I do not describe myself as an addict. I am a person in longterm recovery.
Jessica Lareau used to drink too much. She tried to stop many times, but was unable to on her own. Finally, she sought help. And she has not had a drink in four years. But do not call her an alcoholic. “I’m a person in long-term recovery,” says Lareau, a 28-year-old graduate student in the School of Social Work.
That distinction is significant to her.
She doesn’t believe anyone should be labeled as an alcoholic—or a drug abuser or an addict, for that matter. “That’s stigmatizing language,” says Lareau, who is studying to be a licensed clinical social worker (LICSW) and a licensed alcohol and drug counselor (LADC), “and it reinforces the view that it’s a moral failing and not a disease for which people need treatment.”
People being the crucial word. Label Jessica Lareau an alcoholic and you erase all the other things that define her as a young woman—a BU straight A student from Connecticut, a violinist, a swing dancer, a backpacker, a fly fisherwoman, and a former Peace Corps volunteer in Ethiopia.
Now, Lareau is on a new mission. This semester she launched a campaign—Support Recovery Initiative—to get SSW faculty, staff, and students to replace that stigmatizing language, in teaching, in conversations, in course curricula, and in field placements, with terms that put the person first, not the illness—as in person in recovery or person with a substance use disorder.
The reception has been overwhelmingly positive. “Language is a social construct,” says Jorge Delva, dean of SSW. “As the context changes, new words come in or old words become obsolete and some words become inappropriate. We’re taking Jessica’s work around substance use disorder as an opportunity to make nonstigmatizing language in all areas a more salient conversation at the school.”
Lareau would like to make it a University-wide conversation. She’s met with addiction expert Richard Saitz (CAS’87, MED’87), a School of Public Health professor of community health sciences and a School of Medicine professor of medicine, to enlist his help. Saitz has spoken publicly about the importance of using nonstigmatizing language.
Lareau is bringing to SSW a movement that has been gaining momentum among health policy experts, addiction researchers, and healthcare professionals who work with people with substance use disorders. Not referring to a person as an alcoholic or a drug abuser is not about political correctness, they say, but about being scientifically accurate and describing substance use disorder as a disease of the brain—and as in any physical illness, without judgment.
More important, say experts at Boston Medical Center (BMC) and its Grayken Center for Addiction, which have been leaders in this movement, the use of nonstigmatizing language may significantly encourage more people to seek treatment. Studies show that healthcare professionals and the treatment decisions they make are influenced by how addiction is talked about.
Even journalists who chronicle the nation’s opioid epidemic are making efforts to change their language. In 2017, the influential Associated Press Stylebook declared that journalists should no longer use the word addict as a noun. Instead, they should “choose phrasing like he was addicted, or people with heroin addiction,” the revised stylebook says.
The New York Times is also grappling with the issue, but has not yet made similar institutional changes. “We’re aware of the movement among many experts and others to avoid the word addict as stigmatizing,” Philip Corbett, the paper’s associate managing editor for standards, wrote in an email. But he also said that since the word is so commonly used and familiar and the alternatives can be awkward, any change is complicated.
“Times journalists are already using a range of descriptions,” Corbett wrote, and many avoid “addict” when possible.
For Laureau, that shift can’t come soon enough.
On a frigid morning in February, she stood in front of her teacher, Ashley Davis, an SSW clinical associate professor, and classmates in the course Social Work Research 1. “I’m a person in long-term recovery,” she began. “I spent a really long time calling myself an alcoholic because that’s what AA taught me to do.”
It’s okay for people in AA to use that term, she said, and she herself didn’t give it much thought until last semester, when she enrolled in a class on addictions taught by substance use disorder treatment expert Eric Devine, a School of Medicine assistant professor of psychiatry. Devine talked about the harm inflicted by stigmatizing language around addiction. He directed students to research indicating that doctorate-level mental health and substance use disorder clinicians were significantly more likely to assign blame when a person was described as a substance abuser rather than a person with a substance use disorder.
Devine told the class about the Words Matter pledge, which has been a core part of the mission of BMC and the Grayken Center for Addiction since 2017, when Michael Botticelli, who is in long-term recovery from a substance use disorder, became Grayken’s executive director. The pledge is modeled after guidelines Botticelli helped introduce for federal agencies when he led the Office of National Drug Control Policy under President Obama. The pledge asks all hospital personnel to “use clinically appropriate and medically accurate terminology that recognizes substance use disorder as a chronic illness from which people can and do recover, not a moral failing.”
“I thought that was really inspiring, and why couldn’t we do something like that at BU,” Lareau told her classmates that February morning. She has begun a similar conversation at McLean Hospital’s adult drug and alcohol treatment program, where she is a graduate intern.
There are nearly 21 million people in the United States with a substance use disorder and only about 10 percent of them get treatment. People cite stigma as the number one reason why more don’t seek help. Lareau said that it’s why she delayed getting help from Alcoholics Anonymous.
“I didn’t want to be an alcoholic,” she said. “I said to myself, ‘I drink a lot, but I know people who drink more than me so I can’t be an alcoholic, especially if they aren’t.’ It’s a spectrum, and people need to see it that way. That’s probably the reason why so few college kids get help, despite so many drinking at unhealthy rates. They have an idea of what an alcoholic is, and it is not a 23-year-old college student with high grades, great relationships, great work ethic, and a promising future.”
After she finished speaking, she passed around the Words Matter pledge and a separate Support Recovery Initiative pledge, which asks students to commit to changing their own language. Davis, and her fellow students, gave her a round of applause.
Two students raised their hands to thank her and volunteer that they, too, were in recovery and had internalized the stigma brought on, at least in part, by language.
Davis described Lareau’s efforts as a “great example of social action.”
Davis sits on the SSW curriculum committee, which heard Lareau’s pitch last month asking the department to change its language. “There was unanimous support among the faculty,” Davis says. “There was no pushback. If anything, it was, look at what our students are doing—we need to catch up.”
The BU Collegiate Recovery Program connects students in recovery from substance use and provides a support network for wellness and long-term recovery. BU students in recovery can email email@example.com to learn more. If you are a BU student questioning your substance use, Behavioral Medicine offers free, confidential counseling and is available 24/7 for emergencies. Call 617-353-3569 for a fast and free appointment.
As a person in recovery it my responsibility pass on a message of hope, compassionate abiding, connection and connection.
I did not want to change my life, but I needed to.
You are not alone may you access the help and support readily available in the rooms of 12step recovery.
My recovery began the moment I surrendered.
Yours can too.
BE WELL. YOU ARE NOT ALONE.
ASAM Strategic Plan 2018 – 2021
Strengthens Focus on Full Spectrum of Addiction Science and Care
Our new strategic plan strengthens the focus on a full spectrum of addiction care: prevention, treatment, remission, and recovery. ASAM’s portfolio now includes: the voice of patients and their families and will highlight the personal experience of addiction in much closer view. The plan outlines ambitious research goals aimed at leading scientific and medical progression in the field. It also exemplifies a firm recommitment to providing continued education for all treatment providers.
ASAM’s renewed and redesigned goals amass to form a robust foundation and profound course of action in the spirit of the organization’s mission. With a new map leading the way, ASAM will continue to set standards, pioneer research, educate professionals and the public, and challenge stigma. ASAM will always endeavor to enhance the goal of treating addiction and saving lives. The following strategic plan provides a road map to guide and prioritize the work of our organization.
A future when addiction prevention, treatment, remission and recovery are accessible to all, and profoundly improve the health of all people.
To be the physician-led professional community for those who prevent, treat, and promote remission and recovery from the disease of addiction, and to provide resources for continuing innovation, advancement, and implementation of addiction science and care.
- Inclusive Leadership: evidenced in a commitment to lead a field of addiction prevention, treatment, remission and recovery unified through partnership and collaboration.
- Innovation and Integrity: evidenced in an uncompromising commitment to foster innovation and disseminate evidence based practices.
- Openness: evidenced in inclusion of a diverse community of medical specialists delivering the best available addiction care.
- Compassion: evidenced in our advocacy for and devotion to the health and wellbeing of our patients, members, and the public.
ASAM is the leading organization developing and defining the field of addiction medicine, and is the convener of the many voices and perspectives shaping the future of addiction prevention, treatment, remission, and recovery.
ASAM creates robust opportunities and diverse settings for member connections to peers and partners.
- Facilitate connections between appropriate subject matter experts and members of the public, legislators, policy makers, and other stakeholders.
- Expand reach of ASAM’s influence and intensity of connections between/among members.
- Launch new and expanded member support for physicians-in-training.
- Invest in an intentional partnership and relationship strategy.
ASAM defines and promotes evidence-based best practices in addiction prevention, treatment, remission and recovery.
- Develop and promote guidelines.
- Invest in planning for the roll out of new organizational focus on integrating evidence based. prevention into many aspects of our work.
- Develop tools and resources to implement clinical recommendations into practice.
- Develop quality criteria for care and both short and long-term metrics to assess outcomes.
- Develop and promote best practices for integrating evidence based addiction medicine into clinical, criminal justice and community settings.
ASAM leads the transformation of the addiction workforce through competency-based education for all healthcare providers.
- Expand portfolio of competency-based educational offerings to meet the needs of the addiction medicine specialists.
- Create and promote access to career development resources which can offer multiple entry points into addiction medicine, including mid-career entry points.
- Expand and implement ASAM medical education content on addiction for healthcare professionals at all levels to support rapid expansion of a well-trained workforce.
ASAM develops opportunities to integrate perspectives of people with addiction and their families into policy, education, and advocacy work in addiction prevention, treatment, remission and recovery resources.
- ASAM will explore opportunities for incorporating the voices of people with addiction, their families and communities into ASAM’s strategy.
ASAM advocates that research, patient voices and clinical practice be highly interactional and mutually influential: research findings will influence clinical practice, and clinical experience will influence the research agenda.
- Identify mechanisms to support ASAM members in participating in research programs.
- Strengthen academic partnerships for the benefit of ASAM member research.
- Develop opportunities to engage discussion on current clinical and basic science research.
- Advocate for research into effective prevention programs.
- Advocate for research into pharmacological and non-pharmacological treatments for addiction.
ASAM identifies and advocates for policies and practices that ensure equitable access to comprehensive high-quality addiction prevention, treatment, remission and recovery for all.
- Continue advocacy for parity, parity enforcement, reimbursement and growth of the addiction specialty workforce.
- Ensure fair compensation and coverage for delivery of addiction prevention, treatment, and recovery care and services.
- Continue to advocate for access to quality evidence based addiction prevention, treatment, remission and recovery for all people.
ASAM maximizes organizational effectiveness.
- Ensure the financial health of the organization.
- Optimize governance structure and function.
- Protect our brand reputation.
In collaboation with the ASAM we are scheduling a ASAM and Unversal Healthcare symposium in Edinburgh, October 14th & 15th, 2019
Details of the presenter led, trainings and workshop will be updated in May 2019.
“Until one is committed, there is hesitancy, the chance to draw back, always ineffectiveness. Concerning all acts of initiative and creation, there is one elementary truth the ignorance of which kills countless ideas and splendid plans: that the moment one definitely commits oneself, then providence moves too. All sorts of things occur to help one that would never otherwise have occurred. A whole stream of events issues from the decision, raising in one’s favor all manner of unforeseen incidents, meetings and material assistance which no man could have dreamed would have come his way. Whatever you can do or dream you can, begin it. Boldness has genius, power and magic in it. Begin it now.”
Johann Wolfgang Von Goethe
October, 12, 1988 in a rare moment of clarity…it occurred to me, I did not need to follow an impulse to drink alcoholically… (one was too many and thousand never enough) take a prescription or illicit drug….because the craving would pass…
“For addicts and alcoholics, such experiences are usually the catalysts that turn despair into hope and the helplessness of addiction into the promise of recovery.” Christopher Kennedy Lawford
If addiction is a disconnection from reality, and recovery is about being in community… do whatever you can to find your recovery tribe.
In the early stages of my recovery, an intervention led to being admitted as an outpatient at Smithers in NYC.
After Smithers addiction counselling I went deeper, and committed to psychotherapy weekly 1-1 and group therapy and daily 12step meetings… and soon found my urban recovery 12step home group.
Three months into recovery I heard about the American Society of Addiction Medicine evidence based criteria addiction is a brain disease.
My tribe, the universal recovery community is available to all who seek help, support, suggestions and sustainability. Addiction is as individual as you are. There are many pathways to recovery. A few links I recommend are:
From the safety and sanctuary of 12step meetings in Park Avenue Churches to prisons, we were advised to do service from day one in 12step recovery. Pass it on. Help other addicts. Connections. Community. Carry the message of HOPE.
When there was more or me and less of my self-obsession I upped my service commitments…In 1990 I volunteered at the Manhattan Centre of Living founded by Louise Hay and Marianne Williamson.
Compassionate humility was essential in my role as a companion to people dying from AIDs who came to the Centre on a daily basis, for treatments, a meal and a monthly visit with Marianne Williamson…whose talks on “A Course in Miracles” resonated with all of us…
The benefits of seeking meaning in life is central to all who embrace recovery, the thirst that Carl Jung defined as a characteristic of addiction shifts into being a thirst for connection & community.
In 1991 I returned home to live in London and trained as an addiction counsellor, hyno-psychotherapy, Reiki, EFT, and Meditation teacher.
Today, colleague and friend Mike Delaney and I are implementing universal addiction medicine trainings and programmes/treatment: COMPASSIONATE UNIVERSAL HEALTHCARE PROGRAMMES in partnership with the ASAM: “Addiction Medicine Medical Emergency Clinic” in Edinburgh October/November, 2019.
The ASAM fundamentals of addiction science and medicine are the backbone of my work in addiction healthcare. It is our birthright to be healthy and happy. And to receive care when we need it. The addiction medicine programmes Mike and I are formulating will support, sustain and empower people who are suffering from active addiction – the programmes are for life…life in recovery.
ASAM & WHAT IS ADDICTION:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy, self-care related behaviors.
Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.
The neurobiology of addiction encompasses more than the neurochemistry of reward.1 The frontal cortex of the brain and underlying white matter connections between the frontal cortex and circuits of reward, motivation and memory are fundamental in the manifestations of altered impulse control, altered judgment, and the dysfunctional pursuit of rewards (which is often experienced by the affected person as a desire to “be normal”) seen in addiction–despite cumulative adverse consequences experienced from engagement in substance use and other addictive behaviors.
The frontal lobes are important in inhibiting impulsivity and in assisting individuals to appropriately delay gratification. When persons with addiction manifest problems in deferring gratification, there is a neurological locus of these problems in the frontal cortex. Frontal lobe morphology, connectivity and functioning are still in the process of maturation during adolescence and young adulthood, and early exposure to substance use is another significant factor in the development of addiction. Many neuroscientists believe that developmental morphology is the basis that makes early-life exposure to substances such an important factor.
Genetic factors account for about half of the likelihood that an individual will develop addiction. Environmental factors interact with the person’s biology and affect the extent to which genetic factors exert their influence. Resiliencies the individual acquires (through parenting or later life experiences) can affect the extent to which genetic predispositions lead to the behavioral and other manifestations of addiction. Culture also plays a role in how addiction becomes actualized in persons with biological vulnerabilities to the development of addiction.
Other factors that can contribute to the appearance of addiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include:
The presence of an underlying biological deficit in the function of reward circuits, such that drugs and behaviors which enhance reward function are preferred and sought as reinforcers;
The repeated engagement in drug use or other addictive behaviors, causing neuroadaptation in motivational circuitry leading to impaired control over further drug use or engagement in addictive behaviors;
Cognitive and affective distortions, which impair perceptions and compromise the ability to deal with feelings, resulting in significant self-deception;
Disruption of healthy social supports and problems in interpersonal relationships which impact the development or impact of resiliencies;
Exposure to trauma or stressors that overwhelm an individual’s coping abilities;
Distortion in meaning, purpose and values that guide attitudes, thinking and behavior;
Distortions in a person’s connection with self, with others and with the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others); and
The presence of co-occurring psychiatric disorders in persons who engage in substance use or other addictive behaviors.
Addiction is characterized by:
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.
The power of external cues to trigger craving and drug use, as well as to increase the frequency of engagement in other potentially addictive behaviors, is also a characteristic of addiction, with the hippocampus being important in memory of previous euphoric or dysphoric experiences, and with the amygdala being important in having motivation concentrate on selecting behaviors associated with these past experiences.
Although some believe that the difference between those who have addiction, and those who do not, is the quantity or frequency of alcohol/drug use, engagement in addictive behaviors (such as gambling or spending)3, or exposure to other external rewards (such as food or sex), a characteristic aspect of addiction is the qualitative way in which the individual responds to such exposures, stressors and environmental cues. A particularly pathological aspect of the way that persons with addiction pursue substance use or external rewards is that preoccupation with, obsession with and/or pursuit of rewards (e.g., alcohol and other drug use) persist despite the accumulation of adverse consequences. These manifestations can occur compulsively or impulsively, as a reflection of impaired control.
Persistent risk and/or recurrence of relapse, after periods of abstinence, is another fundamental feature of addiction. This can be triggered by exposure to rewarding substances and behaviors, by exposure to environmental cues to use, and by exposure to emotional stressors that trigger heightened activity in brain stress circuits.4
In addiction there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often manifest a lower readiness to change their dysfunctional behaviors despite mounting concerns expressed by significant others in their lives; and display an apparent lack of appreciation of the magnitude of cumulative problems and complications.
The still developing frontal lobes of adolescents may both compound these deficits in executive functioning and predispose youngsters to engage in “high risk” behaviors, including engaging in alcohol or other drug use. The profound drive or craving to use substances or engage in apparently rewarding behaviors, which is seen in many patients with addiction, underscores the compulsive or avolitional aspect of this disease. This is the connection with “powerlessness” over addiction and “unmanageability” of life, as is described in Step 1 of 12 Steps programs.
Addiction is more than a behavioral disorder. Features of addiction include aspects of a person’s behaviors, cognitions, emotions, and interactions with others, including a person’s ability to relate to members of their family, to members of their community, to their own psychological state, and to things that transcend their daily experience.
Behavioral manifestations and complications of addiction, primarily due to impaired control, can include:
Excessive use and/or engagement in addictive behaviors, at higher frequencies and/or quantities than the person intended, often associated with a persistent desire for and unsuccessful attempts at behavioral control;
Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviors, with significant adverse impact on social and occupational functioning (e.g. the development of interpersonal relationship problems or the neglect of responsibilities at home, school or work);
Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems which may have been caused or exacerbated by substance use and/or related addictive behaviors;
A narrowing of the behavioral repertoire focusing on rewards that are part of addiction; and
An apparent lack of ability and/or readiness to take consistent, ameliorative action despite recognition of problems.
Cognitive changes in addiction can include:
Preoccupation with substance use;
Altered evaluations of the relative benefits and detriments associated with drugs or rewarding behaviors; and
The inaccurate belief that problems experienced in one’s life are attributable to other causes rather than being a predictable consequence of addiction.
Emotional changes in addiction can include:
Increased anxiety, dysphoria and emotional pain;
Increased sensitivity to stressors associated with the recruitment of brain stress systems, such that “things seem more stressful” as a result; and
Difficulty in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and describing feelings to other people (sometimes referred to as alexithymia).
The emotional aspects of addiction are quite complex. Some persons use alcohol or other drugs or pathologically pursue other rewards because they are seeking “positive reinforcement” or the creation of a positive emotional state (“euphoria”). Others pursue substance use or other rewards because they have experienced relief from negative emotional states (“dysphoria”), which constitutes “negative reinforcement.“ Beyond the initial experiences of reward and relief, there is a dysfunctional emotional state present in most cases of addiction that is associated with the persistence of engagement with addictive behaviors. The state of addiction is not the same as the state of intoxication.
When anyone experiences mild intoxication through the use of alcohol or other drugs, or when one engages non-pathologically in potentially addictive behaviors such as gambling or eating, one may experience a “high”, felt as a “positive” emotional state associated with increased dopamine and opioid peptide activity in reward circuits. After such an experience, there is a neurochemical rebound, in which the reward function does not simply revert to baseline, but often drops below the original levels. This is usually not consciously perceptible by the individual and is not necessarily associated with functional impairments.
Over time, repeated experiences with substance use or addictive behaviors are not associated with ever increasing reward circuit activity and are not as subjectively rewarding. Once a person experiences withdrawal from drug use or comparable behaviors, there is an anxious, agitated, dysphoric and labile emotional experience, related to suboptimal reward and the recruitment of brain and hormonal stress systems, which is associated with withdrawal from virtually all pharmacological classes of addictive drugs. While tolerance develops to the “high,” tolerance does not develop to the emotional “low” associated with the cycle of intoxication and withdrawal. Thus, in addiction, persons repeatedly attempt to create a “high”–but what they mostly experience is a deeper and deeper “low.”
While anyone may “want” to get “high”, those with addiction feel a “need” to use the addictive substance or engage in the addictive behavior in order to try to resolve their dysphoric emotional state or their physiological symptoms of withdrawal. Persons with addiction compulsively use even though it may not make them feel good, in some cases long after the pursuit of “rewards” is not actually pleasurable.5 Although people from any culture may choose to “get high” from one or another activity, it is important to appreciate that addiction is not solely a function of choice. Simply put, addiction is not a desired condition.
As addiction is a chronic disease, periods of relapse, which may interrupt spans of remission, are a common feature of addiction. It is also important to recognize that return to drug use or pathological pursuit of rewards is not inevitable.
Clinical interventions can be quite effective in altering the course of addiction. Close monitoring of the behaviors of the individual and contingency management, sometimes including behavioral consequences for relapse behaviors, can contribute to positive clinical outcomes. Engagement in health promotion activities which promote personal responsibility and accountability, connection with others, and personal growth also contribute to recovery. It is important to recognize that addiction can cause disability or premature death, especially when left untreated or treated inadequately.
The qualitative ways in which the brain and behavior respond to drug exposure and engagement in addictive behaviors are different at later stages of addiction than in earlier stages, indicating progression, which may not be overtly apparent. As is the case with other chronic diseases, the condition must be monitored and managed over time to:
Decrease the frequency and intensity of relapses;
Sustain periods of remission; and
Optimize the person’s level of functioning during periods of remission.
In some cases of addiction, medication management can improve treatment outcomes. In most cases of addiction, the integration of psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provides the best results. Chronic disease management is important for minimization of episodes of relapse and their impact. Treatment of addiction saves lives †
Addiction professionals and persons in recovery know the hope that is found in recovery. Recovery is available even to persons who may not at first be able to perceive this hope, especially when the focus is on linking the health consequences to the disease of addiction. As in other health conditions, self-management, with mutual support, is very important in recovery from addiction. Peer support such as that found in various “self-help” activities is beneficial in optimizing health status and functional outcomes in recovery. ‡
Recovery from addiction is best achieved through a combination of self-management, mutual support, and professional care provided by trained and certified professionals.
1. The neurobiology of reward has been well understood for decades, whereas the neurobiology of addiction is still being explored. Most clinicians have learned of reward pathways including projections from the ventral tegmental area (VTA) of the brain, through the median forebrain bundle (MFB), and terminating in the nucleus accumbens (Nuc Acc), in which dopamine neurons are prominent.
Current neuroscience recognizes that the neurocircuitry of reward also involves a rich bi-directional circuitry connecting the nucleus accumbens and the basal forebrain. It is the reward circuitry where reward is registered, and where the most fundamental rewards such as food, hydration, sex, and nurturing exert a strong and life-sustaining influence. Alcohol, nicotine, other drugs and pathological gambling behaviors exert their initial effects by acting on the same reward circuitry that appears in the brain to make food and sex, for example, profoundly reinforcing.
Other effects, such as intoxication and emotional euphoria from rewards, derive from activation of the reward circuitry. While intoxication and withdrawal are well understood through the study of reward circuitry, understanding of addiction requires understanding of a broader network of neural connections involving forebrain as well as midbrain structures. Selection of certain rewards, preoccupation with certain rewards, response to triggers to pursue certain rewards, and motivational drives to use alcohol and other drugs and/or pathologically seek other rewards, involve multiple brain regions outside of reward neurocircuitry itself.
2. These five features are not intended to be used as “diagnostic criteria” for determining if addiction is present or not. Although these characteristic features are widely present in most cases of addiction, regardless of the pharmacology of the substance use seen in addiction or the reward that is pathologically pursued, each feature may not be equally prominent in every case. The diagnosis of addiction requires a comprehensive biological, psychological, social and spiritual assessment by a trained and certified professional.
3. In this document, the term “addictive behaviors” refers to behaviors that are commonly rewarding and are a feature in many cases of addiction. Exposure to these behaviors, just as occurs with exposure to rewarding drugs, is facilitative of the addiction process rather than causative of addiction. The state of brain anatomy and physiology is the underlying variable that is more directly causative of addiction. Thus, in this document, the term “addictive behaviors” does not refer to dysfunctional or socially disapproved behaviors, which can appear in many cases of addiction. Behaviors, such as dishonesty, violation of one’s values or the values of others, criminal acts etc., can be a component of addiction; these are best viewed as complications that result from rather than contribute to addiction.
4. The anatomy (the brain circuitry involved) and the physiology (the neuro-transmitters involved) in these three modes of relapse (drug- or reward-triggered relapse vs. cue-triggered relapse vs. stress-triggered relapse) have been delineated through neuroscience research.
Relapse triggered by exposure to addictive/rewarding drugs, including alcohol, involves the nucleus accumbens and the VTA-MFB-Nuc Acc neural axis (the brain’s mesolimbic dopaminergic “incentive salience circuitry”–see footnote 2 above). Reward-triggered relapse also is mediated by glutamatergic circuits projecting to the nucleus accumbens from the frontal cortex.
Relapse triggered by exposure to conditioned cues from the environment involves glutamate circuits, originating in frontal cortex, insula, hippocampus and amygdala projecting to mesolimbic incentive salience circuitry.
Relapse triggered by exposure to stressful experiences involves brain stress circuits beyond the hypothalamic-pituitary-adrenal axis that is well known as the core of the endocrine stress system. There are two of these relapse-triggering brain stress circuits – one originates in noradrenergic nucleus A2 in the lateral tegmental area of the brain stem and projects to the hypothalamus, nucleus accumbens, frontal cortex, and bed nucleus of the stria terminalis, and uses norepinephrine as its neurotransmitter; the other originates in the central nucleus of the amygdala, projects to the bed nucleus of the stria terminalis and uses corticotrophin-releasing factor (CRF) as its neurotransmitter.
5. Pathologically pursuing reward (mentioned in the Short Version of this definition) thus has multiple components. It is not necessarily the amount of exposure to the reward (e.g., the dosage of a drug) or the frequency or duration of the exposure that is pathological. In addiction, pursuit of rewards persists, despite life problems that accumulate due to addictive behaviors, even when engagement in the behaviors ceases to be pleasurable. Similarly, in earlier stages of addiction, or even before the outward manifestations of addiction have become apparent, substance use or engagement in addictive behaviors can be an attempt to pursue relief from dysphoria; while in later stages of the disease, engagement in addictive behaviors can persist even though the behavior no longer provides relief.
The benefits of accessing accessing primary healthcare when there is a medical emergency ensures a person is being regarded, treated and compassionately cared for.
Mike & I have worked in the field of addiction and mental healthcare within the UK, Australia, U.S. & India for may years as clinicians, programme directors, presenters and broadcasters.
CONFERENCES & TRAINING:
Soon we will be posting conference and training dates.
May you be well and happy.
MEDITATION: It’s simply one of the world’s best ways to strengthen your focus, preserve your natural power and insulate your inner peace. There’s a lot of wonderful science confirming the value of a regular meditation ritual, so, even if you want to dismiss the method, the data says it works—phenomenally—as a human optimization habit. Current research proves that regular meditation helps lower levels of cortisol, thus lowering your stress. It’s also a strong way to grow the relationship you have with yourself. You need to make more time for you. To scale your fluency and intimacy
Sharma, Robin. The 5 AM Club: Own Your Morning. Elevate Your Life. (p. 220). HarperCollins Publishers. Kindle Edition.
FROM CRISIS TO COMPASSIONATE CARE: HARM REDUCTION, ADDICTION ASSESSMENT, TREATMENT AND LONGTERM RECOVERY STRATEGIES.
Stability & Resilience:
That is when your commitment to practice is of greatest value. It keeps you engaged in the process. The momentum of regular practice helps to maintain a certain mental stability and resilience even as you go through states of turmoil, confusion, lack of clarity, and procrastination.
Kabat-Zinn, Jon. Letting Everything Become Your Teacher: 100 Lessons in Mindfulness . Random House Publishing Group. Kindle Edition.