I'm going to change tracks a little bit. So as we've put together this course, there's actually been a lot of debate about the use of the term addiction. We have very differing ideas. And we thought it would be really kind of fun or interesting to let the students know about that debate and the differing opinions around that. And so I am actually going to ask a Rob to get started. >> Probably asked me to get started because I was very vocal about my concern about the use of the word addiction as the overall guiding idea for the course. My concern about it is that the word addiction itself is I think at times stigmatizing. When patients use the word addict or addiction, it often it in itself comes with extremely negative connotations. That I am unable to change. I'm powerless over my addiction, as AA might say. And so I think that even the DSM has refrained from using that term anymore and prefers instead substance use disorder, specifically to avoid that kind of stigmatizing pejorative language. So I think that was the biggest part of my concern. >> Was the stigma surrounding it. >> The stigma surrounding it. And perhaps also I think that the word addiction might be too limiting and too focused on a particular. I think it is has again the connotation of a reductionist, biologically driven understanding of a process. Where I think that we, in general, would like to think of it in a broader context. That it isn't simply a problem that's located within an individual person, but it's a social and cultural problem as well. And that context is important for how that manifests itself. And the word addiction seems to, I think, make it very individualized. >> So kind of makes everything small for a very complex problem. >> Very complex thing. It makes it small and puts the onus of the problem on the individual and not on the social context where it presents itself. >> I have another problem with the word addiction and that is that we often conflate the word addiction with with drug use in general. And there are lots of people who use drugs who don't need addiction or substance use treatment services. Who are then, because of the confusion of use and addiction, are forced into treatment that they neither want nor would benefit from. >> Right. >> Robert can you expound? I want you to be very clear about this to our audience. Can you just give us an example? >> Sure, and all of these things have shades of gray. But vast numbers of people are mandated to get treatment for marijuana when there's probably no need for it. People who's problems with drugs are only that they've run afoul of the law. And not that it's, other than that it's not causing them any social problems. Are forced into treatment programs that if they fail, they are going to be harshly penalized for. And none of that makes any sense from the standpoint of social benefit. From the broader point of view criminalizing people, putting them in jail, breaking up families, is incredibly destructive. And we've destroyed whole communities by doing that. And if we continue to do that, the price to pay is the continued disenfranchisement of large swaths of the American public for reasons that have nothing to do with evidence, science, or medicine. >> So and and also in an addiction, we have such a scarcity of resources. It's a waste to treat people who don't actually have a diagnosis. >> Yeah, [LAUGH]. >> I think this got to one of the questions that I recall us thinking about. If substance use disorder sort of is across a spectrum from low, moderate, to severe. And addiction sort of has the image of more of the severe substance use disorder. I don't know that that's right or wrong. But in some ways it does, I think you're saying that creates a particular image of a severity that doesn't capture the full spectrum. >> And there's even drug use that is not disordered in any way shape or form, but is in fact individually therapeutic. Some of which is allowed by law, the cocktail we have at night to relax or the whatever else is legal these days depending where you are. [LAUGH] But certainly even the use of some of the stronger drugs may have medically valid purposes for which people can't get prescriptions for them. And use them at their peril, but are not doing themselves or their community any harm. >> I totally agree with this conversation, I guess. And I 100% agree with Rob about the term addict, right? And we should never define a person by their disease, or by their substance use, or anything. So avoiding the word diabetic and cirrhotic and- >> Schizophrenic. >> Schizophrenic, exactly, thank you. You saw me struggling there with finding the word. So I totally agree with that. I guess in my mind addiction as defined really captures the idea of loss of control. Which I think is an important term in contradistinction to substance use disorder, which is very diagnostic right? There are specific criteria you have to meet, there's levels of severity. And quite frankly, there's differences in the way your substance use disorder presents, where you are in your recovery or your treatment. And addiction is a term that allows for a little bit more colloquial conversation. So that's why I've been a proponent of keeping it. Because I think, while I agree that there are some clearly stigmatizing ways the term can be used, if used appropriately it sort of gets at that loss of control piece. Which I think, in my mind, really spans between those folks who are using substances in either a periodic or an unhealthy way but not necessarily meeting a substance use disorder. Once they start losing control, that's when we're starting to slip into that really concerning area where I think all of us would agree treatment of some form is necessary. >> Thank you. And I think I won't add to that because that's kind of been my opinion as well. But what I'm hearing is that there's an enormous amount of stigma. That certainly some words that we use are very stigmatizing, like addict. Used in certain ways addiction can be stigmatizing. Sometimes it kind of pigeonholes people. And it doesn't distinguish between the continuum of a substance use disorder, nor does it allow for the difference between substance use and a loss of control or an actual substance use disorder or diagnosis.
