Thursday, August 18, 2011

Banish the Deceptive Label “Drug Abuse”

Language Matters The terms “abuse” and “abuser,” in reference to persons who misuse opioid analgesics or other drugs in some way, appear rather casually in everyday conversation and published articles. Everyone thinks they know what is being described, but do they really? A recent essay challenges the continued use by healthcare providers, researchers, government agencies, and the public of these vague and potentially damaging terms.

William White, MA, and John Kelly, PhD, begin their essay in the journal Alcoholism Treatment Quarterly with a quote emphasizing the vital importance of words: “If you want to care for something, you call it a ‘flower’; if you want to kill something, you call it a ‘weed’” [White and Kelly 2011]. They observe, “The language used to label alcohol and other drug (AOD) problems exerts a significant influence on people experiencing such problems and on how professional helpers, policy makers, and the public view such people.” In that regard, they advocate for the immediate and permanent removal of the terms “abuse” and “abuser” within the context of AOD problems.

White, who is a senior research consultant with Chestnut health Systems, Bloomington, IL, is a widely published and respected advocate of the Recovery Movement; that persons with substance use problems often can and do attain long-term remission from these disorders. Kelly is with the Center for Addiction Medicine, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School in Boston.

They propose 5 arguments in support of their recommendation, briefly summarized as follows:

  1. Technically, applying the term “abuse” to substance misuse is inaccurate, since common definitions of the term abuse focus on acts of willful mistreatment, verbal intimidation or insult or humiliation, physical injury, and/or deception. “To suggest that people with serious alcohol and other drug problems disregard, mistreat, or defile the psychoactive substances they consume is a ridiculous notion,” they write.

  2. Applying the terms “abuse/abuser” to the misuse of substances reflects the misapplication of morality-based language to depict a medical condition, they assert, with historical roots not in medicine but religion. Sermons and religious texts have condemned the “abuse” of alcohol and other drugs as “from Satan.” And, the abuse/abuser vocabulary has long implied the willful commission of abhorrent (wrong and sinful) acts involving forbidden pleasure.
    “The terms have also come to characterize those of violent and contemptible character — those who abuse their partners, their children, or animals,” White and Kelly observe. Furthermore, in all of medicine, there is no diagnosis whether officially or informally that includes the term “abuse”; other than in conjunction with alcohol and other substances.

  3. The terms “abuse/abuser” contribute to the social and professional stigma attached to substance use disorders and may inhibit help-seeking, they continue. “To refer to addicted individuals as alcohol, drug, or substance abusers misstates the nature of their condition and may contribute to their social rejection, sequestration, and punishment. Allegation of this effect has been made for quite some time, but recent scientific studies confirm that the words we use to depict individuals with AOD problems do make a very real difference in how people perceive and respond to these problems.” In one research study, even mental health professionals believed that a “substance abuser” should be punished, whereas persons described as having a “substance use disorder” were judged as needing appropriate and compassionate treatment.

  4. “The terms abuse/abuser inaccurately portray the role of personal volition in substance use disorders,” they write. The words denote AOD problems in terms of personal values, character, and personal decision-making. By implying that AOD problems are merely due to bad choices and that people should be accountable for such choices, the terms provide a rationale for egregious regulations and policies of forced treatment or incarceration for persons with severe AOD problems. Use of these terms ignores how volitional control over decision-making when it comes to AOD misuse can be compromised by genetic vulnerabilities and drug-induced neurological changes in the brain.

  5. The use of an “abuse diagnosis” by the current American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV) perpetuates and legitimizes the continued stigmatization of people with AOD problems. There have been growing concerns about the scientific validity of alcohol/substance abuse as a diagnostic classification and it should be banished from the diagnostic language of psychiatry, White and Kelly believe.

    Along with that, the names of the field’s major U.S. research and policy organizations should be changed: The National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Drug Abuse (NIDA), and the Center for Substance Abuse Treatment (CSAT) [and, we presume, also the Substance Abuse and Mental Health Services Administration (SAMHSA)]. All of the names reflect biased perspectives and are due for an updating.

They conclude that, if we truly believe that substance use disorders constitute serious health problems, legitimate medical disorders, and at their core are brain diseases, then the terms “abuse/abuser” should be dropped from the vocabularies of healthcare professionals, as well as patients, government agencies, and the public.

COMMENTARY: We agree with White and Kelly; the terms “abuse/abuser” in reference to substance misuse and related disorders is a short-hand, almost colloquial, use of language that is imprecise and misleading, and can be stigmatizing, demoralizing, and potentially damaging to patients.

As the authors point out in their essay, people do not actually “abuse” alcohol and other drugs; rather, they treat these substances “with the greatest devotion and respect at the expense of themselves and everyone and everything else of value in their lives.” White and Kelly provide a telling anecdote of how a person in long-term alcoholism recovery responded to the question of what he thought would constitute abuse of alcohol: That would be “mixing Jack Daniels Tennessee Whiskey with Hawaiian Punch: anyone who would commit such an abhorrent act deserves serious punishment!” he responded.

Mea culpa — yes, we have been guilty at times in these UPDATES of using “abuse” as a broad term to connote a range of problems associated with the use and misuse of opioid analgesics and other drugs, both prescribed and illicit. Yet, we often have pointed out in critiques of research how the term “abuse,” and even “misuse,” without proper definition can be egregiously uninformative and misleading.

For example, opioid analgesic “misuse” can be for medical or non-medical purposes; eg, taking more than prescribed to alleviate pain symptoms versus taking the drug for recreational purposes to get “high” or relax. The differences in volition and expected results are of great consequence in identifying and addressing the problems. In some of the research even underuse of a prescribed opioid is counted as aberrant behavior or opioid abuse, when such therapeutic noncompliance may reflect economic pressures motivating patients to stretch-out their supply of medication by taking it less often than prescribed.

In many cases, research and government reports lump together a range of problems in a “prescription opioid abuse” category that inflates the data and obfuscates the underlying issues. A reassessment of all such data might be appropriate for better characterizing the true scope of the problems. Without precise definitions and categorizations of substance use disorders and misuse behaviors there will always be uncertainty about the accuracy and biases of data that have been produced by various researchers, organizations, and government agencies.

To their credit the American Psychiatric Association does not use the term “abuse” in reference to substance misuse or substance use disorders in their proposed fifth revision of the DSM [website here] — although, the phrase “drug of abuse” still lingers in places. We doubt, however, that government agencies — NIDA, NIAAA, CSAT, or SAMHSA — will be changing their names to reflect more current, less biased thinking. Similarly, we may need to keep the “Abuse/Addiction” keyword topic category in these UPDATES, since so many items are already cross-indexed that way.

Meanwhile, at the least, we and, hopefully, professional colleagues can immediately stop using in conversation or in writing the terms “abuse/abuser” in reference to substance use problems or misuse behaviors. It’s seems the “right thing” to do.

REFERENCE: White WL, Kelly JF. Alcohol/Drug/Substance “Abuse”: The History and (Hopeful) Demise of a Pernicious Label. Alcohol Treatment Quarterly. 2001;29:317-321 [article accessible here].