ASAM - Operational Definition of Addiction - The Way Forward

The new ASAM Definition of Addiction sets the limiting parameters for what are and what are not legitimate areas of interest for anyone trying to talk about or do research on the previously non-specifically defined field of drug dependence. "Non-specific" being the operative element.  It would be naive to ignore the implications for the discussion that I am prosing for the blog on specifically the pathophysiology of alcoholism. I have recently noticed a number of references to the "ASAM Definition," without any one of them including any descriptive information.  Indeed the authors of this prodigious undertaking have been careful to include a nod to each of the various traditions that have been the subjects of LinkedIn Debates.  Here, we have the vede mecum from which we ought to discern the causes of, the natural history of, and the treatments for any a substance that fits the exclusionary criteria:

Inability to consistently [A]BSTAIN

Impairment of [B]EHAVIORAL control

[C]RAVING

[D]IMINISHED recognition of significant problems

Rather than offer comments or suggest interpretations, which would be hasty and even offensive to the brave men living and dead who struggled with this task, I would like to restrict our attention to only those parts of the 8 pages long "definition" that mention alcohol specifically. First things first. We need to relate symptoms to pathophysiology:[D]IMINISHED recognition of significant problems
Where in the brain are these functions localized - or what is the rate controlling process?

Why just alcohol? (From a LinkedIn duscussion)

Hi Howard.  thank you so much for your valuable insights.  I would like to restrict my blog to discussing a possible pharmacodynamic disease model for alcoholism for this reason.  Alcohol and alcohol addiction is unique in human history. Alcohol isn't just a feel good drug - or a poison.  Alcohol sterilizes water.  Literally, Western civilization could not have spread into Northern Europe if people did not seek alcohol laden liquids.  Western man became vulnerable to water born disease as soon as they stopped migrating and stayed in one place long enough to pollute their own water supplies. Only those who experienced twilight hour craving for alcohol, when, for millions of years, the men returned from the day time hunt back to the settlement, those who felt a desire to find their way back to a source of alcohol were assured of not contracting a fatal water born disease. Those who did not have that genetic variation, simply died out in a generation or two.  For what ever reason, our aldehyde sensor, that tells us when we turn acidotic from starvation, some how (random mutation highly selected for) got crossed with the resident endorphin Circadian rhythm generator on part of the opiate receptor. In plain English, when the other endocrine receptors peak at around 4 pm, we get a hyper-alert starvation warning which is either extinguished immediately with an ounce or so of alcohol or simply wears off gradually after a carbohydrate load that also satisfies that starvation alarm for another 24 hours.  Like all biosystems, there is a bell shaped distribution of receptor sensitivity (which we experience as craving intensity).  Some people have no mechanism to generate cravings for alcohol at all, but on the other end of the curve, some of us got stuck with a balky receptor that won't turn off with just one or two ounces of alcohol or even with a gluttonous carbo load. Our entire brain gets taken over until we find a pathway back to alcohol, which is the most efficient way to turn off the rogue receptor.  Even though the defect is just like a silent switch that we can't feel directly,every bit of brain matter at higher conscious levels (that we call the emotional and spiritual) is held hostage until that nasty receptor finally gets pickled enough to stop functioning.  Nomadic peoples, the Native Americans or Arabs, never had the survival pressure to develop this pattern. Orientals seem to have boiled everything since the dawn of their civilization, and hence, Chinese never were threatened with lethal water born illness.  They just get very flushed when they consume alcohol because they can't metabolize the aldehyde byproducts.  But neither Arabs, Native Americans nor Orientals have a turn off switch when they drink alcohol...they just keep on until they get cellular addiction. I have a lot more to suggest on this topic,which is why I decided to take those discussions to a more specifically technical blog, but I wanted to answer your question as part of this discussion because it does lead us to a very very important insight:  Now we can fit the physical level with the emotional and spiritual under one holistic model that easily accounts for the different observations that different discussants have been making.  Every one is totally correct at some time during the natural progression of the illness.

Is there a generally accepted physical mechanism that explains alcohol addiction?

I created this blog in response to an issue that kept arising in LinkedIn discussions about addiction;

What is the cause of alcohol addiction, and what can be done to treat the cause successfully?

Most of the LinkedIn discussions dealt with the 12 Step approach to treatment.  With those favoring 12 Step programs proclaiming that only strict obedience to the principals articulated in the Big Book of Alcoholics Anonymous could help alcoholics stay sober, and those opposed generally attacking the 12 Step approach for being quasi-scientific or for requiring acceptance of a Higher Being Who could and would relieve the alcoholic's addiction if He were accorded the correct propitiation.

As both a recovering alcoholic with over 13 years of daily attendance at 12 Step Meetings and as a psycho-pharmacologist with over 20 years research experience at Harvard Medical School, I realized that both pro and con arguments assumed that the basic defect causing some people to crave alcohol had to do with a "spiritual loss of values," thus making the  disease of alcoholism by definition an affliction of those who were ignorant of or who had rejected the moral imperatives of Christianity.

In essence, nearly all the LinkedIn discussions about alcohol addiction hinged on a system of beliefs rather than evidence about a disease process that results in devastating physical deterioration.  If alcoholics only suffered from inappropriate behaviors alone, or behaviors that a Christian would find repugnant - without any other characteristic psychophysiology - then accepting spiritual salvation would be the "cure" for the alcoholic without which no improvement could be possible. Furthermore, the obverse would also be true - that those who could not stay sober would have to be suffering from profound moral decay manifested by a definite pattern of seriously reckless and illegal behavior.  The physical manifestations would not be the defining characteristics of the illness.   The thought of a chronically relapsing alcoholic would who was not also a criminal would be unthinkable.

This is not far from the status quo for American alcoholics and those who abuse other substances that follow a pattern of cravings and relapses.  In America, addiction is definitely a moral/criminal issue.  We imprison and stigmatize those who cannot stay sober AS IF they were simply bad people who could be driven into submission by determined civil authorities with the power to imprison rather than an obligation to do biomedical research. 

The cynic in me wants to say that, here, we lock up our treatment failures.  We marginalize those who lack the financial means to live a law abiding life.  We disenfranchise anyone who has done jail time - for which the most common crime is possession of substances that have been made illegal by the same people who profit from running prisons and chasing down users.