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What's in a word? Definitions and interpretations of terms commonly used to describe substance use issues.

Dear Editor,

Professionals in the field of addictions treatment have long debated the terms used to describe addictions and persons with addiction issues and calls for clarity in language have been made (Fainsinger, Thai, Frank, & Fergusson, 2006; Walters & Gilbert, 2000). While some professionals prefer to use terms such as addict or alcoholic, others prefer the use of criteria-based terms such as substance abuser or substance dependent person. The release of DSM 5 has added to this debate with the introduction of the term substance use disorders (American Psychiatric Association, 2013) rather than substance abuse or dependence.

Tantamount to this debate is the issue of respect for persons suffering from issues with alcohol and drugs. Some contend that terms such as substance abuser, drug abuser, and alcohol abuser are pejorative and/or imprecise and therefore not useful (Kelly 2004; Miller, 2006). Other authors make similar assertions about terms such as addict, addiction, alcoholic, and alcoholism (Erickson, 2008; Erickson & Wilcox, 2006; Streltzer, Sullivan, & Johnson, 2006; Walters & Gilbert, 2000). Based on the existing body of literature, the authors decided to further examine the terminology debate.

The purpose of the study was to assess how participants define and interpret common terms used in the substance abuse and addictions treatment field. For consistency, the phrase "alcohol and other drug problems" (AODP) will be used in this article to describe terms associated with substance abuse and addiction. Qualitative and quantitative data survey methodologies were employed in the study. The study was designed to be exploratory rather than confirmatory in nature with the overall goal of encouraging further professional discourse, promoting preliminary theory, and developing hypotheses for future study. Because of the changing and emerging nature of the terminology debate, these methods were seen as particularly appropriate for the current study.

Potential participants were invited to take part in the study via email. Participants submitted their responses anonymously via an online survey. Data were aggregated so that the researchers were not able to individually identify participants. In addition to the initial email requests, snowballing data collection techniques were used. Each person who received the email request was asked to forward the study invitation to persons with whom they had either a personal or professional relationship. This process was not tracked by the researchers so the number of surveys actually distributed is unknown.

To collect data, the first author created the Drug and Alcohol Opinion Questionnaire (DAOQ). The DAOQ consists of nine questions assessing participants' definitions, opinions, and reactions to terms commonly used to describe AODP. Four of the questions were multiple-choice, of which two items were demographic prompts (i.e., gender and profession). The third multiple-choice question assessed participants' self reports of how much they knew about (a) drug and alcohol treatment, (b) drug and alcohol disorders, (c) types of drugs, (d) effects of drugs and alcohol and (e) effects of drugs and alcohol on families. Participants ranked their responses on a four-point Likert scale with 1 = very familiar, 2 = familiar, 3 = unfamiliar and 4 = very unfamiliar. Because the DAOQ was designed as an exploratory instrument it was not standardized nor were reliability or validity examined.

The final multiple choice question was a five-point Likert scale item asking participants to rank their perceptions of the following terms: (a) addict, (b) alcoholic, (c) substance abuser, (d) problem drinker, (e) addiction, (f) substance dependence and (g) person with a substance abuse problem. Scoring for the scale was 1 = extremely negative, 2 = negative, 3 = neutral, 4 = positive and 5 = extremely positive. The term substance use disorder was not included because of its newness in the field with the publication of DSM 5 (APA, 2013).

The remaining five questions on the DAOQ were openended. In these questions, participants were asked to define five terms in their own words. These terms were: (a) addiction, (b) substance abuse, (c) addict, (d) substance abuser and (e) person with a substance abuse problem. No word limit was placed on participants' responses. Again, the term substance use disorder was not included.

Through both qualitative and simple quantitative analysis the authors were able to glean several interesting findings from the data. The quantitative portion of this study was primarily used to gamer a quick view of participants' perceptions of the terms outlined in the DAOQ. The results, therefore, communicate a description of the sample and offer a brief overview on participants' familiarity with and opinions about the terms presented.

The gathering and analysis of qualitative data was the main focus in this study. The first step in our qualitative analyses involved open coding. The open coding procedure consisted of category construction, sorting data and category refinement. Following initial "analytic leads" the identification of categories was developed through an iterative process, which involved multiple coders. The processes culminated by identifying categories present in the data.

Sixty-four females and 32 males participated in the study. Another four participants did not identify a gender. Information on participants' occupations is presented in Table 1. Additionally, information on participants' self-reports about their knowledge of the terms presented in the DAOQ is presented in Table 2. Lastly, participants' responses concerning their perceptions of terms included in the DAOQ are presented in Table 3.

For the qualitative portion of the DAOQ, results were divided into five subsections. These were (a) addiction, (b) substance abuse, (c) addict, (d) substance abuser and (e) person with a substance abuse problem. Results of the qualitative analysis are outlined below. Based on this analysis, qualitative data emerged into two categories: (a) definition and (b) consequence.

To begin, participants defined addiction in a general way, using terms like "substance" (n = 31) followed by "something" (n = 21). Some participants used more specific language in defining addiction including "drugs" (n = 18), "behavior or activity" (n = 16), "alcohol" (n = 15), "food" (n = 5), "sex" (n = 3), "exercise", "nicotine", "shopping" and "work" (n = 2), "social media", "relationships" and "chaos" (n = 1). In regard to the consequence of addiction, participants used a variety of language. The most common terms used to articulate the consequences related to addiction were "need", "urge", "craving", "obsession", "habit" (n = 24), followed by "lack of control" (n = 15), "negative impact" (n = 13), "withdrawal" (n = 5), "lack of willpower" and "coping" (n = 4). A few participants included the consequences "tolerance," "lack of logic and rationality" and "interferes in relationships and responsibilities" (n = 3).

Participants defined the term substance abuse in many ways. The most frequent definition was the general term "substance" (n = 38). Other participants were more specific in their definition and noted "drugs" (n = 23) and "alcohol" (n = 19). Though still broad categories, some participants added additional specificity: "chemical" (n = 5), "product" (n = 3), "cigarettes" (n = 1), "crack/cocaine" (n = 2), "LSD" (n = 1) and "heroin" (n =1). Interestingly, a few participants suggested the definition include "legal versus illegal" (n = 4), "food" (n = 1), "caffeine" (n = 1), "something" (n = 2), and "prescription and over the counter medication" (n = 2). Participants defined the consequence of substance abuse as "harm to self' (e.g., physical, emotional) (n = 26), followed by "excessive or overuse" (n = 14), "harm to others" (e.g., school, work, family) (n = 13), "misuse" (n = 8), "uncontrollable use" (n = 8) and "safety concerns" (n = 2).

Participants used a variety of terms to define addict. Many participants used the general term "substance" (n = 27). Several participants included more specific terms including "drugs" (n = 16), "alcohol" (n = 11), "nicotine" (n = 3), "chemical" (n = 2) and "pornography" (n = 1). Few participants used the term "something" (n = 6) to refer to substance. In addition, some participants identified that the substance could be a "behavior" (n = 8) or "activity" (n = 7). Some additional examples include "gambling" (n = 1), "shopping" (n = 1) and "eating" (n = 1). Participants defined the consequence of the term addict as an "inability to control use" (n = 16). Further, participants defined consequences as "physical" (n = 13) and several as "psychological" (n = 11). In addition, consequences included "inability to function without a substance" (n--8), "dependence" (n = 4) and "negative impact" (n = 3). A few participants indicated the "need for an intervention to recover" (n = 2), defined an addict as "feeling powerless" (n = 1) and "coping with life" (n = 1).

Participants primarily defined the substance abuser category using the general term "substance" (n = 32). Some participants were more specific in their definitions and said "drugs" (n = 17), with some distinguishing between "illegal and legal" (n = 2). In addition, participants specified "alcohol" (n = 11) and "nicotine" (n= 1). Some participants' definitions were more global and general: "something" (n = 3), "behavior" (n = 2) and "product" (n = 3). In defining the consequence of the term, many participants defined it as "excessive use" (n = 17) and "creating harm to self' (n = 15). To a lesser degree, participants' definitions included "harm to others" (n = 8), "altered mental state" (n = 5) and having an "overall negative impact" (n = 5). Further, participants included "legal versus illegal" (n = 2), "negative consequences" (n = 2), "impact of functioning at work and school" (n = 2) and "a crutch" (n = 1).

The majority of participant responses defined the term person with a substance abuse problem in a general way, directly using the term "substance" (n = 19). Many participants provided more specific definitions that included "drugs" (n = 13), "alcohol" (n = 11), "huffing" (n = 1), "pills" (n = 1) and "nicotine" (n =1). One person defined the substance as a "behavior" or "product." Participants defined the consequence associated with this term as "negative" (n = 7), "lack of control" (n = 7) and "excessive use" (n = 5). Further, some participants indicated "harm to self' (n = 4), "having impact on others" (n = 3), "impact on job" (n = 2) and "leading to avoidance" (n = 1). Few individuals included "a need for counseling" (n = 2).

Moving to a discussion of these results, the purpose of this study was to explore participants' views of terminology used in the AODP field and the types of meanings drawn from these often-used terms. The study was exploratory in nature with the overall goal of establishing a preliminary theory and developing hypotheses for further study. Based on data analysis, it is concluded that a lack of clarity does indeed exist regarding the terms used to describe AODP. Descriptive quantitative and qualitative results indicated that very few distinctions were made by participants between the terms included in the study, specifically regarding term definition or consequence of use. In other words, significant overlap existed between the definitions provided for each of the terms and a lack of specificity was evident. Pursuant to this, several interesting results emerged during data analysis and therefore warrant further discussion.

From the inductive qualitative data analyses conducted in this study, patterns of meaning evident in participants' responses emerged and were classified into the categories of definition and consequence. Across definitions, many participants used general terms to define "substance." Across the category of "consequence", participants indicated that consequences were negative and broad, including harm to self and others, overall functioning in daily life and lack of control.

Common descriptors across the terms that participants were asked to define suggest a blended understanding and lack of distinction between definitional constructs. However, while some of the same terms were used to construct definitions (e.g., substance), they were used with variable frequency. For example, the general term "something" was used by participants in the definition category for both addiction and substance abuse. For addiction, the term was used by 21 participants. In contrast, for substance abuse, it was only used twice. This suggests that participants' meaning might be influenced by the phrasing of the question (i.e., a prompt to define substance abuse may illicit a circular definition) or their perception of the severity of the term. In addition, while "substance", "something", "drugs" and "alcohol" were commonly used within the definition category, participants included a vast array of concepts within these definitions. These included concepts such as activity, behavior, chemical, product, food, sex, exercise, shopping, work, social media, gambling, pornography and relationships.

Across the five terms examined in this study, participants noted consequences to varying degrees for each term. Examples here include "lack of control" and "harm to self and others." Within the five terms, two speak more to the actual diagnosis and phenomena (i.e., substance abuse and addiction), where three of the terms speak to individuals (i.e., person with a substance abuse problem, addict and substance abuser). Some participants recognized this distinction as evidenced by the definitions they provided. For example, participants noted "needed counseling" in their definitions for a person with a substance abuse problem and an addict. Humanistic ideas, such as coping with life, harm and avoidance were present in the results associated with the terms addict, substance abuser and a person with a substance abuse problem to a greater degree or with greater frequency than addict and substance abuse which focused more on the negative impact of use and continued use.

Although interesting, results of this study may be limited by several methodological issues. Results of the study should therefore be interpreted with caution. First, non-random sampling methods were employed in the study. The fact that all participants were volunteers may have led to bias in the study results. Results of the study may also be limited by a possible lack of diversity in the sample, although this is speculation as the authors did not gather information across demographics of diversity. While these limitations are important to note, they may be less pertinent because of the exploratory nature of the study. Still, it is recommended that future confirmatory studies utilize data sets that articulate differences within and between participants' backgrounds.

Based on the results of this study, the authors concluded that further research in the area of terminology in the AODP field is needed. While few differences between terms examined in this study were identified, the clinical and lay connotations associated with each of the terms may lead to different types of biases. Bias relative to each of these terms can certainly have impact on the types of services recommended for potential clients, interactions with family and friends, professional status and other areas of life. It is therefore incumbent on researchers and professionals in the AODP field to promote language resulting in the least amount of negative impact for persons suffering from substance use issues. This exploratory study provides a base for future research in this area.

Jeremy M. Linton, PhD, Associate Professor of Counseling and Human Services

Joseph A. Campbell, PhD, Assistant Professor of Counseling and Human Services

Julia Gressick PhD, Assistant Professor of Instructional Technology, Indiana University South Bend

REFERENCES

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders 5. Washington, DC: Author.

Erickson, C. (2008). In defense of dependence. Alcoholism: Clinical and Experimental Research, 32(1), 1-3.

Erickson, C., & Wilcox, R. (2006). Please, not addiction in DSM-V. American Journal of Psychiatry, 163, 2015.

Fainsinger, R., Thai, V., Frank, G., & Fergusson, J. (2006). What's in a word? Addiction versus dependence in DSM-V. American Journal of Psychiatry, 163, 2015.

Kelly, J. F. (2004). Toward an addiction-ary: A proposal for more precise terminology. Alcoholism Treatment Quarterly, 22(2), 79-87)

Miller, S. (2006). Language and addiction. American Journal of Psychiatry, 163, 2015.

Streltzer, J., Sullivan, C., & Johnson, B. (2006). Addiction versus dependence in pain management. American Journal of Psychiatry, 163, 2016.

Walters, G., & Gilbert, A. (2000). Defining addiction: Contrasting views of clients and experts. Addiction Research, 5(3), 211-220.
TABLE 1
Participants' Professional Backgrounds

Profession                                         Frequency

Full-time student                                     14
Part-time Student                                      4
K-12 educator                                          3
K-12 administrator                                     1
K-12 student services                                  1
Professor or instructor of higher education           26
Student services in higher education                   9
All other higher education employees                  17
Substance abuse professional                           2
Licensed counselor, social worker, marriage and        3
  family therapist
Other social services professional                     2
Skilled trades and labor                               1
Private business                                       1
Non-profit business                                    1
Employed in the home                                   1
Volunteer                                              2
Unemployed                                             2
Other                                                  9

TABLE 2
Participants' Familiarity with Terms and Concepts

                    Very                                 Very
Terms              Familiar   Familiar   Unfamiliar   Unfamiliar

Drug and Alcohol
  Treatment           22         47          23           5
Drug and Alcohol
  Disorders           24         56          14           3
Types of Drugs        24         50          19           4
Effects of Drugs
  and Alcohol         40         52          5            1
Effects of Drugs
  and Alcohol         42         49          5            1
  on Families

TABLE 3
Perceptions of Terms

Term                                     Extremely   Negative   Neutral
                                         Negative

Addict                                      23          46        10
Alcoholic                                   21          47        12
Substance abuser                            15          54        13
Problem drinker                             14          57        10
Addiction                                   15          44        22
Substance dependence                        16          45        20
Person with a substance abuse problem       10          48        23

Term                                     Positive   Extremely
                                                    Positive

Addict                                      2           0
Alcoholic                                   2           0
Substance abuser                            0           0
Problem drinker                             1           0
Addiction                                   1           0
Substance dependence                        1           0
Person with a substance abuse problem       1           0
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Article Details
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Author:Linton, Jeremy M.; Campbell, Joseph A.; Gressick, Julia
Publication:Journal of Alcohol & Drug Education
Article Type:Letter to the editor
Date:Apr 1, 2016
Words:2790
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