrongly diagnosed as “addicted”, they will never be able to get strong enough pain relief medication.
Medical professionals are ethically required to get the diagnosis right so that they can get the treatment right.
Ethics doesn’t seem to matter much anymore in our predatory capitalist healthcare system.
A doctor who is ethical can now be severely punished by what is essentially a difference in opinion. A doctor who knows their patient and the extent of their patient’s pain may determine this patient needs opioid medication to preserve their quality of life.
However, an outsider like an agent of the DEA without any medical expertise can look only at milligrams prescribed simply decide that the prescriptions were not necessary and start criminal prosecution. The agent needs no other evidence than a series of legitimate prescriptions.
Nowadays, the patient’s diagnosis and condition are irrelevant. Even though the CDC guideline stated it would evaluate the outcomes of forced tapers, they have not taken a single step in that direction.
I just don’t understand why government agencies can create policies and take actions like this without any monitoring of outcomes. The CDC is clearly a morally bankrupt agency and I fear what the future holds for a country that uncritically enforces politically motivated “guidance” as medical reality.
Author: Jonathan N. Stea is a registered and practicing clinical psychologist in Calgary and an adjunct assistant professor at the University of Calgary. He specializes in the assessment and treatment of concurrent addictive and psychiatric disorders. Follow him on Twitter @jonathanstea.