Addiction is More Than a Substance Use Disorder
People with the disease of “Addiction” may engage in substance use or not. The American Society of Addiction Medicine (ASAM) definition clearly states: “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 with the use of substance and other behaviors.” The term “substance use disorder” is a diagnostic and statistical manual-5 classification that is entirely behavioral and does not refer to the disease of Addiction.
The ASAM policy statements are also very clear about treatment, where recovery is the mainstay of treatment for Addiction. The term medication-assisted treatment (MAT) is a bit of a misnomer, as the more accurate term is medication-assisted recovery (MAR). It is sad that MAT has become prominent as Dr Wakeman notes and further states, “…MAT still implies that medications are a corollary to whatever the main part of treatment is (ie, they assist treatment).” She makes an accurate statement yet strangely disparages it further in her commentary. Addiction treatment, as clearly stated in the ASAM policy statements, involves a biological, psychological, social, and spiritual approach, which emphasizes recovery. Hence, MAR is the more accurate term rather than MAT.
Dr Wakeman further calls for “Medications for Addiction Treatment” as an alternative for the current acronym for MAT, which is patently misguided. Her assertion, “Medication management in primary care and minimal counseling with buprenorphine has been shown to be as effective as buprenorphine plus formal counseling with cognitive behavioral therapy” is a reflection of poor treatment services and limitations of research; not necessarily a valid conclusion. People with Addiction involving opioids often lead opioid-free lives in recovery; and people with Addiction involving opioids on opioid maintenance therapy (OMT) enjoy a better quality of life, when engaged in recovery. Further, there is no one who has just “opioid use disorder” as that is a reflection of Addiction and it is not synonym for addiction. The ASAM definition of Addiction has clear implications regarding behavior (substance use) being a symptom or consequence of the disease and it must not be confused with the disease itself, nor be considered to be a cause of the disease. Further, it must be appreciated that treatment for Addiction requires much more than cessation of substance use or maintenance, which in the case of opioids is even more accurately called opioid agonist therapy (OAT).
I would implore colleagues (readers), authors, reviewers, and editors of JAM to be more diligent with accuracy and terminology, to ensure better understanding of Addiction and its full treatment, rather than just focusing on maintenance medications.