If you think addiction is all about booze, drugs, sex, gambling, food and other irresistible vices, think again. And if you believe that a person has a choice whether or not to indulge in an addictive behavior, get over it. The American Society of Addiction Medicine (ASAM) blew the whistle on these deeply held notions with its official release of a new document defining addiction as a chronic neurological disorder involving many brain functions, most notably a devastating imbalance in the so-called reward circuitry. This fundamental impairment in the experience of pleasure literally compels the addict to chase the chemical highs produced by substances like drugs and alcohol and obsessive behaviors like sex, food and gambling.
The definition, a result of a four-year process involving more than 80 leading experts in addiction and neurology, emphasizes that addiction is a primary illness—in other words, it’s not caused by mental health issues such as mood or personality disorders, putting to rest the popular notion that addictive behaviors are a form of "self-medication" to, say, ease the pain of depression or anxiety.
Indeed, the new neurologically focused definition debunks, in whole or in part, a host of common conceptions about addiction. Addiction, the statement declares, is a “bio-psycho-socio-spiritual” illness characterized by (a) damaged decision-making (affecting learning, perception, and judgment) and by (b) persistent risk and/or recurrence of relapse; the unambiguous implications are that (a) addicts have no control over their addictive behaviors and (b) total abstinence is, for some addicts, an unrealistic goal of effective treatment.
The bad behaviors themselves are all symptoms of addiction, not the disease itself. "The state of addiction is not the same as the state of intoxication," the ASAM takes pains to point out. Far from being evidence of a failure of will or morality, the behaviors are the addict's attempt to resolve the general "dysfunctional emotional state" that develops in tandem with the disease. In other words, conscious choice plays little or no role in the actual state of addiction; as a result, a person cannot choose not to be addicted. The most an addict can do is choose not to use the substance or engage in the behavior that reinforces the entire self-destructive reward-circuitry loop.
Yet ASAM pulls no punches when it comes to the negative consequences of addiction, declaring it an illness that “can cause disability or premature death, especially when left untreated or treated inadequately.”
The new definition leaves no doubt that all addictions—whether to alcohol, heroin or sex, say—are fundamentally the same. Dr. Raju Haleja, former president of the Canadian Society for Addiction Medicine and the chair of the ASAM committee that crafted the new definition, told The Fix, “We are looking at addiction as one disease, as opposed to those who see them as separate diseases. Addiction is addiction. It doesn’t matter what cranks your brain in that direction, once it has changed direction, you’re vulnerable to all addiction." That the society has stamped a diagnosis of sex or gambling or food addiction as every bit as medically valid as addiction to alcohol or heroin or crystal meth may spark more controversy than its subtler but equally far-reaching assertions.
The new definition comes as the American Psychiatric Association (APA) is undertaking a highly publicized, decade-in-the-making revision of its own definition of addiction in its Diagnostic and Statistical Manual of Mental Disorders—the bible of the mental health profession. The APA’s DSM will have a larger effect on public health policies that guide addiction treatment, largely because insurance companies are mandated by law to use the DSM diagnostic categories and criteria to decide which treatments they will pay for.
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