The Reply

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I appreciate the response to my commentary on the importance of language when discussing medications for addiction treatment (Wakeman, 2017). The letter writer argues that describing individuals with addiction as people with a substance use disorder is a “totally inaccurate statement.” His reasoning for this is that the term substance use disorder is a Diagnostic and Statistical Manual of Mental Disorders 5 classification that does not fully encompass the American Society of Addiction Medicine definition of addiction. He highlights the fact that substance use is a behavior and a symptom of the broader disease of addiction. While these are interesting points, for better or worse, Diagnostic and Statistical Manual of Mental Disorders 5 is the diagnostic tool we have for identifying people with substance-related problems including addiction. The American Society of Addiction Medicine definition offers a more holistic and possibly more accurate description of addiction; however, it has yet to be operationalized and cannot currently be measured with validated clinical tools.
The author goes on to recommend the term “Medication Assisted Recovery” to refer to the use of pharmacotherapy for the treatment of addiction. His reasoning is that successful treatment for addiction requires a “biological, psychological, social, and spiritual approach, which emphasizes recovery.” Such a patient-centered biopsychosocial approach is necessary not just in Addiction Medicine, but also in caring for any chronic illness (McInerney, 2015). And yet for no other illness do we discuss treatment with reference to the desired outcome. For example, we do not call chemotherapy “medication for cancer remission.”
There has been tremendous effort around the need for parity related to addiction. This includes parity for how patients with this illness are treated, for insurance coverage of care, and for the very field of addiction medicine. If we truly believe that addiction is a disease like any other, language for its treatments ought to align with those for other medical conditions. Names of medical therapies do not explicitly refer to the existence or benefit of other interventions. The relentless insistence on diminishing the role of medication in the treatment of opioid addiction through the very words we use is damaging and arguably deadly. It is also not based in science. The unanswered question is not whether medication management alone is effective to treat opioid addiction, but rather whether there is additional benefit to psychosocial intervention (Schwartz, 2016). A wonderful piece by Dr Walter Ling highlights many of these issues. In reference to the focus on psychosocial interventions in conjunction with pharmacotherapy, Dr Ling writes:
No other medication has been approved for use in any other patient population with [psychosocial counseling] requirements. What does that tell you about the attitude of those in control toward these patients and toward the physicians who treat them? It was argued that the reason for the psychosocial support requirement was that psychosocial conditions were part of the reported clinical trials that led to FDA approval. Does anyone really believe that cardiovascular and cancer trials are conducted without psychosocial support and therefore no such support is required by stipulation for their use? Several years ago we undertook a study in which... added psychosocial treatment had produced no added benefits... We were told that the usual medical care provided in the trial was too effective to allow the therapeutic benefits of these other treatments, required as a matter of policy, to come through. What are we saying, really? (Ling, 2016).
Lastly, and perhaps more controversially, recovery or remission may be an ideal goal, but it is not always desired or attainable.
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