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American Society of Addiction Medicine
Terminology Related to the Spectrum of Unhealthy
Substance Use
Background
Terminology in Addiction Medicine has presented challenges to clinicians, patients, family
members, policy makers, the media, and the general public. Even the name of the American
Society of Addiction Medicine (ASAM) has evolved from previous terms found in the titles of
predecessor organizations: alcoholism, alcohol and other drug dependencies, addictionology,
and addiction medicine.
ASAM has adopted policies which define Addiction and Treatment of Addiction. The ASAM
Board endorsed the establishment of a Descriptive and Diagnostic Terminology Action Group
(DDTAG) to develop additional terms to clarify matters for the various stakeholders in clinical
and policy approaches to substance use, addiction, treatment, and recovery. Addiction
commonly involves the pathological pursuit of reward and/or relief via the use of substances
such as ethanol (e.g., in alcoholic beverages), nicotine (e.g., in tobacco products), or certain
pharmaceuticals (e.g., opioid analgesics or psychostimulant drugs). Addiction Medicine
physicians and other specialist and generalist physicians and others may work with individuals
who have an unhealthy pattern of use of substances, even if addiction is not present. In fact,
addiction is best conceptualized not as an abnormality in substance use, but as an abnormality
in the brain’s response when a person with the disease uses substances as a pathological
source of reward or relief. In ASAM’s definition of addiction8, developed by ASAM’s DDTAG, it
is stated that “a characteristic aspect of addiction is the qualitative way in which the individual
responds to such exposures, stressors and environmental cues” more that addiction being
distinguished by “the quantity or frequency of alcohol/drug use, engagement in addictive
behaviors (such as gambling or spending), or exposure to other external rewards (such as food
or sex).” Thus some persons can use substances frequently or in large amounts and not have
addiction; and some persons with addiction actually do not have a pattern of use involving high
dose or high frequency exposure to psychoactive substances.
The scope of practice of Addiction Medicine, as defined by the American Board of Addiction
Medicine, includes providing “medical care within the bio-psycho-social framework for persons
with addiction” but also providing medical care for “the individual with substance-related health
conditions, for persons who manifest unhealthy substance use, and for family members whose
health and functioning are affected by another’s substance use or addiction.” Non-addictive but
otherwise unhealthy use of alcohol, tobacco, and other drugs, including some prescription
drugs, is thus germane to the practice of Addiction Medicine and to the members of the
American Society of Addiction Medicine (ASAM).
This aim of this document is to provide definitions for terms that address the entire spectrum of
alcohol and other drug use associated with health consequences. The focus is on terms that do
not describe “addiction” or DSM-V “substance use disorder,” though it is recognized that
addiction and substance use disorders are included in the spectrum and are of course harmful
to health. Definitions for terms that are specifically related to addiction can be found elsewhere.
Terms that are not preferred, and the rationale for not using them in professional discourse,
appear at the end of this document.
Recommendations
In light of the need to clarify terminology, the DDTAG has drafted and the ASAM Board has
approved the following terms, and ASAM recommends their use to describe various nonaddictive states of substance use.
I.
Overview of Preferred Terms for the spectrum of alcohol and other drug use:
1) Low or lower risk use (and non-use)
2) Unhealthy (alcohol, other drug) use
a) Hazardous use or at-risk use
b) Harmful use
c) Addiction (not defined in this document)
Note: “Unhealthy” covers the entire spectrum including all use related to health consequences
including addiction. Hazardous and harmful are mutually exclusive of each other, and of
diagnosable disease (i.e., addiction).
Note also: The terms herein have been largely defined, studied and used for substances
(alcohol and other drugs). They also include prescription (and non-prescription or over-thecounter drugs). However, although there has been less theoretical discussion of and empirical
evidence accumulated for other potentially addictive behaviors (e.g. gambling), the framework
and preferred terms in this document are also applicable to those behaviors (e.g. low or lower
risk gambling, unhealthy gambling, hazardous gambling, harmful gambling).
Specific definitions:
1. Low risk use (alternatively, Lower risk use), including no use
Definition: Consumption of an amount of alcohol or other drug below the amount identified as
hazardous (see below), and use in circumstances not defined as hazardous.
Discussion: The term recognizes that risk may not be entirely absent at low levels of
consumption. In fact, no amount of use of smoked tobacco has been defined as safe, risk-free
or healthy, and no amount of substance use during pregnancy has been defined as safe, riskfree or healthy. The term has been most often applicable to alcohol but may be applied to other
drug use, though it is recognized that risks associated with use of specific amounts of other
drugs associated with risk are not well-delineated.
2. Unhealthy use1
Definition: Unhealthy alcohol and other drug (substance) use is any use that increases the risk
or likelihood for health consequences (hazardous use), or has already led to health
consequences (harmful use).
Discussion: The term is an “umbrella” term because it encompasses all levels of use relevant
to health, from at-risk use through addiction. Unhealthy use is a useful descriptive term
referring to all the conditions or states that should be targets of preventive activities or
interventions. It is not a diagnosis.
The exact threshold for unhealthy use is a clinical and/or public health decision based on
epidemiological evidence for measurably increased risks for the occurrence of use-related
injury, illness or other health consequences. For some substances, any use is considered
unhealthy (i.e. any cocaine use can increase risk for myocardial infarction; one-time use of
hydrocarbon inhalants can lead to sudden cardiac death; no known level of tobacco use is
considered risk-free; alcohol is a known carcinogen so there is likely no use that is completely
risk free). On the other hand, there are thresholds at which the risk increases substantially for
alcohol, and these have been specified widely (see “at-risk” use).
Note: the term “unhealthy” (just as with the descriptors “unsafe” or “hazardous” or “harmful” or
“misuse”) does not imply the existence of “healthy” or “safe” or “non-hazardous” or “harmless”
use, or that there is a way to use the substances properly (i.e. without “misuse”).
2.a. Hazardous use (alternatively, At-risk use)
Definition: Use that increases the risk for health consequences.
Discussion: This term refers only to use that increases the risk or likelihood of health
consequences. The term does not include use that has already led to health consequences.
Thresholds are defined by amount and frequency of use and/or by circumstances of use. Some
of these thresholds are substance specific and others are not. For example, use of a substance
that impairs coordination, cognition or reaction time while driving or operating heavy machinery
is hazardous. Non-medical use or use in doses more than were prescribed of prescription
drugs can be hazardous. Any alcohol or nicotine use during pregnancy is hazardous. Any use
by youth likely increases risk for later consequences. Use of any potentially addictive substance
is more hazardous for persons with a family history or genetic predisposition to addiction than it
is to those at average risk in the general population. Use of substances that interact (e.g. two
drugs with sedative effects like benzodiazepines and buprenorphine) is hazardous. Use of
substances contraindicated by medical conditions is hazardous (e.g. alcohol use and hepatitis C
virus infection or alcohol use and post-gastrectomy states). At-risk amounts of alcohol are
discussed below.
Hazardous use has been defined previously (consistent with this current definition) as a level or
pattern of use that confers a risk of harmful health consequences.2-4
The concept of “risk factor” is relevant here. Just like an elevated cholesterol or consumption of
excessive calories are risk factors or increase risk for worse health outcomes, hazardous use
increases risk for use related consequences.
An acceptable variation in the use of the terms “hazardous use” or “at-risk use” is to refer to
hazardous or at-risk amounts where these have been defined (as for alcohol). Hazardous (or
at-risk) amounts of alcohol consumption including heavy drinking episode/heavy episodic
drinking have been defined for the US and elsewhere. In the US, hazardous amounts of
alcohol consumption are, for men, 5 or more standard 12 gram drinks (e.g. 1.5 oz 80 proof
liquor, 4-5 oz. wine of regular strength, 12 oz regular strength beer) in a day or more than 14
drinks per week on average. Thresholds for women, and for men 65 years and older, are 4 or
more drinks in a day or more than 7 drinks in a week on average. A heavy drinking episode
occurs whenever a person’s alcohol consumption meets or exceeds the daily threshold of 5
drinks or more for men or 4 drinks or more for women, and for men 65 years and older). Heavy
episodic drinking is defined as repeated heavy drinking episodes.
Hazardous amounts of alcohol consumption for adults are determined by consensus and
epidemiological evidence. Similar definitions exist in other countries (with amounts defined and
described in more culturally relevant terms for those countries). These terms have only been
defined and are therefore only applicable to alcohol use. The exact definitions may change with
evolving epidemiological evidence and can also vary by preferences of those making clinical or
public health decisions regarding thresholds. In addition, the thresholds are not individualized
and although they are useful guides clinically, they cannot be thought of as absolute. For
example, it is not the case that drinking just under the threshold is associated with no risk, or
that drinking just above the threshold confers a substantially greater risk. Furthermore,
individual factors beyond age, sex and other risks as listed above can affect risk (e.g. weight).
2.b. Harmful use
Definition: Harmful substance use is use with health consequences in the absence of
addiction.
Discussion: The International Classification of Diseases uses this term as a diagnosis,4 and see
Appendix
defined as repeated consumption that has actually caused some form of physical or
mental damage. The ICD 10 definition also implies that the person with harmful use does not
have ICD 10 dependence. The full definition appears below the references in an Appendix.
Non-medical use or use more than prescribed of prescription drugs (or of over-the-counter
medications not as directed) can be harmful.
II. Terms that are not preferred to be used in clinical or research contexts:
1)
2)
3)
4)
Misuse
Problem Use
Inappropriate Use
Binge or binge drinking
Note: This list is not exhaustive. Terms that have been used widely were chosen for discussion
here.
Specific Definitions
1. Misuse
The WHO Lexicon defines misuse as use for a purpose not consistent with legal or medical
guidelines.2 It notes that the term “misuse” may be less pejorative than the term “abuse.” In its
screening efforts, the US Department of Veterans Affairs describes misuse as the target of
screening and intervention. The definition in that context has been the spectrum of use that
increases consequences (similar to unhealthy use as defined above). A journal, Substance Use
and Misuse, has been published in the United Kingdom since 1996. The main reason the term
misuse is not preferred is because there is confusion about whether or not it includes addiction
or substance use disorders. For example, the Department of Veterans Affairs uses “severe
misuse” to mean dependence. But “misuse” is not an appropriate descriptor for “dependence”
or “addiction” because it minimizes the seriousness of the disorder and suggests the disorder is
due to choice (to “misuse” the substance). “Misuse” also seems to have value judgment at least
potentially implied, as if it were an accident, mistake, or alternatively purposeful, neither of which
would be appropriate for describing the varied states incorporated in “unhealthy use.”
“Misuse” is often used to refer to hazardous or harmful prescription (or non-prescription but
potentially addictive) drug use. However, for similar reasons as those described above, it is not
a preferred term. “Misuse” of prescription or non-prescription over the counter drugs has been
used to describe the spectrum of unhealthy use or to denote hazardous or harmful use but not
addiction. In addition, “misuse” in this context is sometimes used to refer to non-adherence to
(e.g. non-psychoactive) medication (e.g. missed doses of an anti-hypertensive medication).
Therefore to avoid confusion and to clearly describe use of potentially addictive drugs in ways
that risk or have caused consequences, ASAM recommends the preferred terminology
framework described in this document.
2. Problem use
The meaning of this term is the same as “harmful” use. The term is not preferred because when
used with patients it has connotations that are not helpful and can be seen as pejorative if the
patient is viewed as being the problem or having a problem, as opposed to the substance being
a problem.
3. Inappropriate use
The definition of “inappropriate” is unclear and some may find it pejorative. Questions arise as
to who determines if use is “inappropriate” and adjudged by what criteria.
4. Binge or binge drinking
These terms can be useful in public health discourse because a “binge” is often understood to
be a heavy drinking episode. The US Centers for Disease Control uses the term to mean
heavy drinking episode. However, because it is used variably with different meaning it is not
generally preferred. Some who have heavy drinking episodes will consider “binge” to be
pejorative. Heavy drinking episode is simply descriptive and therefore preferred for that use.
The Journal of Studies on Alcohol and Drugs proscribes use of the term “binge” because it has
been used to mean many different things, from 4 standard drinks in a day for a woman, to a
“bender” during which a person drinks continuously for several days in a row. The general
public often uses the terms “binge” and “bender” interchangeably to describe a days-long
episode of heavy drinking. The National Institute on Alcohol Abuse and Alcoholism has a
specific definition for a “binge.”5 and Appendix The NIAAA definition can be useful for research
purposes. But even in research, data definitions have not been used in various studies with
consistency: “binge drinking” can mean drinking in a “binge” (a single heavy-drinking episode)
once per week, twice per week, once per month, twice per month, etc. Similarly, some have
used the term “frequent binge drinking” but there is no standardly accepted sense of how
“frequently” an individual must “binge drink” to be described as a “frequent binge drinker.”
III. Diagnostic and Statistical Manual of Mental Disorder (DSM) terms
The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been published by the
American Psychiatric Association for decades and is the most commonly used manual of
nosology for insurance coding and claims payment and for epidemiological research, at least in
North America. The fourth edition of the DSM (DSM-IV) ,6 described two Substance Use
Disorder conditions: Substance Abuse and Substance Dependence. The fifth edition (DSMV),7 and see includes a list of Substance Use Disorders (from mild to moderate to severe) and
abandons the use of the terms Substance Dependence and Substance Abuse. DSM terms are
not particularly relevant to defining the spectrum of substance use that affects health. The
same is true for the International Classification of Diseases. The reason is that unlike for other
medical conditions (e.g., impaired glucose tolerance and diabetes, pre-hypertension,
hypercholesterolemia and heart disease), the bodies responsible for the development and
publication of DSM and ICD have ignored the spectrum of relevance to health and have not
addressed “sub-threshold” conditions or risk factors. They define “disorders” and not substance
use states that fail to meet their own diagnostic criteria for a “disorder.”
It is important to note that there is overlap between some terms for the spectrum of use as
found herein, and the conditions which constitute DSM-V substance use disorder and ICD 10
dependence. Some with hazardous or harmful use will meet criteria for a DSM-V substance
use disorder (most likely “mild” or “moderate). Harmful use described above is essentially an
ICD 10-defined condition (except that ICD 10 requires recurrence in a specific time frame—see
Appendix).
IV. Moderate drinking
Moderate drinking is not preferred as a term because it implies safety, restraint, avoidance of
excess and even, health. Since alcohol is a carcinogen (and breast cancer risk increases at
amounts lower than those generally defined as hazardous, and lower limit amounts harmful to
the fetus are not well defined), better terms for amounts lower than at-risk amounts include
“lower risk” or “low risk” amounts or simply the term “alcohol use.”
REFERENCES
1. Saitz R. Unhealthy alcohol use. N Engl J Med 2005; 352:596-607.
2. Babor T, Campbell R, Room R, et al. Lexicon of Alcohol and Drug Terms. Geneva:
World Health Organization; 1994. (ISBN 92 4 154468 6). Available at
http://whqlibdoc.who.int/publications/9241544686.pdf, accessed May 27, 2013.
3. Saunders JB, Lee NK. Hazardous alcohol use: its delineation as a subthreshold
disorder, and approaches to its diagnosis and management. Comprehensive Psychiatry
2000; 41(2 suppl 1):95-103.
4. Saunders JB, Room R. Enhancing the ICD system in recording alcohol’s involvement in
disease and injury. Alcohol 2012:47(3):216–218.
5. NIAAA Newsletter, winter 2004, Number 3, page 3.
6. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text rev.).doi:10.1176/appi.books.9780890423349.American
Psychiatric Association: Diagnostic and
7. Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC, American
Psychiatric Association, 2013.
8. American Society of Addiction Medicine “Definition of Addiction”,
http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/publicpolicy-statements/2011/12/15/the-definition-of-addiction, accessed July 24, 2014.
APPENDIX
WHO/International Classification of Diseases definition of (International Classification of
Diseases (ICD) 10 harmful use
http://www.who.int/substance_abuse/terminology/definition2/en/index.html accessed May 27,
2013.
Harmful use
Definition
A pattern of psychoactive substance use that is causing damage to health. The damage may be
physical (e.g. hepatitis following injection of drugs) or mental (e.g. depressive episodes
secondary to heavy alcohol intake). Harmful use commonly, but not invariably, has adverse
social consequences; social consequences in themselves, however, are not sufficient to justify a
diagnosis of harmful use.
The term was introduced in ICD-10 and supplanted “non-dependent use” as a diagnostic term.
The closest equivalent in other diagnostic systems (e.g. DSM-IV) is substance abuse, which
usually includes social consequences.
ICD-10 Clinical description
A pattern of psychoactive substance use that is causing damage to health. The damage may be
physical (as in cases of hepatitis from the self-administration of injected drugs) or mental (e.g.
episodes of depressive disorder secondary to heavy consumption of alcohol).
ICD-10 Diagnostic guidelines
The diagnosis requires that actual damage should have been caused to the mental or physical
health of the user.
Harmful patterns of use are often criticized by others and frequently associated with adverse
social consequences of various kinds. The fact that a pattern of use or a particular substance is
disapproved of by another person or by the culture, or may have led to socially negative
consequences such as arrest or marital arguments is not in itself evidence of harmful use.
Acute intoxication, or “hangover” is not in itself sufficient evidence of the damage to health
required for coding harmful use.
Harmful use should not be diagnosed if dependence syndrome, a psychotic disorder, or another
specific form of drug- or alcohol-related disorder is present.
ICD-10 Diagnostic criteria for research
There must be clear evidence that the substance use was responsible for (or substantially
contributed to) physical or psychological harm, including impaired judgment or dysfunctional
behavior, which may lead to disability or have adverse consequences for interpersonal
relationships.
The nature of the harm should be clearly identifiable (and specified).
The pattern of use has persisted for at least 1 month or has occurred repeatedly within a 12month period.
The disorder does not meet the criteria for any other mental or behavioral disorder related to the
same drug in the same time period (except for acute intoxication).
National Institute on Alcohol Abuse and Alcoholism definition of “binge”
NIAAA Newsletter, winter 2004, Number 3, page 3.
On February 5, 2004, the NIAAA National Advisory Council approved
the following definition/statement:
A “binge” is a pattern of drinking alcohol that brings blood alcohol
concentration (BAC) to 0.08 gram percent or above. For the typical
adult, this pattern corresponds to consuming 5 or more drinks
(male), or 4 or more drinks (female), in about 2 hours.
In the above definition, a “drink”refers to half an ounce of alcohol
(e.g., one 12­oz. beer, one 5­oz. glass of wine, or one 1.5­oz. shot of distilled spirits).
Binge drinking is distinct from “at-risk” drinking (reaching a peak BAC
between .05 gram percent and .08 gram percent) and a “bender” (2 or
more days of sustained heavy drinking). For some individuals (e.g., older
people or people taking other drugs or certain medications), the number
of drinks needed to reach a binge­level BAC is lower than for the “typical’ adult.
Adopted by the ASAM Board of Directors July 2013
© Copyright 2013. American Society of Addiction Medicine, Inc. All rights reserved. Permission to make
digital or hard copies of this work for personal or classroom use is granted without fee provided that copies are
not made or distributed for commercial, advertising or promotional purposes, and that copies bear this notice
and the full citation on the first page. Republication, systematic reproduction, posting in electronic form on
servers, redistribution to lists, or other uses of this material, require prior specific written permission or license
from the Society. ASAM Public Policy Statements normally may be referenced in their entirety only, without
editing or paraphrasing, and with proper attribution to the Society. Excerpting any statement for any purpose
requires specific written permission from the Society. Public Policy statements of ASAM are revised on a
regular basis; therefore, those wishing to utilize this document must ensure that it is the most current position
of ASAM on the topic addressed.
____________________________________________________________________________
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