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. In the practice of medicine for accurate diagnosis, prognosis, and treatment, we must rely on such manifestations of disease (eg, blood sugar in diabetes, affective symptoms for depression, where those manifestations are not direct measures of an underlying pathophysiologic process such as metabolic derangements or neurotransmitter imbalance). Although we rely on such tools for diagnosing classic medical diseases (eg, enzyme levels to surmise that a myocardial infarction has occurred), this reliance is especially true in mental (including substance use) disorders and is in part the rationale for the pursuit by the National Institute of Mental Health of Research Domain Criteria (National Institutes of Mental Health, 2017).
But for clinical practice, we need to use the best validated tools we have now, even while more conceptual terms (eg, addiction) inform our thinking about the disease. We have a long way to go to better and more accurately define and diagnose substance use disorders and its (likely many) subtypes that have different prognoses and treatments. In fact, our inability to do so, to date, likely accounts for why many treatments have such modest efficacy (with the possible exception of opioid agonist treatments that target a disorder that has a specific manifestation that we can reliably diagnose—compulsive use of opioids as defined reliably by applying DSM criteria).
Hajela understandably contributes to confusion surrounding the DSM-5 and the term addiction by stating that the DSM-5 classification does not refer to the disease of addiction; this confusion was recognized by DSM-5 authors. With the development of the latest version of the DSM, some (including National Institutes of Health directors; O’Brien et al., 2006) recommended the use of the term “addiction” to in fact mean substance use disorder. The DSM-5 states that “some clinicians will choose to use the word addiction to describe more extreme presentations,” and that “substance use disorder is used to describe the wide range of the disorder, from a mild form to a severe state of chronically relapsing, compulsive drug taking.” “The word is omitted from the official DSM-5 … because of its uncertain definition and its potentially negative connotation (American Psychiatric Association, 2013, p. 485).” Thus, not only do some clinicians use addiction to mean DSM-5 substance use disorder, the term addiction almost became a DSM-5 term for the disease, but for 1 committee member vote (O’Brien et al., 2006). Thus, the term addiction certainly has its place—defining the disease conceptually, and as a term, shorter than substance use disorder (and thus favored by journalists and clinicians alike), that refers to the disease and even the specialty (addiction medicine)—so long as users of the term state whether they mean ASAM's definition or whether they’re using it to refer to the full spectrum of the DSM-5 diagnosis or only to the severe end of the spectrum. What the term addiction is not yet useful for is for studying treatment efficacy and prognosis and applying research results to clinical practice.
For a specialty and condition to become part of mainstream medicine, a goal widely shared by many in the field of addiction medicine and by our patients desperate to have their illness treated, it is time to be diligent and demand the use of accurate, reproducible, clinically applicable, and definable terms that have a basis in science and minimize stigma. Use of such terms is a prerequisite for determining which treatments have efficacy (and which constitute “full” treatment versus adding no measurable benefit) and should therefore be offered to patients, and for informing us about prognosis (one cannot have a prognosis without a diagnosis). Hopefully these are goals with which all can agree.
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