Tuesday, 18.05.2021

Peter R. Martin: Historical Vocabulary of Addiction




        According to the current electronic version of the Oxford English Dictionary (OED), the noun screening was formed within English by derivation and combination of the verb screen and the suffix -ing.  The verb screen itself was formed in English by conversion of the noun screen, a variant or alteration of the French escrein, which evolved to écran, meaning “fire screen (13th century), protective shield (mid-13th  century), dividing screen, partition (1538)” and most recently defined in OED as “A movable panel, and related senses.”  The verb screen has very many meanings in OED, including its first listed meaning in the English language, which is now obsolete (“To protect, conceal, or divide, and related senses. As an intransitive: To interpose oneself between (also betwixt) a person and something harmful or unpleasant, as a protective shield.”) 

        It was not until the 20th century that the verb screen acquired a meaning now used in medicine and is relevant to the field of addiction (“To examine [a person, especially as one of a large group] for the presence of disease or abnormality, especially as part of a survey rather than as a response to a request for treatment.”). The first use of the noun screening in the English language (“The action of sheltering, protecting, or concealing someone or something with or as with a screen. Also figurative: the action of hiding or keeping something from knowledge.”) is not relevant to this discussion.  However, the contemporary meaning of screening that is applicable to addiction is defined in OED as: “Medical examination of a person or group to detect disease or abnormality, especially as part of a broad survey rather than as a response to a request for treatment.”

        As just indicated, the meaning of screen/screening has evolved over the centuries — initially, these words referred to an impermeable, protective barrier, then the barrier became permeable, letting some of everything through and eventually, the barrier became selectively permeable and could ideally exclude all but entities that met decided-upon criteria.  The first meaning of the verb screen in the English language was as used by William Shakespeare (1564–1616), the English playwright, poet and actor, widely regarded as the greatest writer in the English language, in his play Hamlet (1604): “Tell him… your grace hath screend and stood betweene Much heate and him.”  An example of the meaning of screen, relevant to addiction, appeared in an article in the Journal of the Royal Statistical Society (Jones 1938): “A coefficient of correlation... provides a measure of the general association of an index with clinical assessment, whereas practical interest is directed on the particular boys whom it is desired to screen.”  The noun screening was first used in the English language as follows (Watson 1651): “If these Flames warme by degrees at a distance (and some danger drawes on of being scorch'd without screening) their dutie should prompt them to withdraw in due season.”  The first use of screening as relevant to addiction was in an article in Archives of Diseases in Childhood (Anonymous 1920): “ The working party persist in using the term screening as a synonym for the detection of abnormality while claiming to be scientific in their approach for surveillance.”  

        This last quotation refers to screening as, putatively, the first step in identifying with some certainty, an affected person from amongst many who likely do not have a particular condition.  In medicine, screening typically is followed by the process of diagnosis to establish, with greater certainty still, the presence of the condition in question.  Thus, the role of screening is to select the persons who should undertake the full effort required to establish the diagnosis of a disorder and simultaneously, to exclude those who have only a small, but finite likelihood of having the condition, as all screening tests have some level of uncertainty.  An individual can present without previous screening for evaluation and diagnostic testing should they believe there is a health concern; this can be called self-screening.  Screening is an important issue in all branches of medicine, especially in the diagnosis of disorders that may be occult, but nonetheless harmful to health — classic examples are screening for cancer, an infection or a genetic abnormality which may increase risk for developing a disorder.  The goal is identifying a condition that neither the physician nor the patient may know is present, in order to choose an appropriate treatment or, equally important, to provide reassurance that the patient is not affected.  Diagnosis has been fundamental to medicine throughout history (Ritchie 1820): 

        “As there is nothing which can more immediately affect the accuracy or success of a physician's practice than the truth or fallacy of the diagnosis which he is accustomed to form; so there is nothing which ought so powerfully to excite his attention as the peculiarities which different diseases assume. This is a subject of inquiry so essential in our profession indeed, and one which is so apt either to be neglected, or conducted on improper principles, that it cannot be too frequently recurred to, or too strongly insisted on. The experience of the medical practitioner is constantly presenting him with pathological facts to which he is a stranger, and with combinations of disease which he has never anticipated; while the precepts of his art, the most general in their application, are often fettered with exceptions, and the best established of the principles which direct him are subject to changes. A physician, in the exercise of his professional duties, is thus like a mariner in an unknown sea. The leading features of the scene may be familiar in both cases to the imagination, and their probable dangers estimated pretty correctly from analogy, but those of a minuter character cannot be so well judged of, and must consequently require an incessant examination.

        “In attempting the solution of a case in medicine, we will be often deceived, and almost always perplexed in our conclusions; for, as we have little save analogy to guide us, and are ever in danger of being misled in the application even of this, it cannot be expected that medicine will have either the precision or the constancy of a regular science. But methinks the very disadvantages under which medicine labours, as a science, should operate on properly tempered minds, as so many additional inducements to cultivate an acquaintance with it.”

        A distinctly different challenge is to determine whether a patient is suffering from addiction, a diagnosis that the physician may only suspect and might feel uncomfortable to address for a number of reasons (Mendelson, Wexler, Kubzansky et al. 1964).  Also, the patient may not easily divulge this problem to the physician for significant shame they experience from the associated stigma or, additionally, may not actually believe they have the disorder and completely deny the issue (Morey and Martin 1989).  So, even if the physician desires to help, they and the patient may be at cross-purposes.  Hence, there are two tasks of screening under these circumstances: first, to support the accuracy of the physician’s suspicions and second, to help the patient accept the problems associated with addiction and understand the challenges they face in order to achieve a more fulfilling and healthful life.  There certainly are other situations in medicine, aside from addiction, that similarly challenge the physician’s diagnostic and therapeutic acumen, but not many. 

        An example of an analogous clinical trial faced by physicians over the centuries is described in the following editorial, “On the Diagnosis of Syphilis” (Anonymous 1806):

        “It has been justly lamented, by accurate and eminent practitioners, that no criterion could be formed, at least by appearance, of the difference between, the true and spurious venereal sore; this, I confess, in numerous cases, is a difficult and almost impossible thing, and whoever solely trusts to the appearance of either a primary or secondary affection, without being guided by the history of the case, will be subject to perpetual error.”  

        This quotation suggests that an accurate diagnosis requires understanding of as much of the historical foundations of the clinical situation as can be obtained with the caveat that the patient may not feel free to discuss this.  If there are missing elements of the historical underpinnings due to denial of the problem by the patient, the physician is at a distinct disadvantage.  Accordingly, the physician must rely on clinical acumen or intuition and any and all the tools in the armamentarium. 

        For syphilis, laboratory testing has telescoped screening into diagnosis with a high level of confidence (Browne and Coffey 1958).  In contrast, skillful clinical evaluation has remained the standard for recognition of alcoholism, as discussed by O’Hollaren and Wellman (1958) in their article Hidden Alcoholic

        “In light of data on the prevalence of alcoholism and the recent indications of drastic change in the general description of the typical alcoholic, it seems logical to point out the following factors:

1. Alcoholism is a major medical problem.

2. Approximately 6 per cent of the total alcoholic population is receiving treatment of some type.  It is certain that the vast majority of alcoholics have physiological symptoms as a result of their alcoholism.  Many of them must be under medical care for these symptoms but have not yet been discovered to be alcoholics. Physicians are treating alcoholics in many cases without the benefit of realizing they are alcoholics.

3. Because of the ‘hidden’ alcoholic's compulsive need to keep his addiction hidden, he will usually not report to a physician the full extent of his drinking or the effect that alcohol has on his general health.  In such cases, the importance of obtaining an accurate history of the patient's characteristic response to alcohol cannot be overemphasized.  Where hidden alcoholism is suspected, the physician should carefully check the history of the patient with the spouse or some other member of the immediate family.  If a positive history of hidden alcoholism is obtained, the patient should be confronted with the diagnosis and advised to face the problem and the need for treatment.

4. Because of the popular misconception of the ‘typical’ alcoholic, physicians are failing in many cases to recognize alcoholism as the underlying cause of physical symptoms.”

        It is, of course, important to understand that the term “hidden” equally applies to other drug use disorders and behavioral addictions and an analogous explanation can be advanced for why diagnosis is so difficult (Martin Weinberg and Bealer 2007).  

        Screening for addiction can be accomplished by a range of approaches, from a few clinical questions related to consequences of alcohol/drug use elicited in the clinical exam or through a paper and pencil task (Manson 1949; Mayfield, Mcleod and Hall 1974; Ewing 1984; Morey and Martin 1989), validated comprehensive questionnaires that are now often computerized for self-completion (McLellan, Luborsky, Woody and O’Brien 1980) and laboratory or toxicological tests which identify abnormalities resulting from alcohol or drug use or the presence/quantification of the substance(s) in body fluids (Magliozzi,  Kanter, Csernansky and Hollister 1983; Skinner, Holt, Schuller et al. 1984; Eckardt, Rawlings and Martin 1986; Mueller, Fleming, LeMahieu et al. 1988; Schwartz 1988; Neumann, Beck, Helander and Böttcher 2020; Trana, Mannocchi, Pirani et al. 2020).  The results of these measures typically have undergone validation research studies so as to be able to yield probabilistic statements about the likelihood that the tested individual has the condition in question (Griner, Mayewski, Mushlin and Greenland 1981; Sox 1986).  For example, an approach using a simple screening test comprised of four questions which can seamlessly be incorporated into a clinical examination has striking sensitivity and specificity (Bush, Shaw, Cleary et al. 1987). 

        A clinically useful strategy is simply to ask whether there is a family history of alcohol use disorder, which can support the presence of alcohol and drug use disorder in a patient in which this disorder may be suspected on the basis of the clinical presentation (Miller,  Gold, Belkin and Klahr 1989).  Multiple testing approaches using laboratory tests have been implemented over the years, but none are strikingly superior to skillfuly asking the patient the questions identified in the simplest screening tests (Bernadt, Taylor, Mumford et al. 1982).  An inclusive screening/assessment/diagnostic approach is provided by the Addiction Severity Index (McLellan, Luborsky, Woody and O’Brien 1980).  This instrument provides a comprehensive assessment of the disorder and its complications via a problem severity profile across six domains: substance (drug and alcohol) abuse, medical, psychological, legal, family and social and employment/support and can also be utilized for developing a treatment plan.  Finally, single or combined laboratory findings can be used to provide enhanced mathematical modelling of the presence of a drug use disorder (Ryback, Eckardt, Rawlings and Rosenthal 1982).

        Screening tests can serve to anchor the physician’s understanding of the clinical situation and allow them to more confidently approach the patient with the perceived problem.  Perhaps more important, the results of screening can provide an entrée to a therapeutic interchange with the often reluctant patient.  The goal of this clinical discussion is to help the patient begin to appreciate that a problem does exist.  Therefore, screening can serve as a useful starting point for initiating progression of the patient through the stages of change using motivational interviewing, a heuristically useful behavioral approach with demonstrated efficacy in treatment of addiction (Miller 1983; Prochaska and DiClemente 1983).  Nevertheless, every one of these validated tests must be combined with clinical skills and judgement as there is no single test which alone renders the positive results into a diagnosis with certitude.  For addictive disorders, making the diagnosis does not mean that the physician can treat and “cure” the patient as has become possible for the previously discussed sexually transmitted disease, syphilis, for which diagnosis and treatment are now both widely available (Ropper 2019).  Rather, clinical identification of addiction is a call to action for the patient (and perhaps also the physician), a challenge which they may choose, or not, to transform a harmful disease into the process of recovery (Martin 2020).



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February 11, 2021