by Chris Hilburn-Trenkle
Growing up in the Washington D.C. metropolitan area in the 1990s, Orrin Ware saw the damage that was caused because of the stigma surrounding individuals struggling with substance use disorder. Instead of receiving help, care and treatment, those individuals were often incarcerated and left behind by society.
Ware, an assistant professor at the University of North Carolina at Chapel Hill School of Social Work, focuses on adult substance use disorder treatment, a subject that has changed rapidly over the last 70 years. He’s written about substance use extensively, recently publishing “Lean/Sizzurp ingredients, use, and coping with mental health symptoms” on Sept. 22 and “Poor sleep quality and other risk factors for unemployment among patients on opioid agonist treatment” in 2022, as well as co-authoring countless additional publications.
Ware recently approached the subject of substance use disorder treatment from another angle. He analyzed the diagnostic components of opioid use disorder and the way the definition of the disorder has changed over time, using the five editions of “Diagnostic and Statistical Manual of Mental Disorders” as his source.
His chapter, “Opioid use disorder: Diagnostic history and current understanding”, co-authored with Kelly Dunn (Johns Hopkins University), was published in August of 2023 in The Oxford Handbook on opioids and opioid use disorder.
Through his background research, which lasted roughly six months, Ware combed through all five editions of the DSM to examine the way substance use disorder was defined over time. Accurately diagnosing substance use disorders is vital for providing the requisite care, and Ware saw through his research the evolution of how substance use disorders were understood.
“It was really fascinating to see how the definition of addiction changed over time,” Ware said. “For example, in the DSM 1, the only real examples that they used were related to alcohol use disorder or what we would now call alcohol use disorder. Opioids barely even popped up in the DSM 1. It was ultimately interesting to see how early on substance use disorders, or addiction, were initially seen as personality disorders and now they’re seen as their own category of mental health disorders. That’s really fascinating to see how this has changed over time and fallen into its own category when at first it fell under the category of a personality disorder.”
Ware is encouraged by the growth in the field regarding how substance use disorders are viewed, with more emphasis put on compassion, treatment and help for individuals who are struggling with addiction. Part of the change over time was precipitated by those who have shared their struggles and used them as a framework for others who need help, such as becoming peer recovery specialists to assist those in need.
“As more and more folks are coming forward and describing their story it really adds a human component that I feel like the earlier editions of the DSM were missing,” Ware said. “Just speaking from my experiences of working in residential, outpatient and crisis facilities, I would be one of the first faces that someone would see after they were transferred to our clinic after they had an overdose and were brought back to life. What I can say is that people need our help and care, not stigma or blame or any negative feedback toward them.”
While there is still work needed to be done in the field, Ware noted that there are more resources available than ever before, thanks to the emphasis on public care, treatment and rehabilitation.
However, he stated the importance of realizing that the way we view substance use disorders is constantly changing — what we view as symptoms and conditions today could be drastically different in the future.
“There may even be conditions today that may not be conditions tomorrow or symptoms of conditions today that may not be symptoms of conditions tomorrow,” Ware said. “Having a greater understanding of how the field determined what these diagnostic criteria may be is essentially helpful in any clinical practice, or research practice, etc. Diving deep into the opioid use disorder history unlocked a broad range of factors I wasn’t even aware of in terms of history, how there was something called the soldier’s disease during the Civil War (preceding the first DSM in the US), which was essentially opioid withdrawal because of morphine, and so it really gives you a broader appreciation of what these conditions are, how they’re defined and how these conditions may change in the future.”
