Disease Redefined

The American Society of Addiction Medicine (ASAM) has issued a new definition of “Addiction” as of August, 2011. This definition stresses the neurobehavioral aspects of addictive disorders and essentially defines them as “brain diseases.” The short version of this definition reads as follows:

“Short Definition of Addiction: Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

“Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”

While this is an interesting way of looking at addictive disorders, I see several problems with it. First, the term “disease” has connotations that are not always useful in the behavioral management of substance abuse and dependence. “The Disease Model” was used for many years as a synonym for 12-step approaches to addiction, specifically the “Minnesota Model,” and in fact served as a sort of philosophical litmus test for substance abuse counseling (the first question on the Illinois drug and alcohol counselor certification application a number of years ago was, “Do you believe in the disease model of addiction?” To which I was sometimes tempted to give Winston Zeddmore’s answer from “Ghostbusters” – “If there’s a steady paycheck in it, I’ll believe in anything you say.”)

Another issue with the concept of disease is that it suggests a biological cause and a biological treatment as the first and most obvious choice. In the case of ASAM, I suspect that the development of new medications intended to curb cravings for alcohol (especially naltrexone and acamprosate) has influenced the science being used to study addictive behavior. (In other words, “my neurotransmitters made me do it.”)

The marketing of these medications among treatment programs and health professionals has been aggressive, and, if you are a pharmaceutical company, it makes good business sense to encourage health providers to adopt a mechanistic neuro-biological view. The recent push to remove the “stigma” of mental illness and substance abuse also fits neatly into this framework. On the whole, if it helps more people to defeat their addictions and lead healthy and satisfying lives, it is an effort well spent. But if it discounts the value of self-management and other psychological approaches to dealing with addiction, it may be counter-productive.

Certainly, we experience reward and pleasure by means of signals sent from one set of neurons to another. Dopamine, among its many functions, has been linked to these “reward pathways.” This has allowed the inclusion of compulsive gambling, overspending, and sexually inappropriate behaviors under the heading of “Addictions.” If you run a treatment program for these problems, you want people to accept that they are disorders which require treatment. Depression is another example of a psychological/psychiatric disorder, and it certainly merits treatment.

However, the fact that dopamine is involved in the experience of reward does not mean that tinkering with one’s dopamine activity will eliminate addictive behavior. Strengthening the operation of thinking, planning, and what is called “executive functioning” can be the most helpful approach. As Hyrum W. Smith, the inventor of the Franklin Day Planner, used to say, addictive behavior is what gives a reward in the short run but has a bigger cost in the long run. Teaching people to think longer-term can be a very helpful approach to battling any kind of compulsive or addictive behavior.

Of course, every thought, emotion, and decision we make is biological, in the same way that every great novel is comprised of text data. Our lives are lived in an electrochemical matrix that we interpret as reality. But we also cannot separate our neural events from our experiences of life. We need to adopt some philosophical approaches to manage addictive disorders, and cannot expect that simply taking a pill will cure the disease. For one thing, people need to learn how to mistrust their “circuitry,”, since it may be giving false data. For example, the thought, “I deserve a beer, it’s been a hard day,” may actually be the disguise for an addictive thought: “Without alcohol you will die. You must have some.”

The ASAM definition, you may note, also includes reference to “spiritual” effects of the disease. This is a nod to the 12-step tradition, which sees addiction as a “spiritual disease” with a spiritual solution (the higher power). There is also a variant of the concept of “denial,” which here comes as “diminished recognition of significant problems with one’s behaviors…” I might quibble with that. Plenty of addicted people know and recognize the problems that their addiction is causing them (or may cause them in the future), However, the addictive thinking patterns simply serve to discount those considerations. It’s like the smoker who says, “Well, I’m gonna die of something, so it might as well be something I enjoy.” Psychoanalytic theories like to call this distorted thinking either “denial” or “rationalization,” depending on how aware the individual is about the distortion. (Adlerians tend to call these “excuses.”)

The final part of this definition that makes me a bit cautious is the part that says, “Like other chronic diseases, addiction often involves cycles of relapse and remission.” It’s pretty obvious that although remissions and relapses in other diseases (like cancer, for example) may be influenced by actions that a patient may take or not take (such as continuing to smoke, or missing checkups), remissions are essentially not under the individual’s control in medical diseases. In addictions, relapses are (strictly speaking) voluntary. No irresistible pattern of brain circuitry can force a sober alcoholic to walk into a liquor store, take out money, buy a bottle, pick it up, remove the cap, and drink. Those are all voluntary movements. They just don’t SEEM like they are voluntary, to the person, at the time. Many alcohol-dependent people report a kind of depersonalization, in which the decision to relapse seems to have already been made, and is a “done deal” that cannot be argued with. They report watching themselves relapse as if they were powerless to stop it, or as if it were a movie scene that they cannot do anything to change while they watch it play out. This is just another excuse, albeit a very clever one, concocted by the addicted person in pursuit of the buzz of alcohol.

So success in recovery is always a choice. It may feel like there is no choice, but that is a motivation issue, not a cicuitry issue. The pleasure given by the substance (as muted as it becomes with heavy use) combines with the fear of withdrawal and the anticipation of relief, to override the indivdiual’s better judgment. If you want to think of this as happening in the “circuitry,” that’s fine, but we are human beings who can and must make choices every waking moment of teh day.

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