ASAM Blunders in New Definition of Addiction

Alcoholism & Drug Abuse Weekly

Volume 23 Number 33
August 29, 2011

ASAM admits error in omitting NIAAA in definition publicity


In announcing its new broader definition of addiction to include non-substance addictions such as sex and gambling (see ADAW, August 22), the American Society of Addiction Medicine (ASAM) made an almost fatal error. It treated alcohol like an afterthought and pointedly omitted any mention of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) while suggesting — incorrectly, as it turns out — that the National Institute on Drug Abuse (NIDA) was involved in crafting the definition, ADAW has learned.

ASAM past president Michael Miller, M.D., told ADAW last week that nobody from NIDA was involved officially in the process leading to release of the definition. “The press release did not state things in a clear manner and clearly led people to believe that we had some kind of formal connection with NIDA,” Miller said.

It strains belief for some leaders, however, to think that ASAM physicians were not aware of the bitter struggle between NIDA and NIAAA
researchers over the upcoming merger of the institutes, which will create a new, single institute of addiction — a merger NIDA supported
and NIAAA opposed. NIAAA officials were furious when the definition — and the press release — came out, published August 15 on the ASAM website.

“We recognize that ASAM is extremely important to physicians who are specializing in substance use disorders,” said Howard B. Moss, M.D., associate director for clinical and translational research at NIAAA. “But we are concerned that the narrow definitional focus on neuroscience
doesn’t really address the psychological and sociocultural aspects of addiction,” he told ADAW. “We view it as reductionist.”

Moss also said the timing of the definition’s release was awkward, since the DSM-5 process is taking place at the same time. “DSM will
have definitions that will be discussed in the diagnostic criteria,” he said. And finally, calling addiction a disease is hardly new.

NIAAA is also very concerned about binge drinking, underage alcohol use, and drinking and driving — problems that aren’t necessarily facets
of addictive disorders, said Moss.

“We met with NIAAA to explain to them how sorry we are that we did not vet this with them more officially,” ASAM’s Miller said. “They
are at least embarrassed and extremely disappointed because they were blindsided with people coming to them with questions about
things they haven’t even seen.”

When we talked to Miller last week, no decision had yet been made about whether ASAM would publicize a correction about NIDA/
NIAAA involvement. But, he said, “We have apologized to NIAAA very publicly.”

NIAAA is “not aware of any public apology,” according to a NIAAA press officer.

Sensitivity issues

Miller blamed some of the “lack of sensitivity” to the fact that ASAM has a new CEO and a new staffer in charge of communications. “ASAM
has learned through this process that it must be much more sensitive to these delicate differences of the two institutes, and that so many
people are looking for messages in the tea leaves that may not be there.”

ASAM has “no official position” on the proposed merger of the institutes, said Miller.

Sources at NIAAA said people there are “absolutely furious.” They believe that ASAM is saying — just as the pro-merger researchers had
said — that all neurochemical pathways to addiction are the same. In fact, they say, alcohol is not the same — it goes everywhere in the
brain. There is no alcohol receptor, said Moss.

Not diagnostic criteria

The ASAM definition is just that — it is not diagnostic criteria, and it can’t be used for diagnosis, said Miller. That is the province of the
American Psychiatric Association (APA), which field-tests its criteria.

ASAM really wanted to update its definition because the organization had two different definitions out there — one that applies only to alcoholism
and that dates back to 1990, and one for addiction that was created in 2001 in collaboration with the American Pain Society, Miller said. “These two did not align, there were subtle differences,” he said. So the new definition eliminated the old definition of alcoholism and added various “process” addictions.

“We did get some cautionary advice from different quarters,” said Miller. For example, alcoholism researcher Carlton Erickson “blasted the whole project,” said Miller. Erickson suggested not to talk about spirituality or non-substance addictions, but to “stick to what is known,” recalled Miller. But in general there was consensus, he said.

“Most clinicians said this makes sense, and the board of directors of ASAM unanimously approved it,” said Miller.

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I think I'm ready to again take up my lance and tilt at the windmill of changing the paradigm of treatment in this country (if not everywhere!) I haven't been posting mostly because I've been overwhelmed with the realities of trying to earn a living seeing patients in a heavily managed care environment. I've learned a lot, some of it quite painfully. I think in the long run it will serve me, and hopefully others, well, because this is a harsh, difficult and treacherous environment. I understand much better why physicians avoid particularly challenging patients, and why they are so conservative in their approach. Everyone is overwhelmed. There are so many patients we really don't have any treatment for or even understand what is wrong with them. It feels like we are putting Band-Aids on gaping infected wounds and sending people out the door. Many are simply left to cope on their own. All of this has been exacerbated by the Great Recession, which is wreaking havoc on anyone but the wealthy, and by a system of care heavily dominated by procedure-oriented specialty care rather than compassionate, comprehensive care. One reason for feeling overwhelmed is that it all seems so well, overwhelming. How can anyone hope to change this terribly dysfunctional system? Lately I've adopted the strategy of focusing on smaller, more achievable goals. This fall I will start seeing more patients in private practice and fewer in a managed care setting. I hope to build on this seedling to establish the first ALLTYR Clinic. Wish me luck.