The American Society of Addiction Medicine (ASAM) recently released a statement outlining an updated definition of addiction:
Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.
Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.
In comparison to the 2011 iteration, this definition is much more concise and words like spirituality are notably absent. Their differences are important, and nuanced, and will be excellent fodder for a different post.
I’m here to reflect more broadly on the importance of definitions with respect to shaping policy.
In the ASAM press release accompanying the new definition, Drs. Early and Olsen reflect upon the difference between substance use disorder (SUD) and addiction:
Mild SUD involves people excessively using substances and experiencing at most one or two related problems. Often, people in this situation reduce their use in response to changing environments, life circumstances, or upon recognition of their condition. Addiction, meanwhile, reflects the underlying disturbances and changes in brain function that manifest themselves as symptoms of moderate to severe SUD. People with addiction can absolutely achieve stability and some healing of dysfunctional brain functions, while no longer exhibiting symptoms of their disease. However, some of the brain changes are so deeply embedded that they persist, leaving patients at risk for relapse even after years of remission and recovery.
As policy changes (spurred largely by an abrupt shift in the demographic of people affected by addiction as a result of opioid overprescribing) move addiction treatment more squarely into the purview of medicine, definitions become increasingly important in determining who gets help and the types of help available to them. The increased medicalization of addiction is characterized by terms like “evidence based” and “FDA approved,” and often there is little space left in definitions for the experiential knowledge that has helped people recover from addiction for almost a century. The term ‘substance use disorder’ is a harbinger of this shift; in placing anyone misusing substances on a single spectrum, it fails to differentiate problematic use from the experience of spiritual bankruptcy associated with true addiction. Subsequently, available treatments cater to those at the center of the spectrum to the exclusion of those on the margins. The great irony of the disease model of addiction could be that it becomes a mechanism to further marginalize the truly addicted.
ASAM’s assertion of the difference between SUD and addiction comes at a critical time, as dollars and publicity continue to flow from the fallout of the so-called opioid epidemic. Opioids are the cash cow that I hope we can ride to true parity for the treatment of behavioral health conditions with physical conditions, but along the way it is critical for those with experiential and specialized knowledge to participate in defining the terms.