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.


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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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  • This article is a joke, of course methadone and suboxone users are still addicted. They can just now get their drugs, not have to run the streets, blow through money and destroy their lives. The medication BINDS to the opiate receptors flooding the brain with endorphins, feel good chemicals, dopamine etc. This is NOT SOBRIETY. Letting the receptors heal without drugs binding to them is sobriety. If all of a sudden those drugs are not available the user will run out to the streets to get what they need because they will be in vicious withdrawal. Suboxone and methadone withdrawal is worse than heroin, I know from personal experience, what does that tell you. Methadone is a full opiate agonist, same as heroin, oxy, ect ect. Its a total lie to believe your sober on methadone or suboxone. But some people cant get sober and need it. Oh well. Big pharma can keep making the big bucks

    • CR5- little by slow……,came… came to……. came to believe……. consider the alternative. Being on a medicine, following up with a doc, taking the medication as prescribed without supplementing it with what someone scores on the street, not sticking a needle in your arm, in between your toes, ….. and on and on, is a far cry from doing what the addict knows so well….. your science sounds good, but the addictive BEHAVIOR goes beyond what is physically happening in the brain even though the seat of it is rooted in it’s chemistry. Having the willingness to not practice the old insidious behavior may be (for some) the first step to asking for and getting the help needed to stay alive.

    • Jasminesola1- I understand what you are saying. This crisis is not a little by slow problem. It’s a detox yourself, go through the agony, and start to pick up the pieces and put your life back together without crutches. I have personally NEVER met anyone to get sober with methadone. I personally know MANY opiate addicts. 100% of them, did the try maintainance route, followed by an even worse relapse and worse bottom, even if things did get better for a time. I’m sure it has been done, get life back together, do the taper and move on, but the mind needs to be removed from the opiates for many many months to allow some neuroplasticity to happen in abstinence of the chemical pull of the opiate or the person will taper, find themselves craving immensely and that craving will not be able to respond to any sort of inner reason because the brain simply will be under the spell of the craving, and reasoning wont even touch that craving. Its either stay on them forever and live with the opiates in the brain, or do the inevitable and suffer through withdrawal and brain repair.

  • I’ve been sober on methadone for 9 days and it has saved my life I’m very happy I took the steps to go to the clinic and get medication not only do I go there daily to dose but I’m monitored by a doctor and nurses and assessed to make sure I’m on the right dose I also see a therapist weekly to help with getting my mind right so a clinic is not just about medication it’s about getting Clean off opiates and in no way is using methadone or suboxone meaning that your not clean anyone who has that thinking maybe educate yourself!!! There is not one right way to get sober everyone uses a different path and I’m using methadone and Im considering myself sober for 9 days and counting and very VERY PROUD of myself I’ve worked so hard!! Nobody can tell me anything different.

  • As stated by Bonnie Franks MAY 24, 2017 AT 3:49 PM, yes there is a mind body connection that must be attained. Know that as there are persons who are not able to change their diets to get of insulin, persons that are not able to lose those 10 pounds, there are those persons that are not able to complete that 5k, those who return to thumb sucking we do not assault them on their relapses, we encourage them, let us do so for those who have trouble stopping the use of substances that are impairing their life. Those who are active in their recovery in methadone maintenance have achieved that mind body connection and will eventually detoxify off methadone and be successful in their recovery. There are others that are still making strides in their recovery and may never feel comfortable to come off methadone. While in treatment with methadone their are also additional resources that are available to include counseling, groups, and support groups (NA/AA) that will assist all persons while they are on their road to a better quality of life. The are many roads in the achievement of releasing from the harmful use of substances, let each person experience the various paths, and one or many of those paths will lead to a higher productive quality of life for themselves, family and community.

  • For anyone who is interested in the cited study regarding labels, here is the reference to it:
    Kelly, J.F. and Westerhoff, C.M. 2010. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. International Journal of Drug Policy 21: 202 – 207.

  • I love this article! I’m in a program an it has saved my life!! I’ve gotten my life back! I’ve accomplished so many things since I started!! The medicine is God sent but it can’t do it for u! U have to be willing to put as much effort in staying clean as u did getting high!! Going to meetings and getting a sponsor is very important! I don’t care how long I have to stay on it as long as I’m not abusing it and working the program I feel no one has the right to judge!! Addiction is a horrible disease an people need to realize this!!

  • This article is spot on. I used pain pills for years and graduated to Heroin. I wasn’t sure what to do. I was miserable. I got on methadone because I desperately wanted my life back. It worked. I have been on methadone for 6 years. I have decreased my dose to become comfortable, I NEVER increased throughout the years. I am able to function like a “regular” person. I do NOT get high or feel high. If I don’t take it I feel like I have the flu and can not function. People seem to think those on methadone get high everyday. That is a myth, we take the methadone to feel normal. I have achieved many things while on methadone. I have worked in policy and changed laws, I started an NGO, I secured speaking engagements to educate people on prevention. Methadone gave me my life back. I don’t care if I have to take it forever. I have been able to accomplish so much. Why would anyone want me to go back to self medicating and just existing. If it works use it, and it it is not broken, don’t fix it.

  • LOL this article is nothing but addicts making up excuses to still use drugs that they are addicted to, and get high, and that they are not really addicted to the opiate drugs they take, and they are only fooling themselves.

    • This is MGH clinic dr writing this…addicts dont hv to justify anything…I wld like to see source of how the death rate cut by 50% by using these drugs…cld fool me

    • Suzanne Roy : Your comment is shocking. This has been a non-debate for close to 20 years. There is ample, demonstrated and undeniable evidence of methadone and buprenorphine treatment reducing mortality.
      Here is some :
      https://www.ncbi.nlm.nih.gov/labs/articles/15955014/ (3.78 fold reduction in mortality with medication vs not).
      https://www.ncbi.nlm.nih.gov/m/pubmed/18031430/ (10 fold reduction in mortality)
      I can cite you at least 10 other published articles.

      I am shocked to read that you are/pretend to be a doctor.

  • This is BS, if someone is on suboxone or methadone, then they are still on opiates and are still addicted. These drugs are meant to be used as a stepping stone to being sober and living a sober life. If you smoke weed you are not sober either. Man up and get off all opiates and all drugs like most of us have already done.

    • Same as anyone who drinks alcohol is addicted to it? There are many chronic pain patients who could easily prove you wrong. your attitude seems emotional and not based on scientific findings, as are the premises in this article.

  • What you fail to address is that taking Methadone ‘keeps’ the addict in the ‘addict mind set’ Your mind & body are still in addict mode. That is why the majority of Methadone users go back out or use as well. Because the mind & body has not been removed from the opioid effects. Yes there are success cases but those people are bound & determined to get off Methadone & stay clean. The fact that Methadone users ‘have’ to increase their doses says it’s not working. If you have any opioid in your system you are not clean. You may be in a recovery program but until your body & mind can function without opioids you will not be clean in a 12 step program. The 12 steps teach us how to live without drugs. Yes there are exceptions but opioids are not one. ‘I’ believe that a medical withdrawal& detox followed closely with extensive treatment (minimum 3 months) would be cheaper in the long run & give a better chance of successfully staying clean. It is not enough to just stop using your drug of choice & substituting with another drug. Talk to the people that have 10 years plus ‘clean’. Ask them ‘how it works’. The addict that is using Methadone instead of ?? cannot give you accurate feedback. Everyone I know & have known that uses Methadone is scared to death of coming off it. Remove that fear & you will have better success. Telling a Methadone user that his support group & family are wrong about his clean time is giving him half a message & encouraging him to not to go down on his dose with the intention of getting off it. Total abstinence will help give you a productive worth living life.

    • Said perfectly .. The fear of coming off is unreal.. And I think its absolute ludicrous I was there for so long, and not one time did any one ask if I wanted to come down, or even talk to me about decreasing, even when I was decreasing I still initiated the conversation of dosing down… Every single time.. I will say until I cleared my head and really wanted to get off, I saw nothing wrong with the clinic and how it was run, now I see everything.

    • It is a very difficult drug to come off of….even when done properly..I dont see it guaranteeing ppl not doing H or other drugs while on it. U are getting a synthetic opiate to replace a nonsynthetic…same w suboxone. It seems to me any drug abused..used over period of time…changes brain chemistry…and comes with obsession to use when trying to get clean. I have never understood why heroin treated differently. U dont get alcohol to get u sober…benzos…stimulants..pot etc to get clean. U gonna get clean then do it….granted i hv seen really mostly negatives with “medically managed” tx..

    • In the 12 Step model, we have no opinion on outside issues and do not engage in any controversy. If a patient is working with their doctor honestly and is following a protocol, then who am I to judge a persons journey toward personal health and wellness. It’s about progress not perfection, right????? I’ve seen addicts managed on either methadone or suboxone who have had positive results when working closely with their doctors. And yes, they were able to come off of all drugs in time. If I’m not honest with myself, then I am only fooling one person. Bottom line, being followed/managed by the medical community certainly produces a greater potential for success vs. nodding out on Heroin Alley near Boston City Hospital.

  • This article was forwarded to me by my daughter. She is a 31 year old woman who is now in recovery (18 months) from years (5-6) of heroine addiction using methadone. She got her BS degree in Social Work in 2008 and next year will finish her internship to become a certified addiction counselor. This treatment works. Now we have to make politicians and others believe in this treatment so others can get their lives back. I feel blessed to have her back!

    • My son is in suboxene. Best thing ever. He actually can function and stay clean I pin a month his health insurance runs out. He will not be able to b
      Pay for his treatment apps or meds. I’m petrified of him not having it. I wish I knew where to get help for hom

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