Some conditions are used as a basis for commemoration. Years ago, the U.S. Postal Service released a stamp for breast cancer awareness. “Fund the fight. Find a cure,” is the motto appearing on the colorful stamp. Over 785 million stamps have been sold, despite costing a few pennies more than the actual postage rate, which resulted in raising $58.3 million for breast cancer research since 1998. Since 1991, individuals have worn pink ribbons to raise awareness of various breast cancer issues. In 1981, the U.S. Postal Service released a stamp for alcoholism awareness. The stamp carried the unfortunate wording, “Alcoholism You Can Beat It.” Postal customers were understandably reluctant to frank their letters with such a stamp. The result: one of the lowest-selling stamps of the time period. Even without such wording, however, I suspect that the stamp would not have sold in anything close to the numbers seen for the breast cancer stamp.

Part of the difficulty here is that the public does not perceive substance use disorders as having a conclusion. Indeed, our language concurs: Patients are “in recovery,” not “recovered.” Patients have a diagnosis of substance dependence, “in remission,” as opposed to having no diagnosis. Once an alcoholic, always an alcoholic, even if you can beat it! What good is remission or recovery if you’re not better? And why would you send a “Get Well Soon” card to someone who would simply reply, “Sorry, that’s not possible as I’ll always have cocaine dependence. The best I can hope for is remission.” Even with cancer, there’s a possibility that remission is representative of a cure, and that the patient is actually cured. But with alcoholism, that’s just never the case.

And what do our summarizing statements mean? Place these words in order as seen in the typical disease course: sobriety, recovery, abstinence, remission. Do you think that readers will all agree on their responses? Will patients agree with our order? Even with the word remission, there are multiple possible interpretations. If you look at the DSM-IV, you’ll find separate entries for alcohol dependence and sedative dependence. So, if a patient decides to switch from beer to benzo, his alcohol dependence would be in full remission — but he’d have a new disease, sedative dependence. \

Alcoholism, however, has always been defined as applying to any sedative agent, of which alcohol is simply the prototype. Alcoholism is, therefore, just as present in someone using benzo or barb as it is in someone using alcohol. No remission would be present, so your patient would have alcohol dependence in full remission and sedative dependence per DSM, but plain old alcoholism, if we ignore the psychiatric manual.

We can look at this another way — with DSM-IV, one can meet all the criteria for alcohol dependence, then reduce alcohol intake such that the specific criteria are no longer met for a period of time. That patient, despite continued alcohol intake, would have a diagnosis of alcohol dependence in full remission during this period. But the patient is still drinking! We know from experience that this situation will not persist. There is no remission here at all. This is akin to a patient having cancer, then having the bulk of the tumor removed. The tumor size is now reduced; morbidity related to tumor mass is reduced or even eliminated. It is even possible that the patient has no subjective symptoms of cancer. We would not call this remission because we can still easily detect the cancer, just as we can easily detect alcoholism in the patient who is still drinking, despite minimizing intake.

So, remission from one disease is defined as different from remission from another disease. However, most people think alcohol dependence and alcoholism are synonymous — don’t they? The two disease states are defined quite differently along a number of parameters; as a result, a state of remission from one is not necessarily remission from the other. And what about recovery? Does recovery differ from remission? In recovery, is the patient “all better,” as opposed to remission, where a relapse seems to be an expected eventual outcome? Since remission doesn’t necessarily imply abstinence or sobriety, and since recovery may be something else entirely, would you change the ordering of the four diagnostic terms discussed above?

My own opinion has abstinence coming first, indicating nothing more than cessation of substance use. Sobriety comes next, with the psychological overtones that the term carries implying that sobriety equals abstinence plus something more. Remission, from a medical perspective, indicates that there are no more signs or symptoms of a disease state. Since substance use disorders are much more than substance use, remission equals sobriety plus something more. Recovery would represent the final step, as it indicates remission plus some additional functional improvement that would substantially lower the risk of any future disease episodes.

Would the general public respond better to this disease if we were to switch to “recovered” so that there is a sense of conclusion? Or would this totally disrupt the need for such patients to continue actively participating in that recovery? Would it make people think that the former patient can now use drugs “normally?” How can we fix one side of the equation without breaking the other? I’m happy to hear feedback at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

This column represents Dr. Gitlow’s personal opinion and does not imply any position or policy taken by either the AMA or ASAM.

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cl****jr  - "ed" for 'Past Tense'   |68.229.220.xxx |2008-11-24 08:44:37 I have had two bouts with cancer; one was prostate in which general prognosis is often grim if not detected early and attacked aggressively. When I was diagnosed, I was immediately sent to schedule a procedure that would determine severity, and then a course of action to remove and/or irradicate the diseased flesh and based upon that result, decide the amount, seriousness, and the quantity of action required to manage OR get rid of the cancer. Today, as a result of the treatments pursued, I have been totally cancer free for almost 1 1/2 years. (The onset was almost two years before the pronouncement 1 1/2 yrs ago.) When the course of action was determined, I was considered "in treatment" for the disease; then, upon success of the initial treatment, I was said to be "in remission". Finally, after being in "remission" for a medically predetermined period of time without any further recurrence, I... Reply 1   0

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