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
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.”
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.