Improving Our Language About Addictive Problems, Pt. I
By Tom Horvath, PhD
I recommend the term “addictive problems” to replace several other similar terms, and no longer using the term “recovery,” which has several better alternatives depending on context. In this two-part series on improving the language about addictive problems, part 1 will focus on addictive problems, and part 2 will focus on “recovery.”
The diagnostic manual, DSM5-TR, identifies 10 categories of substance problems. The substances are alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedative/hypnotics/anxiolytics, stimulants, tobacco, and “other.” There is also one category of activity problems (gambling). There are 11 criteria (9 for gambling) which identify common consequences which can arise from substance use. The consequences manifest themselves as impaired functioning or subjective distress or both. Depending on how many criteria (consequences) someone has, the diagnosis is Mild (2-3 criteria), Moderate (4-5), or Severe (6+) Substance Use Disorder (SUD).
Levels of addictive problems
For simplicity, I will discuss only alcohol, but the ideas presented here apply to any substance or activity. The continuum of alcohol problems has 6 levels:
1) Severe Alcohol Use Disorder (AUD)
2) Moderate AUD
3) Mild AUD
4) misuse (fluctuating problems over time, not substantial enough to meet 2 diagnostic criteria for that specific substance or activity)
5) moderation (benefits exceed costs for that specific substance or activity)
6) abstinence (no engagement with a specific substance or activity)
Misuse might also be called subclinical use, high risk use, problematic use, or other terms. There are many ways for someone to qualify for this level. Someone might fall short of meeting 1 or several diagnostic criteria, or meet 1 criterion only. Such a person is not moderating, but not at the level of a diagnosis. Someone does not jump from moderation to Mild AUD in one moment, and during that time they are in misuse. Many people are in misuse for decades, and do not progress to higher levels.
Perhaps the most important reality about these problem levels is that, from any of these levels, someone can move up or down over time. Contrary to what many seem to believe, being at one level at one point in time does not definitively identify where someone will be at a future time. If you use the term “alcoholic,” then once an alcoholic, always an alcoholic. The term alcoholic was removed when DSM3 was published in 1980. Although a member of AA, or anyone, is free to think this way (and there can be advantages to doing so), as a diagnostic term alcoholic is 43 years out of date.
We could identify a place for each of us, at any specific time, for each substance or activity, each of which has its own continuum of problems. For instance, someone might abstain from opioids, stimulants, and all other substances, except they might moderate caffeine and cannabis use, and might misuse alcohol. We could, if we chose to, break alcohol into the categories of beer, wine, and liquor, or separate the opioid category into fentanyl and heroin.
Whether we choose to combine or separate categories, the term addictive problems refers to being anywhere within levels 1-4 on the specific continuum we are focused on. Contrary to what many also believe, someone’s position on one continuum does not necessarily indicate their position on any other. Although there is a widely used term “chemical dependency,” the term is misleading. It suggests that if you have one substance problem you will have all of them (except caffeine and tobacco). Some individuals may indeed have multiple SUD’s, but many individuals only have one or a few.
Why is “addictive problem” a useful term?
1) Services and support for addictive problems should be available even if my problems are only at the level of misuse. If I can address my problems there, I could prevent myself from progressing to higher levels. Progression can happen, even though it does not necessarily happen. However, it would be good to prevent progression when we can. Even if no progression occurs, misuse is worth changing
2) Misusers typically do not identify with terms like addict, alcoholic, and substance use disorder, and are more likely to identify with a broader term like addictive problems. Based on that term I am more likely to seek support for addressing these problems. If I misuse I could easily rationalize: “I may have problems, but I’m no addict (or alcoholic).” With that rationalization I could decide to do nothing.
3) The majority of addictive problems occur at levels 3 and 4. Many people at level 3 (and even levels 2 and 1) will also rationalize that “I’m not an addict (or alcoholic),” and also not address their problems.
4) The term addictive problems respects the reality that across the range of addictive problems there may be different levels of treatment and support intensity, but fundamental similarities also. Someone at level 1 might need residential treatment while someone at level 4 might need only brief psychotherapy. However, the fundamental activities of change (maintain motivation, cope with urges, address and resolve related problems, live a more balanced life, improve my relationships, and develop greater meaning and purpose in life) are typically the same.
5) The term addictive problems also respects the reality that there are multiple pathways for change. The terms addict, alcoholic, and substance use disorder tend to point to one pathway, a disease-oriented, 12-step approach to change. However, a substantial percentage of individuals resolve addictive problems without seeking any outside support or services, or if they do, they do not use the traditional approach.
In short, the term addictive problems is more inclusive, less stigmatizing, and more likely to encourage someone to seek support and services (because they would not immediately be agreeing to an unwanted approach to change). Even if someone does not seek outside help, with the term addictive problems they are more likely to address these problems rather than rationalizing “I’m not that bad.” Addictive problems should replace, for most people, the terms addict, alcoholic, and substance use disorder (SUD).
SUD’s should be diagnosed only by professionals. Even though anyone can read the criteria, it requires extensive training and experience to apply them accurately (as the diagnostic manual states). However, nearly anyone can identify some level of addictive problems, and realize they are worth addressing.
If someone has freely chosen the term addict or alcoholic, and it is useful to them, their chosen language about addictive problems should not be argued with. There are many roads out of addictive problems. The term addictive problems is particularly helpful in getting someone started on the road to change. How they move forward after that should be respected.
Part 2 of this 2-part series on improving our language about addictive problems will focus on replacing the term “recovery.”
If you or a loved one are interested in receiving cutting-edge care for addictive problems, give us a call. We’re not just improving our language about addictive problems, we’re providing leading-edge care that treats the whole person, not just the symptoms.