Valid, Reproducible, Clinically Useful, Nonstigmatizing Terminology for the Disease and Its Treatment: Addiction, Substance Use Disorder, and Medication

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There is no need for or place in scientific discourse for assuming the motives of those who write in and edit the Journal. In his letter in this issue of the Journal, Hajela makes an assumption that “colleagues (readers), authors, reviewers, and editors of [the Journal]” have not been “diligent with accuracy and terminology (Hajela, in press).” That assumption could not be farther from the truth. The Editor has not only published editorials and letters on the subject (Saitz, 2015; Saitz, 2016a), he has also led an American Society of Addiction Medicine (ASAM) policy statement on the topic (ASAM, 2013), led an internationally approved statement regarding the use of stigmatizing language (eg, “abuse” and disease first language such as “addict) (Saitz, 2016b),” and added and implemented guidance for authors who write for the Journal (Instructions and Guidelines, 2017), all with broad consensus (Broyles et al., 2014; Botticelli and Koh, 2016).
Hajela also incorrectly states that the Journal focuses on (what he terms) maintenance medications. In fact, only 1 in 5 original research articles published in the Journal in 2016 was on any medication treatment; one could make the case that we should publish more on the topic, given its proven efficacy in placebo-controlled randomized trials (out of proportion to the level of evidence for improving specified outcomes of importance to patients than many other treatments).
The fact that it has been difficult to detect a benefit of counseling in randomized trials that add counseling (or levels of intensity of counseling) to opioid agonist treatments for opioid use disorder is not the main issue here (Carroll and Weiss, 2016; Schwartz, 2016). Moreover, Wakeman, 2017 addresses the strong rationale for why medication as a treatment for substance use disorder should be called, simply, medication, or medication treatment, or medication for addiction treatment for those wedded to the acronym MAT. Medication is a treatment. Counseling is a treatment. We don’t call it “counseling-assisted pharmacotherapy” (Friedmann and Schwartz, 2012).
What is the main issue is a looseness of terminology reflected in Hajela's letter that is far from what is useful for clinical science and practice. The ASAM definition of addiction is certainly based on the latest scientific understanding of the disease conceptually (American Society of Addiction Medicine, 2011), though many argue vehemently against the chronic brain disease concept and the consequences of viewing the disease through that lens (Satel and Lilienfeld, 2013; Hall et al., 2015). Regardless of that controversy, from a practical perspective, there are no studies of addiction treatment or prognosis that use a validated method of diagnosis of “addiction,” so that results could actually be applied to people with the disease [eg, see US Food and Drug Administration (FDA) indications for treatments—they are invariably indicated for Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses (American Psychiatric Association, 2013), because that accurately and reliably describes the patients in whom the treatments were tested]. This fact substantially limits the clinical and research utility of the term “addiction.” Researchers could develop tools to validly and reliably measure addiction and apply them, but it just has not happened yet.
On the contrary, what we know about the efficacy of treatments (psychosocial, medication, and otherwise) and prognosis is largely based on high-quality studies that carefully and accurately diagnose patients using validated reproducible tools, an effort which anyone interested in accuracy, terminology, and patient outcomes would necessarily support. Like it or not, these diagnoses are based on the DSM [and in other countries, the International Classification of Diseases (World Health Organization, 1992)]. Hajela points out that the DSM-5 relies on observable behaviors that result from an underlying disease process.
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