A New View of Addiction Stirs Up A Scientific Storm
The statement conforms, in its general outlines, with the prevailing premise in cutting-edge addiction science that the natural reward system designed to support human survival becomes overtaken or highjacked by the chemical payoff provided by substance use or addictive behaviors. “The reward circuitry bookmarks things that are important: eating food, nurturing children, having sex, sustaining intimate friendships,” says Dr. Mark Publicker, medical director of Mercy Recovery Center in Portland—Maine’s largest rehab—and former Regional Chief of Addiction Medicine for Kaiser Permanente Mid-Atlantic Region.
When we use alcohol or drugs, Publicker says, the chemical reward—the "high"—is many times more powerful than the natural circuitry’s reward, and the neurological system adapts to the flood of neurotransmitters. “But because we didn’t evolve as a species with OxyContin or crack cocaine, that adaptive mechanism overshoots. So it becomes impossible to experience a normal sense of pleasure,” he continues. “Use of the substance then happens at the expense of what otherwise would promote survival. If you think about it from that standpoint, it begins to account for illness and premature death.” An active addict has a very high risk of early death via sickness or suicide.
The statement raises repeated alarms about the danger posed by the development by teens and young adults of habits of consumption of substances because their brains are still in the process of maturation, and the chemical "hijacking" of the reward system may result in earlier and more serious addiction behaviors. While firmly grounded in the neurological disease model of addiction, the definition by no means discounts genes (it attributes about half of the cause to your DNA inheritance). It’s careful to say that environmental factors affect whether and how much the genetics will tip the scales. The statement notes that “resiliencies” acquired through parenting and life experience can inhibit genetic expression of addiction. “Genetics is tendency, not destiny,” Capretto says.
Psychological and environmental factors, such as exposure to trauma or overwhelming stress, distorted ideas about life’s meaning, a damaged sense of self, and breakdown in connections with others and with “the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others)" are also acknowledged as having an influence.
In addition, ASAM further says that understanding reward systems is just a part of understanding addiction’s neurobiology. Scientists are still trying to comprehend how some addicts become preoccupied with certain drugs or behaviors and other addicts with others; how some addicts become triggered to use by some events that don’t affect others; and how cravings can persist for decades after a complete recovery.
The statement attempts to put forth diagnostic hallmarks, all of which are behavioral: inability to abstain; impaired impulse control; cravings; diminished grasp of one’s problems; and problematic emotional responses.
Is it a problem that the definition is incapable of pointing to a quantifiable diagnostic marker of this illness? “I may be stating the obvious, here,” Publicker says, sighing, “but you don’t need to do brain imaging to identify an active alcoholic.”
In fact it emphasizes that "the quantity and frequency" of addictive symptoms—like how many drinks you down in a day or how many hours you spend masturbating—is no more or less of a marker than the "qualitative [and] pathological way" the addict responds to stressors and cues by continued pursuit in the face of growing adverse consequences.
The new ASAM definition arose partly out of a disagreement with the DSM committee, which will define each type of addiction as a separate disease. “In terms of treatment, it is very important that people don’t focus on one aspect of the disease, but the disease as a whole,” says Haleja.
He draws the analogy with depression: “If you ask most people what depression is, they’ll answer it’s a serotonin deficiency disorder and that the solution is to put somebody on an SSRI [antidepressant medication]. But that’s a simplistic and inefficient way of managing depression. Medication can be helpful, but it needs to be combined with talk. We live in an era now where talk is not reimbursed.”It remains to be seen whether ASAM’s new branding of addiction as a full-bore biological illness will help addicts obtain reimbursement for treatment. In terms of insurers, clarifying that the illness has “biological roots”—stipulating that it’s not the patient’s fault he or she has the illness—may break down reimbursement roadblocks.
Capretto agrees: “Things like this definition help bring addiction more into the scope of other diseases, so for the future it will mean fewer barriers for people wanting to get help.”
One of ASAM's unstated goals was obviously to fight against the stubborn social stigma against addiction experienced by many addicts. “There’s no question they set out to de-stigmatize addiction,” Publicker says. “Nobody chooses to be an addict. The concern that I have is placing blame on the patient. It takes a very long time for the brain to normalize. While it’s waiting to happen, you’re feeling bad, your thinking is impaired, and it’s a setup for relapse. Patients are likely to be blamed for relapse, and families see them as unmotivated and weak. But that’s the disease of addiction.”
Jennifer Matesa writes about addiction and recovery issues on her blog, Guinevere Gets Sober. She is the author of two nonfiction books about health issues, including the award-winning journal of her pregnancy, Navel-Gazing: The Days and Nights of a Mother in the Making.
Jed Bickman contributed additional reporting for this article. He has written for The Nation, The Huffington Post, and Counterpunch.com and will publish his first piece for The Fix next week on the new definition of addiction in the revision of the APA's DSM and its political and policy implications for people.