O'Brien 1 focuses on debates between clinicians and non-clinicians over the use of the terms ‘addiction’ and ‘dependence’ in various versions of the DSM. In this commentary, we highlight several issues relating to the politics and ethics of diagnostic instruments such as the DSM. Our first point is that all diagnostic instruments and practices construct their objects rather than describe a pre-existing ‘reality’. Recent work in science and technology studies is especially helpful in understanding this point (e.g. 2-6). This work sees reality as partially produced within the scientific processes used to ‘observe’, ‘measure’ or ‘diagnose’ it. That is, our tools for making knowledge help to constitute the very phenomena under observation. Viewed from this perspective, diagnostic instruments such as the DSM-V inevitably shape the ‘disorders’ associated with drug use as they diagnose them. This approach allows us to ask some important questions about drug use. What happens when a set of practices come to be diagnosed as representing ‘addiction’ or ‘dependence’? What framings and effects result from such diagnoses? One effect of the framing implicit in the DSM's diagnostic criteria is the construction of particular types of human beings who are not only identified with, but defined by, pathology. In the case of substance use, the category of ‘addiction’ inscribes those included in it as deficient in the rationality and self-control regarded as fundamental to moral agency and productive citizenship. Because the designation ‘addict’ is often applied to already marginalized and disempowered individuals, it can easily be used to dismiss the validity of their claims and the significance of their suffering 7. It can also be used to justify discriminatory and coercive treatment, in that ‘addicted’ subjects are understood as being controlled by their need for drugs and therefore incapable of making sensible decisions about their own lives 8, 9. The power of the addict identity is demonstrated in one of the arguments given for the proposed replacement of ‘dependence’ with ‘addiction’ in the DSM-V. O'Brien and others have argued convincingly that adopting the term ‘dependence’ for ‘compulsive’ drug use has caused unnecessary suffering to pain patients denied adequate treatment because of physicians' fear of producing addiction. We are told that the problem with ‘dependence’ is that it promotes confusion between the ‘normal’ physiological responses of opiate-treated pain patients and the ‘disorder of uncontrolled drug seeking’ demonstrated by addicts; but the distinction between normal dependence and addiction is produced in part by the different status of these two groups. Unlike illicit drug users, pain patients have access to a legitimate and controlled supply of opiates with which to manage their symptoms 10. However, pain patients sometimes behave like ‘uncontrolled’ addicts. The concept of ‘pseudoaddiction’ was developed in pain medicine to describe the disordered behaviour of patients who increase their dose without approval, complain aggressively or lie to obtain more drugs, and turn to street drugs or ‘doctor shopping’11. Significantly, pseudoaddiction is understood as an iatrogenic condition caused by under-treatment. Once pain is properly managed, the desperate drug-seeking ceases. Reflecting on pseudoaddiction, Passik & Kirsh (11, p. 291) note that it is ‘a somber realization that patients can be pushed to uncharacteristic ways of behaving . . . driven by our failure to optimally treat them’. The same point could be extended to the behaviour of ‘addicts’, especially in relation to the effects of opioid pharmacotherapy. However, because addicts are already characterized as erratic and antisocial, their conduct is interpreted as a sign of their pathology rather than the result of a particular social context 7. This is certainly not to deny that pain patients deserve effective and sensitive medical treatment, but it is to question the differential ethical response to drug-dependent populations promoted by the category of ‘addiction’. Moreover, as many have observed, despite their framing as objective descriptions of harm and impairment, the DSM criteria rely on ethical and moral judgements about life-style, conduct and priorities 12, 13. For example, the criterion that ‘important social, recreational or occupational activities are given up because of substance use’ assumes that drug use is external to and destructive of the everyday life of friends, family, work and leisure. However, for many, drug use is associated with enhanced functioning, sociability and productivity 14, 15. Here, we have been able to sketch only the broad contours of a critical approach to the DSM and its effects. Recognizing the DSM as active in constituting addiction and those called ‘addicts’, rather than merely describing them, opens up complex political and ethical issues that should be central to future discussions. None. The National Drug Research Institute receives core funding from the Australian Government Department of Health and Ageing.