Contact: Alexis Geier‐Horan
(301) 656‐3920 x103 ageier@asam.org ASAM RELEASES NEW DEFINITION OF ADDICTION
Addiction Is a Chronic Brain Disease,
Not Just Bad Behaviors or Bad Choices CHEVY CHASE, MD, August 15, 2011 – The American Society of Addiction Medicine (ASAM) has released a new definition of addiction highlighting that addiction is a chronic brain disorder and not simply a behavioral problem involving too much alcohol, drugs, gambling or sex. This the first time ASAM has taken an official position that addiction is not solely related to problematic substance use. When people see compulsive and damaging behaviors in friends or family members—or public figures such as celebrities or politicians—they often focus only on the substance use or behaviors as the problem. However, these outward behaviors are actually manifestations of an underlying disease that involves various areas of the brain, according to the new definition by ASAM, the nation’s largest professional society of physicians dedicated to treating and preventing addiction.
“At its core, addiction isn’t just a social problem or a moral problem or a criminal problem. It’s a brain problem whose behaviors manifest in all these other areas,” said Dr. Michael Miller, past president of ASAM who oversaw the development of the new definition. “Many behaviors driven by addiction are real problems and sometimes criminal acts. But the disease is about brains, not drugs. It’s about underlying neurology, not outward actions.” The new definition resulted from an intensive, four‐year process with more than 80 experts actively working on it, including top addiction authorities, addiction medicine clinicians and leading neuroscience researchers from across the country. The full governing board of ASAM and chapter presidents from many states took part, and there was extensive dialogue with the National Institute on Drug Abuse (NIDA). The new definition also describes addiction as a primary disease, meaning that it’s not the result of other causes such as emotional or psychiatric problems. Addiction is also recognized as a chronic disease, like cardiovascular disease or diabetes, so it must be treated, managed and monitored over a life‐time. Two decades of advancements in neurosciences convinced ASAM that addiction needed to be redefined by what’s going on in the brain. Research shows that the disease of addiction affects neurotransmission and interactions within reward circuitry of the brain, leading to addictive behaviors that supplant healthy behaviors, while memories of previous experiences with food, sex, alcohol and other drugs trigger craving and renewal of addictive behaviors. Meanwhile, brain circuitry that governs impulse control and judgment is also altered in this disease, resulting in the dysfunctional pursuit of rewards such as alcohol and other drugs. This area of the brain is still developing during teen‐age years, which may be why early exposure to alcohol and drugs is related to greater likelihood of addiction later in life. There is longstanding controversy over whether people with addiction have choice over antisocial and dangerous behaviors, said Dr. Raju Hajela, past president of the Canadian Society of Addiction Medicine and chair of the ASAM committee on the new definition. He stated that “the disease creates distortions in thinking, feelings and perceptions, which drive people to behave in ways that are not understandable to others around them. Simply put, addiction is not a choice. Addictive behaviors are a manifestation of the disease, not a cause.” “Choice still plays an important role in getting help. While the neurobiology of choice may not be fully understood, a person with addiction must make choices for a healthier life in order to enter treatment and recovery. Because there is no pill which alone can cure addiction, choosing recovery over unhealthy behaviors is necessary,” Hajela said. “Many chronic diseases require behavioral choices, such as people with heart disease choosing to eat healthier or begin exercising, in addition to medical or surgical interventions,” said Dr. Miller. “So, we have to stop moralizing, blaming, controlling or smirking at the person with the disease of addiction, and start creating opportunities for individuals and families to get help and providing assistance in choosing proper treatment.” To read the full Definition of Addiction, visit: http://www.asam.org/DefinitionofAddiction-LongVersion.html Dr. Miller is past president of ASAM. Dr. Hajela is past president of the Canadian Society of Addiction Medicine and is a board member of ASAM. The American Society for Addiction Medicine is a professional society representing close to 3,000 physicians dedicated to increasing access and improving quality of addiction treatment, educating physicians and the public, supporting research and prevention, and promoting the appropriate role of physicians in the care of patients with addictions.
American Society of Addiction Medicine 4601 North Parke Avenue, Upper Arcade, Suite 101 Chevy Chase, MD 20815‐4520 Phone (301) 656‐3920 ● Fax 301‐656‐3815 ● Web www.asam.org ### |
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DEFINITION OF ADDICTION: FREQUENTLY ASKED QUESTIONS
1. QUESTION: What’s different about this new definition?
Answer: The focus in the past has been generally on substances associated with addiction, such as alcohol, heroin, marijuana, or cocaine. This new definition makes clear that addiction is not about drugs, it’s about brains. It is not the substances a person uses that make them an addict; it is not even the quantity or frequency of use. Addiction is about what happens in a person’s brain when they are exposed to rewarding substances or rewarding behaviors, and it is more about reward circuitry in the brain and related brain structures than it is about the external chemicals or behavior that “turn on” that reward circuitry. We have recognized the role of memory, motivation and related circuitry in the manifestation and progression of this disease. 2. QUESTION: How is this definition of addiction different from previous descriptions such as DSM?
Answer: The standard diagnostic system has been the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. This manual lists hundreds of diagnoses of different conditions, and the criteria by which one makes a diagnosis. The DSM uses the term ‘substance dependence’ instead of addiction. In practice, we have been using the term ‘dependence’ interchangeably with addiction. However, it is confusing. The method that psychiatry has relied upon has been the patient interview and outwardly observable behaviors. The term that is
used most often is ‘substance abuse’--some clinicians use this term interchangeably with ‘addiction’ which also causes confusion. Therefore, ASAM has elected to define addiction clearly, in a way that accurately describes the disease process that extends beyond overt behaviors such as substance-related problems. The editions of the DSM published since 1980 have been very clear that the DSM approach is “atheoretical” – a diagnosis does not depend on a particular theory of psychology or a theory of etiology (where a disease comes from). The DSM just looks at behaviors you can see or symptoms or experiences that a patient reports through an interview. The ASAM definition of addiction does not exclude the role of environmental factors in addiction – things such as neighborhood or culture or the amount of psychological stress that a person has experienced. But it definitely looks at the role of the brain in the etiology of addiction – what is happening with brain functioning and specific brain circuitry that can explain the outward behaviors seen in addiction. 3. QUESTION: Why is this definition important? Answer: Addiction, almost by definition, involves significant dysfunction in a person – their functional level at their job, in their family, in school, or in society in general, is altered. Human beings can do all sorts of dysfunctional things when they have addiction. Some of these behaviors are frankly antisocial – doing certain things can be a violation of social norms and even societal laws. If one simply looks at the behavior of a person with addiction, one may see a person who lies, a person who cheats, and a person who breaks laws and appears to not have very good moral values. The response of society has often been to punish those antisocial behaviors, and to believe that the person with addiction is, at their core, “a bad person.” When you understand what’s really happening with addiction, you realize that good people can do very bad things, and the behaviors of addiction are understandable in the context of the alterations in brain function. Addiction is not, at its core, just a social problem or a problem of morals. Addiction is about brains, not just about behaviors. 4. QUESTION: Just because a person has the disease of addiction, should they be absolved from all responsibility for their behaviors? Answer: No. Personal responsibility is important in all aspects of life, including how a person maintains their own health. It is often said in the addiction world that, “You are not responsible for your disease, but you are responsible for your recovery.” People with addiction need to understand their illness and then, when they have entered recovery, to take necessary steps to minimize the chance of relapse to an active disease state. Persons with diabetes and heart disease need to take personal responsibility for how they manage their illness--the same is true for persons with addiction. Society certainly has the right to decide what behaviors are such gross violations of the social covenant within a society that they are considered criminal acts. Persons with addiction may commit criminal acts, and they could be held accountable for those actions and face whatever consequences society has outlined for those actions. 5. QUESTION: This new definition of addiction refers to addiction involving gambling, food, and sexual behaviors. Does ASAM really believe that food and sex are addicting? Answer: Addiction to gambling has been well described in the scientific literature for several decades. In fact, the latest edition of the DSM (DSM-V) will list gambling disorder in the same section with substance use disorders. The new ASAM definition makes a departure from equating addiction with just substance dependence, by describing how addiction is also related to behaviors that are rewarding. This the first time that ASAM has taken an official position that addiction is not solely “substance dependence.” This definition says that addiction is about functioning and brain circuitry and how the structure and function of the brains of persons with addiction differ from the structure and function of the brains of persons who do not have addiction. It talks about reward circuitry in the brain and related circuitry, but the emphasis is not on the external rewards that act on the reward system. Food and sexual behaviors and gambling behaviors can be associated with the “pathological pursuit of rewards” described in this new definition of addiction. 6. QUESTION: Who has food addiction or sex addiction? How many people is this? How do you know? Answer: We all have the brain reward circuitry that makes food and sex rewarding. In fact, this is a survival mechanism. In a healthy brain, these rewards have feedback mechanisms for satiety or ‘enough.’ In someone with addiction, the circuitry becomes dysfunctional such that the message to the individual becomes ‘more’, which leads to the pathological pursuit of rewards and/or relief through the use of substances and behaviors. So, anyone who has addiction is vulnerable to food and sex addiction. We do not have accurate figures for how many people are affected by food addiction or sex addiction, specifically. We believe it would be important to focus research on gathering this information by recognizing these aspects of addiction, which may be present with or without substance-related problems. 7. QUESTION: Given that there is an established diagnostic system in the DSM process, won’t this definition be confusing? Isn’t this competing with the DSM process? Answer: There is no attempt here to compete with the DSM. This document does not contain diagnostic criteria. It is a description of a brain disorder. Both this descriptive definition and the DSM have value. The DSM focuses on outward manifestations that can be observed and the presence of which can be confirmed via a clinical interview or standardized questionnaires about a person’s history and their symptoms. This definition focuses more on what’s happening in the brain, though it does mention various outward manifestations of addiction and how behaviors seen in persons with addiction are understandable based on what is now known about underlying alterations in brain functioning. We hope that our new definition will lead to a better understanding of the disease process that is biological, psychological, social and spiritual in its manifestation. It would be prudent to better appreciate addictive behaviors in that context, beyond the diagnoses of Substance Dependence or Substance Use Disorders. 8. QUESTION: What are implications for treatment, for funding, for policy, for ASAM? Answer: The major implication for treatment is that we cannot keep the focus just on the substances. It is important to focus on the underlying disease process in the brain that has biological, psychological, social and spiritual manifestations. Our long version of the new definition describes these in more detail. Policy makers and funding agencies need to take notice that treatment must be comprehensive and focus on all aspects of addiction and addictive behaviors rather than substance specific treatment, which may result in switching of pathological pursuit of rewards and/or relief by using other substances and/or engagement in other addictive behaviors. Comprehensive addiction treatment requires close attention to all active and potential substances and behaviors that could be addictive in a person who has addiction. It is common for someone to seek help for a particular substance but comprehensive assessment often reveals many more covert manifestations that would be and are often missed in programs where the focus of treatment is substances only or substance specific. |
