This question was the title of the keynote address Dr. Charles O’Brien, founding director of the Center for Studies of Addiction at the University of Pennsylvania, gave at Addictions Old and New a mind opening conference that I attended in October at the University of Richmond. Organized by historian David Courtwright, the conference examined similarities and differences between behavioral addictions, such as gambling and sex, and traditional substance use disorders.
Dr. O’Brien focused on neurobiological aspects of the issue, describing addiction as a brain disorder – specifically a disorder of the brain reward system related to learning and memory. His research group was one of the first to describe how the activation of the endogenous opioid system by alcohol is a key part of the pleasurable response that many people have to drinking alcohol. This came as a surprise to many of us who, up to that time, saw the biology of opioid and alcohol issues as being quite separate.
Some people have genetic differences in their endogenous opioid system that render them particularly sensitive to this process, resulting in an increased vulnerability to alcoholism. Dr. O’Brien’s group went on to demonstrate that the opioid receptor antagonist, naltrexone, could reduce alcoholic drinking. He lamented that the traditional addiction recovery community has thus far largely resisted the use of this medication in the treatment of alcoholism despite evidence of its effectiveness.
Dr. O’Brien recently supervised the revision of the section of the Diagnostic and Statistical Manual (DSM-5) devoted to addictions. He oversaw the inclusion into the chapter of gambling as the first disorder that did not involve substance use. In his talk, he argued that anything that activated the brain reward system could potentially be addicting. On the other hand, his task as the head of the DSM addictions related section was to examine the evidence supporting that a particular behavior could be officially considered to be an addiction. (Readers may be interested to know that alcoholism was categorized as a personality disorder in the first DSM, and as late as 1980, there was significant resistance to the inclusion of tobacco in the addictions section.)
Dr. O’Brien is of the opinion that the next behavior for which the greatest evidence exists for inclusion is internet gaming. As yet, problematic behaviors relating to food and sex do not have sufficient evidence for them to be included as diagnostic categories. This assertion stimulated considerable reaction in the question-and-answer period that followed. Subsequent presentations at the conference on the topics of food (by David Courtwright) and sex (by Robert Weiss) as addictive behaviors made me think that at some point in the not too distant future they will be strong contenders for inclusion.
I recommend that you watch these presentations yourselves and make up your own minds. In addition, an outstanding presentation on slot machine gambling (by Natasha Schull) makes clear why gambling has already made the cut.