Substance Abuse, Dependence Becomes Substance Use Disorder
Posted by Dr. Vollmer on January 19, 2016
Substance use disorder, also known as drug use disorder, is a condition in which the use of one or more substances leads to a clinically significant impairment or distress. Although the termsubstance can refer to any physical matter, ‘substance‘ in this context is limited to psychoactive drugs.
DSM 5 changed our language from substance abuse to substance use disorder. Further, the diagnostic system requires that the substances be specified such that the DSM IV diagnosis of “poly substance abuse” has become “opiate use disorder, methamphetamine use disorder, tobacco use disorder and cannabis use disorder.” More specificity in the diagnosis will help big data analyze “population health,” the new buzzword for focusing on trends and not on individuals. I wonder if there is a difference between “heroin use” and “heroin use disorder”. Clearly, outlining the nature of the substances that the patient uses helps us understand the chemical feeling they are seeking. Yet, my experience in working in drug rehabilitation centers is that the majority of patients use all substances available to them including opiates, cannabis, alcohol, meth amphetamines and tobacco. I salute Lance Dodes MD http://www.lancedodes.com/ who says that substance abuse, like so many behaviors, are about self-sabotage, and not so much about the exact chemical that the patient is drawn to. He states, rightly so, that alcohol abuse is not qualitatively different from opiate abuse, but rather they are the result of self-hatred.This matches my clinical experience. If a patient goes from an alcohol use disorder to a gambling disorder, he does not have a new diagnosis, only a new symptom of an old diagnosis, which, in my mind would be a lost self. Rehabilitation centers need to help people love themselves, and how to do this is up for debate. Being tough, setting limits, or giving them understanding and compassion. Both approaches have successes and failures and both approaches do not know who to target and so most programs use a one-size fits all approach to a problem which uniquely develops in each person. In my mind, the diagnoses should be “escape disorder,” to group people together who need to escape from themselves, such that the major challenge is to find out what they are escaping. If they no longer have to escape, the substance will recede in importance. Is this oversimplifying a complex disorder? I do not think so. It is a hard job to find out what the patient is scared to face, and, of course, the pain they are avoiding is layered and often not obvious. Still, if the focus was on the escape and not the drug, there would be more hope. Our diagnostic system is important since it helps patients understand themselves and their family members. To speak in terms of “use disorders” misses the point.