Using the 2011 Definition of Addiction of the American Society of Addiction Medicine as well as its historical roots, attendees will learn how addiction is not just about alcohol or other drugs, but it’s about brains; and how it’s not just about mesolimbic reward circuitry, but is about the role of other brain regions in the relationship that persons with addiction develop with sources of reward and relief. Learn more at http://RogersHospital.org

1. Michael M. Miller, MD, FASAM, FAPA
mmiller@rogershospital.org
Medical Director, Herrington Recovery Center (HRC)
Rogers Memorial Hospital
Oconomowoc, Wisconsin
Associate Clinical Professor
University of Wisconsin School of Medicine and Public Health
Associate Clinical Professor
Medical College of Wisconsin, Dept of Psychiatry & Behavioral Health
Past President and Board Chair
Wisconsin and American Societies of Addiction Medicine
Director
American Board of Addiction Medicine

2. Description
Through an exploration of the 2011 Definition of Addiction of the American
Society of Addiction Medicine as well as its historical roots, attendees will
become equipped to teach patients and families about how addiction
is not about alcohol or other drugs, but it’s about brains; and how it’s
not just about mesolimbic reward circuitry, but is about the role of other
brain regions in the relationship that persons with addiction develop
with sources of reward and relief.
The presentation will help attendees discriminate between descriptions
and definitions that focus on substances and behaviors that provide
reward or relief, versus the underlying biology which leads to altered
the thoughts, emotions, and behaviors seen in persons with addiction.

4. ASAM’s Mission
The American Society of Addiction Medicine’s mission is to:
• Increase access to and improve the quality of addiction treatment;
• Educate physicians (including medical and osteopathic students),
other health care providers and the public;
• Support research and prevention;
• Promote the appropriate role of the physician in the care of patients
with addiction;
• Establish addiction medicine as a specialty recognized by
professional organizations, governments, physicians, purchasers and
consumers of health care services, and the general public.
Approved by ASAM Board, 7-2006;
http://198.65.155.172/CMS/images/PDF/General/Strategic%20Plan.pdf

5. Addiction Medicine:
The specialty of medicine devoted to diagnosis, treatment,
prevention, education, epidemiology, research, and public
policy advocacy regarding addiction and other substance-
related health conditions

6. How to Identify a Physician Recognized for
Expertise in the Diagnosis and Treatment of
Addiction and Substance-related Health
Conditions (ASAM Public Policy Statement)
www.asam.org/HowToIdentifyaPhysicianRecognizedforExpertness.html

7. www.asam.org/HowToIdentifyaPhysicianRecognized
forExpertness.html
• Completion of a residency/fellowship in Addiction
Medicine or Addiction Psychiatry
• Certification in Addiction Medicine by the American Society
of Addiction Medicine (ASAM)
• Subspecialty certification in Addiction Psychiatry by the
American Board of Psychiatry and Neurology (ABPN)
• A Certificate of Added Qualification in Addiction Medicine
conferred by the American Osteopathic Association (AOA)
• Board Certification in Addiction Medicine by the
American Board of Addiction Medicine (ABAM)

9. Scope of Practice for Addiction Medicine
Physicians (ABAM)
The addiction medicine physician provides medical care within
the bio-psycho-social framework for persons with addiction,
for the individual with substance-related health conditions,
for persons who manifest unhealthy substance use, and for
family members whose health and functioning are affected by
someone’s substance use or addiction.

10. American Board of Addiction Medicine
Mission Statement
ABAM’s mission is to contribute to the improvement of care
for patients suffering from addiction to alcohol, nicotine and
other addicting drugs (including some prescription drugs), and
to establish and maintain standards and procedures for
certification, recertification and maintenance of certification of
physicians who specialize in Addiction Medicine.

11. How is it that DRUGS are
different from BROCCOLI?
• It’s because of what ‘drugs’ do to the BRAIN
• Drugs enter the body via various routes
– Oral, Intravenous, Intramuscular, Intranasal, transdermal,
transbuccal, or transalveolar
• Drugs that affect mood/thought/behavior cross the
‘blood brain barrier’
• Drugs act on nerve cells by binding to specialized
portions of the outer membrane of nerve cells

12. The Irony...
• Addiction is not about DRUGS !
• Addiction is about BRAINS!
• It’s not about the quantify/frequency of use
• It’s about the
– Quality of use
– Pattern of use
– Relationship the person has to ‘their drug’
• It’s about how the person with addiction is changed when using

13. New Understandings about Addiction
• Addiction is a disease of the brain
• Dopamine in the VTA and the Nucleus Accumbens is
important in Drug Reward (the ‘Reward Pathway’ of the
MFB etc.)
• BUT we now understand that the Nuc Acc is where
REWARD HAPPENS, whereas ADDICTION resides in the
OFC and in connections among the Nuc Acc, the OFC, the
hippocampus and the amygdala

16. Addiction ‘Resides’ in the Orbitofrontal Cortex (OFC)
and in connections between OFC et al.
• Addiction is use despite adverse consequences, returning
to use after periods of abstinence even with previous life
catastrophes, inability to control use, cognitive
preoccupation, conscious and unconscious craving
• It involves memory, judgment, ‘executive functions’ of
planning and deciding to defer gratification
• All these are Frontal Lobe functions

17. Addiction ‘Resides’ in the Orbitofrontal Cortex (OFC)
and in connections between OFC et al.

18. Addiction ‘Resides’ in the Orbitofrontal Cortex (OFC)
and in connections between OFC et al.
• The site of action for reward/drug-induced euphoria is the
nucleus accumbens (an oversimplification)
• The site of action for addiction is interplay between the
frontal lobes and the Nuc Acc, and among the Nuc Acc, the
hippocampus (memory), and the amygdala (motivation)
– Judgment / Evaluation
– Planning
– Drive (drug hunger/craving; drug seeking/use)
– Recalling past experiences

19. PFC
ACG
OFC
SCC
Hipp
NAc
c VP
Amy
g
REWARD
CONTROL
INHIBITORY
CONTROL
MOTIVATION/
DRIVE
MEMORY/
LEARNING
Circuits Involved in Drug Abuse and Addiction

20. Addiction ‘resides’ somewhat in the Orbitofrontal Cortex
(OFC) and in other areas with connections to Reward Circuitry
• The site of acute action for euphoriants is the nucleus
accumbens (an oversimplification)
• The site of action for the chronic, recurrent, relapsing
exposure to euphoriants--as is see in addiction—is the
interplay among the Nuc Acc, the hippocampus (memory;
recalling past experiences), the amygdala (motivation,
drive, drug hunger/craving; drug seeking/use), and the
frontal lobes (judgment/evaluation, planning, delay of
gratification, inhibition of urges/impulses)

21. Construction Anatomy
Brain Development:
Proliferation and pruning occurs
from back to front
Back:
Region that mediates direct contact
with environment
Next:
Regions that coordinate those
functions
Last:
Prefrontal Cortex

22. Source: Gogtay, Nitin et al (2004) Proc. Natl. Acad. Sci. USA 101; 8174-8179
Copyright 2004 by the National Academy of Sciences
Right Lateral and Top Views of the Dynamic Sequence of
GM Maturation Over the Cortical Surface

23. Understanding drug abuse and addiction from a developmental perspective
has important implications for their prevention and treatment
Exposure to drugs of abuse during adolescence could have
profound effects on Brain Development and Brain Plasticity

24. Cartoon Break

25. Control
DriveSaliency
Memory
Non Addicted Brain Addicted Brain
Control
Saliency
Memory
Drive
STOP
GO

26. The Physiology of Addiction
Certain substances have the ability to interact with the
brain’s Reward Circuitry and are thus euphoriants; they are
reinforcing, and, in lab animals, self-reinforcing. They act first
by being external ligands for neuro-transmitter receptors, or
by causing release of (or otherwise altering levels of) neuro-
transmitters.
They hijack the reward system, and the individual
compulsively pursues these rewards instead of natural
rewards.

27. The Physiology of Addiction
Once the Reward Circuitry is turned on, there are changes in
related brain areas or neuronal circuits, and these result in the
characteristic manifestations of addiction [altered memory of
past intoxication experiences, altered cue response, changes
in motivation so that ‘the drug’ (which can be a substance, or
a pathologically rewarding activity) becomes ‘the salient
reinforcer,’ replacing other healthy rewards]. All this
contributes to preoccupation and loss of control. The most
contemporary term for all this circuitry is the brain’s “incentive
salience circuitry.”

28. The Physiology of Addiction
• Changes in frontal lobe function (executive functioning;
the inhibition of impulses to use) are key: the brain fails in
efforts to inhibit the drive to obtain/use the drug to create
‘the high’.
• Impairment in control and preoccupation are the key
behavioral/cognitive characteristics of addiction, and have
an anatomical/physiological substrate in the brain.
• Relapse is intrinsic to virtually all chronic diseases; the
animal model of relapse is “reinstatement” of drug use or
drug preference.

29. Addiction is…
• A BRAIN DISEASE
• A primary, relapsing and remitting CHRONIC
DISEASE….
• A PEDIATRIC DISEASE….

30. Age at tobacco, at alcohol and at cannabis dependence, as per DSM IV
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
5 10 15 20 25 30 35 40 45 50 55 60 65
THC
ALCOHOL
TOBACCO
70 75
National Epidemiologic Survey on Alcohol and Related Conditions, 2003
%ineachagetodevelop
first-timedependence
Age
Addiction is a Developmental Disease

31. Griffith Edwards (1976)
Edwards (Griffith), Gross (Milton)
“Alcohol dependence: provisional description of
a clinical syndrome”
British Medical Journal, 1:1058-1061 (1976)

32. Griffith Edwards (1976)
Essential elements of the syndrome:
• subjective awareness of a compulsion to drink
• reinstatement of the syndrome after abstinence
All these elements exist in degree, thus giving
the syndrome a range of severity.

33. The Definition of Alcoholism
(NCADD / ASAM – 1990, JAMA 1994: Morse et al.)
Alcoholism is a primary, chronic disease with genetic,
psychosocial, and environmental factors influencing its
development and manifestations. The disease is often
progressive and fatal. It is characterized by continuous or
periodic: impaired control over drinking, preoccupation with
the drug alcohol, use of alcohol despite adverse
consequences, and distortions in thinking, most notably
denial.

34. What is Addiction?
American Society of Addiction Medicine • April 2011
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.”

35. Definition of Addiction
American Society of Addiction Medicine • April 2011
“Addiction is characterized by inability to consistently
abstain, impairment in behavioral control, craving,
diminished recognition of significant problems with
one’s behaviors and interpersonal relationships, and a
dysfunctional emotional response. Like other chronic
diseases, addiction often involves cycles of relapse
and remission. Without treatment or engagement in
recovery activities, addiction is progressive and can
result in disability or premature death.”

36. ASAM’s New Definition of Addiction
http://www.asam.org/for-the-public/definition-of-addiction

37. Downward Spiral / Progression
Addiction
(constriction –of
affects, behaviors,
social network)

38. Atrophy
• Of social network
– People…
• Of activities / interests
– Places, Things
• Of emotions
– Flatness, less expressive, dysthymic / alexithymic
• Of rewards
– Salience

39. Copyright (c)2011, Covington, Griffin, & Dauer
Downward Spiral of Addiction and
Upward Spiral of Recovery
Addiction
(constriction –of
affects, behaviors,
social network)
Recovery
(expansion—
of feelings, rewards,
activities, social
connections)

40. How to come out of the depths?
How to RECOVER?
• “Re-people-ization”
– AA
– Sponsor
– Church
– Social clubs
– Activities with others
– Family
• Professional Treatment (group therapy, meet others)
• Re-Connectedness

41. ASAM Public Policy Statement:
Definition of Addiction (Long Version)
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.

42. ASAM Public Policy Statement:
Definition of Addiction (Long Version)
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.

43. 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, [and] altered judgment….

44. …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.

45. 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.

46. 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.

47. Footnote 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.

48. Footnote 1 (continued): 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.

49. Footnote 1 (continued): 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.

50. Naqvi NH, Bechara A
Trends in Neurosciences, 32:56-67, 2008
“Although the dopamine system clearly has an important role
in addiction to drugs of abuse, drug use does more for the
addicted individual than merely providing a means of
releasing dopamine in the brain. Drug use involves a complex
set of rituals imbued with emotional meaning (both positive
and negative) for the addicted individual.”

51. 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.

52. • Availability
• Social Norms for/against
– Indoor smoking bans
– MADD
– “Those Who Host Lose the
Most”
• Perceived Harm
• Consequences (legal
status; drug-free schools)
• “Peer Pressure”
• Siblings
• Parents
– Their Use
– Their Attitudes (perceived
harm)
– Their Rules/Consequences
(parents are ‘the antidrug’)
Environmental / Cultural Factors

53. 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;

54. “…neuroadaptation in motivational circuitry leading to
impaired control over further drug use or engagement in
addictive behaviors….”
[O’Brien: “addiction = neuroplasticity”]
changes in motivation/control
changes in cue responsiveness
[See also: Koob GF, Volkow ND. “Neurocircuitry of addiction.”
Neuropsychopharmacology. 2010 Jan;35(1):217-38.]

55. Other factors that can contribute to the appearance of
addiction, leading to its characteristic bio-psycho-socio-
spiritual manifestations, include:
• 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.

56. Addiction is characterized by2:
• 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.

57. Footnote 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.

58. Naqvi NH, Bechara A
Trends in Neurosciences, 32:56-67, 2008
“…Studies using animal models [which] have emphasized the
role of subcortical systems such as the amygdala, nucleus
accumbens and the mesolimbic dopamine system…have
tended to focused on externally observable aspects of
addiction (emphasis added)”

59. 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.

60. 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)…,

61. …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, nicotine and other drug
use) persist despite the accumulation of adverse consequences.
These manifestations can occur compulsively or impulsively, as
a reflection of impaired control.

62. WHO Expert Committee on Mental Health, Alcoholism
Subcommittee (2nd Report, 1952)
“The subcommittee has distinguished two
categories of alcoholics, “alcohol addicts” and
“habitual symptomatic excessive drinkers. For
brevity’s sake the latter will be referred to as
non-addictive alcoholics. In both groups, the
excessive drinking is symptomatic of
underlying psychological or social pathology….”
WHO Technical Report Series No. 48, August 1952, pp. 26-27

63. WHO Expert Committee on Mental Health, Alcoholism
Subcommittee (2nd Report, 1952)
“…but in one group after several years of
excessive drinking “loss of control” over the
alcohol intake occurs, while in the other group
this phenomenon never develops. The group
with “loss of control” is designated as
“alcohol addicts.”
WHO Technical Report Series No. 48, August 1952, pp 26-27

64. WHO Expert Committee on Mental Health, Alcoholism
Subcommittee (2nd Report, 1952)
“The disease conception of alcohol addiction
does not apply to the excessive drinking, but
solely to the ‘loss of control’ which occurs in only
one group of alcoholics and then only after
many years of excessive drinking.”
WHO Technical Report Series No. 48, August 1952, pg 27

65. WHO Expert Committee on Mental Health, Alcoholism
Subcommittee (2nd Report, 1952)
“The ‘loss of control’ is a disease condition per se which
results from a process that superimposes itself upon those
abnormal psychological conditions of which excessive
drinking is a symptom. The fact that many excessive drinkers
drink as much as or more than the addict for 30 or 40 years
without developing loss of control indicates that in the group of
‘alcohol addicts’ a superimposed process must occur.”
WHO Technical Report Series No. 48, August 1952, pg 27

66. Griffith Edwards (1976)
“Perhaps the key experience can best
be described as a compulsion to
drink….
“The desire for a further drink is seen
as irrational, the desire is resisted, but
the further drink is taken.”

67. Griffith Edwards (1976)
“…Awareness of ‘loss of control’ is said
to be crucial to understanding
abnormal drinking….
“Control is probably best seen as
variably and intermittently impaired
rather than ‘lost’.”

68. 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)…,

69. Footnote 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.

70. Footnote 3: 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.

71. 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

72. Footnote 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.

73. 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.

74. 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.

75. 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.

76. “Relapse” or “Reinstatement”
Griffith Edwards (1976)
“Relapse into the previous stage of the
dependence syndrome…follows an
extremely variable time course.
Typically, the patient who had only a
moderate degree of dependence will
take weeks or months to reinstate it….”

77. “Relapse” or “Reinstatement”
Griffith Edwards (1976)
“A severely dependent patient typically
reports that he is again ‘hooked’ within a
few days of starting to drink, even
though there are exceptions: on the
first day he may become abnormally
drunk and be surprised to have lost his
tolerance.”

78. “Relapse” or “Reinstatement”
Griffith Edwards (1976)
“A syndrome which had taken many
years to develop can be fully reinstated
within perhaps 72 hours, and this is one
of the most puzzling features of the
condition.”
[kindling]

79. 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.

80. 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, nicotine 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 correlation with
“powerlessness” over addiction and “unmanageability” of life,
as is described in Step 1 of Twelve Step programs.

81. 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.

82. 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);

83. Behavioral manifestations and complications of addiction,
primarily due to impaired control, can include:
• 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.

84. Griffith Edwards (1976)
“…as dependence advances…the
individual gives priority to maintaining
his alcohol intake; indeed the failure of
unpleasant consequences to deter may
be a clinical indicator of the degree of
dependence.”

85. 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.

86. 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).

87. Memory and Learning
(not in the Definition)
Memory and learning in addiction involves more than recall of
previous positive experiences with alcohol, tobacco or other
drug use or other exposures to rewards, and more than
repression or distortion of memories of the negative
experiences associated with pursing or exposing oneself to
rewards. It also involves more than the cognitive and
emotional aspects of conscious and unconscious craving and
the conditioning, through recollection of previous experiences
with learned triggers, to re-engage with the pathological
pursuit of rewards.

88. Memory and Learning
(not in the Definition)
Memory in addiction also has a behavioral and motor
component, which seems to be mediated by the rostral
(anterior) portion of the ventral tegmental area: certain motor
behaviors associated with pursing rewards, e.g., going out
and finding supplies of drugs, or food, or gambling materials,
may be recalled or ingrained in circuitry of the rostral VTA,
such that those motor behaviors have been “learned” and
reappear in the behavioral repertoire of the person with
addiction without there being a conscious component to the
behavior’s reoccurrence.

89. Memory and Learning
(not in the Definition)
Complex motor behaviors such as reaching for both cigarettes
and ignition materials and “lighting up”—or even getting into
an automobile and driving to a liquor store—may occur based
on unconscious patterns of learned motor or kinesthetic
behavior in addition to the emotional or physiological drive to
experience a drug effect or another reward.
--Michael M. Miller, M.D.

90. 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.

91. 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.

92. 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.

93. 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.

94. 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.

95. Edgar Degas
L 'Absinthe
(The Absinthe Drinker)
1875-76
Musée d'Orsay
Paris, France

96. Griffith Edwards (1976)
“Without withdrawing sympathy from the
non-dependent drinker who is experiencing
harm, society should be asked to realize
that the person who has become
dependent on alcohol is certainly ill; and
the possibility of contracting this illness
awaits anyone who drinks very heavily.”

97. Footnote 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.

98. Footnote 5 (continued): 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.

99. Naqvi NH, Bechara A
Trends in Neurosciences, 32:56-67, 2008
“It is clear that both incentives and internal states (e.g.
withdrawal) jointly determine the motivation to seek drugs.”

100. 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.

101. 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.

102. 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.

103. Griffith Edwards (1976) on progression
“The model need not, of course, propose a rigidly
stereotyped progression.
“…Milder degrees can indeed regress and the
patient can return to normal drinking.”
[Vaillant 1980, The Natural History of Alcoholism:
11% of alcoholics return to controlled drinking]

104. Griffith Edwards (1976) on progression
“A patient with an intermediate degree of
dependence is, if he continues to drink, much
more likely to progress to severe dependence
than to move backwards down the curve.
“Very severe dependence is usually irreversible,
and if the patient will not accept abstinence he
will repeatedly reinstate the syndrome.”

105. 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.

106. • 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 †

107. BEHAVIORAL CHANGES
• Eliminate alcohol and other drug
use behaviors
• Eliminate other problematic
behaviors
• Expand repertoire of healthy
behaviors
• Develop alternative behaviors
BIOLOGICAL CHANGES
• Resolve acute alcohol and other
drug withdrawal symptoms
• Physically stabilize the organism
• Develop sense of personal
responsibility for wellness
• Initiate health promotion
activities (e.g., diet, exercise,
safe sex, sober sex)
Targeted Therapeutic Changes in
Addiction Treatment

108. COGNITIVE CHANGES
• Increase awareness of illness
• Increase awareness of negative
consequences of use
• Increase awareness of addictive
disease in self
• Decrease denial
AFFECTIVE CHANGES
• Increase emotional awareness
of negative consequences of
use
• Increase ability to tolerate
feelings without defenses
• Manage anxiety and depression
• Manage shame and guilt
Targeted Therapeutic Changes in
Addiction Treatment

109. SOCIAL CHANGES
• Increase personal responsibility
in all areas of life
• Increase reliability and
trustworthiness
• Become resocialized:
reestablished sober social
network
• Increase social coping skills:
with spouse/partner, with
colleagues, with neighbors, with
strangers
SPIRITUAL CHANGES
• Increase self-love/esteem;
decrease self-loathing
• Reestablish personal values
• Enhance connectedness
• Increase appreciation of
transcendence
Targeted Therapeutic Changes in
Addiction Treatment
Miller, Michael M. Principles of Addiction
Medicine, 1994; published by American Society
of Addiction Medicine, Chevy Chase, MD

110. • Question: Why is ASAM,
as a medical organization,
talking about “spirituality”?
• Answer: Because the
members of the DDTAG,
and of the BOD, recognize
the multidimensional aspect
of both the disease and of
recovery
• Values matter
• Violating your own values,
then re-establishing your
values, matters.
• Connectedness matters.
• Meaning in life matters.
• Recovery is many things,
including a search for
meaning.
Dysfunction in these circuits leads to characteristic biological,
psychological, social and spiritual manifestations.

111. 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.

112. 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. ‡

113. Recovery from addiction is best achieved
through a combination of self-management,
mutual support, and professional
care provided by trained and certified
professionals.

114. NIDA Principles of Drug Addiction Treatment
(1999, rev 2009)
1. Addiction is a complex but treatable disease that
affects brain function and behavior. Drugs of abuse
alter the brain’s structure and function, resulting in
changes that persist long after drug use has ceased.
2. No single treatment is appropriate for everyone.
NIH Publication No. 09–4180

115. www.drugabuse.gov

116. Griffith Edwards (1976)
“Doctors should be aware that not every
patient who drinks too much (for whatever
reason) is necessarily dependent on
alcohol, and different patients need
different help and treatment.”

117. Herrington Recovery Center

118. Thank you!
Herrington Recovery Center
at Rogers Memorial Hospital
For more information, call
800-767-4411
or visit
rogershospital.org
Michael M. Miller, MD, FASAM, FAPA
mmiller@rogershospital.org

119. 800-767-4411
rogershospital.org
Rogers treats children, adolescents
and adults with:
• Anxiety disorders
• Mood disorders
• Eating disorders
• Substance-use disorders