A patient came to see me after his most recent near-fatal opioid overdose. Once again, he had stopped his prescribed medication, even though we had agreed together that the safest course of action was to continue. Once again, he had relapsed — and had to be revived with naloxone. It wasn’t that he didn’t find the medication helpful or that he had side effects — on the contrary, it had nearly eliminated his cravings and stabilized his mood.

But his family and friends kept telling him he wasn’t “truly sober” or “really in recovery.” And inside, he, too, believed that taking one of only two FDA-approved medications that have been shown to cut opioid addiction death rates by 50 percent or more meant that he was “still addicted.”

My patient was lucky: He didn’t die because of a widely held, and completely inaccurate, definition of addiction — one that was recently supported by remarks from Health and Human Services Secretary Tom Price, who disparaged medication use as merely “substituting one opioid for another.” But until politicians, the media, and the public catch up with addiction science, we will not be able to stop the epidemic of overdose deaths.


As the medical director of Massachusetts General Hospital Substance Use Disorder Initiative, I treat patients with addiction; my coauthor, Maia Szalavitz, is a journalist who herself experienced opioid addiction during her 20s. We, and many of our colleagues, are greatly concerned by how common misunderstandings about addiction like this undermine evidence-based care. While semantic issues are often dismissed as trivial, in this case, they are having devastating results.

Here’s what has gone wrong. In 1987, the authors of the Diagnostic and Statistical Manual — the “bible” that lists official psychiatric diagnoses and their attributes — designated two acceptable substance-related diagnoses. They were “substance abuse” for short-term but potentially dangerous problems (think: college binge drinking), and “substance dependence” for the chronic, relapsing condition we typically call addiction.

Unfortunately, both of these terms turned out to be inaccurate and actively harmful: This is why, in 2013, they were dropped from DSM-5 and replaced with a spectrum category called “substance use disorder,” which runs from mild to severe. In the case of opioids, the diagnosis is labeled “opioid use disorder,” and when it is “severe,” this corresponds with what most people call addiction. But the media and the public don’t seem to have gotten the memo.

Instead, dependence is frequently used as a synonym for addiction, which causes numerous problems. Most importantly, depending on a drug to function without withdrawal symptoms is not itself pathological: This is a normal, physiological result of taking certain medications long-term. If “drug dependence” was the best way to define addiction, then people with diabetes would have “insulin addiction,” people with high blood pressure would have “antihypertensive addiction,” and everyone would have “food, water, and air addiction.”

In contrast, addiction, as defined by the DSM and the National Institute on Drug Abuse, isn’t simply needing a substance. It is compulsive drug use that continues despite harm.

This definition accurately includes cocaine as addictive — even though it doesn’t involve significant physical illness during withdrawal — while accurately excluding appropriate use of medication in chronic disease. It also means that people stabilized on medications like methadone are not addicted — they don’t engage in compulsive use despite consequences — but merely dependent. (When opioids are taken in a steady, regular dose appropriate for a particular patient, that person will not be impaired and can safely drive, work, and parent.)

The phrase “drug abuse” also misleads. It derives from a term meaning “willful misconduct,” which basically labels addiction as a sinful choice. “Abuse” is also associated with harms to children and sexual assault: It’s not a word that belongs in our medical lexicon.

These may sound like academic distinctions, but they can have deadly implications. Labels affect even highly trained clinicians. One study, for example, found that doctoral and masters level therapists were significantly more likely to recommend punitive measures such as sending a court-ordered patient to jail for relapse when that person was labeled as a “substance abuser,” rather than as a “person with substance use disorder.” And research shows that harsh methods actually backfire in treating addiction.

Moreover, confusing “dependence” and “addiction” spurs bias against the most effective known treatment for opioid addiction: long-term use of methadone or buprenorphine (Suboxone).

Decades of research show that these medications dramatically reduce the risk of death, HIV infection, and recurrence of drug use. (A recent review of the scientific literature involving more than 100,000 patients found that death rates were two to three times lower for people in methadone or buprenorphine treatment, compared to people not taking medication). No other method — including abstinence-only residential rehab — has such strong support.

Yet the common myth is that people taking these medications are “still addicted” and that residential treatment is a better option. Failure to understand that addiction is not dependence leads many — including family members and people with addiction themselves — to avoid lifesaving care.

Mistaking dependence for addiction can also harm patients with chronic pain. Those who benefit from opioid therapy can be mislabeled as addicted, when, in fact, they are physically dependent. This can lead to cessation of an effective treatment — and sometimes even suicide.

If, as a society, we really believe that addiction is a disease, we can’t exempt it from the standards we use to discuss other illnesses. That means dropping inaccurate medical terms from the past. It also means that addiction physicians must do a much better job of educating the public and even other doctors — especially non-specialists like Tom Price — about how our understanding of addiction has changed and why using medication to treat it is not just continuing the problem.

The language that we use about addiction helps determine what we do about it and how we treat people who are affected. People with addiction won’t get appropriate, evidence-based care until both addiction physicians and the media explain in up-to-date and unbiased terms what that really means and why it matters.

Sarah Wakeman, MD, is assistant professor of medicine at Harvard Medical School and medical director of the Massachusetts General Hospital Substance Use Disorder Initiative. Maia Szalavitz is the author of “Unbroken Brain: A Revolutionary New Way of Understanding Addiction” and a freelance journalist specializing in neuroscience and addiction.

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  • Excellent article!!! As a member of a step recovery program I have seen a lot of opposition to methadone and suboxone. As a result I’ve seen many people relapse and die. These medications are far better than the alternative.
    Thank you for this very insightful article!

  • The flaw with this logic is in discarding the term addiction and using piecemeal definitions like “substance abuse”. The medical industry has no treatment for the mental obsession, the belief that the proper way to live life is to use some kind of mood altering substance, be it a person, place or thing.

    You have nothing to sell, no pill to patent, so the ignore what you can’t solve and sell a remedy for the physical problem. The abuse of a “substance”.

    Codependency, gambling, porn, violence, are all avenues the addict (there I said it) will employ to alter their mood.

    Addiction comes in people, not bottles or bags.

    This is simply treating the symptom because treating the disease isn’t so easy to monetize.

  • Since the medical industrial complex and big pHarma took over the care and treatment of addiction disorder things have gone from bad to worse

    • Brianne, I think there’s more than one approach re: treatment.(short and long term) Especially, in light of the opiate epidemic, the fentanyl which is being used to enhance potency and the deaths as a result. Addiction treatment is not a one size fits all answer to the problem…. If it were, we’d have a lot success stories. I think you already know, that the “addiction” itself is only a symptom of a deeper problem. So if meds are used with direction and under the care of a physician in tandem with therapy, it just might buy some time for the user and perhaps with that time, a desire to stay clean and sober. What’s gone from “bad to worse,” are the chemicals being added and how lethal they are in even the smallest of amounts. However, I do agree that the drug industry has definitely been a major stakeholder with respect to having to assume responsibility for owning the initial problem. 60 minutes did an amazing segment perhaps 2 yrs. ago about the companies which were culpable.

  • I Recently finished Recovery Coach Academy and I am looking for an opportunity to work in the field. I’d also love to make a difference

  • What about Visiting? I was addicted to heroin and this monthly injection saved my life. Suboxone and methadone are used daily and some patients are on them for decades. Vivatrol is an opioid blocker meaning that you can’t get high. The patient can learn to live without drugs rather than using Suboxone or methadone in place of other drugs.

  • How long does medication such as opiods stay in your system once you stop using them, and not replacing it with something else. Just stopping the drug. I know there is withdrawal unless something else is given in place of the drug, how long will the withdrawal last?

    • The length of time a drug “stays in your system” is irrelevant to the length of time to withdraw. 50% of those drugs are gone within 6-8 hours,100% within 2-3 days. It’s the recovery of your neuroreceptors that takes time.

      In direct answer to your question, a standard short-acting opioid such as hydrocodone, oxycodone, heroin, or morphine that one has become dependent on will likely result in about 5-7 days of acute withdrawal.

      The problem is the protracted phase that often results in anxiety, craving, amotivational state and depression that more often than not ends with relapse and can last up to 16 months. If it were as simple as getting everyone through the 7 days of withdrawal, the epidemic would be solvable.

      This is where medication assisted treatment enters, as discussed in the above article. For those who have become addicted, tried abstinence-based treatment, failed and even come near death upon relapse, it saves lives and families.

  • This article fails to mention the origin of this idea of “not being Truly Sober” because of taking prescribed medicine – it’s from 12-step programs, specifically Alcoholics Anonymous – the belief is that taking any mind-altering substance prevents one from being in touch with God, believed to be the only entity that can provide permanent sobriety. AA even addressed the problem in a pamphlet from 1984 (“The A.A. Member – Medications and Other Drugs” – especially page 6), but very few 12-step adherents read anything but their own fellowship’s equivalent of the AA Big Book if even that, and this idea still pervades “recovery culture.” Despite the availability of more modern and even more accurate literature, even from AA itself, 12-step groups are still as much “word of mouth” fellowships as they were in the early years before the Big Book was written.

    • “this idea of not being Truly Sober” is “truly” up to the individual and their idea of what it means to be sober. No one in AA defines someone else’s sobriety for them. AA as an organization, has no opinion on outside issues. Someone who is prescribed a medication for a mental illness or any med for an illness, is under the care of a doctor, follows dosing instructions can be “sober.” (depending on the level of honesty that patient has with their doctor and sponsor.) We all have opinions… If anyone tells me the advice they’ve gotten from somewhere/someone regarding what “truly sober” means, and it’s inclusive of coming off medication….. I suggest they speak with someone else and their doctor. Members are not doctors, nor psychiatrists. After 3+ decades of sobriety, I would never make that recommendation and put someone’s life at risk. That’s a life and death call. Certainly, one I would never want to assume responsibility for.

  • Also I might add, unless your born with diabetes, high blood pressure and every other “disease” accumulated by peoples bad decisions- taking a medication is a bandaid to not do the right thing. Obviously addiction doctors think methadone is great, because it pays their bills. It probably does save lives, and that’s a good thing, but lets not lie and say its sobriety. Just like there will be people that no matter what, will keep eating bad food and clogging their arteries despite having high cholesterol and warning signs of heart disease, or keep smoking despite knowing it will kill you, there will be people taking methadone, anti depressants, etc etc, because its all the easy way out, to not face your reality- because reality is scary, and its easier to take a pill. Fear is what perpetuates all disease- fear of facing reality and taking ACTION to change your life to be healthy. But that’s the world we live in, a world of shortcuts, excuses- which all leads to a poorer quality of life than the person was born to have. We are comfortable with existence rather than living these days- its a sad world. We can all slump over into our cellphones and have the souls sucked out of us, and live in convenience day in and day out, getting lazier and lazier. Its ok if you use methadone to get by, just like some people use anti depressants, benzos for anxiety because they cant learn how to exercise, meditate, breath right and face fears, or get over crap from the past that haunts them. Welcome to the world of endless excuses. Lets just all admit what the reality of the situation is here.

    • I’m interested in knowing what you’re going to be like when you have to take one of “these pills” (of course- after you’ve exhausted every other avenue)

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