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A New View of Addiction Stirs Up A Scientific Storm

A group of leading American addiction experts recently released a sweeping new definition of addiction, sending the the powerful psychiatric lobby into a tail-spin

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Addiction is a disease of the brain. But how should it be treated? Photo via

If you think addiction is all about booze, drugs, sex, gambling, food and other irresistible vices, think again. And if you believe that a person has a choice whether or not to indulge in an addictive behavior, get over it. The American Society of Addiction Medicine (ASAM) blew the whistle on these deeply held notions with its official release of a new document defining addiction as a chronic neurological disorder involving many brain functions, most notably a devastating imbalance in the so-called reward circuitry. This fundamental impairment in the experience of pleasure literally compels the addict to chase the chemical highs produced by substances like drugs and alcohol and obsessive behaviors like sex, food and gambling.

The definition, a result of a four-year process involving more than 80 leading experts in addiction and neurology, emphasizes that addiction is a primary illness—in other words, it’s not caused by mental health issues such as mood or personality disorders, putting to rest the popular notion that addictive behaviors are a form of "self-medication" to, say, ease the pain of depression or anxiety.

Indeed, the new neurologically focused definition debunks, in whole or in part, a host of common conceptions about addiction. Addiction, the statement declares, is a “bio-psycho-socio-spiritual” illness characterized by (a) damaged decision-making (affecting learning, perception, and judgment) and by (b) persistent risk and/or recurrence of relapse; the unambiguous implications are that (a) addicts have no control over their addictive behaviors and (b) total abstinence is, for some addicts, an unrealistic goal of effective treatment.

The bad behaviors themselves are all symptoms of addiction, not the disease itself. "The state of addiction is not the same as the state of intoxication," the ASAM takes pains to point out. Far from being evidence of a failure of will or morality, the behaviors are the addict's attempt to resolve the general "dysfunctional emotional state" that develops in tandem with the disease. In other words, conscious choice plays little or no role in the actual state of addiction; as a result, a person cannot choose not to be addicted. The most an addict can do is choose not to use the substance or engage in the behavior that reinforces the entire self-destructive reward-circuitry loop.

Yet ASAM pulls no punches when it comes to the negative consequences of addiction, declaring it an illness that “can cause disability or premature death, especially when left untreated or treated inadequately.”

The new definition leaves no doubt that all addictions—whether to alcohol, heroin or sex, say—are fundamentally the same. Dr. Raju Haleja, former president of the Canadian Society for Addiction Medicine and the chair of the ASAM committee that crafted the new definition, told The Fix, “We are looking at addiction as one disease, as opposed to those who see them as separate diseases. Addiction is addiction. It doesn’t matter what cranks your brain in that direction, once it has changed direction, you’re vulnerable to all addiction." That the society has stamped a diagnosis of sex or gambling or food addiction as every bit as medically valid as addiction to alcohol or heroin or crystal meth may spark more controversy than its subtler but equally far-reaching assertions.

The new definition comes as the American Psychiatric Association (APA) is undertaking a highly publicized, decade-in-the-making revision of its own definition of addiction in its Diagnostic and Statistical Manual of Mental Disorders—the bible of the mental health profession. The APA’s DSM will have a larger effect on public health policies that guide addiction treatment, largely because insurance companies are mandated by law to use the DSM diagnostic categories and criteria to decide which treatments they will pay for. 

Dr. Haleja told The Fix that the ASAM definition arose partly out of a disagreement with the DSM committee; although the DSM will define addiction as a disease, its symptoms (and therefore diagnostic criteria) will still be viewed mostly as discrete behaviors. Also, the DSM will define each type of addiction as a separate disease, instead of the singular and unified notion of disease that the ASAM proposes. “In terms of treatment, it becomes very important that people don’t focus on one aspect of the disease, but the disease as a whole,” says Haleja. Far from being a failure of will or morality, addictive behaviors are the addict's attempt to resolve the general "dysfunctional emotional state" that develops in tandem with the disease. In other words, conscious choice plays little or no role in the actual state of addiction; as a result, a person cannot choose not to be addicted.

Though addicts can’t choose not to be addicts, they can choose to get treatment. Recovery, ASAM says, is best realized not just by self-management and mutual support groups such as 12-step fellowships, but also with trained professional help.

Some addiction-medicine specialists see the sweeping new definition as a validation of what has, since the publication of Alcoholics Anonymous in 1939, come to be known as “the disease concept” of addiction. “Many people in the population at large see addiction as a moral problem—‘Why don’t they just stop?’” says Dr. Neil Capretto, medical director of Gateway Rehabilitation Center in Pittsburgh and an active ASAM member. “For experienced people working in addiction medicine for years, we know it’s a brain disease.”

Does this statement push the 12 steps, the mainstay of many treatment centers, programs and clinicians, toward obsolescence? After all, when a problem is declared to be a “medical” issue, doesn’t that imply that the solution should also be “medical”—as in doctors and drugs? “Both approaches have applicability,” says Dr. Marc Galanter, professor of psychiatry at New York University, founding director of its Division of Alcohol and Substance Abuse as well as director of its Fellowship Training Program in Addiction Psychiatry. “The fact that addiction is a disease doesn’t mean it’s only susceptible to drugs.”Says Capretto: “This new definition does not say that psychological or spiritual approaches are not important. My concern is that some people who really don’t understand the broader scope of addiction will see it only as a disease of brain cells. We’re not treating computers—it’s in the total human being who is, as the definition says, a 'bio-psycho-socio-spiritual' creature, and who will still need help in those areas.”

With its no-stone-unturned statement (it runs to eight pages, single-spaced, including footnotes), ASAM has come down—mostly—on one side of the chicken-and-egg question that has long befuddled people interested in addiction, physicians and recovering addicts alike: which came first, the neurological disorder or the compulsive behaviors and substance use? The definition states that abnormalities in the neurological system’s reward wiring—communication between areas of the brain, particularly those that process memory, emotional response and pleasure—come first, and drive the addict into a doomed pursuit to compensate for the reward-system imbalance through the addictive behavior. But later, the document notes that these behaviors themselves can damage the reward circuitry and lead to impaired impulse control and addiction.

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