What is Addiction?

Kelly J. Clark, MD, MBA

President, American Society of Addiction Medicine
San Diego, CA
April 12, 2018
Let’s start with what Addiction is Not
• Start with some definitions of terms
• Use: taking a substance for a desired purpose

• Misuse: the use of a medication for a purpose other than as

prescribed
Risky Dosages Do Not Imply a Disorder or Addiction
Risky / unhealthy drinking is the consumption of
more than:

• 1 drinks on any given day • 2 drinks on any given day

• 7 drinks per week • 14 drinks per week
 Physical Dependence Is Not Addiction
• Dependence: a physiological state in which the person has
physical tolerance (taking more to get the same response) or
has physical withdrawal when the substance is not supplied

• Drug Addiction: a chronic brain disease which looks like a

person losing control of their drug use and then losing control
of their lives because of that drug use
 Substance Use Disorder Is Not Addiction
• Substance Use Disorder involves either:
– Impairment in functioning, or
– The individual’s distress
• E.g.: Most people who have a mild alcohol use disorder will
move through that with neither support groups nor treatment
 Opioid Dependence Leads to Withdrawal
• Within 6-36 hours of last opioid use withdrawal can look like:
– Muscle and joint pain
– Gut cramping with diarrhea
– Vomiting
– Chills, running eyes, running nose, agitation
– FETAL RISK in pregnant women

• This happens due to dependence, not addiction

– This can happen when people take opioids just as prescribed
– This can STOP within minutes/hours of taking another opioid
 What happens if a dependent person runs out of
opioids? Sickness. What do they do?
• Emergency Departments
• Look to get opioids on the street (family, friends are primary
sources)
• Suicidality (hopelessness)
 ASAM’s Definition of Addiction
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.
 Addiction Looks Like:
• People lose control of drug use

• People lose control of their lives due to their drug use

– (This is one way we know using Medications for Addiction Treatment
(MAT) is not just “substituting one drug for another.” People on
medication treatment REGAIN control of their drug use and REGAIN
control of their lives. This medication use is consistent with
abstinence).
 “Chronic” “Brain” “Disease”
Requires a wholistic
People must fight Medical approach can be
approach to helping
stigma and moral effectively used for
people manage their
blaming treatment
illness

Desired outcomes of managing any chronic disease:

get and stay healthy, increase quality of life and get back to work
 Chronic Disease Management Goals:
• Decrease risk of death from disease
• Decrease risk of health complications
• Decrease total cost of care
• Increase functioning / Quality of Life
• Goals are NOT:
– Perfect adherence to treatment plan
– “cure”

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 Chronic diseases:
• Relapse and remit (remission is lack of signs and symptoms of a
disease)
• Require patients to actively manage their condition, striving for
their best possible lives, which is the process of recovery.
 Addiction is a Chronic Brain Disease
• Prevention

• Harm reduction

• Treatment
 Prevention of Addiction:
Evidence Shows These Are Helpful
• Decrease exposure of the brain to addicting substances
• Decrease risk factors for developing addiction
– Genetics are what we get; 50% of risk
– Chaotic childhood environment, abuse/neglect, parents missing form
home, parents dead
TREATING ADDICTION is PRIMARY PREVENTION for CHILDREN
• Skill-based training (ie “LifeSkills” program)
 Prevention of Addiction:
Evidence Shows These Are NOT Helpful
• Education Based Programs:
– The old DARE program
– Sending police / celebrities / people in recovery into schools to speak
– The evidence shows these not only are not helpful, but actually
INCREASE the risk youth will use drugs
 Opioid Addiction Harm Reduction Approaches
• Naloxone Rescue during overdose
• Needle Exchange
• New approach of purity testing of opioid by users
• Supervised Injection Facilities (not legal in US)

• Harm reduction approaches are NOT treatment; they are

interventions to keep people alive and as healthy as possible until
they can get into treatment
 Opioid Addiction Treatment: How to approach a
Chronic Brain Disease
• What are we treating?
• What outcomes do we seek?
• What approaches are helpful?
• What approaches are not helpful / potentially harmful?
 Management of Chronic Conditions:
• Biological, Psychological, Social Care

• Individualized care within structured best practice

guidelines

• The need is treatment at the “right place, right type, right

provider, right dose, at the right time