Addiction redefined

The American Society of Addiction Medicine has issue a new definition of addiction. The short version good, but the long version is REALLY good.

Here are some of the new elements, some of them are followed by my responses:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.

Nothing new or exciting here, but any definition more than 15 years old probably needs to have this added.

The neurobiology of addiction encompasses more than the neurochemistry of reward.

This is important. Even people who have some basic literacy about the neurobiology of addiction often reduce addiction to being about pleasure. This is only part of the story, though it’s probably the easiest part of the story to explain, and reducing addiction to this has the potential to reinforce stereotypes of addicts as unrestrained pleasure seekers.

Genetic factors account for about half of the likelihood that an individual will develop addiction.

Good to include this, as it seems to have gotten less attention in coverage in recent years.

Other factors that can contribute to the appearance of addiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include:

  1. The presence of an underlying biological deficit in the function of reward circuits, such that drugs and behaviors which enhance reward function are preferred and sought as reinforcers;
  2. The repeated engagement in drug use or other addictive behaviors, causing neuroadaptation in motivational circuitry leading to impaired control over further drug use or engagement in addictive behaviors;
  3. Cognitive and affective distortions, which impair perceptions and compromise the ability to deal with feelings, resulting in significant self-deception;
  4. Disruption of healthy social supports and problems in interpersonal relationships which impact the development or impact of resiliencies;
  5. Exposure to trauma or stressors that overwhelm an individual’s coping abilities;
  6. Distortion in meaning, purpose and values that guide attitudes, thinking and behavior;
  7. Distortions in a person’s connection with self, with others and with the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others); and
  8. The presence of co-occurring psychiatric disorders in persons who engage in substance use or other addictive behaviors.

This is decidedly and surprisingly old school, and by that I mean holistic. This is good news, particularly in light of some of the efforts to further medicalize treatment. I believe that addiction has profound direct and indirect impact on the addict’s social, emotional and spiritual life. Some of this may self-resolve with abstinence, but much of it won’t and will require the addict to develop new ways to address those problems and meet those social emotional and spiritual needs. In some cases, this needs to be done in the context of professionally directed treatment, in most cases it requires some form of sustained recovery support.

More highlights:

Addiction is characterized by2:

  1. Inability to consistently Abstain;
  2. Impairment in Behavioral control;
  3. Craving; or increased “hunger” for drugs or rewarding experiences;
  4. Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and
  5. A dysfunctional Emotional response.

The power of external cues to trigger craving and drug use, as well as to increase the frequency of engagement in other potentially addictive behaviors, is also a characteristic of addiction, with the hippocampus being important in memory of previous euphoric or dysphoric experiences, and with the amygdala being important in having motivation concentrate on selecting behaviors associated with these past experiences.

In addiction there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often manifest a lower readiness to change their dysfunctional behaviors despite mounting concerns expressed by significant others in their lives; and display an apparent lack of appreciation of the magnitude of cumulative problems and complications. The still developing frontal lobes of adolescents may both compound these deficits in executive functioning and predispose youngsters to engage in “high risk” behaviors, including engaging in alcohol or other drug use. The profound drive or craving to use substances or engage in apparently rewarding behaviors, which is seen in many patients with addiction, underscores the compulsive or avolitional aspect of this disease. This is the connection with “powerlessness” over addiction and “unmanageability” of life, as is described in Step 1 of 12 Steps programs.

Addiction is more than a behavioral disorder. Features of addiction include aspects of a person’s behaviors, cognitions, emotions, and interactions with others, including a person’s ability to relate to members of their family, to members of their community, to their own psychological state, and to things that transcend their daily experience.

Cognitive changes in addiction can include…The inaccurate belief that problems experienced in one’s life are attributable to other causes rather than being a predictable consequence of addiction.

The also address emotional changes that can easily be mistaken for a co-occurring psychiatric disorder:

Emotional changes in addiction can include:

  1. Increased anxiety, dysphoria and emotional pain;
  2. Increased sensitivity to stressors associated with the recruitment of brain stress systems, such that “things seem more stressful” as a result; and
  3. Difficulty in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and describing feelings to other people (sometimes referred to as alexithymia).

Finally, they embrace recovery. (This is surprisingly controversial. I’ve recently been involved in a discussion group where members rejected the notion of recovery.)

Addiction professionals and persons in recovery know the hope that is found in recovery. Recovery is available even to persons who may not at first be able to perceive this hope, especially when the focus is on linking the health consequences to the disease of addiction. As in other health conditions, self-management, with mutual support, is very important in recovery from addiction. Peer support such as that found in various “self-help” activities is beneficial in optimizing health status and functional outcomes in recovery.

Of course, not everyone is a fan. And, while I believe it’s appropriate to acknowledge the spiritual dimensions (life purpose and meaning), I think I agree with her that, pragmatically, they probably should have left it out.

For the record, the reason I believe it’s appropriate is that I believe the spiritual dimensions of addiction are uniquely profound.  Every person with a serious illness, particularly serious chronic illnesses, needs to wrestle with questions about how it happened, what it means, why me, what does it say about me, who was I before, who am I now, what does it say about my place in the world, etc. These are particularly difficult in an illness whose primary and secondary symptoms do so much to destroy social connections, hijack priorities, erode values, consume personal identity and diminish volitional control.

5 thoughts on “Addiction redefined

  1. Reads quite radical and elements of it will no doubt be received controversially on this side of the Atlantic. Thanks for highlighting relevant parts.


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