Is it addiction or dependence?

“Born Addicted: The Number of Opioid Addicted Babies is Soaring,” reads the headline of a recent news story on the dramatic increase in babies born afflicted by neonatal abstinence syndrome. It’s great that media outlets are reporting on the important public health issue of the national opioid crisis, but its terminology is not accurate. Babies cannot be born addicted.

Unfortunately, there is often confusion regarding certain terms describing addiction, and such confusion can exacerbate widespread stigma.

Some of this confusion began in 1987, when the Diagnostic and Statistical Manual of Mental Disorders (DSM) was being revised, and clinicians and non-clinicians disagreed about diagnosing compulsive, uncontrolled, drug use. Clinicians were in favor of calling the disorder ‘addiction’ or ‘addictive disorder.’ Non-clinicians were vocally opposed, arguing that such terminology is “pejorative and would lead to alienation of the patients whom we want to help;” they advocated for using the term ‘dependence’ as a more neutral diagnosis. But the clinicians pointed out that ‘dependence’ was already used to describe another completely different condition.

Specifically, ‘dependence’ described a naturally developed tolerance to substances and medications, including opioids, whether they be legal or illegal, and exhibiting symptoms of withdrawal upon discontinued use. Despite the obvious conflict, ‘dependence’ was formally used to describe both drug tolerance and uncontrollable drug use in the DSM-III-R.

Unsurprisingly, confusion soon followed. Educators and physicians encountered problems when describing addiction to students and patients. Some attempts, albeit misleading, were made to distinguish between the two ‘dependences.’ ‘Physical dependence’ or ‘physiological dependence’ was coined for the natural tolerance to drugs affecting the nervous system, and ‘dependence’ reserved for compulsive, uncontrollable drug use. This distinction in terminology, however, was lost on many who used or heard the terms.

The DSM-5, published in 2013, attempted to assuage the confusion. ‘Substance use disorder’ is now the accepted term to describe what is commonly referred to as addiction, leaving dependence as the term to describe the physical tolerance that develops to alcohol and drugs, including opioids. 

With the appropriate vocabulary arsenal we can now return to the problematic “addicted babies” headline. Neonatal Abstinence Syndrome is a group of medical complications that affect newborn babies when the mother has used addictive opiate drugs during pregnancy.  This exposure results in infants sometimes being born in withdrawal. If untreated, the babies, exhibit a number of symptoms like excessive crying, diarrhea, vomiting, and irritability, among others. Fortunately, treatment for a few days to weeks eliminates these symptoms. The accurate terminology for these babies is that they are born dependent or in withdrawal, not addicted. An infant, cannot exhibit the uncontrollable, compulsive drug use that defines an addiction. Calling babies addicted feeds into the stigma surrounding addiction and can dissuade pregnant mothers who suffer from substance use disorder from seeking necessary care.

Like all language, how we talk about these issues will likely continue to evolve. But words matter. A precise vocabulary is critically important when engaging individuals afflicted by addiction, as well as correcting discriminatory attitudes and biases.