Dr. Joe Cruse stimulated an interest in developing a glossary of terms for the field of psychology in the 80s. It was hoped that a glossary would bring about a commonality, a uniformity of terms, a similarity of meaning in the field, which at the time sounded like "speaking in tongues" -- a virtual Tower of Babel.
As a result, the American Medical Association (AMA) collected about 1,200 terms, and after much effort reduced the list to about 50.1 This was not to be the final word by any stretch of the imagination, but an attempt to create some order out of chaos.
As a clinician who has been confused and confounded by the language of this field for over 30 years, I would like to add a few personal thoughts.
Get rid of the term abuse. It is an absolutely useless, counterproductive term. Is it the same as heavy drinking? Social drinking? Furthermore, how does one abuse alcohol, cocaine or any other drug? Misuse? Maybe. Overuse? No, since the definition of addiction does not have a quantitative component.
Dependence. Is it psychological? Physiological? Is it basically a physiological concept with tolerance and withdrawal? But again, if I drink and exhibit withdrawal, am I dependent? No. Does abuse lead to dependence? Maybe, yes -- maybe, no.
Does dependence equal addiction? Not in my book. In a recent issue of Time magazine: "Dependence is not the same biological phenomenon as addiction."2 In the Harvard Mental Health Letter: "Cigarette smoking and other forms of tobacco use fit the reasonable definition of substance dependence (another term for addiction)."3 I don't think so. Does abuse lead to dependence and then to addiction? Maybe. Certainly not always. No more than fatty liver always leads to cirrhosis.
Whatever happened to the term alcoholism? I do not think alcoholism should be used interchangeably with the term dependence, or used as a quaint colloquialism.
Whatever happened to the word disease? Are we back to the days of Dr. M. Chafetz and, rather than disease, use the word illness or syndrome? Also, is the term addict/addiction becoming lost in today's vocabulary?
What is the meaning of the word moderate? When applied to drinking, is it the same as social, responsible, controlled, disciplined, safe? By whose criteria?
What is the optimal definition of remission? Is it a time factor? Is it quantitative? What is a partial remission -- half drunk? What is an effective program -- an efficient program? By what criteria? What is the meaning of "harm reduction"? To me, it is a smudge term, similar to the center in politics.
If the field of addiction medicine is going to be more intimately linked to dual diagnosis, it is going to need some clear-cut boundaries with regard to language and concepts.
American Society of Addiction Medicine (ASAM) is engaged in raising the level of awareness, as well as the level of education, among professionals. But where is the field? Does the National Institute of Drug Abuse (NIDA) or the National Institute on Alcohol Abuse and Alcoholism (NIAAA) exert true leadership, or do we have a group of individual entities with each group doing its own thing? Is it possible to bring all these various pieces into an integrated whole?
Alcoholism is a disease of addiction, as with cocaine, heroin and other drugs. It is not exactly the same as dependence. Until other terms/issues are clarified, remission means total abstinence of all mind-altering drugs -- unless there is a valid reason for the presence of a drug. For once one has crossed the line -- once the addiction process has taken over -- a gradual loss of control plus an abusive use in spite of adverse circumstances, anything less than total abstinence makes long-term treatment and recovery meaningless. In time, the patient will go back as if he or she never stopped.
Abstinence by itself is in no way to be considered treatment -- but it is what makes treatment possible for the addict.
This seeming cacophony of language, in my opinion, does not help the field internally or externally.
References
Jokichi Takamine is past chairman of the AMA Task Force on Alcoholism and past member of the AMA Task Force on Drugs. He is in private practice in Santa Monica, Calif.
