As a follow-up to a previous post, Addiction vs dependence | National Institute on Drug Abuse, here’s an article from the Scientific American pointing out the messy confusion between the two created by the DSM-5.
It is no secret that misinformation about addiction is rampant in popular media. One particular area of misinformation concerns what language gets used when describing topics related to addiction.
all sorts of individuals—medical professionals, journalists, parents, people who use substances, people in recovery—incessantly argue over terminology such as “addiction,” “dependence,” “abuse,” “misuse,” “habit-forming,” “recreational use” or “medicinal use.”
the most important and commonly confused distinction is between “addiction” and “dependence.” And it is no wonder.
The scientific construct of addiction has a rich and evolving history. Even the people who dedicate their lives to researching addiction and who are responsible for the very medical texts that we use to diagnose addiction haven’t arrived at a clear consensus about which terms to use when.
If they can’t make this distinction, they are frighteningly incompetent because there are such great differences between the two.
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 use any “pejorative” words to describe people who get stuck in the horrible state of addiction. While they’re at it, perhaps they should avoid describing people as criminals or murderers or child molesters too.
To throw people who need opioids for their pain into the same category as people who use opioids to disengage from real life is outrageously sloppy science. It’s morally, ethically, and scientifically just plain wrong to conflate the two.
I’m sure many people who are addicted hate being in that accursed state, where their whole lives are dominated by the need to find their illicit drug of choice, no matter how or at what cost, no matter how great the risk it may be poisoned by added illicit fentanyl.
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.
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.”
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.
Unhelpfully, however, the DSM-5 does not explicitly and transparently mention this. In fact, the American Psychiatric Association, which developed the DSM, nonchalantly uses the terms “substance use disorder” and “addiction” interchangeably on its Web site.
Can Someone Be Dependent without Being Addicted?
Absolutely. Physiological dependence is common and can occur with many different kinds of substances
Can Someone Be Addicted without Being Dependent?
This is a much tougher debate, but the short is answer is yes.
Why Does it Matter?
My hope for this piece is to clarify rather than further confuse the distinction between “addiction” and “dependence,” something that is not only confusing among nonexperts but among medical professionals as well.
This is a sad state of affairs when even experienced and highly trained medical professionals are confused about the absolutely critical difference between people who need opioids for their intractable pain versus those who need them to feed an addiction.
This is the result of all the misused, misdefined, and mistaken mumbo-jumbo of what should be well-defined medical terms spread by anti-opioid zealots and their lackeys, the unquestioning media.
Whatever happened to verification before publication? When did the media stop vetting their sources and start publishing whatever nonscientific nonsense comes out of some self-proclaimed expert’s mouth?
Even the Centers for Disease Control and Prevention (CDC) 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.”
So the CDC didn’t know what it was talking about when it wrote the opioid guidelines.
The CDC is about “Communicable Disease Prevention”; it was established to manage outbreaks of contagious diseases, like smallpox or measles, which were killing hundreds of thousands of people at that time (not tens of thousands like drug overdoses).
Neither pain nor addiction is a “communicable disease” and opioids aren’t medication used to combat any “communicable diseases”, so this agency has zero expertise in pain and addiction.
Instead, we have the government agency of NIDA, the National Institute of Drug Addiction, which was established for this very purpose.
This is exactly why this agency had no business writing any guidelines for opioids, or pain, or addiction. They clearly overstepped their boundaries, but this doesn’t seem to matter to anyone; I’ve never heard one peep of protest.
the distinction between these two concepts—addiction and dependence—is not trivial.
Medical professionals are ethically required to get the diagnosis right so that they can get the treatment right.
Exactly: doctors are ethically required to understand the difference between these two entirely different medical concepts.