Addiction remains misunderstood despite clear medical consensus

Nearly 15 years after the American Society of Addiction Medicine issued its landmark definition of addiction as a chronic brain disease, many still dismiss sufferers as lacking willpower. Here, Simon Mott of Hope Rehab Thailand sets out the science, its significance, and the dangerous persistence of these misconceptions

More than a decade ago, the American Society of Addiction Medicine (ASAM) issued a landmark definition that settled a long-standing dispute over whether addiction is a disease of the brain or a failure of will.

After a four-year process involving more than 80 experts, ASAM declared in 2011 that 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 relief by substance use and other behaviours.”

In other words, addiction cannot be dismissed as a by-product of another disorder. Trauma, stress or mental illness may set it in motion, but once it takes hold it becomes a primary condition, altering the brain in ways that require specific treatment.

That conclusion continues to underpin treatment approaches today and remains the foundation of modern addiction science, reflected in the hallmarks of the disease itself: the inability to abstain, loss of control, overpowering cravings, diminished recognition of harm and distorted emotional responses.

Treatment specialists, including world-leading centres like Hope Rehab in Thailand, saw ASAM’s definition as a validation of what those in recovery had long argued. For decades, alcoholism had been widely described as a disease — a view embedded in the founding of Alcoholics Anonymous in 1939 — and many hoped the science would finally settle the debate.

But despite ASAM’s definitive judgement nearly 15 years ago, many outside of the treatment community still view addiction as weakness, lack of discipline or moral failing.
The assumption is understandable, but it is wholly and factually wrong — and dangerously so. Like other chronic illnesses, addiction moves in cycles of relapse and remission and, without intervention, is progressive, often leading to disability or premature death.

Cravings, we know, are not ‘failures of willpower’ but the product of neurological change. Addiction develops when the brain’s reward system, designed to reinforce survival behaviours such as eating or nurturing relationships, is hijacked by substances or compulsive actions. Flooded with dopamine, the brain is convinced that the addictive behaviour is essential. Over time this corrupted circuitry pushes food, family and work aside, and the memory of the drug or behaviour can remain stronger than the substance itself, which is why relapse often occurs long after detoxification.

Outside of the treatment community, people often wonder why some become addicted while others do not, a question that fuels the addiction vs willpower debate. The truth is that vulnerability differs from person to person. Low dopamine levels caused by stress, genetics, poor sleep, malnutrition or even certain medications can increase the risk, making substances far more attractive to the brain’s reward system. This helps explain why many turn to drugs or alcohol as a form of self-medication: alcohol to ease anxiety, opiates to dull pain or aggression, stimulants to fight fatigue, or cocaine to lift depression and low self-esteem.

Once established, however, the effects of addiction are biological, psychological, social and spiritual, often marked by disconnection, loss of faith and hopelessness. The consequences can be seen in broken relationships, abandoned careers, diminished freedoms and, all too often, in life-threatening decline. Symptoms such as compulsive behaviour, impaired decision-making, obsession, anxiety, depression, mood swings, denial and loss of motivation are therefore not signs of “weakness” or of limited willpower but evidence of a brain struggling with altered circuitry.

Whilst science has given us a definition of what addiction is, it is yet to offer a cure. Like diabetes or cardiovascular disease, it is best understood as a chronic condition that must be managed across a lifetime. Medication can support recovery, but clinicians emphasise that it is medication-assisted therapy, not therapy-assisted medication. Or to put it another way, medicines may help to stabilise brain chemistry and ease withdrawal, but it is therapy that does the heavier lifting — challenging distorted thinking, building new behaviours and sustaining long-term change.

Successful treatment therefore relies on addressing not only the biological changes in the brain but also the psychological, social and environmental triggers that sustain the disease. Cognitive behavioural therapy is widely used to challenge distorted thinking and encourage new responses, while lifestyle change is essential to sustain progress.

Exposure therapy also helps people rehearse responses to the situations they will face outside. In Thailand, for example, Hope Rehab combines abstinence with coping strategies for stress, anxiety and depression, using the country’s warm culture and restorative climate as part of the healing environment.
Recovery is neither quick nor easy, but it is possible. Addiction may permanently alter the brain, yet the brain has the capacity to adapt. Each day of abstinence weakens old pathways and strengthens new ones.

Each day in recovery is proof that change can happen. As the recovery mantra goes: if you can quit for a day, you can quit for a lifetime — one day at a time.

Further information
Produced with support from Hope Rehab Thailand. To find out more about its clinical programmes and approach to recovery, visit www.hope-rehab-center-thailand.com/

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