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Addiction: The Gap Between Science and Perception

November 27, 2015  |  Falmouth Enterprise

Dr. Michael Bihari

Several years ago, the American Society of Addiction Medicine (ASAM) defined addiction as follows: “...addiction is not about drugs, it’s about brains. It is not the substances a person uses that make them an addict; it is not even the quantity or frequency of use. Addiction is about what happens in a person’s brain when they are exposed to rewarding substances or rewarding behaviors, and it is more about reward circuitry in the brain and related brain structures than it is about the external chemicals or behavior that “turn on” that reward circuitry.” 

40 million Americans age 12 and over have a substance abuse disorder (addiction) involving nicotine, alcohol or other drugs. That is more than the number of people with diabetes, heart disease or cancer. Meanwhile, upwards of an additional 80 million Americans are risky substance users; those who are not addicted, but use tobacco, alcohol and other drugs in ways that may threaten public health and safety.

On its website, the ASAM characterizes a substance abuse disorder (addiction) as follows:

  • Inability to consistently Abstain;
  • Impairment in Behavioral control;
  • Craving; or increased “hunger” for drugs or rewarding experiences;
  • Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and
  • A dysfunctional Emotional response.

In 2012, CASAColumbia, a national nonprofit research and policy organization focused on improving the understanding, prevention and treatment of substance use and addiction, published an in-depth report that looked at how people with an addiction are diagnosed and treated in our country. According to the report (Addiction Medicine: Closing the Gap between Science and Practice), “despite the prevalence of addiction, the enormity of its consequences, the availability of effective solutions and the evidence that addiction is a disease, both screening and early intervention for risky substance use are rare, and only about 1 in 10 people with addiction involving alcohol or drugs other than nicotine receive any form of treatment.” 

This situation may be changing because of the attention being paid to the current opioid (prescription painkillers and heroin) epidemic.

Addiction As a Disease

Using information from the “Gap” report, CASAColumbia dedicated a section of its website to answer questions about addiction as a disease and to dispel myths about its causes and the behavior of people with a substance abuse problem. The following information is from the organizations website. 

Addiction is a complex disease of the brain and body that involves compulsive use of one or more substances despite serious health and social consequences. Addiction disrupts regions of the brain that are responsible for reward, motivation, learning, judgment and memory. It damages various body systems as well as families, relationships, schools, workplaces and neighborhoods.


Addiction is defined as a disease by most medical associations, including the American Medical Association and the American Society of Addiction Medicine. Like diabetes, cancer and heart disease, addiction is caused by a combination of behavioral, environmental and biological factors. Genetic risks factors account for about half of the likelihood that an individual will develop addiction.

Addiction involves changes in the functioning of the brain and body. These changes may be brought on by risky substance use or may pre-exist. If left untreated over time, addiction becomes more severe, disabling and life threatening.


People feel pleasure when basic needs such as hunger, thirst and sex are satisfied. In most cases, these feelings of pleasure are caused by the release of certain chemicals in the brain. Most addictive substances cause the brain to release high levels of these same chemicals that are associated with pleasure or reward. 

Over time, continued release of these chemicals causes changes in the brain systems involved in reward, motivation and memory. When these changes occur, a person may need the substance to feel normal. The individual may also experience intense desires or cravings for the addictive substance and will continue to use it despite the harmful or dangerous consequences. The person will also prefer the drug to other healthy pleasures and may lose interest in normal life activities. In the most chronic form of the disease, addiction can cause a person to stop caring about their own or other’s well-being or survival.  

These changes in the brain can remain for a long time, even after the person stops using substances. It is believed that these changes may leave those with addiction vulnerable to physical and environmental cues that they associate with substance use, also known as triggers, which can increase their risk of relapse.


A chronic disease is a long-lasting condition that can be controlled but not cured.

About 25-50% of people with a substance use problem appear to have a severe, chronic disorder. For them, addiction is a progressive, relapsing disease that requires intensive treatments and continuing aftercare, monitoring and family or peer support to manage their recovery. (This is similar to other chronic healthcare conditions such as diabetes.)

The good news is that even the most severe, chronic form of the disorder can be manageable and reversible, usually with long term treatment and continued monitoring and support for recovery. 


The initial and early decisions to use substances reflect a person’s free or conscious choice. However, once the brain has been changed by addiction, that choice or willpower becomes impaired. Perhaps the most defining symptom of addiction is a loss of control over substance use.  


People with addiction should not be blamed for suffering from the disease. All people make choices about whether to use substances. However, people do not choose how their brain and body respond to drugs and alcohol, which is why people with addiction cannot control their use while others can. People with addiction can still stop using – it’s just much harder than it is for someone who has not become addicted.

People with addiction are responsible for seeking treatment and maintaining recovery. Often they need the help and support of family, friends and peers to stay in treatment and increase their chances of survival and recovery.


Some people think addiction cannot be a disease because it is caused by the individual’s choice to use drugs or alcohol. While the first use (or early stage use) may be by choice, once the brain has been changed by addiction, most experts believe that the person loses control of their behavior.

Choice does not determine whether something is a disease. Heart disease, diabetes and some forms of cancer involve personal choices like diet, exercise, sun exposure, etc. A disease is what happens in the body as a result of those choices.

Others argue that addiction is not a disease because some people with addiction get better without treatment. People with a mild substance use disorder may recover with little or no treatment. People with the most serious form of addiction usually need intensive treatment followed by lifelong management of the disease. 


American Society of Addiction Medicine: Definition of Addiction

CASAColumbia: Why Ending Addiction Changes Everything

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