The American Society of Addiction Medicine (ASAM) defines addiction as “a primary, chronic disease of brain reward, motivation, memory and related circuitry.”
First, what is a primary disease? Is it accurate to define addiction as a primary disease?
A primary disease does not originate from another disease. A primary disease has no mainspring. For example, strep throat and common colds are classified as primary diseases. Consequently, adopting the idea of a primary, chronic brain disease means locating the genesis of addiction in an external, causal agent that perforates its host’s brain and honeycombs the neural circuitry of the reward/pleasure. motivation, and memory centers.
A plethora of substances/behaviors such as illicit and licit drugs, food, gambling, and sex among others, analogously become the pathogens that beget addiction. If addiction is a primary disease, then that would translate into these substances/behaviors being intrinsically and inherently malevolent. They would be the malignant root of addiction, and therefore, complete cessation of such substances or activities (commonly known as abstinence) would logically be the overarching goal of treatment regimes.
Further, defining addiction exclusively as a brain disease presents a complex issue in black and white. Either you have the disease or you do not. In fact, addiction is not a clear and unequivocal concept (and reality) but is equivocal and moot at best. Thus, I propose mapping and delineating addiction on a spectrum.
People can be at varying stages of addiction. Some may be in the midst of treatment, enduring cycles of remission and relapse. Others may teeter on the fringes of the spectrum–straddling the murky area between dependency and habitualness. As the ASAM itself notes, addiction has other factors that may increase its onset and duration, such as strained or disturbed social relations and supports, co-morbid psychiatric disorders, existing traumas, biological and cognitive impairments (particularly within the reward circuitry), and looming genetic susceptibility (affected by the interplay of environment and biology).
Additionally, framing addiction as a disease means largely positioning it under the microscope of medicine. Addiction becomes something that requires a cure. Unfortunately, there is no known cure for addiction. Addiction continues to shirk conventional treatment (medication, counseling, therapies, addressing co-morbidities) because the primary motive in conventional treatment is not only achieving a state of remission, but also complete abstinence as an objective.
Addiction as a Source of Emotional Wounds
Contrarily, solely referring to addiction as a primary disease presents an obstacle in refining and evolving our comprehension of addiction, as well as cultivating and promoting a context of personal and societal healing from the clutches of addiction.
Our focus is on the agents or activities that interact with the neural circuitry. Yet, the molecular level is only one aspect of addiction and does not provide an integrated framework when tackling enquiries about the origins of addiction. The difficult part to grasp while observing and interacting with individuals lost in the cavernous fjords of addiction is the persistent engagement with a drug or behavior, despite negative repercussions.
That is the enigma: indefatigable usage amidst a setting of adverse effects. The Janus-faced nature of addiction is difficult to fathom. On one hand, individuals develop a craving and compulsion while knowing excessive drug/substance use and excessive, risky behaviors are adversely impacting their home, work, and/or social life.
Yet, it is this unyielding, internal struggle of an insuppressible desire and craving entwined with endeavors to resist and thwart these compulsions that reveals deep-rooted conflicts within ourselves–conflicts that transcend the prevailing disease framework. They lead us to ask the question: why would someone want to use knowing the exponential increase in adverse effects?
Addiction is a sequela. It is a tool to help people cope with difficult life circumstances. Addiction is a tool used to momentairly, but also recurringly, reconstruct wholeness within a fractured self. Utilizing alcohol, drugs or engaging in risky behaviors, such as gambling to the point of financial ruin, are tools to help individuals deal with deep-seated, emotional turmoil.
Renowned addiction expert, Dr. Gabor Maté paints a more comprehensive picture of addiction. He argues that addiction stems from childhood adversity and trauma. The brain develops abnormally in children who have suffered abuse, neglect, or abandonment.
He further notes that these early stressors alter the reward, motivation, and stress-response systems of the brain in such a way that they become more susceptible to addiction. Therefore, agents such as alcohol do not have the intrinsic value or worth of being good or bad in themselves.
Instead, because of adverse life situations, the brain circuitry in many people becomes relatively sensitive and increasingly responsive to drugs, alcohol, or any activity in which someone excessively seeks pleasure. Finally, Dr. Maté asserts that emotional pain is at the core of addiction. I propose that it is this pain that reflects our inner conflicts and splintered selves. Thus, we use addiction as a form of self-medication and self-therapy–striving towards completeness and fulfilment in our lives. We want to piece our lives back together.
Neural circuitry in the brain is one aspect of addiction and not the defining feature. The goal is not to undermine the brain disease model, but to embed it in a larger context of influential elements in the addiction puzzle. Strained and stressed social relations and childhood traumas/adversities are not just other factors, they are major triggers and causes of addiction.
Engaging different paradigms of addiction will help us synthesize a more comprehensive framework and integrate different approaches to really understand the dynamics of addiction.
American Society of Addiction Medicine. (2011). Public Policy Statement: Definition of Addiction. Retrieved from https://www.asam.org/docs/default-source/public-policy-statements/1definition_of_addiction_long_4-11.pdf?sfvrsn=a8f64512_4
Maté, G. (2012). Addiction: Childhood trauma, stress and the biology of addiction. Journal of Restorative Medicine, 1(1), 56–63. doi: 10.14200/jrm.2012.1.1005
National Institute on Drug Abuse. (2018). Treatment Approaches for Drug Addiction. Retrieved from https://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction