Substance Use Disorders Are Psychiatric Disorders

To the Editor: I appreciated the dedication of the June 2023 edition of the Journal to advances in our understanding of substance use disorder (SUD). For too long, the field of psychiatry has abdicated its responsibility to the profession and to patients as it concerns addictive disorders (1). The separation of the SUD treatment sphere from the rest of psychiatric care dates to an era when SUD was considered a moral failing and social problem rather than the brain disease research has shown it to be (2). Stigma toward patients with SUD remains pervasive among health care professionals and psychiatrists are not immune (1). Language is an important driver of stigma particularly pertaining to unconscious bias (3). Words matter, and the words we choose to describe SUD have the power to perpetuate or counteract stigma (3).

It was therefore disappointing to see the terminology in the Editor’s Note (“Focusing on Substance Use Disorders, Opioids, and Craving”) contribute to SUD stigma within the psychiatric profession by othering SUD as non-psychiatric (4). Kalin writes, “This issue of the Journal is focused on substance use disorders and how they relate to psychiatric illness” and “It is important to recognize that substance use disorders are highly comorbid with psychiatric disorders.” (4) These assertions, as well intentioned as they may be, are veritably false. Creating an artificial separation between SUD and other psychiatric disorders alienates SUD as not being in the purview of psychiatrists who manage “psychiatric disorders.” The reality is that SUD are psychiatric disorders and our own DSM-5-TR states this plainly by dedicating an entire chapter to Substance-Related and Addictive Disorders (5). At 121 pages, it is the manual’s longest chapter (5), underscoring the importance of recognizing SUD.

Stigma toward addiction in psychiatry is well-known and addressing substance use in psychiatric care is “an old problem with renewed urgency.” (1) To increase accountability and agency among psychiatrists to address SUD we must start by recognizing SUD as a psychiatric illness for which we are responsible to address as part of routine psychiatric care. The clinically accurate terminology “SUD and other psychiatric disorders,” validates SUD as a psychiatric disorder and differentiates it from other categories of psychiatric disorders with which it often co-occurs. Although seemingly semantics, this subtle change has the potential to counteract stigma and unconscious bias. As Zisman-Ilani et al. recently wrote, “Substance use is not separate from mental health.” (1) It is time the language we choose to describe SUD and other psychiatric disorders reflects this reality.