On August 15 the American Society of Addiction Medicine (ASAM) published its new definition of addiction—one that contradicts some prevailing beliefs. The Society holds that addiction is not a behavioral disorder, nor is it a form of “self-medication” for easing emotional pain. Addiction is a single disease of the brain comprising a group of disorders —addiction to alcohol, opioids or other drugs, food, gambling, or sex.
A Primary, Chronic Brain Disease
The ASAM definition calls addiction “a primary, chronic disease of brain reward, motivation, memory and related circuitry.” (“Primary” means addiction is not the result of other causes, such as emotional or psychiatric problems. “Chronic” means it must be treated, managed, and monitored over a prolonged period, for some people, even a lifetime. “Circuitry” refers to nerve networks within the brain, linked with pleasurable activities and rewards—such as eating, sexual activities, and interactions with others.)
Dysfunction in the circuits leads to characteristic biological, psychological, social, and spiritual manifestations. The individual pathologically pursues rewards, or relief, or both, by substance use and other behaviors.
Addiction is characterized by craving, an inability to consistently abstain from the addictive substance or behavior, impaired behavioral control, a diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission.
Linking addiction with brain disease did not originate with ASAM. The National Institute on Drug Abuse (NIDA) has for years reported that addiction is a “chronic, often relapsing brain disease” that over time causes brain changes that “challenge a person’s self-control and ability to resist intense impulses urging them to take drugs.” The best treatment for most patients, according to NIDA, is “combining addiction treatment medications with behavioral therapy.” Also, the National Quality Control Forum has recognized the implications of brain disease in addiction, and has recommended pharmacotherapy.
Genetic and Environmental Factors
The ASAM definition acknowledges that genetic factors “account for about half of the likelihood that an individual will develop addiction.” Genetic factors can combine with environmental factors and lead to “addiction’s characteristic bio-psycho-socio-spiritual manifestations.” More than 80 physicians specializing in addiction, neuroscience, and neurology worked together to frame the ASAM definition, which was developed over a four-year period. The definition is now out for field review and will be finalized in 2013.
Definition Supports the Need for Medication-Assisted Treatment
ASAM’s new definition of addiction explains why opioid treatment programs (OTPs) and medication-assisted treatment (MAT) help many patients with substance use disorders (SUDs)—and why some fail to benefit from treatment without medications. Methadone is effective treatment because it stabilizes brain function—a process that can take months or years—while comprehensive OTP services help patients cope with the psychosocial aspects of addiction.
Debate and Coverage
Some in the field still consider addiction to be based in behavior, not in differences within the brain. Some question whether addiction is a chronic disease. Some take issue with “spiritual factors” as contributors to addiction.
The following appeared in reaction to ASAM’s definition.
Hot Topics: New View of Addiction Stirs Up A Scientific Storm – The Fix • “A group of leading American addiction experts recently released a sweeping new definition of addiction, sending the powerful psychiatric lobby into a tail-spin.”
Time Healthland • Although addiction is indeed chronic in some cases, most people diagnosed with addiction or alcoholism “actually recover without treatment or participation in self-help groups.”
SARx UCLA Substance Abuse Pharmacotherapy Unit • “It’s hard not to ask what took them so long to come to this conclusion . . . but I guess better late than never.”
All Brain and No Soul? – The Fix • Social factors like unemployment, education level, traumatic life experience, and amount of social support for recovery are currently better predictors of recovery than any brain factors yet discovered.
Addiction doesn’t begin—or end—with “pleasure centers in the brain.” If we’re going to address addiction effectively, we need to recognize this reality and devote as much time and money to studying social factors as intensely as we do the brain.
Implications for Treatment
ASAM has cautioned that it’s “important to focus on the underlying disease process in the brain, and its biological, psychological, social, and spiritual manifestations.” It urges policy makers and funding agencies to remember that “treatment must be comprehensive, and to focus on all aspects of addiction and addictive behaviors, rather than substance-specific treatment.”
By defining addiction as a disease of the brain, and recommending comprehensive treatment, ASAM substantiates the key role treatment programs play in SUDs. While medication helps stabilize brain function, programs monitor regimens, maintain continuing contact, and provide services needed to help with the psychosocial aspects of addiction.
To our readers: Tell us your thoughts about the ASAM definition of addiction. Did ASAM take a bold step, or was it lagging behind the field at large? What is the role of psychosocial treatment? Tell us which services make the difference: Adequate doses of methadone? Counseling? Twelve-Step meetings?
ASAM’s Definition of Addiction: Frequently Asked Questions. August 2011
http://www.asam.org/pdf/Advocacy/20110816_DefofAddiction-FAQs.pdf Accessed November 10, 2011.
National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide. U.S. Department of Health and Human Services, National Institutes of Health, NIH Publication No. 09–4180, Rockville, MD; 2009 http://www.nida.nih.gov/podat/podatindex.html Accessed November 10, 2011.
National Institute on Drug Abuse. InfoFacts: Understanding Drug Abuse and Addiction. National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD; 2011.
http://drugabuse.gov/infofacts/understand.html Accessed November 10, 2011.
National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human Services. Drugs, Brains, and Behavior: The Science of Addiction. NIH Pub. No. 10-5605. Bethesda, MD; 2010. http://drugabuse.gov/scienceofaddiction/sciofaddiction.pdf Accessed November 10, 2011.
How Drug Addiction & Other “Highs” Affect the Brain—Phoenix House. August 18, 2011.
Accessed November 10, 2011.
The Next Advancement in Counseling: The Bio-Psycho-Social Model. David M. Kaplan and Sharon L Coogan. In American Counseling Association: Vistas Online.
Accessed November 10, 2011.