Redefining Addiction. Reimagining Solutions.
By Paul Earley, MD and Yngvild Olsen, MD, MPH
Words matter. When it comes to addiction medicine, stigmatizing language and misunderstood terminology may keep some people from seeking effective care, leave families poorly equipped to support their loved ones, and drive policymakers to make counterproductive, even harmful, policy.
In 2011, the American Society of Addiction Medicine (ASAM) — the nation’s largest organization representing medical professionals who specialize in addiction prevention and treatment — set out to revise the society’s definition of addiction. This task was not easy given the complexity and stigma surrounding substance use and the term itself. At a time when the public had limited understanding and acceptance of addiction as a chronic brain disease, ASAM’s revised definition focused heavily on brain circuitry.
Over the past decade, however, more families, policymakers, and members of the media have come to understand that addiction is a chronic, treatable brain disease with the possibility of remission and recovery. There is also a growing recognition that evidence-based prevention, mutual and recovery peer support, and harm reduction services can play important roles in the full spectrum of addiction care.
While these changes are welcome, today’s conversations — whether they take place in the media, Congressional hearings, or among medical providers — still often fail to grasp the complexity and nuance of addiction. This incomplete understanding has likely contributed to an inadequate and unimaginative national response to our addiction and overdose crisis. It has delayed — and in some areas thwarted — comprehensive action plans that fully address the biological, psychological, and social factors that contribute to the development and perpetuation of this disease and has led to punitive approaches that often cause more harm than good.
For these reasons, ASAM updated its definition of addiction this year. The updated definition reads:
Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.
Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.
Why does this updated definition matter?
First, this definition recognizes that people do not develop the disease in a vacuum. The updated definition underscores the complex interplay of unique biological, psychological, and environmental conditions that have a role in any one individual’s addiction. Genetics can determine how brain circuits function in a person predisposed to addiction, and stressors such as adverse childhood experiences, lack of healthy social supports, and limited prospects for employment or stable housing, can exert significant pressure on the brain circuitry of individuals at risk for addiction. These factors influence the depth of vulnerability and can present significant barriers to recovery unless addressed.
Second, the updated definition can help clarify the difference between addiction and the term “substance use disorder,” or SUD. A diagnosis of SUD is made based on the presence of certain symptoms and is identified according to the substance used. Substance use disorders are categorized as mild, moderate, or severe. Mild SUD involves people excessively using substances and experiencing at most one or two related problems. Often, people in this situation reduce their use in response to changing environments, life circumstances, or upon recognition of their condition. Addiction, meanwhile, reflects the underlying disturbances and changes in brain function that manifest themselves as symptoms of moderate to severe SUD. People with addiction can absolutely achieve stability and some healing of dysfunctional brain functions, while no longer exhibiting symptoms of their disease. However, some of the brain changes are so deeply embedded that they persist, leaving patients at risk for relapse even after years of remission and recovery.
Finally, the updated definition underscores that compulsive behaviors associated with addiction often continue despite harmful consequences. We will not be able to punish our way out of this crisis, and we must face the reality that stern talks about drug use will not treat a devastating disease. Blanket punitive policies — including incarceration without access to evidence-based addiction treatment medications — ignore science. We have no evidence that a felony charge or time in a jail cell addresses the underlying disease, and the consequences of incarceration only add further pressures that make it more difficult to manage the illness. While breaking the law must be addressed judicially, incarceration is no more of a treatment for addiction than it is for diabetes or mental illness.
People with addiction deserve compassionate, evidence-based care that reflects the chronic and unique nature of this illness. Individualized treatment and recovery plans should comprehensively address all the factors in a person’s life that will affect their chances of recovery, and reflect their own sense of meaning, purpose, and values (what some refer to as spirituality). Finally, these plans should be revised based on the individual’s response and progress.
We need comprehensive public policy that helps repair, and then steady, our nation’s addiction prevention and treatment infrastructure by bolstering the addiction treatment workforce, supporting nationally recognized standards for addiction treatment programs, and providing meaningful funding for mental health and addiction treatment.
Make no mistake; the solutions are not simple. However, an updated definition of addiction that better captures the nuance and complexity of the disease may lead us to bolder policy interventions that save and improve more lives. Ultimately, public perception and public policy must reflect this nuanced understanding if our nation is to recover.
Dr. Paul Earley has been an Addiction Medicine Physician for 30 years and is based in Atlanta, GA. He is president of the American Society of Addiction Medicine.
Dr. Yngvild Olsen currently serves as medical director of the Institutes for Behavior Resources Inc/REACH Health Services in Baltimore, MD. She is vice president of the American Society of Addiction Medicine.