Definitions and Diagnosis in Addiction Medicine, Dr. Raju Hajela

Dr. Raju Hajela, who has been president of the Canadian Society of Addiction Medicine has always been one of my favorite speakers. His presentation, Definitions and Diagnosis in Addiction Medicine, Implications for Treatment, Past, Present, Future given at the 2010 International Society of Addiction Medicine, 12th Annual Conference, Milan, Italy was just such a thought provoking presentation. He began by explaining how his background experience covering military medicine, family medicine, public health, and Addiction Medicine had served to shape his thinking on the concept of labeling. He has always had a deep interest in spirituality and showed how spirituality was more physics these days than anything else. Heisenberg had shown how the observer observing affected the observed and objectivity was really only shared subjectivity as facts were always processed subjectively. Ideas and opinions therefore were a product of consensus and restrained two fold by the fact that not only is Seeing Believing but Believing is also Seeing.
Substance Abuse as a term didn't exist in the ICD and the DSMV appeared to moving backwards in their definitions partly because abuse meant different things to different people as evidenced by the various amounts and frequencies sometimes put forward. The fact remained that substance abuse was still seen in a moral sense as a choice by many, especially those who would not acknowledge this outmoded idea.
Alcoholism as a disease had been proposed in 1935 by Bill Wilson and Dr. Bob S. with Dr. Jellineck in 1960 at the American Medical Association declaring it a disease, physically, spiritually, socially and mentally. Dr. Hajela said that despite all the evidence to date in support of this view he had teachers at the Harvard School of Public Health who 'didn't believe'. He went on to describe several case studies of predictive significance and several generations of transmission from his own practice to underline the biological disease evidence. He described Dr. John Savage introducing him to AA which addressed the disease as a disease alone and didn't subscribe it to any 'underlying disorders'. Use of substances was clearly shown to lead to Thought Disorders, Mood Disorders, Perceptual Disorders, Neurological Damage, and End Organ Damage making it sufficient unto itself as a primary disorder.
He spoke to the persisting Stigma associated with the diagnosis and how this affected definitions and epidemiological data.
DSMIV attempted to separate Dependence from Abuse. The notion of a spiritual disorder was related to the loss of meaning, values, relationship with self and the rest of the universe that went along with the experience of addiction.
Addiction as a brain disease was put forward by NIDA's Dr. Allan Leschner from 1994 to 2001. Dr. Twerski wrote a book 'Addictive Thinking' demonstrating the 'underlying self deception' which was a product of the brain disease of addiction. Anger by others only increased the resistance while protection by others only allowed the disease to progress. Willpower had no meaning in this process.
ISAM and CSAM maintain that the disease of addiction is a primary chronic disease. This was well documented in 2004 Scientific American showing common reward pathways. Volkov's work in 2006 demonstrated effects on dopamine ultimately.
ASAM 2010 defined addiction as a primary chronic disease of the brain reward, motivation, memory and related circuitry. It resulted in the such phenomena as inability to abstain, impaired behavioral control, craving or craving equivalents,, diminished recognition of significance of the problem etc.
Harm Reduction was a useful means to an end not dissimiliar to the treatment of hypertension which is associated with steps 1, 2 and 3 to be used in the event the problem persists or worsens. In addition there is naturally a continuing care model, with detox, rehab, and recovery associated with standard medical models for other disease entities.
Dr. Hajula concluded by discussing the addictions of the famous and quoted Gandhi who had been unable to help his eldest son who died of addiction, and was the person he'd not been able to help to his greatest regret.
Gandhi: Be the change you want to see in the world."


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