Does Canada Have it Right…Yet?
I am very interested in organized medicine reworking the current definition of addiction. There are two problems with the definition as provided by DSM IV currently. The first is that the definition is limited to substance dependence and doesn’t allow for addiction using behaviors or what are commonly called process addictions. The second problem is that the definition is based on behavior rather than biological state. In the last entry I spoke of ASAM’s and ABAM’s use of the current defining ideas. Lately, in the healthcare debate, a lot of people have been looking at Canada, so I thought I would too as there is a Canadian Society of Addiction Medicine as well. Here’s the definition of addiction that they put on their website:
Addiction (Adopted 99.10.14) - A primary, chronic disease, characterized by impaired control over the use of a psychoactive substance and/or behaviour. Clinically, the manifestations occur along biological, psychological, sociological and spiritual dimensions. Common features are change in mood, relief from negative emotions, provision of pleasure, pre-occupation with the use of substance(s) or ritualistic behaviour(s); and continued use of the substance(s) and/or engagement in behaviour(s) despite adverse physical, psychological and/or social consequences. Like other chronic diseases, it can be progressive, relapsing and fatal.
Consider adding qualifiers such as full, partial remission, etc. based on DSM IV.
You can see right away that the CSAM doesn’t limit the idea of addiction to substances, and you know I’m happy to see that. Look at the date. This has been their definition for over 10 years. The other day I received a communication from a friend at ABAM who had read my last entry. He pointed out that while the current definition is limited to substances, they would be open to reviewing the limitation when evidence warrants. It looks like CSAM had enough evidence 10 years ago.
But here’s the problem. For those who don’t believe the current evidence for addiction involving behavior rather than substances, CSAM’s definition looks just as ideological as ASAM’s. It comes down to what you believe. That’s because CSAM’s definition lacks any biological focus as much as ASAM’s. It’s a very inclusive definition, but doesn’t exclude enough to be very useful. Any member of American Medicine can look at this definition and quickly decide it doesn’t offer more than the current one in use by ASAM. Progress generally happens when your neighbor one ups you, not when he doesn’t.
If I gave both definitions to a non-addiction physician, I doubt he or she would find either useful in terms of making a diagnosis in a biological sense. You can tell when you have a useful idea when everyone else starts to use it. I have a lot of friends in medicine who don’t practice Addiction Medicine, and they are not drawn to take either of these definitions as useful. That’s one of the reasons they mostly shy away from helping addicts. They have nothing to go on, and doctors like to know what they are doing.
CSAM’s definition is, I think, better than ASAM’s, but still has a way to go. My Canadian friends might take issue with what I feel is a lack of biological focus in their definition. They may point to the sentence that starts “Common features..,” but that’s just it. These are common features, not defining features. To be useful, the definition of an illness must be discriminating enough to tell the doctor what to do. While CSAM’s is better than ASAM’s in including more, it’s less than a helpful improvement because it includes too much. It would include those patients I’ve labeled as “Compulsive Use Syndrome” that are biologically driven to continue to use after first using but are not driven to restart once stopped. There aren’t many doctors who would find it useful to include both groups of patients in the same definition as the treatment would be entirely different.
I’m glad CSAM’s definition is different than ASAM’s. Diversity is good. When everyone is doing one thing in any environment, it’s the beginning to the road to extinction. That’s a big reason why we need definitions based on biological reality rather than someone’s interpretation of a patient’s behavior. DSM has created an ideology of addiction, not a clinical definition. And as the environment changes, the ideology can’t. That’s the end of the road to extinction. I wonder what the Mexicans think.