The Use and Misuse of Language by Addiction Counselors, Part III
This is the final column in a three-part series examining language and the correct and incorrect uses of terms related to addiction treatment.
“Last Use” (of a Substance)
This term is included because of the frequency with which it is calculated inadequately when performing a substance use assessment. Most frequently, information in assessment section of clinical records pertaining to recent use of substances will list only the day of last use for each substance. However, for substances with short half-lives, it is critical to list the time of day as well as the day of last use. For example, when assessing for potential withdrawal problems in a patient with a severe alcohol use disorder, there is a significant difference between documenting last use of alcohol as yesterday if at 12:01 AM vs. yesterday if at 11:59 PM (twenty-three hours and fifty-eight minutes).
Previously, “impaired driving” commonly referred to a blood alcohol level of 0.08 percent or greater and was often referred to as “drunk driving.” However, the causes of impairment are increasing because of the use of drugs (e.g., opioids, cannabis, benzodiazepines) alone or in combination one another or with alcohol. Since impairment does not begin at 0.08 percent BAC, but with the first use of the substance, it is my opinion that using 0.08 percent BAC to determine impaired use is too high. Driving is considered to be impaired at a low of 0.0 percent in Nepal with other countries in Africa following suit with most countries in the European Union at 0.05 percent and a few at 0.02 percent.
“Mental Health Problems”
This all-encompassing term includes those people who have mild and transitory problems (e.g., grief over loss of the substance in early recovery because of giving up the substance), those with mental health signs and symptoms of insufficient number or severity to meet the diagnostic criteria for a mental health disorder (e.g., subclinical or subthreshold), and those individuals who display sufficient signs and symptoms to meet diagnostic criteria for a mental health disorder.
“Mild,” “Moderate,” and “Severe”
“Mild,” “moderate,” and “severe” refer to levels of severity found with all diagnoses in the DSM-5. For a substance use disorder, “mild” means meeting two or three of the eleven criteria akin to the DSM-IV’s substance abuse diagnosis; “moderate” means meeting four or five of the eleven criteria; and “severe” means meeting six or more of the eleven criteria, akin to the DSM-IV’s substance dependence diagnosis.
A desire or wish to achieve some end. Clinicians sometimes describe patients as “not motivated” because they may not yet wish to stop their substance use. In reality, all patients who present for assessment or treatment are motivated, but they might not be motivated for abstinence or recovery. They may be more likely motivated to avoid imprisonment, retain or regain custody of their children or keep their jobs. These types of motivation can become the pathway to motivation for recovery.
“Opiate” and “Opioid”
Opiates are naturally occurring narcotics (e.g., codeine) while the term opioids refers to both naturally occurring and synthetic narcotics (e.g., oxycodone).
“Premature discharge” is a term usually used to indicate discharge prior to the anticipated time. That time is usually determined by a projected discharge date in a fixed length of service treatment program.
This term has no agreed-upon meaning. It may be used to describe drinking that is not severe enough to reach diagnostic levels and also all levels of pathological use of alcohol without regard to diagnosis. In addition to having no agreed upon definition, it appears to characterize addictive alcohol use as if it is under the individual’s control. Most unfortunately, it is sometimes used to describe a research cohort thereby rendering the findings useless in applicability to an alcohol-disordered population.
Recidivism is a criminal justice term used to describe reoffense, a return to criminal behavior. It should never be used in place of relapse to describe a return to the use of substances. Such use reinforces the perception that substance use disorders are criminal behaviors instead of health care problems. No one would consider using the term “recidivism” to describe a relapse in any other chronic illness (e.g., “recidivism” in diabetes or hypertension).
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), recovery from mental disorders and substance use disorders is “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (2012). It is a process by which people with a substance use disorder achieve remission—meaning they no longer meet diagnostic criteria—and then develop their full potential. People unknowledgeable about addictive disorders or who view substance use disorders as an issue of morality may incorrectly describe this phenomenon as “reform.”
“Recovery” vs. “Discovery”
It is not uncommon for clinicians to try to assist their patients to recover from a disorder with which they do identify and about which they have no understanding and/or acceptance. For such patients, a more appropriate interim goal is “discovery,” first developing the awareness that they have the problem.
“Relapse” refers to a return to the active disease state, as in cancer. With substance use disorders it is usually characterized by out-of-control use and possibly significant negative consequences. Relapse is distinguished from “lapse” which is a brief duration, low consequence return to use, often with a desire to return to abstinence. A lapse is often referred to as a “slip” in Twelve Step recovery terminology.
“Remission” vs. “Recovery”
Remission as used in the DSM, implies that the individual no longer meets the diagnostic criteria for the disorder. Recovery on the other hand, is far more all-encompassing, includes emotional and spiritual growth and for many it means attaining a type of existence not even realized before the onset of the disease. When speaking to utilization reviewers, use the term “remission,” which they are likely to understand, rather than recovery, which they may not.
This is a state of mind characterized by ambivalence about a course of action, which is often used too narrowly to describe opposition to engaging in treatment. We have come to understand from learning theory that behavior which is not reinforced, is not continued. Said another way, whatever the negative consequences of the substance use, the user derives some positive gain. It is important from a treatment perspective to search for those positive gains in order to help the patient find other ways to achieve the pay-offs associated with the substance use. A male might find that the only way he can comfortably talk to or pick up a woman is in an alcohol-connected environment, such as a bar, where both he and the object of his quest are drinking. A female might find that the only way she can get her husband’s attention is by being “sick” (e.g., experiencing problems as a result of her substance use that demands his notice). It is characteristic of Proschaska and DiClemente’s “precontemplation” Stage of Change.
“Signs” vs. Symptoms”
A “symptom” is generally subjective, such as when a patient complains about fatigue or insomnia which can only be detected or sensed by the patient—others only know about it if the patient tells them. A “sign,” on the other hand, is objective as the results of a breathalyzer or tremors and can be recognized by a doctor, a counselor, family members, and the patient.
This is a term used to describe both substance use and substance-induced disorders as defined by the DSM-5. Substance-induced disorders are those caused by the substance use and include intoxication, withdrawal, and mental health disorders.
“Substance Use Disorders”
The term used to describe both substance abuse and substance dependence disorders, as defined by the DSM-IV or substance use disorders of varying severity as defined by the DSM-5. This is discriminated from “substance-related disorders” which includes both “substance use disorders” and “substance-induced disorders.”
“Success” and “Progress”
Treatment success or progress should be defined or measured by a reduction in the severity/intensity, the duration, and the frequency of symptoms rather than the “all or nothing” view of symptoms/no symptoms which is often associated with the concept of “abstinence-based treatment.” For example, if an individual diagnosed with a severe alcohol use disorder, who has been unable to achieve a single twenty-four hour period of abstinence in the three years prior to treatment, was able to achieve a year of abstinence with the exception of a five-day drinking episode in the year following treatment, it would be difficult not to consider this a success, even though the ideal would have been for the patient to have had no drinking days at all. Another example of such success would be the person with schizophrenia who after treatment “still hears voices,” but no longer has to do what the voices tell him to do and does not have to be rehospitalized.
“Tolerance” may be defined as a state of progressively decreased responsiveness to a drug as a result of which a larger dose of the drug is needed to achieve the effect originally obtained by a smaller dose.
The phrase “completing” treatment implies a fixed course of treatment, only applicable to an acute illness. When applied to chronic illness, treatment usually consists of a period of primary treatment followed by the management of the illness to maintain stability (think diabetes). An individual with a chronic illness never completes treatment, since completion implies the illness is not chronic and there is no need to manage the illness after the completion of primary treatment.
This relates to the group of symptoms that occur upon the abrupt discontinuation or decrease in intake of medications, recreational drugs or alcohol to which the individual has developed physiological dependence. Withdrawal is dose dependent and varies based upon the drug consumed. The result of untreated, severe withdrawal to drugs such as alcohol, barbiturates, and benzodiazepines can result in very serious consequences including death. Withdrawal is different from “hangover,” which consists of a constellation of symptoms of toxicity from consuming large amounts of the drug, usually associated with alcohol.
This concludes this three-part column on language. My hope is that they have clarified, explained, simplified, and corrected the language that we as clinicians use every day, and that I have opened our awareness to some new information. We have an opportunity to help people understand that what we deal with on a day-to-day basis is a disease, we can reduce the stigma, and we can further develop a common language.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2012). SAMHSA’s working definition of recovery. Retrieved from http://store.samhsa.gov/shin/content//PEP12-RECDEF/PEP12-RECDEF.pdf