Substance Use Disorders as a category

Push_vs_Pull_MarketingThere’s been a big change in the way professionals and advocates talk and think about drug and alcohol problems over the last several years.

On one end, we have professionals changing the classifications and mental models for substance use problems.

On the other end, we have recovery advocates changing the definition of recovery.

Before we dig into these changes, let’s start with a little background.

One attempt to classify drinkers

I’ve no doubt that there is a long history of classifying drug and alcohol users and, honestly, I’m not interested in digging into it right now. So . . . one easy to find attempt is AA’s. They were making no attempt to be authoritative–they were just trying to describe what they’d observed.

First, “normal” drinkers:

For most normal folks, drinking means conviviality, companionship and colorful imagination. It means release from care, boredom and worry. It is joyous intimacy with friends and a feeling that life is good.

Next, the various types of heavier drinkers:

Moderate drinkers have little trouble in giving up liquor entirely if they have good reason for it. They can take it or leave it alone.

Then we have a certain type of hard drinker. He may have the habit badly enough to gradually impair him physically and mentally. It may cause him to die a few years before his time. If a sufficiently strong reason – ill health, falling in love, change of environment, or the warning of a doctor – becomes operative, this man can also stop or moderate, although he may find it difficult and troublesome and may even need medical attention.

But what about the real alcoholic? He may start off as a moderate drinker; he may or may not become a continuous hard drinker; but at some stage of his drinking career he begins to lose all control of his liquor consumption, once he starts to drink.

To review, they seemed to identify 4 types of drinkers:

  1. normal drinkers,
  2. people who find that they have been drinking more than they want to and choose to cut back or quit,
  3. people whose drinking gets them into trouble and may need some professional help to moderate or quit, and
  4. alcoholics who have lost control of their drinking for whom abstinence is the only solution.

While these distinctions were observed by lay people in the 1930s, for decades, drug and alcohol professionals too frequently failed to recognize these differences and often treated types 2 and 3 as though they were a type 4.

The DSM – From Abuse/Dependence to a Continuum

apples_aint_oranges_by_tootieofrutyIn 1980, the DSM-III created the diagnosis of substance “abuse” (similar to AA’s type 3, but may include some type 2 drinkers) as separate from substance “dependence” (similar to AA’s type 4 but, unfortunately, still captured many type 3s). These categories continued through the DSM-IV.

Unfortunately, it took too much time for professionals to catch up. (Since Dawn Farm began providing outpatient services in 2000, we have offered 2 “tracks”. The first is for people who meet DSM abuse criteria and/or prefer moderation as a goal. In this track, clients choose moderation or abstinence as their goal. The second track is for people with the more severe and chronic substance problems and abstinence is the goal.)

Over time, it’s my impression* that most professionals did catch up. These categories seemed to become more widely used and shaped care. These were conceptualized as different in kind rather than a difference in severity. Most people meeting “abuse” criteria will never progress into “dependence” and moderation being a perfectly appropriate goal for patients diagnosed with “abuse.” (* My impression is based on professional publications, conference presentations and my admittedly regionally limited interaction with other professionals. This impression is disputed by others and I’m open to the suggestion that many professionals persistently failed to make these distinctions.)

In 2013, the DSM 5 eliminated abuse and dependence, combining them into a single disorder measured on a continuum from mild to severe.

This means that the new diagnostic manual conceptualizes types 2, 3 and 4 as different in severity rather than a difference in kind.

Shifting Definitions of Recovery

This coincides with advocacy efforts that had been seeking to broaden the definition of recovery. In 2001, groups like Faces and Voices of Recovery (FAVOR) formed and sought to include people using non-12 step approaches and people on maintenance medications like methadone under the banner of “recovery.” It was my impression that, at this time, the concept of recovery was confined to those recovering from the disease of addiction.

By 2011, recovery advocates had embraced what has become an important talking point, that 23.5 million Americans are in recovery.

According to the new survey funded by OASAS, 10 percent of adults surveyed said yes to the question, “Did you once have a problem with drugs or alcohol, but no longer do?” – one simple way of describing recovery from drug and alcohol abuse or addiction.

10%? . . . 23.5 million? Those numbers are a powerful advocacy tool. However, to me, this constituted an important transition. This expanded the label of recovery to AA’s type 2 and 3 drinkers, meaning that groups like FAVOR were now applying the label of recovery to people who had short-lived and mild substance use problems, and people who are using substances non-problematically.

To me, the de-coupling of recovery and addiction seems like a very important development.

Not an argument for “dependence”

Dependence was far from perfect. This is not an argument for a return to the abuse/dependence model. (Though I will argue that we should return to conceptualizing as addiction as a different kind of problem from low to moderate SUDs, rather than a different severity.)

Let’s start by stating that addiction/alcoholism is the chronic form of the problem is primary and characterized by functional impairment, craving and loss of control over their use of the substance.

Problems with the categories of abuse and dependence include:

  • Dependence has often been thought of as interchangeable with addiction/alcoholism, but this is not the case.
  • Dependence criteria captured people who are not do not have the chronic form of the problem. We know that relatively large numbers of young adults will meet criteria for alcohol dependence but that something like 60% of them will mature out as they hit milestones like graduating from college, starting a career or starting a family.
  • Dependence criteria captured people who are not experiencing loss of control of their use of the substance.
  • The word dependence leads to overemphasis on physical dependence which, in the case of a pain patient, may not indicate a problem at all.
  • The word abuse is morally laden.
  • For me, there are serious questions about whether abuse should be considered a disorder at all.

Several of these problems are related to doing a poor job in distinguishing which kind of user the patient or subject is.

The abuse/dependence model fell short in distinguishing between kinds of users. Rather than taking a step forward in distinguishing between the kinds of users, the continuum approach implies that there is only one kind with different levels of severity.

Does it really matter?

Reasonable people can disagree, but I find this problematic for a few reasons.

Stigma

I tend to believe that failing to distinguish between kinds of problem users will actually add to stigma. It will perpetuate the conversations that sound something like, “Greg, when your Uncle Bob was in the Navy, he drank too much and got into some trouble. Then he had kids and knocked it off. Why can’t you just do the same?” The reason they can’t do the same was that Uncle Bob was a problem drinker and Greg is an alcoholic.

Non-alcoholics using the drinking experience of non-alcoholics (themselves or others) to understand the experience of alcoholics only increases stigma.

It’s not a different degree of the same thing. It’s a different kind of thing.

In my experience, it’s only when people understand that it’s a different kind of thing—that the experience of the alcoholic cannot be understood by reflecting on your own experience of drinking too much in college—that stigma can be challenged.

Disease and non-disease under the same diagnosis?

The continuum approach becomes especially troubling when you think about the idea of giving people with low severity SUDs and people with the disease of addiction the same diagnosis, only with different severity ratings.

There’s little doubt that large numbers of young people on college campuses meet diagnostic criteria for an alcohol use disorder under the DSM 5. I doubt anyone would argue that all of these young people have a disease process? Even a mild one?

This seems likely to undermine the acceptance of addiction as a disease. Not just by the public, but also by insurers and policy makers.

Others are more concerned, arguing that abuse should be thought of as a behavior and dependence as a disease, and by combining them it becomes easier for payers to deny clinically appropriate care. Even worse, it might signal a shift to the idea that any professional with “behavioral” health training would be eligible.

One frequent example of how this conceptualization undermines the disease model is one of last year’s most popular posts.

In arguing that the causes of addiction are environmental (non-nurturing environments) and social (lack of connection) Johann Hari pointed to returning Vietnam vets discontinuing heroin without treatment as proof that addiction is not a disease.

However, these Vietnam stories often ignore an important fact:

“. . . there was that other cohort, that 5 to 12 per cent of the servicemen in the study, for whom it did not go that way at all. This group of former users could not seem to shake it, except with great difficulty.”

Hmmmm. That range….5 to 12 percent…why, that’s similar to estimates of the portion of the population that experiences addiction to alcohol or other drugs.

To me, the other important lesson is that opiate dependence and opiate addiction are not the same thing. Hospitals and doctors treating patients for pain recreate this experiment on a daily basis. They prescribe opiates to patients, often producing opiate dependence. However, all but a small minority will never develop drug seeking behavior once their pain is resolved and they are detoxed.

My problem with all the references to these vets and addiction, is that I suspect most of them were dependent and not addicted.

So…it certainly has something to offer us about how addictions develops (Or, more specifically, how it does not develop.), but not how it’s resolved.

How useful is it as a diagnostic category?

What’s the purpose of a diagnosis?

Isn’t it to give us a way to think about the causes, course, symptoms and treatments for an illness?

In plain language, a diagnosis is supposed to help us think about, talk about and understand what happened, what’s happening, what’s likely to happen, what will help, what is unlikely to help and what might be harmful.

What do someone with the disease of addiction and someone with a low severity SUD have in common? Do they have anything in common other than some harms (symptoms)? I can think of very little.

When we have one diagnosis that includes problems with radically different causes, courses and treatments, what use is it?

Really, it’s hard for me to see how this category would give helpers any insight into the patient’s experience or help in developing policy responses.

It feels a little like a diagnostic category of “respiratory disease.” It could be acute or chronic; it could be viral, bacterial, congenital, malignant or benign; it could be mild, moderate, severe or terminal; it could require aggressive and invasive treatment or no treatment; it could be progressive, nonprogressive or relapsing and remitting; etc.

Combining addiction and problem use into one continuum seems to like it brings confusion rather than clarity to understanding what happened, what’s happening, what’s likely to happen, what will help, what is unlikely to help and what might be harmful.

Will it eventually undermine advocacy efforts?

Doug Rudolph, of the advocacy group Young People in Recovery, suggested that messaging using SUDs as a category is misleading, undermining integrity and credibility.

I believe that we need to stop merely talking at the public, using the same language, playing to emotions, overgeneralizing data, and commanding them to agree with us, no questions asked. We need to stop using oversimplified, polarizing language that basically characterizes anyone who struggles with drugs and alcohol as suffering from a life-long, incurable, chronic brain disease because that will not, and hasn’t yet, resonated with the silent majority of America. We need to stop skewing statistics to further an agenda, unlike how the above cited statistic is often used, because that calls our integrity and credibility into question. Rather, we need to start digging deeper to develop an effective method that will bridge the gap and reconcile the inconsistencies between messaging and reality. And most difficult of all: we need to be objective.

He added that it risks drawing the attention of advocates away from important questions:

To do this, we need to start asking more nuanced questions that the recovery community has historically glossed over, and which many people believe are taboo to even ask or mention.

For example, while there is a significant difference between a free-of-charge mutual aid, community-driven support group and treatment, should treatment centers be employing and profiting off a method of treatment that a person could receive for free down the street? Should treatment centers be held to a higher, better regulated standard? Do we (as advocates) have a duty to constructively criticize the methods of treatment by which Big Treatment earns profits? While people attending community-driven support groups can do whatever they wish to help themselves maintain recovery (as long as it’s legal), how can we blame Americans at large for not believing that addiction is a bona fide medical disease when the oldest and most popular form of addiction treatment, for which people (or insurance companies) pay big bucks, relies on prayer, character defects, and admitting wrongs? How many other medical diseases or psychiatric disorders are primarily treated this way? Would it be appropriate to treat schizophrenia, PTSD, or diabetes this way? What’s the difference? Do people notice or think about this? Would acknowledging this and incorporating it into our messaging hurt or help our advocacy efforts?

Will it inflate “addiction” rates?

These changes were intended to clear up language problems, specifically the conflation of dependence and addiction leading to “false positives” for addiction. Looks like the DSM-5 is causing its own language problems before it’s even adopted. [emphasis mine]

Many scholars believe that the new manual will increase addiction rates. A study by Australian researchers found, for example, that about 60 percent more people would be considered addicted to alcohol under the new manual’s standards. Association officials expressed doubt, however, that the expanded addiction definitions would sharply increase the number of new patients, and they said that identifying abusers sooner could prevent serious complications and expensive hospitalizations.

What’s the solution?

It’s my opinion that thinking and talking about high severity SUDs and low severity SUDs as different kinds is important for good treatment and good advocacy.

Unfortunately, that means a lot more work for treatment providers and researchers. And, less impressive numbers for recovery advocates.

Why would it be more work for treatment providers and researchers? Because trying to sort type 3 and type 4 is not easy and takes time.

For example, when I have a young adult who meets criteria for alcohol dependence, I have to work with them to figure out if they are a type 3 (Meaning moderation might be a good goal and that might be achieved through education, motivational interviewing, contingencies or help addressing other problems leading to excessive drinking.) or a type 4 (Meaning abstinence should be the eventual goal and they may require specialty treatment followed by long term monitoring and support to achieve that goal.).

I’ll often have a conversation that sounds something like this:

One of the things we’d have to sort through is the kind of alcohol problem you have. There are 2 big categories. The first is the progressive, more severe and chronic type–alcoholism. The second is a lower severity problem that people often mature out of with little or no help, often making the change after some consequence or because of a life transition like graduating or parenthood. Research suggests that something like 60% of young people meeting criteria for alcohol dependence fall into the second category. The kinds of things that suggest someone is likely to fall into the first category are use of other substances, loss of control, euphoric recall of first drug contact, atypical tolerance, continued use despite growing consequences and family history.

Of course, it may take some time and some trial and error to agree on whether the patient is a type 3 or type 4. This conflicts with the goals of DSM writers, researchers, insurers and too many practitioners, but I don’t see a way around it.

Another Vietnam cohort?

This entire issue could be of significant consequence as the current opioid epidemic continues to unfold.

Let’s take a look at comments from the researcher who did the returning veterans study and how it has been misunderstood:

The argument that addiction in Vietnam was a response to war stress, and therefore remitted on exit from the Vietnam war theatre, is still frequently cited as though it were self-evident, because it sounds so plausible. Yet accepting this argument is difficult in the face of the facts. Heroin was so readily available in Vietnam that more than 80% were offered it, and usually within the week following arrival. Those who became addicted had typically begun use early in their Vietnam tour, before they were exposed to combat. Further, the dose-response curve that is such a powerful causal argument did not apply: those who saw more active combat were not more likely to use than veterans who saw less, once one took into account their pre-service histories. (Those with pre-service antisocial behavior both used more drugs and saw more combat. Their greater exposure to combat was presumably because they had none of the skills that kept cooks, typists, and construction workers behind the lines.)

These men were in an environment where it was readily available and presumably less stigmatized, leading to high rates of social/recreational use. This social/recreational use led to high rates of dependence, giving the impression that they had the disease of addiction when, in fact, it appears that only a minority did. This misunderstanding leads to false understandings about the causes, course and treatment required for addiction. These false understandings shape research and public understandings of the problem and solutions.

When one considers this Vietnam story along side what we know about young people meeting criteria for alcohol dependence, it opens the door to some frightening possibilities for this opioid epidemic.

Given the dramatic increases in opioid misuse, is it possible we’ll see a large numbers of people presenting with opioid dependence who are not actually addicted?

If so, will each group get the right treatment for their problem? Will people with opioid-dependence-but-not-addiction be given treatment that focuses on things like maintenance medication, lifelong abstinence and recovery maintenance, when something that looks more like an acute care model would be more appropriate?

Will the research done on treatment provided during this epidemic make any attempt to distinguish between types and each type’s response to various treatment interventions? I wonder if we’ll find that the the opioid-dependent-but-not-addicted group responds well to office-based buprenorphine treatment and are restored to a good quality of life, while addicted groups get stuck or have poor retention and continue to use other substances.

6 Comments

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6 responses to “Substance Use Disorders as a category

  1. David Macmaster

    I really like this comprehensive, well-thought out paper, Jason. It makes a significant contribution to our literature in my opinion. I have been an addiction specialist since 1975 and in personal alcohol and tobacco recovery since 1956, so I have been part of both mutual help recovery and professional addiction prevention, treatment and recovery. It has helped being a provider and a recovery consumer. I hope your paper gets wide-spread distribution.

    Your points and observations are valid in my opinion, and I share most of them. Most of what you note covers alcohol and some on opiates. I wonder how applicable your points are relative to tobacco use disorders as they are now called in DSM-5? I bet there are both similarities but some major diferences with implications for treatment and recovery.

    Somewhere in the 70’s when our modern addiction treatment and services were being created and discovered, tobacco companies had succeeded in their denial that nicotine is addictive. The providers and government agencies created to establish and maintain the nation’s (and state’s) addiction treatment services excluded treatment of nicotine dependence as it became known as. That treatment exclusion continues to this day except in New York State and some other state programs.

    We have been working for more than 10 years here in Wisconsin to have tobacco and nicotine addiction integrated into our state’s addiction and mental health treatment services. It is a difficult task, but we are making progress. We are getting support for our efforts because we are complying with the requirement that Tobacco Prevention & Control Programs must develop programs that address disparity populations. Guess what populations prevalence studies identify as being major disparity populations?
    More then 80% of those entering addiction treatment programs have tobacco use disorders compared to 18% in Wisconsin’s general population. Similar high prevalence was identified with those with mental health disorders.

    We don’t have decades of experience treating tobacco use disorders as we have treating the other substance use disorders because those with these disorders have not been eligible for treatment in our addiction treatment services. I wonder how your understanding of tobacco use disorders and their treatment fits with the ideas and theories you propose. Your attention to this issue will be interesting to read.

    Best wishes and thank you for your important contributions to our knowledge of addictions.

    David “Mac” Macmaster

  2. chuck gehrke

    This kind of thoughtful and comprehensive discussion is what we need to help sort out the complexities of what collectively are called Substance Use Disorders. This is the kind of discussion you frequently hear related to a multitude of other medical conditions as more is learned about them over time. As you point out the simplistic approach to a complex condition does a disservice to both the person afflicted by the disorder and the people attempting to provide care. Thanks Jason. Chuck

  3. apatino2014

    Jason- This is a fantastic post. Thank you.

    On Wednesday, March 23, 2016, Addiction & Recovery News wrote:

    > Jason Schwartz posted: “There’s been a big change in the way professionals > and advocates talk and think about drug and alcohol problems over the last > several years. On one end, we have professionals changing the > classifications and mental models for substance use problems. ” >

  4. While I agree with much of the above – esp Doug Rudolph’s quotes!! And the point about the 5-12% Vietnam vet cohort (suspiciously similar to general population – nice catch) – there is one major point missing:
    I do not believe that mild SUDs, or all SUDs, for that matter, are necessarily fixed types – esp in terms of severity. A mild AUD this year, can absolutely become a moderate-severe AUD by next year.
    Sure, to say that mild and severe SUDs are objectively different is absolutely true. And while many/most with severe AUD may never successfully moderate their drinking, it isn’t also a given that those with 1-3 AUD criteria can rest assured they’ll never move further along the continuum of severity or ultimately lose control. But our field was done a great service by shifting the conceptualization to one that views addiction and SUDs along a continuum, and that recognizes that not all heavy use is addiction – nor is all addiction necessarily heavy use.

    • Thanks. No doubt that some fraction of patients presenting with mild to moderate SUDs will progress into addiction. However, it’s going to be a minority of them. And, we can still do some sorting if we’re less focused on symptom counting and more tuned in to things like loss of control, euphoric recall of first drug contact, atypical tolerance and family history.

      All the best,

      Jason