March 13, 2014 Liz Borkowski, MPH 6Comment

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 They note that while the science of addiction has advanced, outdated public attitudes about it persist and interfere with effective treatment.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.

6 thoughts on “Changing language around addiction

  1. Medicalization of human behavior ought to be driven by science, not law. It is pretty clear that alcohol, for all its demonstrated health and longevity benefits when used moderately by American – or European – definitions, has more detrimental effects when used to excess than does marijuana. Defining one toke as “risky use” when one drink is not so defined makes no sense, unless by taking into account what militarized policing or a prison term might do to the health of a casual user.

  2. AAA seems to me to be the ultimate exercise in shame. I don’t understand why it is so popular. It emphasizes that addictive behaviors are a matter of personal choice.
    AAA is not a medical model.
    AAA has a low success rate. But there are not a lot of other models for treating the addictive brain. This country needs better—less shaming, and more successful. less recidivist—options for an individual to address addiction.
    Also, as testimony to the point about “get rid of one addictive behavior and end up with a new one” at many AAA meetings, there is ample supply of donuts and coffee (alcoholics are used to self-medicating with sugars, and simply swap one kind for another), and many resort to smoking.
    There is not enough focus in AAA on addiction in general; the concern is over one substance (e.g. alcohol) or another and not the whole smorgasbord of addictive possibilities.

  3. Alcohol is implicated in half of all murders, suicides, and automobile fatalities. One out of four families in America has an alcoholic, and an alcoholic parent is a known cause of PTSD in children.

    Secondhand smoke is obnoxious and a long-term health risk, but “secondhand drink” can be abruptly and violently fatal.

    The rationalizations for “moderate or social drinking” effectively turn into excuses that provide cover for problem drinking and for not taking a hard line on its effects on others. If a kid had a parent who was smoking crack or snorting meth, that parent would lose custody in a heartbeat. Yet if the kid’s parent was drinking and going on rampages every night…. … nothing, nada, the sound of crickets.

    As for marijuana, while it should be legal for all the usual principled and pragmatic reasons, we also need to prepare for the fact that some percentage of the population will abuse it like crazy and also be hazards to others, for example if they smoke and drive.

    What I find laughable if not outrageous, is that tobacco has become a scapegoat, while alcohol gets a free ride (and marijuana will likely get another free ride). The situation of about 10 – 20 years ago was reasonable, where restaurants and other indoor public places were all nonsmoking, and smoking was de-glamorized, and so on.

    But banning smoking in open outdoor areas and in rental properties (by city ordinance), and putting graphically grotesque pictures on cigarette packets, is an exercise in witch-hunting rather than public health. Along the way it makes a mockery of other public health measures in exactly the same way as “reefer madness” propaganda made a mockery of other anti-drug efforts.

    How’bout banning alcohol consumption in rental properties, and putting graphically grotesque pictures of the consequences of drinking, on every bottle and can? What’s good for the goose is good for the gander. Think about it next time you hear about some drunk driver causing a multiple-fatality accident.

    Lastly, enough is enough with the language “alcohol, tobacco, and drugs.” It needs to be “alcohol, tobacco, and OTHER drugs,” because a drug is a drug is a drug, and playing favorites in the language is logically and empirically absurd.

  4. Good point about “other drugs,” G – I updated that sentence.

    I don’t know that I’d call anti-tobacco tactics “witch hunting,” but I do think it makes sense to use some of the ones that have been found to be effective on alcohol. There is an important difference between tobacco and alcohol, though: Moderate alcohol consumption is actually linked to some health benefits, so public-health professionals aren’t working to eliminate it altogether. I don’t doubt that what some people describe as “moderate drinking” is actually a risky or problematic behavior, but many of us are able to have a glass of wine with dinner a couple of times a week without causing problems for ourselves or others.

    Drunk driving does indeed pose huge and terrible social costs, and I’ve been pleased to see some media campaigns targeting it over the past few years (e.g., “buzzed driving is drunk driving.”) Of course, the likelihood of drinking leading to drunk driving depends in large part on local transportation options.

  5. Liz- Thanks for the update.

    Where the antismoking measures backfire is where they go overboard to the point where they set up two dynamics:

    One, “I’m better than you.”

    That’s the obvious subtext of measures that use “nudge” tactics: the nudger is superior to the person being nudged. “Nudge” is obnoxious in general for exactly that reason: it’s manipulation with plausible deniability, it directly conveys an attitude of superiority/inferiority, and “you’re not smart enough to make your own decisions so I’m going to make them for you.”

    Two, “reefer madness.”

    Steps such as banning smoking in uncrowded outdoor areas and in rental housing (yes this goes on) backfire precisely because they have no basis in protecting others, only in “protecting people from themselves,” which is nearly universally seen as illegitimate over-reach. The well-known result is for health warnings to be disregarded as propaganda, and for restrictions to be disregarded as prohibitionism, and for respect for the law to decline.

    The use of grotesque graphic images on cigarette packs is precisely equivalent to the mid 20th century “reefer madness” propaganda about marijuana, and it is 100% certain to backfire in exactly the same manner. After the initial shock value wears off it will be seen by smokers as a joke and have no effect. It will also piss off nonsmokers who see the jarring and nauseating images in random places, in a manner analogous to dog excrement on sidewalks: when sidewalks are fouled, people don’t blame dog-walkers, they blame the city government for failing to keep them clean.

    As for apartment buildings:

    The underlying risk is shared air: if I can smell your smoke, I can also catch your airborne contagious illnesses. This is going to become a big deal during the next major flu pandemic with high CFR, mark my words. Building codes need to be updated to prohibit “shared air” ventilation systems and require ventilation that exchanges air from each unit with outside air only. There is an energy cost for this (heating/cooling) but it can be recouped through heat exchangers and other means.

    Realistic policies:

    Prohibitionist measures are doomed, we’ve already seen that with alcohol and marijuana. The early history of tobacco also includes instances where governments banned it under penalty of death, and that didn’t stop it.

    There is always going to be a baseline percentage of a population that uses any given drug. Prohibition is only justifiable where there is an immediate risk to public safety, as with crack cocaine and methamphetamine (even heroin can be managed via risk reduction such as prescription maintenance: heroin addicts don’t commit crimes if they have a safe supply).

    The #1 policy we need is: Replace the “sin taxes” on tobacco (and alcohol and marijuana) with federal “pay-as-you-go” health risk user taxes that are based on the empirical health cost data from the populations of users. The amount of the tax would be printed on the label: an empirical fact that users can’t deny, without the overboard emotionalism that causes backlash. This would zero-out the health costs of tobacco, alcohol, marijuana, etc. to society at-large. (I once did the calculations on this for cigarettes and the tax is slightly higher than the “sin tax.”)

    Combine that with a ban on advertising in public places, and an age limit on access to retail outlets (cigar stores, liquor stores, marijuana stores, bars), and a ban on usage in venues that are not restricted to users (e.g. no smoking in indoor public spaces, drinking OK in bars, smoking OK in cigar stores). Contextualize outdoor smoking in the same way as civic manners in general: “don’t litter, pick up after your dog, don’t smoke where nonsmokers are nearby, don’t throw chewing gum on the pavement.” Fix the “shared air” problem in apartment buildings, which will have other public health benefits in reducing the spread of contagious illnesses.

    Those types of policies are rational, they don’t come across as scapegoating or puritanism, and they are unlikely to provoke backlash. At that point, the level of smoking in society drops to its “natural minimum,” and the health costs are paid for in the health risk taxes.

    Some people will always choose to put themselves at risk one way or another. Personally I think mountain climbing and skydiving are downright crazy, but if the costs of those risks are borne by those who do the activities, they aren’t my problem.

    What bugs the hell out of me is going to a restaurant (aside from bars and pubs obviously) and having the waiters push alcohol: “Did you check out our wine list? We have some very special wines this week, how about a complimentary glass…” Try going to one of those places with a friend or family member who is attempting to quit drinking, and you’ll find yourself wishing you didn’t. IMHO that shouldn’t be allowed unless the venue advertises itself as a bar or a pub including on its signage. The principle is the same.

  6. It is encouraging to see scientific findings backing up the assertion that drug and alcohol addiction truly is a disease. These are good points made regarding the continuing stigma associated with addiction as well as the risky behavior practiced by adolescents that eventually will lead into addiction.

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