Among addiction experts and researchers, there’s been a long-running debate as to whether drug or alcohol addiction, and even “behavioral addictions” such as compulsive gambling, are actual diseases or not. It’s not just a matter of semantics — if researchers can trace addiction’s root causes to an actual medical malfunction in the brain, perhaps that disease could be directly treated.
Who am I to disagree with a “four-year process with more than 80 experts actively working on it?”
Their result? Addiction is a “chronic brain disorder and not simply a behavioral problem.”
I suppose if we wanted, one could argue that all mental disorders can be viewed as “brain disorders” and not “simply behavioral problems.” After all, where does thinking and emotions come from, if not the brain?
But does this change anything? Does it help us in really getting to the heart of addiction? I’m not so sure.
The actual new definition of addiction proposed by the American Society of Addiction Medicine was first published on April 12 2011, but apparently didn’t get much notice. So the Society released a press release yesterday to help draw attention to it. Here’s the intro to the new definition:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy, self-care related behaviors. Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.
With just a few minor changes, the following paragraph is also just as true, but replaces the word “addiction” with “human behaviors and social interactions:”
Human behaviors and social interactions are a primary, chronic condition of brain reward, motivation, memory and related circuitry. Human behaviors and social interactions affect neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and rewarding behaviors supplant less-rewarding behaviors. Human behaviors and interactions with others also affect neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in those behaviors in the future.
The point? Everything we do affects these areas of the brain, especially anything we personally find enjoyable — like most of us do when socializing with other people (whether in-person or online). When we are having an enjoyable conversation with another person, it leads to a biological and behavioral response. We can even “crave” talking to that person again, since we often make a date to see that person again. None of these things are necessarily unique to addiction.
What does it mean when 54 percent of respondents in a recent survey felt some level of addiction to their social network of choice? If the majority of people feel something, doesn’t that become the new normal, so it is by definition not something unusual or disordered? Words like “addiction” quickly become meaningless if they describe a sense or behavior most of us are feeling.
These supposedly new descriptions of addiction are simply restatements of what we know about the brain and its reward circuitry. We don’t know — yet, anyway — exactly how these brain interactions are going wrong in people who become addicted (since not everyone who drinks becomes an alcoholic). Is it a virus? A malformed gene?
The medical biases here are throughout the document, emphasizing the biology over the other messy stuff — like environment and psychology. For instance, one paragraph emphasizing the biology starts with the sentence:
Genetic factors account for about half of the likelihood that an individual will develop addiction.
Which naturally means that the other half of the likelihood that an individual will develop an addiction is related to non-genetic factors — your environment and your psychological makeup. Things you can influence and change (or that other people can influence and change on your behalf, if need be). But the definition doesn’t actually say that… instead it bogs down in its own heavy, obtuse language making it sound like genetics is a key to understanding this “chronic brain disorder.”
While I commend the American Society of Addiction Medicine for sharing their latest understanding of addictions with us, I don’t believe this helps clarify anything. Instead, all it does is open up dozens of new questions for me. It re-emphasizes how little we actually understand about what the brain is doing, and why it’s doing certain things in some people, but not others.
By emphasizing the “brain disease” model over the more accepted bio-psycho-social model of addiction, the Society is putting the focus and spotlight on the brain — an organ scientists still just barely understand. Yes, our understanding has increased 100 fold in the past two decades, but it’s still a drop in the bucket of what remains.
Addiction is a complicated process. Simplifying it down to a “brain disease” seems to really remove much of the complexity of the problem, and gives people who don’t bother reading the new long definition (linked below) a short-hand way of saying, “It’s not my fault.”
It’s not a person’s fault if they develop an addiction. But they do have to take ownership of the problem, and work toward its resolution — no matter what we call it. If “brain disease” helps someone get help for their addiction, well then, maybe it’s not all bad.
Read the press release: ASAM Releases New Definition of Addiction
Read the new definition: Public Policy Statement: Definition of Addiction
27 comments
Good article John. Re-writing that paragraph with just these two words, “human behaviors” and “social interactions” instead of addiction, really hits the mark.
These scientists just seem so off the mark to me. I find the notion of addiction as a “brain disease” totally unconvincing and untennable.
Adam, are you an addict/alcoholic yourself? If not, then perhaps you just don’t get it. If you are, then good luck.
One of your best posts in a long, long time. Good job! Now see if you can get someone from the ASAM to respond, and let the debate be joined!
Wow, what a brazen play by the pharmaceutical industry.
I am not going to waste my time doing it, but if someone is interested and there is an internet trail worth traveling, Google “American Society of Addiction Medicine & Pharmaceutical Industry relations” and I would be expecting to find hits of interest.
Man, the DSM 5 is going to be such a joke. To my colleagues who read psychiatric journals, will we have psychotropic ads interspersed in the pages of this book? That may be a ludicrous comment outwardly, but really, would it surprise those with a conscience to not be surprised that the APA would be so bold to do this just to make a few extra bucks on the publication?
Jaded and cynical. Meet my half brothers.
I suggest everyone take the time to read the long definition. You can not simply substitute “any human behavior” like Doc John did. If you are an addict/alcoholic you’ll get it. Addiction is a disease and is well explained in the long definition. People who like Facebook won’t steal, or not eat, or stop all “healthy, self-care related behaviors” to use Facebook, or other normal human behavior, as Doc John suggests. We will do all that or more to get our alcohol or drugs. It’s not about will power.
Yes, each addict has to decide to accept help to get recovery. Recovery is very complex and multi-faceted: physical, mental and spiritual. All three aspects must be treated, one day at a time, for the rest of our lives.
Doc John’s haste/resentment to condemn big drug companies hurt his argument. And I am no fan of big drug companies either. But like a stopped clock, even they are right some of the time. Many of us in recovery need medication to help us with various mental/emotional conditions.
12stepper – I didn’t mention drug companies in my article, perhaps I’m not the only one who has been hasty.
My point wasn’t to compare drug or alcohol addiction to Facebook addiction. It was to compare the ridiculous definition they came up with — which was so generalized as to be meaningless — to everyday human behavior. Yes, addiction is characterized by a craving, but we also have cravings in normal everyday life too.
The point is that the brain mechanisms for these two kinds of cravings are exactly the same. The only difference is in degree. The new definition sheds no additional light on ‘degree’ and why the brain seems to control cravings in some people for some things (and only for some things), and not for others.
Here’s one last example — many people are addicted to things you need to survive, like food. This new definition sheds no new or helpful light on this kind of concern, and in fact, only complicates the conversation.
12stepper, I hear the “you don’t know what its like” excuse often. The reality is “you don’t know what its like because you are.” The “Id” will not allow for you to take direct responsibility. There has to be some “uncontrolable cause” in which the super ego and rectify and the ego can act upon. That is the only way the 3 can come to an agreement. An addict has an “Id” (subconscious in nature) problem to begin with. They can’t say “no” to their “inner child”.
Anyway, I know plenty of FBers and especially WOW player who forgo all those things. They will not eat, hide their activites from family members who have chastised them, even steal the games or money to buy the games if they can not afford them. It leads to social problems and all the other things related to addictions. The big differnce is that they are not illegal, so they don’t have to hide their behaviors from the law.
Excellent article but “simply a brain disease” hardly does the research or the article justice. It is imperative the patient see this is a fight against a fatal disease. A fight against the only fatal disease that tells you, you are not sick in your own voice.
That disease concept must be instilled in many patients before behavioral work, work as simple as surrendering can begin to unwrap the addict from the convoluted bonds of a twisted denial system.
Hey John, again a superb article.
Yes, Addiction, or rather ‘dependence’, is a complex issue and whilst we’ve made huge strides forward in beginning to understand some of it’s myriad complexities, we understand very little.
I agree that the term ‘addiction’ is overused and has lost it’s power. After all everyone’s addicted to someone these days hey? Shopping chocolate ,shoes, the internet. defining clinical dependence is another thing altogether.
Also, oversimplification can give people a potential escape hatch (we know they’re grasping at any potential ones anyway) and finding a more comprehensive definition may allow people to more readily assume responsibility for their ‘illness’ and be accountable for recovery.
Love reading your pages and had no idea that the ‘long version – addiction definition’ had been released despite their press release second attempt, so thanks for sharing!
Best from Cape Town, South Africa.
Well done ..my first read of this statement by ASAM was “‘so what else is new” , Exactly as you stated, everything we do alters neural activity to varying degrees and either we return to that activity due to the perceived reward or not. This seems like a fairly transparent attempt to medicalize a very complex condition/illness. As an addictions professional for 30+ years the bio-psycho-social model works infinitely better. I believe Bill Wilson and William James might have a small problem with this view and the ensuing discussion would be fun to watch.
Your article brings to front and center some of my observations of patients in a Rehab.facility. Those who were ready to take responsibility for lifting that glass, or snorting, injecting or swallowing that drug, seemed to be the most successful in overcoming their addiction. The Mental Health practitioners may jump on this and try to give a physiological reason (excuse?)to “make nice” to the patient. A person is much more willing to get into a Rehab. program (translate BIG $$) and find a “reason” to blame something rather than get honest and get real about their addiction.
These were my observations of 3 months at a Rehab. for supposed behavioral therapy (BIG mistake-I was inundated with addiction lectures and very little Trauma Therapy).
Again, I SAW results when the person took responsibility for the addiction. Maybe this “disease thing” has hurt the addicted in their healing, but HELPED the Mental Health Industry to collect billions. Notice the REPEAT business…
Dear John,
You summarized my own concerns in this sentence :
“By emphasizing the “brain disease†model over the more accepted bio-psycho-social model of addiction, the Society is putting the focus and spotlight on the brain — an organ scientists still just barely understand.”
At this point in time there is very little we can do in a medically targeted way to help people with these very real issues. At the same time, it seems quite possible to offer real help through interventions in the psychological and social realms.
While these sorts of medical models may be effective in soothing academics suffering from “science envy”, the move away from the biopsychosocial model towards a model which characterizes disorders within a context which has very little to offer to in the way of effective interventions is one I find worrisome as well.
As most current studies seem obliged to say, “it’s hoped that the results our study will lead to new and effective treatment interventions” but from what I can tell, most academics won’t even begin to speculate as to what form such treatment interventions might eventually take….aside from the ever-present assumption of new drugs, that is.
While I believe we all have good reason to encourage and applaud basic neurological research, it’s curious to realize that any comfort such models may offer to real clients ( i.e. It’s not my fault) currently takes place within the very psychological context that the “brain disease” people seem so eager to abandon.
Thanks again for your perceptive writings in this area.
There will be no progress in the treatment of addiction, so long psychiatrists and psychologists, view this phenomenon as a “behavioural” or “psychological” problem. Addiction has “psychological” symptoms, but these should not be mistaken for “causes” of addiction. Addiction is a physiological illness, that can be treated by non-drug means. Please read:
Drug Addiction is a Nutritional Disorder at:
http://www.hypoglycemia.asn.au/articles/drug_addictions_nutritional_disorder.html
Pam Killeen, Addiction: The Hidden Epidemic at:
http://www.addictionthehiddenepidemic.net/author.html
Once the drugs and alcohol, gambling, shopping and other “addictive” behaviors are gone, I have a “THINKING DISEASE”…Yes, it’s always there unless I do the maintenance on a daily basis to life the obsession. I have no craving to use just to eradicate my “stinking thinking”.
A heart with a leaky valve, a lung with clogged congestion, a limb that has severed nerves are example of physical biological dysfunctions. Putting these parts next to a person without the problem you can see (metaphorically speaking) that they work differently. Research has been done to prove such a dysfunction exist in the brain that causes addictions. They have made bold claims that addictions were “hereditary†and “caused by genes†or “chemical imbalanceâ€. The pharmaceutical and medical community wants it to be a physical thing, a detectable dysfunction. Because then they can treat it with a procedure or a pill. Treating a way of thinking, a behavioral preference caused by our social environment is impossible. We see people using self medicating techniques commonly in our culture. Its on our TV, in our movies, sports events where everybody is celebrating and/ or drowning their depression, and in our homes we witness the assignment of emotions to use of drugs and alcohol. It is a part of our culture and can’t be treated with a pill or a surgery. We are trained like rats to be addicted to coffee, nicotine, alcohol, Viagra, antidepressants, and sex. You can’t undo with nature what nurture did.
I have a theory have done a laymen’s research to try to debunk it. The basics of it is that we are perfectly nourished (food), secure/ protected (shelter), and warm (clothing) in the womb. Our baseline is formed there. From the moment we are born we seek to maintain that baseline. Anxiety stems from a feeling of not being able to maintain one of the 3 needs. When we find something that fulfils one of those needs chemicals like dopamine are released and associated with the behavior encouraging the brain to repeat that behavior. Food and warmth are pretty straight forward needs to fulfill as they have physical constraints. But the individuals understanding of “security†is almost entirely a perceptual attribute. It is an evolving trait. Our understanding of the things we are afraid of, the things that we need not fear is ever changing. Added to that is the options available to us to either “fight†or “flee†that which we fear.
That is the theory in a nutshell anyway and it fits together better then any about “geneticsâ€. However, you would need many years and dollars of expensive therapy to unlearn to associate a behavior with fulfilling a need. We in the west don’t have such resources or patients.
How would babies that are born addicted to things, be it caffiene or heroin, fit into your model?
Recently, a lecturer summarised one current scientific school of thought about addiction in this way:
– our organism keeps itself alive more or less automatically through numerous and complex processes managed by the brain/nervous system;
– two vital processes however require conscious and willed management: procreation and nutrition;
– to make sure they happen and the organism/species survives, both processes have evolved to be pleasurable and in a way that the brain/nervous system ensures they are executed (either regularly or by being triggered);
– if an organism repeatedly engages in something that is experienced as highly pleasurable, the brain/nervous system eventually considers this activity equally necessary for survival;
– proof of concept: when telling an addict that they have to stop using, they are likely to reply: “I can’t, it would kill me!”
If you want to take a pure biological perspective to addiction as a possible mechanism for survival, then addiction should select itself out.
Think about it, cocaine studies in the 1980’s showed that animals will minimize simple needs like eating and procreating just to continue the use of a substance. Talk to heroin addicts in recovery and they will admit they do not engage in routines of daily living needs, and they sure do look fairly cachetic as a group.
And some societies have deemed addiction and selling drugs as crimes that merit a death sentence. So, in the end, addiction should be a self limiting behavior for a species.
Unfortunately, overtolerance by those who engage in enabling and codependency allow addicts to survive much longer than evolution would allow. I am not supporting opposite intolerance, but, coddling and rationalizing addictive behaviors for alleged needs outside substance abuse has to be reframed. Anything that someone is engaged in that meets the definitions of either abuse or dependency has to be challenged by those being disrupted by the addict. Otherwise, fairly much guilty by association.
Joel,
You are making the mistake of viewing an addiction as a dysfunction, and thus something that needs “selected out.†It’s not a dysfunction but an over function. Addiction is to psychology what cancer is to biology.
You (as we all) are technically addicted to everything you do. (Humans will always do what is perceived as the most pleasurable choice.) You are addicted to eating, breathing, beating your heart, and even writing in this blog. But addiction becomes a mental dysfunction when it becomes all consuming and unhealthy. Just as your cells are designed to reproduce in order to replace the dying ones. It isn’t considered the dysfunction of cancer until they start producing them at an unhealthy rate. However you can’t “select out†the ability to reproduce cells, just as you can’t select out the minds mechanism to seek pleasure.
Now that said. The biological mechanisms that are triggered when the person experiences something pleasurable are just that, mechanical. The triggers are all psychological. The types of additions we are subject to are the result of our cultural environment. Stopping and controlling addictions starts with understanding what causes the choice to say “get drunk†to be the most pleasurable option in the first place.
Whenever the medical establishment seeks to label something a ‘disease’ it is to prepare us for the onslaught of drugs that will be introduced to treat this ‘disease’. It is an age old marketing trick. If you call something a disorder or injury it implies it can be healed.
If you call something a ‘disease’ then it implies it is out of your control and you need to take a drug for it. This is the way pharmaceutical companies operate. Most of the funding for these medical organizations that write the DSM etc comes from pharmaceutical companies. They heavily influence these ‘decisions’ to label things certain ways. They make billions and most people are absolutely oblivious it is going on.
Just the fact that addictions run through generations of families should be proof of some kind of brain disease causing mechanism. To say addicts raise up addicts blaming it all on the family of origin simply doesn’t completely explain this. Often addicts will stop the behavior before they even have children yet these children still show signs of the same addictive tendencies. The better explanation for addiction is that it is caused by a dysregulation of neurotransmitters in the brain such as dopamine and serotonin and this is passed down from generation to generation. This dysregulation makes the addict suffer from below the baseline mood, a type of dysthymia and their addiction of choice is simply a way to medicate this problem and bring them up to normal baseline mood. The trouble is most addictive substances and behaviors do not work well in achieving this goal. The brain shuts down it’s own ability to produce neurotransmitters due to the fact that the addiction is creating them artificially causing the addict to indulge in more extreme behaviors or to ingest more of the mood altering substance. Self medication through addiction is like killing an ant with a hammer. More research is needed to explore various treatments to increase serotonin and especially dopamine without using an addictive substance or behavior.
Perhaps a change in definition would help. Here’s a medical definition. “Any deviation from or interruption of the normal structure or function of any body part, organ, or system that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown.” This seems to fit what happens in the brain of many people who abuse substances. There’s also the idea that for some, a word like disease can add to the shame and stigma still associated with addiction. As a person who currently calls them-self a “recovered” alcoholic, it’s clear to me that alcoholic and addict are strong words to some people. The stereotype comes to mind for many. I’m a very high bottom alcoholic, and I was more of a problem drinker than anything else, but when I tell someone I’m a recovered alcoholic I can see uneasiness on some people’s faces. Clearly we need new definitions, and to find a way to remove the shame and stigma attached to drug and alcohol addiction. When I compare alcoholism or drug addiction to a disease like cancer, I can understand the debate. However, I wish people would stop debating, and in many cases arguing about the disease concept of addiction. We simply need to begin working together in a common effort to help those suffering from “any unhealthy, morbid, or desperate condition.” By that definition, I believe addiction can truly be called a malady.
This either/or mentality isn’t helpful. Perhaps trying to insist upon determining a hierarchy of influences isn’t either. We do know that “human behaviors” as a general concept don’t result in dopamine production/reuptake being depressed, but we do know it’s the case with long term methamphetamine abuse. Then there are the fMRI studies comparing addicts and non-addicts (and I’m NOT referring to Amen).
But just like diabetes has a physiological basis, there is a psychological and behavioral base as well. So also, with addiction.
I think that to call “chronic brain disorder†to the addiction problems not offers help neither understanding about what is the problem and how must be treat. I think that it is only one of the three approaches of the theory bio-psycho-social, but it is very risky to make this kind of definitions, which go against to the sense of the responsability of the patient.
I think drug addiction is not a disease ..We have to guide, educate and rehabilitate to these youngsters and if we succeed in this steps ..we can easily fight with drug addiction in society …
The bible says life and death is in the power of the tongue; it also says so a man speaketh so it is, meaning if a person refers to himself as an “alcoholic or drug addict” a self fulfilled prophecy occurs.
The bible says we are in a spiritual warfare meaning satan will use any tool in his tool box (addictions) to steal people’s soul. The average non-Christian believes they have an addiction problem but in reality they have a much bigger problem and not even aware of it as satan is using addiction to weaken them, enslave them, and in process stealing their souls. What if it was times of the beast (666) and a person with addiction issues is binging and craving intensely, satan comes along and says “here is all the coke, pills, alcohol etc you want, just take my mark– what would the person do who is binging? Christians know that accepting the mark dooms you to the lake of fire. From a Christian perspective the way to overcome addiction is by developing a relationship with Christ; people have difficulty accepting what they don’t see; with Christ there is no pharmaceutical companies, mental health systems getting rich off people with addiction issues, but it is the individual themselves who reap the rewards through the development of a relationship with Christ; he takes away the desire thru his strength and grace and in return the individual receives eternal life, a peace and joy beyond understanding, his never ending love. Addiction is a spiritual battle requiring spiritual tactics; the bible instructs us to put on the armor of God to overcome–what do you have to lose? Just remember the closer you become to Christ the harder satan will work to block your progress. Awareness is the key, you can’t change what you aren’t aware of; you can’t over come through Christ if you are not aware of who he is. Discover Christ and you will beat any addiction.
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