Summary
The issue is around the terminology for substance use/misuse/abuse. At present there is inconsistency in this area of the terminology and we are keen to rationalise this to the most up to date clinical representation. In some instances misuse and abuse terms are used synonymously, attached to the same concept as below – in this instance Substance misuse is flagged in the terminology as the UK preferred description so a system would pick this up for display in the record:
In other instances these terms are used on separate distinct concepts:
conceptId1 | Description1 | conceptId2 | Description2 |
84758004 | Amphetamine abuse (disorder) | 428659002 | Amphetamine misuse (finding) |
231462006 | Barbiturate abuse (disorder) | 428623008 | Barbiturate misuse (finding) |
37344009 | Cannabis abuse (disorder) | 428823006 | Cannabis misuse (finding) |
78267003 | Cocaine abuse (disorder) | 429782000 | Cocaine misuse (finding) |
ICD-11, though still in Beta, seems to be proposing “harmful pattern of use of <substance>” (with ‘abuse’ as a narrower term) and <substance> dependence as distinct categories.
DSM-V , I believe has dropped the abuse and dependence descriptions (used in DSM IV) and uses ‘substance use disorders’ on a continuum of severity, mild, moderate, severe.
Advice sought from UK Clinical Lead for addictions who advised that ‘abuse’ is not used. Misuse, harmful use and dependence are clinically useful terms. Misuse is used as a collective term for the ICD-10 categories of ‘Harmful use’ and ‘dependence’. But the latter are used instead of misuse if referring to specific pathways of care as they are different clinical pathways.
Discussion at UK Edition Committee who are keen to have the work associated with project tracker item https://jira.ihtsdotools.org/browse/IHTSDO-405 progressed. We have also discussed a limited interim solution for our April 18 Edition release so the UK clinicians are not forced to use content that contains ‘abuse’. Additions to UK extension of the type ‘Harmful use of X based on the subtypes of 66214007 | Substance abuse (disorder).
We would be interested to hear if other countries are experiencing similar issues with this content. The UK clinicians are happy to continue to input in to discussions.
| Date | Requested action | Requester(s) | Response required by: | Comments |
|---|---|---|---|---|
Relevant documents
Actions
| Date | Requested action | Requester(s) | Response required by: | Comments |
|---|---|---|---|---|
| 13 December 2017 | Request for information on members identified issues with current conent plus priority of clean up of area. |
| Please post your final responses in the Country response table below. Discussion comments can be made as comments. |
Links
IHTSDO-405 - Getting issue details... STATUS
Country response
| Country | Date | Response |
|---|---|---|
| Denmark | December 14 2017 | January 25th 2017 I submitted a request through CRS: "Is there a difference between concepts CID: 429782000 |Cocaine misuse| and CID: 78267003 |Cocaine abuse| ? Both concepts exist in Clinical finding, one as a 'Behavior finding' the other as a 'Drug-related disorder'. Translation into DK gives some difficulties. Misuse could perhaps be thought of as a 'wrong way to use cocaine' but that is hardly the meaning of the concept." This is the answer I go back ""Drug misuse is defined as the use of a substance for a purpose not consistent with legal or medical guidelines (WHO, 2006). It has a negative impact on health or functioning and may take the form of drug dependence, or be part of a wider spectrum of problematic or harmful behaviour" https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015201/ 429782000|Cocaine misuse (finding)| describes a behaviour and is a clinical finding, 78267003|Cocaine abuse (disorder)| is a drug related disorder. Both concepts appear to be appropriate for inclusion in SNOMED CT. " Perhaps the synonymes of these concepts should be reviewed too e.g. 66214007 |substance abuse | has both 'nondependent abuse of substance', 'nondependent abuse of drugs' and 'harmful substance use' which probably cannot all be true at the same time... Just a little add on. Please note that the definition of 'moderate alcohol consumption' mentioned in Australias input is not universal. In Denmark our authority talks about 'low risk of becoming ill due to alcohol consumption' (7 units a week for women and 14 for men) and 'high risk of becoming ill due to alcohol consumption' (more than 14/21 units of alcohol a week). |
| Sweden | 2017-12-15 | The Swedish translation is using one word for abuse and missuse: "missbruk" (literally "missuse") so the exact same issue does not exist in Swedish. We have had the same translation problems as our Danish friends and 429782000 |Cocaine misuse| and 78267003 |Cocaine abuse| have the same Swedish preferred term. Also in Sweden, there is an increasing scepticism towards the use of the word(s) "missuse"/"abuse" and "dependence" or "harmful use" is used instead. |
| Australia | 20171218 | Agree with everything in the attached slides, sorry I missed the presentation. We have had researchers contact us about this content area, so it is of some national interest. And we certainly agree with the problems outlined, so there is definitely an opportunity to improve this content. "Misuse" implies there is some "correct use". Then there's the judgement against moral/legal/social acceptability considerations, which I don't think are defining in the sense we'd think about within the terminology. "Alcohol abuse" "Amphetamine abuse" "Cannabis abuse" "Cocaine abuse" - It's possible the meaning of each of these varies depending on the context... (e.g. between countries...). I just noticed we have the Preferred term in our AU extension for 361055000|Misuses drugs (finding)| is "Substance abuser". Both have accidental and intentional variants, so that's that's not the distinguishing factor... See : 82782008|Ethanol poisoning| vs 25702006|Alcohol intoxication|. Is every episode of a drunk patient an episode of alcohol poisoning ? ... From the information provided by UK, I'd probably lean to something like what DSM-V. A simple "Uses Substance (clinical finding)". (non-drugs are also abused). e.g. "moderate alcohol consumption" is currently "one drink per day for women and up to two drinks per day for men". Ideally i suspect it'd be best to define concepts with quantifiable values, and then the preferred terms change over time/context. The caution on Slide 12 about impacts to existing implementations is valid, and I think sometimes why nothing is touched... Implementing any changes within a single release would be useful for analytics. (knowing the point in time things changed). |
| Netherlands | 20171221 | We also had some issues with these concepts, especially in the translation of the concepts. Misuse and abuse have the same translation in Dutch. I do understand the difference of the English words Misuse and Abuse, but the slightly different definitions aren't correctly/consistently used in Snomed CT. In the Netherlands we now have three of these concepts in our reference lists for hospitals: abuse, use and dependency. The misuse is not used (yet) in the Netherlands but I can understand it could be used for medication registration (deviate from prescription). |
| New Zealand | 22Jan2018 | It appears that the different clinical areas (and within areas) have differing approaches to the application of these terms. It would be helpful to add clear definitions to the concepts to clarify intent of use and ensuring they are appropriately placed within the hierarchy. Overall there are a range of areas that should be improved in the ‘toxicology’ area and having a review/input by experts in the area would be helpful (e.g. exposure, overdose, poisoning, intoxication). Consider poisons control/information centers where a lot of (non SNOMED) coding is done and the International Programme for Chemical Safety (IPCS). |
| Canada | Jan 24 2018 | We have experience same issues as Netherlands when translating from English to French. The Translation Editorial team at the time provided guidance to the translators to assure consistency at least in the translation. I would be in favor that a definition be added as a synonym for the 'parent' concepts for each of the categories identified, where there is a potential for incorrect or inconsistent use of some of these concepts. I think this would help users to guide them in their choices if they could rely on definitions that are recognised internationally and are intrinsic to the terminology... if we can have a consensus of course! |
| US | Jan 24 2018 | SNOMED CT also uses X use disorder, as in 11061003 | Psychoactive substance use disorder (disorder) |. One solution might be to generalize this pattern for specific substance or groups thereof. For example, "Opioid use disorder" is ther term of choice used by the U.S. National Institute on Drug Abuse. |
| Member countries without a CMAG rep |
CMAG response
| Date | CMAG Response | Next steps |
|---|---|---|
Final outcome:
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