Chapter 1–Conceptualizing and Defining Addiction
Understanding the definition of addiction in American society helps us to understand how the condtion affects the addict, their family, and community systems. We need to consider what addiction encompasses in its truest sense. Our definition must also establish common ground across an array of demographic groups, in order to lay a foundation for intervention and advocacy that can best serve those affected by addiction.
However, the task of defining addiction presents challenges to the public health sector, as well as policy makers and the legal system. While some common threads have been established across demographic groups, the definition of addiction can take on different meanings depending on each group’s concerns. These differing opinions pose new challenges in understanding the wide scope of the issue and agreeing upon how to best assist those who struggle with substance abuse.
The Current Definition for Addiction
The American Society of Addiction Medicine has put forth a definition of addiction adopted in 2011 that states the following:
“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.”
ASAM goes on to state the following:
“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.”
Since the current definition of addiction focuses on the brain and its associated reward, neurobiological factors come to the forefront of the discussion. The fundamental areas of concern are the frontal cortex, along with the underlying white matter connections between the frontal cortex and the circuits that regulate reward, motivation, and memory. In these areas, substances alter impulse control and judgment. As a result, the rewards that an addict continues to pursue become ‘normal,’ despite the cumulative and often adverse consequences experienced.
Addiction is characterized by an inability to consistently abstain from substances and an inability to control behavior. An addicted individual experiences a craving (or an intense, insatiable hunger) for more drugs and/or alcohol—which produce a desired reward in the brain—despite any adverse consequences. Ultimately, there is an emotional response in the addict that deviates from normative behavior.
There are different ideas about the origins of an addiction, ranging from genetics to traumatic experiences to a learning disorder. What we do know is that addictive patterns of behavior are brought to the surface by environmental cues. Two major environmental factors are regular engagement in substance use and frequenting places like bars and clubs where potentially addictive behavior can occur.
If an addict does achieve a period of abstinence, or even several periods of abstinence, there is a persistent risk of relapse back into addiction, which is brought on by the presence of environmental cues that trigger the stress circuits of the brain. This increased stress, along with a lack of proactive, healthy coping skills, typically leads an addict to seek relief through the use (and subsequent abuse) of substances. Ultimately, addiction causes behavioral, cognitive and emotional changes that have a profound effect on the addict and his or her ability to maintain their day-to-day existence.
Issues with the Current and Accepted Definition of Addiction
With this definition, emphasis is placed on genetics as an important factor in the development of addiction. In the definition proposed by the American Society of Addiction Medicine, genetic factors account for half of the likelihood that an individual will develop an addiction. Within this framework, environmental factors, such as exposure to alcohol, drugs, or a substance-using culture, are thought to interact with the individual’s biology. From that interaction, the individual’s genetic factors come into play and exert their influence. Additionally, genetic predisposition and culture play a role in the degree to which addiction becomes actualized.
The concept of addiction as a disease dates back to 1956, when the American Medical Association declared alcoholism a disease. The definition proposed by the American Society of Addiction Medicine was an attempt to lessen the stigma attached to addiction and addictive disorders. Using the “addiction as disease” paradigm is useful because it frames empirical evidence that shows addiction is rooted in distinct brain changes, much like mental illness. But, in an article published in 2011 on the TIME magazine website, author Maia Szalavitz argues that using the disease metaphor may not be the ideal definition.
As Szalavitz points out, the brain disease model can further fuel the stigma that still has strong roots to addiction. Similarly, framing addiction as a disorder with neurobiological roots may not help to reduce stigma, either. In fact, it may increase the stigma. The word “disease” is useful to describe the neurological pathology and processes of addiction, but it can also imply that addiction is a fixed or unchangeable state. The inclusion of the word “chronic” may bolster such mindsets.
Furthermore, this label can lead to assumptions that the range of possible addictions are all seen as different expressions of the same disease. The concept of disease implies there are specific biological and psychological mechanisms at work that are shared across all substances. With genetic, familial, societal, and other environmental factors that play a role in the emergence of addiction, the mechanisms at work may differ depending on the substance being abused.
Differences between Addiction, Substance Abuse and Substance Dependence
Many people use the terms addiction, abuse and dependence interchangeably. The fact is these terms imply different conditions. As defined earlier, addiction is a primary, chronic, neurobiologic disease with genetic, psychosocial and environmental factors that influence its development and manifestations. It is characterized by behaviors that include one or more of the following:
There are several theories of addiction that have been proposed and debated, but the most compelling view of addiction is as a multifactorial disease caused by predisposing and precipitating factors. Addiction is described as the interaction between the person who is addicted to the substance, the drug, and prevailing environmental factors.
Substance abuse, on the other hand, is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress. According to the criteria put forth by the Diagnostic and Statistical Manual of Disorders (4th edition, Text Revision—DSM-IV TR), at least one of the following manifestations must be observed in a twelve month period in order to meet the criteria as substance abuse:
- recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
- repeated absences or poor work performance related to substance use
- substance-related absences, suspensions, or expulsions from school
- neglect of children or household
- recurrent substance use in situations in which it is physically hazardous
- driving an automobile or operating a machine when impaired by substance use
- recurrent substance-related legal problems
- arrests for substance-related disorderly conduct
- continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
- arguments with spouse about consequences of intoxication
- physical fights
Additionally, there is the concept of substance dependence. Like the definition for substance abuse, dependence is viewed as a maladaptive pattern of substance use, leading to clinically significant impairment or distress. Using the diagnostic criteria outlined by the DSM-IV TR, there needs to be at least three of these manifestations observed within a twelve month period:
- tolerance, as defined by either of the following:
- a need for markedly increased amounts of the substance to achieve intoxication or desired effect
- markedly diminished effect with continued use of the same amount of the substance
- withdrawal, as manifested by either of the following:
- the characteristic withdrawal syndrome for the specific substance
- the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
- the substance is often taken in larger amounts or over a longer period than was intended
- needing substance to “maintain” daily activities
- accidental overdose
- there is a persistent desire to control substance use, or there are unsuccessful efforts to cut down on substance use
- talking about stopping use, yet never actually doing so
- a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
- visiting multiple doctors
- driving long distances
- chain smoking
- important social, occupational, or recreational activities are given up or reduced because of substance use
- missing events with friends or family
- less engagement in old interests and hobbies
- the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
- current cocaine use despite recognition of cocaine-induced depression
- continued drinking despite recognition that an ulcer was made worse by alcohol consumption
Finding Common Ground in the Definition of Addiction
The concept of addiction has multiple facets which are the topic of great discussion and debate. The current description of substance abuse addiction as a brain disease has been the prevailing definition. It falls nicely within the predominant medical paradigm in substance abuse treatment, which views addiction as a complex condition with several biological mechanisms at its roots.
Yet, focusing primarily on the biological and neurobiological factors that contribute to the development of substance abuse and addiction can be short-sighted. Addiction is a multi-faceted disorder, and equal attention needs to focus on familial, environmental, and societal components. As described earlier, the term “disease” may not change harmful preconceptions about addiction, because its implication that the condition unchangeable may increase the stigmas surrounding substance abuse and addiction.
In order for the definition of addiction to change in a way that is consistent and represents all demographic groups, the stigma that is attached to drug and alcohol abuse needs to be addressed. Addiction is still seen as a personal choice, as if the addict is choosing to ruin their economic situation, damage relationships with family and friends, and cause undue burdens to society.
Much of this stigma is rooted in deep-seated moral underpinnings. Addiction is not a conscious choice or an ingrained character trait. It can be viewed as a confluence of factors that evolve within a conducive environment over a period of time. By removing the stigma and the labels we associate with it, we can address the range of underlying factors that contribute to substance abuse and approach addiction with a more pragmatic and realistic view.