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ASAM Dares to Dispute What Mighty Shrinks Think

An author of the American Society of Addiction Medicine's new addiction definition tells The Fix what's wrong with the heavyweight American Psychiatric Association's version.

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By Jed Bickman

08/18/11

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It's a David and Goliath scrap over some technical and abstruse concepts—with real-world ramifications for millions of addicts. This week the American Society of Addiction Medicine (ASAM) re-defined addiction itself. The group of researchers, therapists, educators and MDs got their retaliation in first for upcoming changes in the Diagnostic and Statistical Manual of Mental Disorder—AKA the bible—to which medical, pharmaceutical and insurance pros defer. The 2013 DSM-5 will determine future treatment and insurance billing practices and is drafted by the American Psychiatric Association (APA), a powerful lobby of conservative shrinks, inclined to fend off impertinent incursions by the less highly-credentialed ASAM-ers. The ASAM thinks the DSM-5's Substance Abuse Work Group, chaired by Dr. Charles O’Brien, is taking the wrong approach to defining addiction for the next decade. But the ASAM’s own view of addiction as a disease of neurological reward, memory and motivation circuits is also controversial, contending, for example, that addiction is the same disease whether the patient is hooked on alcohol, heroin, sex, or the Internet. Dr. Raju Hajela chairs the ASAM committee that wrote the new definition. He told The Fix, “We want to be more neuroscience-based and to encourage people to realize that this is not about bad behaviors but about brain circuitry and where people lose their choice.” The DSM-5 Work Group will not adopt such a stance: Its more behavioral definition of “substance use disorder” includes 11 symptoms that are visible without a brain scan, like failure to fulfill obligations, hazardous use (e.g. drunk driving), and cravings. The ASAM views these behaviors as symptoms of addiction—not addiction itself. Hajela said: “Our frustration is that APA and DSM are going to be very behavioral in their approach. We have been trying to engage them, but they are very committed to staying behavioral. Which is fine—we have agreed to disagree.” He thinks the ASAM definition does more to destigmatize addiction than the DSM one: “What we say is, ‘The disease is not your fault—but recovery is your responsibility.’”

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