When I first joined the American Society of Addiction Medicine years ago, I noticed at my first membership meeting that the organization was completely focused on addiction regarding drugs and alcohol. There was no discussion of addiction as a disease, but rather a pattern of drug and alcohol use as a disease. There seemed to be no possibility that the disease would manifest in any way other than drug or alcohol use. It was very disconcerting, and I asked the president in an open forum why addiction with use of other behaviors was not being considered. I received the answer that the board didn’t feel it was a good time politically to expand from drugs and alcohol. After the meeting two board members approached me to tell me that it was important to keep the focus on drugs and alcohol in order to keep our credibility. Who would believe addiction in relation to eating too much? It didn’t surprise me that both of them were quite a bit overweight.
So I worked on it, eventually got elected to the board and continued to make the point whenever I could that if we are really to be taken seriously the disease would have to be discussed as a brain based illness that could manifest in a variety of ways and be independent of using. It had been my experience talking to lawmakers and judges that they really didn’t get the idea of illness the way the field was talking about drugs and alcohol. Even lawmakers know that illnesses have symptoms that can appear regardless of your behavior, and it seemed that we didn’t want to talk about those in regard to addiction.
It’s been over a decade since my first ASAM meeting, and just a couple of months ago, at it’s July meeting, the board approved a new definition of addiction. I’m very excited about it. Here it is:
“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in the individual pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by impairment in behavioral control, craving, inability to consistently abstain, and diminished recognition of significant problems with one’s behaviors and interpersonal relationships. Like other chronic diseases, addiction involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”
This definition has several new ideas in it. First, that the illness is primary. It doesn’t need a cause. Like diabetes, it can just happen to you. Second, it’s an illness of the brain and is going to have symptoms caused by certain brain dysfunctions. Third, that it is these dysfunctions that cause the seeking of drugs or compulsive behaviors to ameliorate symptoms as opposed to the symptoms and dysfunction being caused by the drug use. Fourth, that the addict doesn’t have to be using drugs, but can have addiction as manifested by different behaviors. In fact, the definition doesn’t limit the behaviors to any group, but rather focuses on the illness. Finally, because addiction is a real illness, not just a set of behaviors, it doesn’t go away when the behavior stops. It’s chronic and progressive.
I think that we will get many more people to understand the nature of addiction and the burden the illness places on our society with this new definition. I also think more people who see the new definition will seek treatment and that more funders of treatment will be willing to help them.
© Howard C Wetsman MD FASAM