Substance Use Terminology

Before we talk about screening and intervening for substance use, there are some related terms that you should consider: dependence, tolerance, and addiction.

If you think that these terms are difficult to pin down, well, they are, and we should all remember that our patients likely struggle with them as well. Many patients see all these terms as being the same. Other patients may bristle at certain terms such as “addiction” and just hearing this word may shut down further open dialogue. So let’s begin by defining these terms for our own clarification before we use them with our patients.

The following definitions are drawn from DSM-IV, NIAAA and NIDA.

Use

  • Any use of tobacco, alcohol or other substance

Physiologic tolerance

  • Decrease in susceptibility to the effects of a drug due to its continued administration
  • Physiologic phenomenon not under control of patient

Physiologic dependence

  • Refers to a state resulting from chronic use of a drug that has produced tolerance and where negative physical symptoms of withdrawal result from abrupt discontinuation or dosage reduction
  • Physiologic phenomenon not under control of patient

Substance abuse

  • Excessive use of a substance
  • No universally accepted definition

Addiction

  • Addiction is a persistent, compulsive dependence on a behavior or substance
  • The term has been partially replaced by the word dependence
  • The term addiction can be offputting to patients, sometimes shutting down conversation.

Alcohol Use Terminology

These terms are used in concert with the previous terms but are used exclusively when discussing alcohol.

Low-risk Use

  • Drinking that is within legal and medical guidelines and is not likely to result in alcohol-related problems

Hazardous Drinking  (“At-risk”)

  • Pattern of substance use carrying with it a risk of harmful consequences to the drinker
  • Consequences may include physical or mental health problems or social consequences
  • Hazardous drinking may present as binge drinking or dependence

Alcohol Use Disorders

  • Abuse or dependence

Binge Drinking

  • Drinking 4-5 drinks in a short period of time (e.g. a few hours)

Alcohol Use Disorder

The new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) no longer distinguishes between abuse and dependence. Instead the term “Substance Use Disorder”is used to outline a cluster of cognitive, behavioral and physiological symptoms experienced by an individual who continues using the substance in spite of significant consequences related to substance use.

Specifically, Alcohol Use Disorder is characterized by a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

  • Alcohol is often taken in larger amounts or over a longer period than was intended
  • There is a persistent desire or unsuccessful efforts to cut down or control alcohol use
  • A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects
  • Craving, or a strong desire or urge to use alcohol
  • Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school or home
  • Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol
  • Important social, occupational or recreational activities are given up or reduced because of alcohol use
  • Recurrent alcohol use in situations in which it is physically hazardous
  • Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol
  • Tolerance, as defined by either of the following:
    • A need for markedly increased amounts of alcohol to achieve intoxication or desired effect
    • A markedly diminished effect with continued use of the same amount of alcohol
  • Withdrawal, as manifested by either of the following:
    • The characteristic withdrawal syndrome for alcohol
    • Alcohol (or closely related substance, such as a benzodiazepine) is taken to relieve or avoid alcohol withdrawal symptoms

Changes to the DSM-V

In 2010, the new DSM-V was released and several changes were made regarding the definitions of substance use disorders. The Substance-Related Disorders Work Group has been responsible for addressing these disorders. Among the work group’s proposals is the recommendation that the diagnostic category include both substance use disorders and non-substance addictions. The work group had extensive discussions on the use of the word “addiction.”  There was general agreement that “dependence” as a label for compulsive, out-of-control drug use has been problematic. It has been confusing to physicians and has resulted in patients with normal tolerance and withdrawal being labeled as “addicts.” This has also resulted in patients suffering from severe pain having adequate doses of opioids withheld because of fear of producing “addiction.” Accordingly, the word “dependence” is now limited to physiological dependence, which is a normal response to repeated doses of many medications including beta-blockers, antidepressants, opioids, anti-anxiety agents and other drugs. The presence of tolerance and withdrawal symptoms are not counted as symptoms to be counted for the diagnosis of substance use disorder when occurring in the context of appropriate medical treatment with prescribed medications.

Words: The Bottom Line

discussionRemember, the important thing about these definitions isn’t so much that you memorize them, but rather that you and your patient (and colleagues) communicate clearly and effective using terminology of which you share a common understanding. Without that common understanding, we may misunderstand our patients, they may misunderstand us, they may answer our questions incorrectly–”No, I’m not addicted.”–because they key into the word and not into their behavior.

Moreover, certain terms, like addiction can be counterproductive to your relationship with your patient. So it is best to avoid using it unless you have already established a pattern of behavior and level of comfort with your patient.