Construction Of The Addiction Process: The Building Blocks
Each individual has building blocks that make them more or less likely to develop an addiction, such as genetics and environment.
The definition of addiction that was adopted by the American Society of Addiction Medicine (ASAM) Board of Directors in September 2019 is, “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.” Compared to the past, ideas on addiction have changed drastically and have led to increased public awareness, decreased stigma, increased research, and the development of successful prevention efforts and treatment methods.
In 2015, there were 20.8 million people aged 12 or older in America that had a substance use disorder. With the increasing ability to be able to diagnosis these people, treatment professionals have a real opportunity to formulate an analysis of their problems and potential solutions. Researchers have made great strides in this field which can be seen when looking at the past definitions of addiction, previous treatment methods, and public opinion.
Before the latest definition of addiction was adopted in 2019, the most recent definition from the ASAM was from 2011. The short definition was: “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.” It is clear that the 8-year gap in these definitions left room for experts to more thoroughly recognize the impact that environment and a person’s life experiences has on addiction. This is an even larger leap from historical beliefs that addiction was caused by a personality disorder, lack of willpower, or moral weakness.
It was after World War II in 1952 that the first Diagnostic and Statistical Manual of Mental Disorders (DSM) was created and formed the idea that drug addiction and alcoholism arose from a primary personality disorder. In 1965, the American Medical Association recognized alcoholism as a disease and declared it to be a medical disorder, accepting those patients into hospitals and developing treatment centers. During this time the development of effective pharmacologic treatments were also introduced. In 1968, the DSM-II recognized 3 types of alcoholism: episodic excessive drinking, habitual excessive drinking, and alcohol addiction, and in 1976 the ASAM defined alcoholism as: “Alcoholism is a chronic, progressive, and potentially fatal disease. It is characterized by tolerance and physical dependency or pathologic organ changes, or both – all the direct or indirect consequences of the alcohol ingested.”
In 1980, the DSM-III continued the trend of separating substance use disorders from other mental health conditions, and acknowledged the cultural perspectives on addiction, offering a diagnostic criterion that a person would have behavioral changes that, “almost all subcultures would view as extremely undesirable.” In 1990, the ASAM defined alcoholism as: “Alcoholism is a disease characterized by continuous or periodic impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial.” Diagnostic criteria continued to evolve with the DSM-IV in 1994, and the most recent edition, the DSM-5 in 2013 which for the first time, includes a behavioral addiction (gambling disorder).
The use of psychoactive substances has been around for nearly as long as recorded history, with evidence of Greeks using opium both medically and spiritually in 10,000 BCE. Around 5,000 BCE, there were reports of alcohol being used to levels of intoxication in Egypt. Cannabis, opium, and alcohol are substances commonly seen throughout history, with almost 2,000 references to wine and vineyards in the Bible alone, and evidence of marijuana use dating back tens of thousands of years in Europe and Taiwan. The attitudes and perceptions towards substances have changed over the years, with religious, cultural, and industrial influences impacting those opinions.
Religious influences have been and still are a weighing factor for those who practice religion. In the Bible, drinking alcohol was acceptable in moderation but was seen as sinful to drink to excess. The temperance movement of the late 19th century solidified the belief that alcohol use was immoral and was demonstrated by the prohibition movement. Today, alcohol use is generally accepted in American culture and is even sometimes promoted and advertised as glamorous, but some religions like Islam and Buddhism reject alcohol, and others like certain branches of Christianity view any excess alcohol use as immoral.
During the industrial revolution, characteristics that are sometimes associated with addiction like poor productivity, reliability, and punctuality in working environments were magnified as Americans moved to factory systems. The view on individuals struggling with a substance use disorder was that they were an unproductive social outcast and should be judged. Substances of abuse like cocaine and cannabis were stigmatized and associated with criminals and the lower class in the 20th century. Today, there has been a shift from viewing addiction as a moral and lifestyle choice to viewing it as a treatable chronic medical disease.
A 2018 poll found that 53% of Americans view addiction as a medical problem, and although this percentage is an improvement from the past, there is still room for advancement. Stigmatizing addiction and mental health disorders does no one any favors, but there is hope that we will continue on this positive trajectory of understanding addiction as a treatable brain disease in which treatment approaches are generally as successful as those for other chronic diseases.