Journal of Pain & Palliative Care Pharmacotherapy. 2015;29:44–47. Copyright © 2015 Informa Healthcare USA, Inc. ISSN: 1536-0288 print / 1536-0539 online DOI: 10.3109/15360288.2014.997855

COMMENTARY

Make Your Words Support Your Message Willem Scholten AB STRACT Correct use of terms in a manuscript or policy statement is important to meet the objectives of the paper. Inappropriate terms can be counter-productive. The World Health Organization (WHO) recommends the following: ‘Terminology in national drug control legislation and policies should be clear and unambiguous in order not to confuse the use of controlled medicines for medical and scientific purposes with misuse’ and terminology should always be respectful. This commentary lists English language terminology that can impair access to controlled medicines for the treatment of pain and suffering (an objective of the international substance control conventions), including pain management and the treatment of opioid dependence. The commentary also suggests alternative wording. Assessment of terminology correctness is language sensitive and should therefore be conducted by native speakers. In all language communities, advocates should explore and discuss the terminology with health-care professionals and their clients/patients, and they should promote the use of correct vocabulary. KEYWORDS terminology, access to medicines, controlled substances, pain treatment, dependence

INTRODUCTION

Promoting Correct Terminology Table 1 lists English language terminology that does not contribute to access to controlled medicines for the treatment of pain and suffering (an objective of the international substance control conventions), including pain management and the treatment of opioid dependence. Alternatives are provided. The author recently circulated a brief document on appropriate terminology for advocating access to opioid medicines for pain management and the treatment of opioid dependence among a small circle of colleagues. Almost one-third responded, and all responses were positive. Of interest, however, some of the respondents have communicated with the author for years and have attended his presentations on these topics. Nevertheless they continue to use some of the contested words. The reason for this may be that one really has to force oneself to change long-held habits and one might even feel that others will laugh at them when they suddenly begin using correct language. Although using preferred terminology may initially require discipline rather than continuing to use the terminology that one “always” has used, not doing so can result in the need for extra effort needed to convey the intended message.

The use of terms—wording—is important in legislation, policy statements, and wherever clear communication is essential. Correct use of terms in a text body contributes to meeting the objectives of the document. Like body language, it is important for a speaker and can send messages contrary to what the speaker is saying. Use of inappropriate terms can be counter-productive for the enforcement of legislation or the implementation of policies. The World Health Organization (WHO) recommends the following: “Terminology in national drug control legislation and policies should be clear and unambiguous in order not to confuse the use of controlled medicines for medical and scientific purposes with misuse.”1 Furthermore, WHO has a general rule that terminology should be respectful towards people.

Willem Scholten, PharmD, MPA, is a Consultant in Medicines and Controlled Substances and former staff member of the World Health Organization. Address correspondence to: Willem Scholten, PharmD, MPA, Lopik, The Netherlands. Tel./Fax: +31 348 769 029. (E-mail: [email protected])

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TABLE 1. Terminology that does not contribute to access to controlled medicines for the treatment of pain and suffering and alternatives TERM

PROBLEM

ALTERNATIVE(S) 1,2

Abuse

Judgmental and ambiguous.

Addict Addiction

See addiction Considered pejorative and stigmatizing by the WHO Expert Committee on Drug Dependence.3 See addiction

Addictive substance Criminal law (if referring to substance control legislation) Dependent person Drug

Harmful use, hazardous use, nonmedical use, recreational use (depending on the situation) Person with dependence Dependence, dependence syndrome Dependence-producing substance

International law on substance control is about the “health and welfare of mankind” and as national law is in most cases based on the conventions, it is too.1

Health law

See WHO Style Guide: this reduces the person to one characteristic only Ambiguous language; in particular, when a controlled medicine is meant, the word interferes with the promotion of its availability.1 Reduces the people to one characteristic only See “Abuse.”2 Archaic terminology to refer to a class of substances by an unimportant side-effect of only some members of the class. Narcotic suggest the side-effect “sleep inducing,” but this is since decades called “hypnotic.” Furthermore, it is hardly a side-effect of any substance in the Single Convention, and certainly not the main side effect for opioids, which is constipation. Moreover, some substances in this convention are stimulants.1 Not in line with chemical nomenclature rules. Suffix “-ate” is reserved for salts and esters.1

Person with dependence (syndrome) Depending on the context: either medicine or substance of misuse

Psychotropic substance

Not really problematic, but just not usual.1

Psychoactive substance

Physical dependence

Usually refers to the symptoms of withdrawal and tolerance, which do not constitute dependence, however. Who says “physical dependence” tells his audience that this is dependence, but at the same time, intends to say that this is not a problem. Contradictory as this is, it is not very likely that the audience will accept or even understand such a message. It is much easier to use “tolerance” and “withdrawal” and to explain that for dependence at least one of four other symptoms are necessary

Withdrawal and/or tolerance

Drug users Misuse Narcotic

Opiate

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REMARKS

People who use drugs

Psychoactive substance (or for specific cases: opioid medicines, opioid analgesics etcetera)

Opioid

See preambles of the Single Convention on Narcotic Drugs and the UN Convention on Psychotropic Substances

Note that using drugs is not the same as being dependent Considered less judgmental than abuse Use of “narcotic” is only justified if it refers to the list of substances regulated by the Single Convention on Narcotic Drugs

See Glossary of WHO Guidelines Ensuring Balance in Controlled Substance Policies for the various different meanings of the word “opioid” Use of “psychotropic” is justified if it refers to the list of substances regulated by the UN Convention of Psychotropic Substances 28th ECDD (1992) decided that physical and psychological dependence cannot be defined properly and abolished the terminology, replacing it by “dependence” and concluded that its definition of dependence is in line with the definition in ICD-10 The four other symptoms required for dependence are: 1. a strong desire to take the drug, 2. difficulties in controlling its use, 3. persisting in its use despite harmful consequences, 4. a higher priority given to drug use than to other activities and obligations (ICD-10) (Continued on next page)

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TABLE 1. Terminology that does not contribute to access to controlled medicines for the treatment of pain and suffering and alternatives (Continued) TERM Shooting galleries StatisticalDDD or S-DDD

Substitution therapy

PROBLEM

ALTERNATIVE(S)

Pejorative/stigmatizing

Safe injection rooms

Linguistically incorrect terminology introduced by INCB

DDD (Defined Daily Dose)

Gives the impression to politicians, civil servants, and other lay people that this therapy is replacing “street drugs” with “state drugs” and therefore this language counteracts availability of therapy

Opioid agonist therapy, opioid agonist therapy for the treatment of dependence, OAT

The WHO Lexicon Consistent use of terminology is difficult anyway, as illustrated by the WHO Lexicon of alcohol and drug terms.2 Although very useful for understanding a number of terms, even this lexicon does not fully follow WHO guidance on the use of terms. For example, the lemma “addiction” is worded in a way that it legitimizes those still using it, in spite of the fact that the Expert Committee on Drug Dependence considers it stigmatizing and pejorative3 and that it is not defined in the WHO International Classification of Diseases (ICD-10), where it is called “dependence.”4 Although abandoned by WHO around 2000, the lexicon also still uses the ambiguous word “drug” for “medicines.”

Interlanguage Portability The terminology listed in Table 1 illustrates this point. It will always be necessary to explore the exact connotation and emotional value of terms, which nearly always requires the input of native speakers. Other speakers have to rely on what native speakers tell them. Table 1 cannot automatically be transposed to other languages, even within the various Anglophonic countries. It is conceivable that the connotation and emotional values of a term are not the same everywhere. For other languages, the process of analyzing the meaning of the words starts anew. A good example of this are the French words “addiction” and “d´ependance.” In French, “addiction” is less stigmatizing than “d´ependance.” “Addiction” was introduced only in the 1990s from English, after the word “d´ependance” became associated (over “toxicod´ependance”) with the word

REMARKS

WHO definition includes that “DDD” is intended for statistical purposes, therefore the addition “Statistical” is a duplication. (A “tautology” in philological terms.)

“toxico” (junkie). (Personal information Dr. Simon Olivier, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.) In some other languages, there is only one equivalent word for both addiction and dependence.

CONCLUSION For advocates of access to opioid medicines, avoidance of pejorative, stigmatizing, disrespectful, or otherwise incorrect language is important for effective advocacy. Advocates will have to explore and discuss the terminology together with health-care professionals and their clients/patients and promote the use of agreed upon, correct vocabulary. For global access to opioid medicines, stakeholders in all language communities should explore their professional terminology. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

REFERENCES [1] World Health Organization. Ensuring Balance in National Policies on Controlled Substances, Guidance for availability and accessibility of controlled medicines. Geneva, World Health Organization, 2011. ISBN 978 92 4 156417 5. Available at http:// www.who.int/medicines/areas/quality safety/guide nocp sanend/ en/index.html. Accessed October 31, 2014. [2] World Health Organization. Lexicon of Alcohol and Drug Terms. Geneva, World Health Organization, 1994. ISBN 92 4 154468 6. Available at http://apps.who.int/iris/bitstream/10665/ 39461/1/9241544686 eng.pdf. Accessed November 2, 2014.

Journal of Pain & Palliative Care Pharmacotherapy

W. Scholten [3] World Health Organization. WHO Expert Committee on Drug Dependence, Thirty-fifth report. WHO Technical Report Series 973, Geneva, 2012. ISBN 978 92 4 120973 1. Available at http://apps.who.int/iris/bitstream/10665/77747/1/WHO trs 973 eng.pdf. Accessed November 2, 2014.

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[4] World Health Organization. International Statistical Classification of Diseases and Related Health Problems: Tenth Revision (ICD-10). 2nd Edition. Geneva, World Health Organization, 2002. [electronic resource] Chapter V, F10-F19. Available at http://www.who.int/classifications/apps/icd/icd10online2003/fricd.htm Accessed November 2, 2014.

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Make your words support your message.

Correct use of terms in a manuscript or policy statement is important to meet the objectives of the paper. Inappropriate terms can be counter-producti...
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