The likelihood for addicts to get effective treatment improved greatly last month, when the American Society of Addiction Medicine (ASAM) released it’s public policy statement on the definition of addiction.
Boldly stating that addiction is a “primary, chronic disease”, ASAM has established the role of neurobiology in the development and maintenance of all addictive behaviors.
The research and science that the report is based on has been around for over a decade, but ASAM is the first medical-based organization to lay out a comprehensive summary of the established research that can potentially be used as a guide for development of public health policy and more effective treatment approaches based on this science.
ASAM Widens the Lens
Declaring that addiction has “bio-psycho-socio-spiritual manifestations”, ASAM widens the lens considerably to focus on the complex interaction between brain functioning and the various aspects of our environment that directly interact with, and sometimes shape, how addictions are developed and maintained.
Environmental influences include exposure to stressful life experiences in our interactions with family and friends. They also include our psychological development, which affects how well we learn the skills of emotional and behavioral regulation. Co-existing mental health problems, such as anxiety disorders, depression and ADHD, intersect with environmental influences and can contribute to the development of addictions.
Major Points of ASAM’s Definition of Addiction
ASAM concludes that addiction is a primary, chronic disease of:
- Brain reward and motivation: Our brains are wired to link activities that are vital for species survival (such as food, sex, and being productive) to the reward, or pleasure centers, of our brains. Addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy self-care behaviors by hijacking these pleasure centers through alteration of brain neurochemistry.
- Memory: Addiction alters the brain chemistry responsible for memories associated with rewards (food, sex, alcohol and other drugs) and leads to a brain and behavioral response to cues outside of the person, rather than previously learned, more adaptive, internal cues. This in turn triggers craving and/or involvement in addictive behaviors.
- Impaired judgment: The brain’s frontal lobes are important to what’s called “executive functioning”: decision-making, thinking rationally and making judgments. Addiction interferes with executive functioning, resulting in problems with perception, learning and impulse control.
Impaired judgment is most commonly seen when addicts are unwilling to change their dysfunctional behaviors despite mounting concerns expressed by others. They can show an apparent lack of appreciation of the magnitude of cumulative problems and complications.
Intoxication vs. Addiction: Getting High vs. “Feeling Normal”
The research now explains why addicts often express the inability to “feel normal” unless they drink alcohol or take other drugs.
Non-addicts will use alcohol or other drugs, get a feeling of being high, and afterward their brains return to a baseline of functioning. Addicts’ altered reward circuits, memory disturbances and impaired judgment, on the other hand, create a chronic “dysfunctional emotional state”, requiring the addict to seek alcohol or other drugs just to get back to a baseline state “to feel normal” again.
The important implication here is that science now establishes that 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 self-destructive reward-circuitry loop.
Important Factors to Consider
- Genetics: ASAM asserts that genetic factors account for about half of the likelihood that an individual will develop addiction. Others, such as Gabor Mate, dispute that genetics play such a powerful role, but we now know through the study of epigenetics that environmental factors (mentioned above) interact with our biology and affect the extent to which genetic factors actually get expressed.
- Resilience: Our ability to bounce back from adversity and go on to live a healthy, fulfilling life affects the extent to which genetic predispositions lead to the behavioral and other manifestations of addiction.
- Culture: The set of shared attitudes, values, goals, and practices that American society, and more specifically, our families and healthcare system, embrace also plays a role in how addiction develops in people with biological vulnerabilities to the development of addiction.
- Spirituality: Interestingly, ASAM adds a spirituality dimension to the disease definition, which reflects a progressive perspective on the nature of healing and acknowledges an important and often misunderstood aspect of addiction and recovery.
People often get stuck on the spiritual aspects of recovery, usually focusing myopically on religion alone. An important part of healing in recovery from any illness is related to how we feel connected to the rest of our community and larger world. This includes making sense out of, and finding meaning in, life. Religion is but one aspect of spirituality, and for many people, their spiritual lives don’t include traditional “organized” religions.
Spiritual issues become a problem in recovery when distortions in a person’s connection within herself (for instance, a very negative view of herself), with others (feeling distrust), and with the transcendent aspects of life--referred to as God by many, the Higher Power by 12-step groups, or higher consciousness by others. ASAM’s addition of a spiritual component to addiction informs us about the damage done to a part of ourselves that isn’t flesh and blood, but is as part of the healing process as any other.
Implications for Adolescents
The still-developing frontal lobes of adolescents may compound any deficits in “executive functioning” and predispose young people to engage in more high risk behaviors, including engaging in alcohol or other drug use.
Besides frontal lobe functioning, the connections of neural pathways throughout the adolescent brain is also in the process of maturation, making exposure to substance use in adolescence and young adulthood another significant factor in the development of addiction.
Risky behaviors and challenging authority are a normal part of a teenager’s development, so it’s important to share science-based information with them to help them make informed decisions.
Co-Occurring Disorders
Co-occurring disorders, such as anxiety, depression, post-traumatic stress disorder (PTSD) and attention deficit hyperactivity disorder (ADHD) are mental health problems that exist alongside addiction when a person’s ability to manage their emotional world becomes a problem in itself.
Anxiety, depression and PTSD sometime start prior to the addiction, when the person turns to drugs or other compulsive behaviors to help manage their difficult emotions better.
Distortions in our thinking and emotions from these mental health problems can contribute to feelings of chronic low self-esteem and a “glass is half-empty” worldview. Fear associated with anxiety, shown by distrust, hyper-vigilance, and paranoia, further impairs perceptions and compromises the ability to deal with feelings.
As you can see, the “chicken or egg” question comes into play, which makes it important for those seeking treatment for addiction get an evaluation by a specialist in co-occurring disorders who can sort out the complex interaction among addiction and mental health problems.
Treatment Implications
ASAM’s guidance for treatment reflects it's multi-pronged definition stating that “recovery from addiction is best achieved through a combination of self- management, mutual support, and professional care provided by trained and certified professionals”.
Interestingly, as befitting any disease, they include the same recommendations given in other health conditions. 'Self-management' is emphasized first, reflecting the need to take personal responsibility and accountability for change. Second is the need to establish a supportive community of people and places to include health-promoting activities. Once these are in place, professional care can best be utilized.
What ASAM is clearly implying in it's findings is, ‘The disease is not your fault—but recovery is your responsibility.’
Because of the damage to neural circuitry it takes a long time for a brain to normalize and for recovery maintenance skills to be properly developed. Therefore, the ongoing risk and/or recurrence of relapse after periods of abstinence is another fundamental feature of addiction. Therefore, treatment of addiction requires the understanding that relapse and remission are a part of the disease process, as in any disease.
This is where harm reduction approaches to treatment become an appropriate alternative to the "one size-fits all" total abstinence programs common to many rehab centers. Harm reduction offers a continuum of strategies from safer use, to managed use to abstinence. Harm reduction strategies meet drug users "where they're at," addressing their specific environments and lifestyle issues as well as patterns of use.
An Exciting Time
The challenge of transforming what we now know about the science of addiction into more effective treatment outcomes makes it an exciting time for me to be working in the addiction treatment community.
Hopefully, understanding more about addiction as a disease will lower the barrier of stigma at least a little bit and encourage more people to seek treatment and enable them to have more successful outcomes.
