MEDICINE Volume 10 • Number 5 • 2009

PERSPECTIVE

DSM-V and the Definitions: Time to Get It Right

The Past DSM significant impairment or distress, as manifested Downloaded from https://academic.oup.com/painmedicine/article/10/5/784/1825548 by guest on 30 September 2021 Over the decades, the Diagnostic and Statistical by three (or more) of the following, occurring at Manual of Mental Disorders (DSM) [1] has any time in the same 12-month period.” It then made very important contributions to the mental lists seven criteria for diagnosing this disorder health field in the classification of mental (Table 1). illness. However, as the manual is updated, some A pain patient can easily meet five of the seven members of the American Psychiatric Association listed criteria simply on the basis of requiring DSM-V Committee believe the word “” for pain treatment [6]. The first two are is still too stigmatizing and argue that the term based on expected physiologic changes of toler- “dependence” should remain [2]. In our opinion, ance and withdrawal, the second two are based on perpetuating this ambiguity is in no one’s best therapeutic need, and the fifth may be due to chal- interest. Much in the same way as we in addiction lenges often met by those seeking to obtain much treatment hope our patients will come to see needed pain treatment that may not be locally things “the way they are, not the way they wish available. Consequently, a pain patient on opioids they were,” the so-called “Golden Moment” [3], may be misdiagnosed with the of addiction we would encourage the DSM-V committee to when he or she is actually experiencing a normal approach this unique situation as a “golden oppor- physiologic consequence of using medica- tunity” to restore the term “addiction” to its right- tion, or simply requiring opioids for the manage- ful place in the medical lexicon. ment of pain [6]. Unfortunately, an active addict may also experience both acute and . In this case, the co-occurring and very treatable The Problem—Dependence and Addiction Are Not may “hide” behind the the Same Things diagnosis of pain. Unfortunately, while the terms “physical depen- Why Does It Matter? dence” and “addiction” are often used inter- changeably, they are not the same at all. In fact, a Of course, the obvious question is “Why does it joint committee comprised of members of the matter?” Unfortunately, the term “dependence” American Pain Society, the American Society of is shared between many disciplines including Pain Medicine, and the American Society of research and clinical fields. For example, depen- , the Liaison Committee for dence to the endocrinologist (i.e., insulin depen- Pain and Addiction, in 2001 developed consensus dence), pulmonologist (i.e., -dependent definitions for , addiction, asthma), pharmacologist (i.e., dependence), and tolerance that were approved by the governing and psychiatrist (i.e., dependence) means bodies of each organization [4]. The key point different things to each group. What is unique here is that physical dependence is an expected, between and the other examples is that neuroadaptive consequence of chronic exposure in the case of , there is no to an agonist class of while addiction is a therapeutic indication for alcohol in the treatment complex, multidimensional biopsychosocial phe- of that condition. In fact, the diagnosis of “addic- nomenon that occurs in at risk individuals when tion” to a drug with a therapeutic indication poses elective reward transitions into compulsive significant challenges to the clinician. When a use [5]. drug does more to you than for you, and yet you con- It is instructive to examine the current DSM-IV tinue to use, frank addiction rather than simple “Criteria for ,” which dependence should be considered [7]. defines substance dependence as “A maladaptive Media reports often interchange dependence pattern of substance use, leading to clinically and addiction, sometimes to the detriment of the

© American Academy of Pain Medicine 1526-2375/09/$15.00/784 784–786 doi:10.1111/j.1526-4637.2009.00654.x Commentary 785

Table 1 Criteria for a diagnosis of substance studies difficult or impossible. Unfortunately, this dependence can also lead to communication breakdown Substance Dependence between clinicians and their patients, resulting in A maladaptive pattern of substance use, leading to clinically diagnostic errors and inappropriate labeling of significant impairment or distress, as manifested by the problematic use of prescribed medications as occurrence of three (or more) of the following during the same “addiction.” As a result, patients who should be at 12-month period: 1. Tolerance, as defined by either of the following: the forefront of the treatment team may become (a) a need for markedly increased amounts of a substance resistant participants in a well-intentioned but to achieve intoxication or a desired effect, sometimes inappropriate -focused treat- (b) markedly diminished effect with continued use of the Downloaded from https://academic.oup.com/painmedicine/article/10/5/784/1825548 by guest on 30 September 2021 same amount of a substance ment plan [8]. 2. Withdrawal, as manifested by either of the following: (a) symptoms characteristic of withdrawal from a substance, (b) the ability to take a substance or one closely related to What We Need it, to relieve or avoid withdrawal symptoms 3. A need to take a substance in larger amounts or over a The DSM-V committee has now been empanelled longer period than intended. and the debate, commenced. Hopefully, there will 4. A persistent desire or unsuccessful efforts to cut down or control substance use. be careful review of the DSM classification of sub- 5. A great deal of time spent in activities necessary to obtain stance use disorders. It should be clear that any a substance (e.g., visits to multiple doctors or driving long harm that might occur due to the pejorative con- distances), to use a substance (e.g., chain-smoking), or to recover from its effects. notation of the word “addiction” is completely 6. Abandonment of or absence from important social, outweighed by the tremendous harm that is now occupational, or recreational activities because of substance being done to those who have suffered needlessly use. 7. Continued substance use despite knowledge of having a as a result of this well-intentioned but unnecessary persistent or recurrent physical or psychological problem confusion in terms. The societal impact of the that is likely to have been caused or exacerbated by the term “addiction” needs to be dealt with through substance (e.g., continued use despite recognition of cocaine-induced depression, or continued drinking education and understanding, not with “softer despite recognition that an ulcer is made worse by alcohol terms.” consumption). Addiction is a perfectly acceptable term [2]. It is used in the names chosen by two major American societies and their respective journals for research truth. For example, babies born to mothers whose into and treatment of addictive medical and psy- lives have been successfully transformed by chiatric disorders: the American Society of Addic- involvement in maintenance agonist treatment tion Medicine and the American Association of with , have inappropriately been Addiction Psychiatrists. In fact, on June 28, 2007, labeled as having been born “addicted” to that the Senate Health, Education, Labor, and Pen- medication, when they are in fact “physically sions Committee passed Senate Bill 1011, the dependent” on the opioid-class of drug. Similarly, Recognizing Addiction as a Disease Act of 2007, many mothers managed appropriately on opioid which will result in name changes for two, major medications for chronic pain suffer needless guilt, federal institutions. Of significance in this debate thinking that they and now their newborn babies is a change in the National Institute on Drug are addicted to . Again, physical dependence Abuse (NIDA) to the National Institute on Dis- and the expected withdrawal syndrome that eases of Addiction (NIDA) [9]. accompanies this phenomenon are being misla- The bill, introduced by Senators Biden, beled as addiction. In the authors’ opinion, the Kennedy, and Enzi, reflects recent scientific concept of a baby being “addicted” to anything is research finding addiction to be a disease that absurd. affects both brain and behavior. Removing the pejorative term “abuse” from the title of NIDA and replacing it with the words “” and The Consequences “addiction” clearly demonstrates these concepts Unfortunately, the consequences of this impreci- are related. It also represents an important step in sion in terminology are significant at many levels. reducing the stigma associated with addictive dis- In the research world, failure to accurately char- orders, and correctly renames the Institute to rec- acterize the population under study or the phe- ognize that addiction is in fact a disease [9]. nomena observed may lead to inaccuracy in the In conclusion, it would be most unfortunate if resultant data set, making comparisons between other areas of medicine were to embrace the term 786 Heit and Gourlay

“addiction” while the DSM-V retains the ideo- References logical term “dependence” to describe this im- 1 Diagnostic and Statistical Manual of Mental portant public health problem. We believe that Disorders—Text Revised, 4th edition. Washington, precise terminology will facilitate improved DC: American Psychiatric Association, 2000. understanding and ultimately improved care for all 2 O’Brien CP, Volkow N, Li TK. What’s in a word? our patients, especially if they have pain, the Addiction versus dependence in DSM-V. Am J Psy- disease of addiction, or both. Addiction is a treat- chiatry 2006;163(5):764–5. able brain disease [10] that causes much , 3 Gourlay D, Heit H. Universal precautions revisited: Managing the inherited pain patient. Pain Med as does the undertreatment of pain. To answer the 2009. In press. Downloaded from https://academic.oup.com/painmedicine/article/10/5/784/1825548 by guest on 30 September 2021 question posed by Drs. C. O’Brien, N. Vokow, and 4 Savage SR, Joranson DE, Covington EC, Schnoll T.K. Li in their editorial published in the American SH, Heit HA, Gilson AM. Definitions related to the Journal of Psychiatry titled “What’s in a Word?” [2]: medical use of opioids: Evolution towards universal A lot of confusion if terminology does not keep up agreement. J Pain Symptom Manage 2003;26(1): with basic science and best clinical practices. 655–67. 5 Koob GF, Le Moal M. Plasticity of reward neuro- circuitry and the “dark side” of drug addiction. Nat Acknowledgment Neurosci 2005;8(11):1442–4. The authors gratefully acknowledge the assistance of 6 Heit HA. Addiction, physical dependence, and tol- Judith A. Heit in the writing and editing of this article. erance: Precise definitions to help clinicians evaluate and treat chronic pain patients. J Pain Palliat Care Pharmacother 2003;17(1):15–29. Howard A. Heit, MD, FACP, FASAM 7 Gourlay D, Heit H. Pain and addiction: Managing Assistant Clinical Professor risk through comprehensive care. J Addict Dis Department of Medicine 2008;27(3):23–30. Georgetown University School of Medicine, Fairfax, 8 Joranson DE. Is the last Virginia, USA resort for some chronic pain patients? American Pain Society Bulletin 1997;7(5):1,4–5. Douglas L. Gourlay, MD, MSc, 9 Community Anti-Drug Coalitions of America FRCPC, FASAM (CADCA). Senate Committee passes legislation to Department of Anesthesiology and Psychiatry, change names of NIDA and NIAAA. 2007. Avail- Wasser Centre able at: http://www.cadca.org/CoalitionsOnline/ Mount Sinai Hospital; article.asp?id=1559 (accessed June 2009). Centre for Addiction and 10 Leshner AI. Addiction is a brain disease, and it Toronto, Ontario, Canada matters. Science 1997;278(5335):45–7.