A 15-year-boy presents for an urgent revision of a previous ankle dislocation after falling off his skateboard. His past history is significant for ADHD, and anxiety and ankle surgery 6 months ago. He started using marijuana when he was 13, and misused his opioid prescription after his previous surgery. He is very concerned about postoperative pain management and states that he had significant pain after his last surgery. On his way back to the OR he admits to using opioids or “whatever he can get his hands on” daily since that surgery, and that he seems to need higher and higher doses. He reports having tried to stop without success and is worried about withdrawal.
Which of the following terms best describes his probable current diagnosis?
The patient’s symptoms fit with a possible diagnosis of substance use disorder. A mental health professional such a psychiatrist would need to formally make the diagnosis and get further history to confirm that the patient meets the criticeria for substance use disorder. The term addict, drug addict or even drug abuser assumes moralistic and judgmental connotation. There is blame, shame and stereotyping, even though increased medical and scientific evidence reveals that addiction is a chronic disease with remission, recurrence and relapse. The public already holds highly stigmatizing views regarding people with SUD; these attitudes as well as those help by the patients themselves can prevent individuals from seeking help, in particular adolescents and young adults 4. The DSM V specifically uses the terminology substance (or specific drug such as opioid) use disorder in contrast to previous editions of the DSM.
The DSM V criteria for substance use disorder is as follows1,2,3 :
1. Taking the substance in larger amounts or for longer than you're meant to.
2. Wanting to cut down or stop using the substance but not managing to.
3. Spending a lot of time getting, using, or recovering from use of the substance.
4. Cravings and urges to use the substance.
5. Not managing to do what you should at work, home, or school because of substance use.
6. Continuing to use, even when it causes problems in relationships.
7. Giving up important social, occupational, or recreational activities because of substance use.
8. Using substances again and again, even when it puts you in danger.
9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.
10. Needing more of the substance to get the effect you want (tolerance).
11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.
We will and do see patients’ with SUD in the operating room, acute pain and chronic pain environments, and avoiding the use of problematic language can make a real difference in patients’ experience and improve compassionate care. The American Academy of Pediatric recently published a paper on the use of the recommended terminology in the care of children, adolescents, young adults and their families 5. There is an incredibly helpful table that makes it easy to appreciate which terms are preferred and why those terms should be used. https://doi.org/10.1542/peds.2022-057529
1. McLellan AT. Substance misuse and substance use disorders: Why do they matter in healthcare?. Trans Am Clin Climatol Assoc. 2017;128:112-130.
3. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders 5th ed. Arlington, VA 2013
4. Hadland S et.al. Stigma Associated with Opioid Use Disorder in young Adults: A Case Series. Addict Sci Clin Pract 2018, 13: 15 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5937046/
5. Alinsky RH et.al. Recommended Terminology for Substance Use Disorders in the Care of Children, Adolescents, Young Adults and Families. Pediatrics.2022: 149 (6) https://publications.aap.org/pediatrics/article/149/6/e2022057529/188090/Recommended-Terminology-for-Substance-Use?autologincheck=redirected