January 2020, Volume XXXIII, No 10
Paul H. Earley, MD, DFASAM
American Society of Addiction Medicine
The American Society of Addiction Medicine (ASAM) recently revised its definition of addiction. Please share this new language.
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 did ASAM consider this change to be necessary?
Since the publication of ASAM’s previous definition of addiction in 2011, the public understanding and acceptance of addiction as a chronic brain disease and the possibility of remission and recovery have increased. At the same time, there is growing acknowledgment of the roles of prevention and harm reduction in the spectrum of addiction and recovery. ASAM’s Board understood that the previous ASAM definition could be difficult to explain to some audiences. Accordingly, in 2018, it commissioned the development of an updated definition of addiction that would be more accessible to many of ASAM’s stakeholder groups, including patients, the media, and policymakers.
Concerted effort went into replacing the word “addiction” with “substance use disorder,” but the new definition uses both terms. What is the new thinking here?
There is a difference between addiction and a “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, is a primary brain disease that 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.
Every physician has many patients who are currently struggling with addiction.
The new ASAM definition describes addiction as a “treatable, chronic illness” with multifactorial comorbidities, which vary widely between individuals. How can this translate into improved treatment outcomes?
Improved treatment outcomes can be realized when addiction is treated as a chronic, rather than an acute, disease and when treatment for addiction is coordinated with treatment for co-occurring disorders and addiction-related medical complications.
Addiction treatment evolved outside of mainstream medicine and has been historically treated with acute interventions. Recognizing its chronic disease nature and impact on a person’s whole health can lead to more integrated services provided in a way that achieves and supports long-term maintenance of remission and recovery.
How could the new definition affect public policy?
The new definition informs and supports policy changes to align addiction prevention and treatment funding and research with that of other chronic diseases that have major public health burdens. It also supports a move away from punitive policy responses to prevention and treatment responses that address the various factors influencing the development and severity of addiction, including social determinants of health. The natural course of addiction is relapse and remission; public policy should be aimed at its chronic nature and the full life cycle of the illness.
More than other chronic illnesses, there is an insidious nature to addiction that poses very difficult treatment challenges. What can you share with us about this?
Stigma associated with addiction complicates its treatment as it prevents patients from seeking treatment and discourages health care providers from offering it. If not initiated early and provided in a way that affirms the dignity of the patient, treatment may be more difficult or less effective. Approaching addiction treatment as we do treatment for any other chronic disease can improve outcomes and reduce stigma.
Further, part of having addiction is an inability to recognize it. When physicians have better diagnostic acumen to recognize the signs and symptoms of addiction, they can use graded communication to help patients recognize their need for treatment.
Current models of treating alcoholism have extremely poor outcomes. What are the failings of the treatment industry and how can they be improved?
The addiction treatment field has long struggled with stigma, isolation from mainstream medical care, and woefully insufficient funding. Integrating addiction treatment into mainstream medical care—meaning, among other things, requiring similar quality oversight and accreditation/certification of programs and adjusting reimbursement for addiction treatment services so that they are on par with those provided for other chronic diseases—can improve quality and accessibility of addiction treatment.
Long-term addiction can “rewire” brain pathways crucial to recovery. How do you address it in treatment?
We know that addiction creates profound changes in the brain’s reward circuitry. This in turn produces changes in motivation, attention, learning, and even higher association circuitry. This accounts for the tenacious nature of the illness. Those who have the illness often need to learn and practice new behaviors, attitudes, and activities that counteract the drive to relapse. Therefore, many individuals with addiction need therapy or coaching in new skills that retrain the brain and decrease the probability of relapse or continued use.
Medical cannabis is finding increasing acceptance and efficacy. Why—or why not—should this be an option for patients in recovery?
Cannabis use is associated with multiple harms, including use disorder, reduced motivation among youth, and increased risk for psychosis among young adults. The most recent review by the National Academies of Science, Engineering, and Medicine found that there is inadequate information to assess the effects of cannabis on any condition save for chemotherapy-induced nausea and vomiting, multiple sclerosis-related spasticity, and chronic pain, for which the effects of cannabinoids are modest. It also found that cannabis use is likely to increase the risk for developing substance use disorder (other than cannabis use disorder). Lack of efficacy plus demonstrated harms and significant risk of exacerbating addiction should preclude its use among patients in recovery.
What advice do you have for physicians who suspect patients may be in denial over addiction issues?
Addiction is a very common illness. In a 2017 study, the NSDUH [National Survey on Drug Use and Health] reported that 6.4% of individuals 26 years of age or older have a substance use disorder (one in 16 adults in the US). Therefore, every physician has many patients who are currently struggling with addiction. Physicians can be a major force in helping patients recognize and address the disease. Here are a few first steps that will help physicians:
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