How the New Definition of Addiction Corrects Long-Standing Misconceptions

By David Sack, M.D.

For decades, many people have gotten the wrong idea about addiction. Even as scientific research piled up supporting the theory that addiction is a brain disease, misunderstandings about addiction have persisted.

In August 2011, the American Society of Addiction Medicine (ASAM) took an important step toward refuting some of these long-held misconceptions, redefining addiction as a chronic brain disease. After four years of research and 80 expert opinions, ASAM’s definition responds to some of the most widespread misunderstandings about addiction.

Misconception #1: Addiction is a choice.

According to ASAM, addiction is a chronic disease, similar to diabetes or heart disease, caused by abnormalities in the reward system in the brain. What is originally experienced as a euphoric high over time becomes less rewarding as the brain adapts to changes in neurochemistry. This is followed by deep emotional lows, reinforcing the addictive behavior.

ASAM clarifies that just as a person cannot choose to be addicted, they cannot choose not to be addicted. The reward system of the brain responds to external cues, triggering a compulsion to use drugs and alcohol and engage in compulsive behaviors such as gambling, food and sex.

It doesn’t matter how much of a drug is used or how frequently; rather, it is the way an individual responds to stressors and external cues that puts some people at increased for addiction. Although there is a strong genetic component that contributes to addiction (accounting for about half of the likelihood that an individual will develop addiction, ASAM reports), culture, social support, trauma, co-occurring disorders and other factors also play a role.

A disease that is “bio-psycho-socio-spiritual” in nature, addiction is characterized by impaired judgment and decision-making and the persistent threat of relapse. Although it starts in the brain, addiction impacts all aspects of a person’s life, including their “behaviors, cognitions, emotions, and interactions with others,” according to the ASAM statement.

“The disease creates distortions in thinking, feelings and perceptions, which drive people to behave in ways that are not understandable to others around them,” said Dr. Raju Hajela, chair of the ASAM committee on the new definition. “Simply put, addiction is not a choice. Addictive behaviors are a manifestation of the disease, not a cause.”

Misconception #2: Addiction is a sign of weakness.

Many people still believe that addiction is a sign of a character flaw or weak morals. In developing the new definition, ASAM sought to de-stigmatize addiction by clarifying that it is a disease of the brain, not a sign of weakness. An addict’s behaviors can be explained as an attempt to resolve a “dysfunctional emotional state” that prevents them from being able to control their unhealthy patterns.

“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.”

Misconception #3: Addiction is caused by underlying emotional or psychiatric disorders.

Addiction is now defined as a “primary” disease. This means it is not caused by an attempt to self-medicate underlying mental health disorders such as depression, anxiety or a personality disorder. Although many people with psychiatric disorders also struggle with addiction, ASAM clarifies that addiction is not caused by these underlying disorders.

Misconception #4: “Process addictions” such as food, gambling and sex aren’t real addictions.

ASAM’s definition of addiction is not limited to drugs and alcohol. Those struggling with gambling, food and sex addiction, among others, are faced with a medical condition in the same way as heroin addicts and alcoholics.

“We are looking at addiction as one disease, as opposed to those who see them as separate diseases,” Dr. Hajela said. “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.”

Misconception #5: People can recover from addiction on their own without treatment.

Addiction is a progressive illness that “can cause disability or premature death, especially when left untreated or treated inadequately,” ASAM advises. While some people may be able to recover on their own, most will require some form of addiction treatment.

Even though addiction is not a choice, addicts can choose to get help. Treatment that combines “self-management, mutual support, and professional care provided by trained and certified professionals” gives addicts the best opportunity to recover, according to ASAM. As a “bio-psycho-socio-spiritual” disease, treatment must address all areas of the individual’s life.

Because addiction is a chronic disease, the decision to get treatment should not be met with shame.

“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.”

With Knowledge Comes Hope

While the new ASAM definition of addiction in large part confirms what addiction experts have known for two decades, the statement could have a significant impact on addiction sufferers and health care providers. Backed by ASAM, the nation’s largest professional society of physicians dedicated to treating and preventing addiction, as well as the top addiction experts, there is potential for the new definition to not only improve medical screenings and insurance coverage for treatment, but also to change the public’s perception of those struggling with this life-threatening disease.

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