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I I I I I I I I I I I I I I ~ I I Preliminary Communication Clarification and Standardization of Substance Abuse Terminology flobert C. Rinaldi, PhD, Emanual M. Steindler. MS; Bonnie B. Wilford: pesiree Goodwin, MPA A four-stage Delphi survey of substance abuse ecperts was conducted to help achieve greater clarity and uniformity in terminology associated with alcohol and other drug-related problems. This multidisciplinary group of experts was asked to reach a consensus on alcohol and other drug-related terms and definitrons. Results produced a list of 50 substance abuse terms deemed important, along with the most agreed on definition for each term. (JAMA iNSZ-9-.sassa7) IN AUGUST 1983, the American Med- ical Associations (AMA's) Council on Scientific Affairs' Panels on Alcoholism and Drug Abuse considered the need for providing greater clarity and uni- formity in the terminology associated with substance abuse disorders. It was recommended that a task force be es- tablished to develop standard defini- tions . Once constituted, the Task Force de- termined to collect data from a cross- disciplinary group of researchers, clini- cians, administrators, and academicians in the field of substance abuse. The Delphi technique, a method for eliciting opinions from experts to reach a com- monh• accepted view was used. This report provides a description of the Delphi process used, definitions for 50 drug- and alcohol-related terms as developed and agreed on by the sub- stance abuse experts, and comments on each definition by the Task Fbrce. (Members of the Task Fbrce were the late Sidney Cohen. MD, Chairman, Sheila B. Blume, MD, Stanley E. Git- 1ow, MD, and George D. Ltuydberg, MD. ) TERMINOLOGY Problems of terminology and classifi- cation related to the use of psychoactive drugs are long-standing.- As early as 1952, the World Health Organization (WHO) acknow•ledged difficulties in this field and attempted to develop a defini- P+om mrDeo.mmerxs a M«w, M.aro, (or wn.a, Ak St.moKr .no Mt Gootlwml.no subaanct Abus~ (MS WMtYO~ Arten04n MeCcv MiOCytcl ChC&qo Fra+rn ieouesn m Dso.R++r}x a M.rxs, mam+ AnKmw AMdca' AuouuKn 535 N purDOm Stt crrapo. IL ios,o (Dr Rw0) tion of "addiction' that could be applied to drugs then under international con- trol.' In 1957, a WHO expert committee introduced nomenclature to distinguish between "addiction" and "habituation,' but in practice, this terminology led to confusion.4 The next attempt at clarifi- cation came in 1964, when the same WHO committee recommended substi- tution of the word "dependence" for both "addiction" and "habituation."' Several dilSculties arise from the lack of consensus on a substance abuse lex- icon. First, an array of concepts and terms is in active use. Second, a variety of professional disciplines are involved in research, treaunent, and education regarding alcohol- and other drug-re- lated problems, with each discipline tending to utilize different terms The lack of precise definitions and universal agreement on language has hampered effective communication among profes- sionals.' Finallx for public policy and third-party reimbursement purposes, the confusing panoply of terms and definitions has tended to impede under- standing and appropriate responses A,dvances in claasifuation and nomen- clature are needed in dealing with the major public health problems posed by excessive use of alcohol and other drugs' Such advances are required to fac9litate research and analysis, provide a better understanding of disease eti- ology, and improve management and decision mr.king in clinical treatment'4~_' METNOOS The research method used in this study was the Delphi technique, a mul- tiple-atage survey processintended to produce a consensus. Information is obtained from a defined target group JAMA. .lin 2?J29. 1988-1bt 259. No 4 Ubl. t .-Peo/wmrt Orqsnueon A.Msknnc tn sa,ay Ar+rncan M.draiA..oo.na, NoohoMre, r,a AadKeon r+....ra+ c«.+o.oon /4,wnun Ameuny a r.a.~ Artw+eo n M.ooeeon br c*~rq r+e Mw+on~cowoA a Hwn Awoaeeon MWcen cowqp a P*ryo.ru MwCan cowp~ a rwr.nov. 4nrne.n r.aer soaay on " or.n tr,e M+w+cr+ Nus~s b.oo.oon k+c N"Snomm Mwm* + P M.oaaon An,N,cyn sawty br crrer Pt~.rnroowpy Anw,ema a..DW Pas~doqa>: Mw+ean Booeb 01 k+1.ma fAedieier A.roor.on br M.e" EouaMn .ne fin..rv, n aubWnn Aeum A.woson ol L4bor M.raQorrwx Aanrrseaem+ v+d corw~ltrea+ a+ Akohoksm Wc dounw a.» Am«rcan M.acy Auoa.eon r.101i o.o.rb}wfu of PUbYC hl.an+ Npa,r At.oa.0oe, a anS. Alca+a ve n a sxw wax.o t w A. ~ ~ n ioa.ao ~ Mataw P.ftr.om, a P.r.ns br aup ir.. Kx,e+ ii.wrsh SoaMy on A~oona~m ViW fYll i~ and resubmitted to that group for rank- ing, rating. or both.' The Delphi technique is well suited to drawing unpublished technical and scientific information from experts.' It assures anonymity and, thus, enhances the participants' ability to make state- ments disregarding expressed public opinion and eliminating peer pressure. In this studx a pool of experts was established by requesting nominees with drug- and alcohol-related exper- tise from among the membership of appropriate professional organizations (Table 1). From this poo1, 99 experts from 23 organizations representing rel- evant disciplines and professions were nominated Mble 2). Four rounds of data gathering were conducted: (1) A list of terms was col- lected, (2) the terms were rank ordered, (3) definitions were assigned to the terms, and (4) the definitions were rank ordered. Both AMA staff and Task Force members were involved in con- densing, editing, and combining like terms between rounds of data collection to keep the project at a manageable level. subsunce abuse-R naitl ec 81 SSS

I I I I I I I I I I I I I I TabN 2-Prof*SsOW D.qrsM R4pre.~ m Sn+ay OpeM No a ko/...anus MO y ft0 19 MSW 4 RN 3 MSoaMA s EdD I Olt+a 13 StaQ. I In stage 1, a letter explaining the scope and goals of the project was sent to the 99 experts nominated by profes- sional organizations. Each participant was asked to generate a list of terms related-but not necessarily limited- to the diagnosis, treatment, education, and research of alcohol- and drug-re- lated problems. Of the 99 participants contacted, 72 provided lists of terms, four declined participation, and 23 failed to respond even after one follow-up telephone call. This constituted a 77% expert partici- pant response rate. More than 1200 terms were submit- ted. By combining similar terma and eliminating those judged to be already well defined, the list was reduced by approximately two thirds. Stop 2 In stage 2, the list of 447 terms was sent to 80 participanta (72 stage 1 respondents and eight original nomi- nees who sought late admissionk Re- spondents were asked to rate each term according to its relative importance to the field of substance abuse. A six-point Likert-type summated rating scale was used, with 6 representing "most impor. tant," and 1, "least unportant." After one follow-up telephone call to nonresponders, 68 completed liata ai^a~e returned, yielding a response rate of 85%. Stp. 3 Mean and median scores were calcu- lated for each ranked term from stage 2. Ninety-three terms reeeived a mean score of 5 or above, and 23 of these terms received a median score ot 6. The 23 terma that received a median score of 6 were:etained for use in stage 3 in that they formed a "natural gtnup- ine The remaining terms that received a mean score of at least 5 were edited to eliminate duplicates and already well- defined terms; this process yielded a complement of 22 term: Five additional terms that received mean scores of less than 5 were deemed important enough by investigators and the Task Fbrce to include in the final list Thua, a list of 50 terms was compiled. Participants were then instructeo to define each of the 50 top-ranked terms Ninety-two participants (80 individuals who were asked to respond in stage 2 plus 12 original nominees who sought late admission) were asked to respond. After one follow-up telephone call, 42 completed lists were returned, yielding a response rate of 46%. Intermsdlate Sta" After systematic analysis of stage 3 data, five de8nitions were selected for each term. With use of a Q-sort rank- ordering technique, definitions were se- lected on the basis that they fairly represented the range of all definitions submitted for a particular term. In the process, "drug addict' was subaumed under "addict," 'drug addiction' under "addiction," and "drug dependence" un- der "dependence" In a continuing effort to keep this project at a manageable level, Task Fbrce members were asked to evaluate and rank the five definitions for each term based on perceived quality and usefulness. Mean scores were calculated on'IUk Fbrce choices to select the three top-ranked definitions for each term. StaqO 4 In the fourth round, participants were sent the list of terms with three definitions assigned to each. They were instructed to select one definition con- sidered best for each term. Ninety-three participants (92 indivi- duals who were asked to respond in stage 3 plus one original nominee who sought late admission) were asked to respond. After one follow-up telephone call, 65 completed lists were returned, yielding a response rate of 70%. RESULTS Itatings for desnttiona .rere sum- mated acrcas respondents. Those re- ceiving the greatest number of votes are listed beloa4 followwg their respeo- tive terms. This list represents 60 sub- stance abuse terms deemed important, with the most agreed on definitions, by a cross-disciplinary national group of substance abuse experta (Only 47 terms and definitions appear because "drug addict" was subeumed under "ad- W rd2Ug iddiCtloD' under raddlC- tion," and "drug dependenee" under "dependeace.") The list includes the following terms: Abstinence: Cessation of use of a psychoactive substance previously abused, or on which the user has devel- oped drug dependence. Abuss PotrRtial: The property of a substance that, by its physiological or psychological effects, or both, increases the likelihood of an individuaih abusing or becoming dependent on that sub- stance. (Drug) Addiet: A person who is phys- ically dependent on one or more psy- choactive substances, whose long-term use has produced tolerance, who has lost control over his intake, and would manifest withdrawal phenomena if dis- continuance were to occur. (Drug) Addiction: A chronic disorder characterized by the compulsive use of a substance resulting in physical. psy- chological, or social harm to the user and continued use despite that harm. Alcohol Abuse: Use of ethyl alcohol in a quantity and with a frequency that causes the individual significant physi- ological, psychological, or sociological distress or impairment. Al.cohol Addiction: Physiological and psychological dependence on alcohol. Alcohol Dependence: Chronic loss of control over the consumption of alco- holic beverages, despite obvious psy- chological or physical harm to the per- son. Increasing amounts are required over time, and abrupt discontinuance may precipitate a withdrawal syn- drome. Following abstinence, relapse is frequent. Alcoholic: Person who has experi- enced physical, psychological, social, or occupational impairment as a conse-• quence of habitual, excessive consunip- tion of alcohol. Alcoholics Anonymous: An interna- tional, nonprofessional organization of alcohol-dependent persons devoted to the achievement and maintenance of sobriety of its members through self- help and mutual support. Alcoholism: A chronic, progressive. and potentially fatal biogenetic and psy- chosocial disease characterized by tol- erance and physical dependence mani- festtd by a loaa of control, as well as diverse personality changes and social consequences. Blackout: Acute anterograde amne- aia with no formation of long-term mem- ory, eg a period of memory loss during which there is no recall for activities, ~ ~from the ingestion of alcohol drugs. Cannabis Dependence: The psycha logical need for a routine pattern of cannabia use to the point where social- occupational functioning is impaired to some degree. Chemical Dependency: Generic term relating to psychological or physical dependency, or both, on an exogenous substance. Ckrmac Alcoholisrn: An obsolete term that should be abandoned. Syn- onymous with "alcoholism." The con- trasting term *acute alcoholism' is now I S5i JAMA. Jan 22/29. 1988-Vb1259. No. 4 Substance Abuse-Ainaid et al

I p I I I I I I I p I I I I I I I I 1 rarely used, and means only severe intoxication by alcohol. Cross-dependenre: The ability of one drug to suppress the manifestations of physical dependence produced by an- other and to maintain the physically dependent state. Cross-tolerance: Tblerance, origi- nally produced by long-term adminis- tration of one drug, which is manifested toward a second drug that has not been administered previously (eg, tolerance to alcohol is accompanied by cross- tolerance to volatile anesthetics or bar- biturates). (Drug) Dependence: A generic term that relates to physical or psychological dependence, or both. It is characteristic for each pharmacological class of psy- choactave drugs. Impaired control over drug-taldng behavior is implied. Detosification: A process of with- drawing a person from an addictive substance, in a safe and effective man- ner. Disease Concept: Recognition that chemical dependency is a chronic, pro- gressive, and potentially fatal bioge- netic and psychosocial disease charac- terized by tolerance and physical dependence manifested by a loss of control, as well as diverse personality changes and social consequences. Drug Abuse: Any use of drugs that causes physical, psychological, eco- nomic, legal, or social harm to the individual user or to others affected by the drug user's behavior. Drug Free: Ongoing disassociation from the use of any psychoactive sub- stance. Drug 1 ntorication: Changes in phys- iological functioning, psychological functioning, mood sutes, or cognitive processes, or all of these, as a conse- quence of excessive consumption of a drug; usually disruptive. Drug Misuse: Any use of a drug that varies from a socially or medically ac- cepted use. Enabling Behavior: Any action by another person or an institution that intentionally or unintentionally has the effect of facilitating the continuation of abuse or dependence. Fhmilial Alcoholism: Pattern of al- coholism occurring in more than one generation within a family, due to either genetic or environmental factors. Fb.mily Intervention: Specific form of intervention involving filnily members of alcohol and drug addicts designed to benefit the target patient as well as fan::ly constellation. Impaired Physician: A physician whose clinical conduct does not meet accepted standards of practice and that is secondary to alcohol-drug use, or psychiatric illness, or physical illness, or all three. Intervention: Act of interceding in behalf of an individual who is abusing, or is dependent on. one or more psycho- active drugs, with the aim of overcoming denial, interrupting drug-taking behav- ior, or inducing the individual to seek and initiate treatment. Loss of Control: The inability to limit the use of substances via an internal locus of control. Maintenance: A form of therapeutic intervention applied to opiate addicts, and consisting of the oral administra- tion of a substitute opiate drug to min- imize the reinforcement of drug and prevent a withdrawal reactio while permitting rehabilitation to achieved. Overdose: The inadvertent or delib- erate consumption of a much larger dose than that habitually used by the indi- vidual in question, and resulting in serious toxic reactions or death. Physical Dependence: A physiologi- cal state of adaptation to a drug or alcohol, usually characterized by the development of tolerance to drug effects and the emergence of a withdrawal syndrome during prolonged abstinence. fblydrug Abuse: Concomitant use of two or more psychoactive substances in quantities and with frequencies that cause the individual significant physio- logical, psychological, or sociological distress or impairment. Prevention: Social, economic, legal, or individual psychological measures aimed at mininuzing the use of poten- tially addicting substances, or lowering the dependence risk in susceptible iur, dividuals Primary Prevention: Attempts to re- duce the incidence of new cases (or problems) in a general population. Problem Drinking: (Two definitions tied for first place): (1) Drinldng pat- ter:u that have resulted in serious dis- turbances of health, work, social ad- justment, or other areas of functionin& (2) A pattern of alcohol consumption that does not satisfy all the criteria of alcoholism, but that is characterized by sufficiently large intake to have gener- ated problems of health or social fiulc- tionin& Paychologiml Dependence: The emo- tional state of craving a drug either for its positive effect or to avoid negative effects asaociated with its absence. Recovering Alcoholic: An alcoholic who is successfully sbstaininir, to em- phasize the concept that no one is ever cured, and that recovery must be eon- tinuously worked at. Recovery: A process of overcoming both physiological and psychological de- pendence on a drug or alcohol. Rehabilitation: The restoration of an optimum state of health by medical, psychological, social, and peer group support for a chemically dependent per- son and his significant others. Relapse: Recurrence of alcohol- or drug-dependent behavior in an individ- ual who has previously achieved and maintained abstinence for a significant time beyond the period of detoxifica- tion. Sobriety: Generally refers to the state of complete abstinence from alcohol and other drugs of abuse in conjunction with a satisfactory quality of life. Substance Abuse: The use of a psy- choactive substance in a manner detri- mental to the individual or society but not meeting criteria for substance or drug dependence. Tbleraxce: Physiological adaptation to the effect of drugs, so as to diminish effects with constant dosages or to maintain the intensity and duration of effects through increased dosage. Natmext: Application of planned procedures to identify and change pat- terns of behavior that are maladaptive, destructive, or health injuring; or to restore appropriate levels of physical, psychological, or social functioning. Wilhdrawal: Cessation of drug or . alcohol use by an individual in whom dependence is established. Withdrawal Syndrome: The onset of a predictable constellation of signs and symptoms involving altered activity of the central nervous system after the abrupt discontinuation oC or rapid de- crease in, dosage of a drug. MMe.ne.. 1. WHO rspert C.MaitLe oR DMqi Liobl. to hetree AddiehoR 'IkhaKal RepoR S~riea third tepat No. 6?. Gesmra. woeld Hsokb or~• ~ 0 6spert Ceania.e ae Ad&etio+aHodue• r,yonwL ToduDW aepm saa w.aaa rep«m No. 116. Geeea. world Hn1W Oetwratwn.1957. 3. rYorid Hnltb Onaniut,ioa: Nomeadaure and da.&nLion oedtva• e+d akoAoi-reLs.d problems: Sborten.d r.eaom of a WHO sewmnndum. Br J Ad&d 1f62:TJ3-2D. 4. IVNO Espert Cewwdttee ewAddietioe•Aodtie• N Gearm iNoeld Halt~ OrPains- 1964. t. o'Briea x, Cabea S: T'Ik Eweye{ooedis ajDrrp AkAw. New York. Gnen SW4 lnc. 196/. i. Hre.a IS F.das! dr+ic P~ ~~': Fba ex allia' J Nstl X.d Aua 1990:T2:51b581. t. Chnaeiel TL: lat.eaatiotul atpcets o! probk:ns woei1t.d .itk the a.e et prydro.eure drum Buil Nsx 19762935.46. i. Ilo.eeviee 1. AsmraveK P. SboeteU S. et 91; }i"kh «rvlee~ naveD tor deaooa o.ke+s: Tr* um e( the Ddphi uefsniqne to deurmne heakh 19T7s 38~ prioritj.a J NaW Potit tblfey L4w .10. 9. Hekmr o: A%Wr•;• of a. tka-: rV oOI* UAAod. S.nts lioeyea. CatifU tbt RAND Corp. 1f67. I JAMA. Jan 2?/29. 1 988-Wd 259. No 4 # SubstAn" Abwe-Ama4 01 V SS7