Issue With The Definition

[sabaijai]

Managing Alcoholism as a Disease

By Thomas R. Hobbs, Ph.D., M.D.

Thomas R. Hobbs, Ph.D., M.D., is medical director of the Physicians’ Health Programs (PHP). The PHP, a program of The Educational and Scientific Trust of the Pennsylvania Medical Society, is a confidential advocacy service for physicians suffering from impairing conditions.

Published February 1998

The debate on whether alcoholism is a disease or a personal conduct problem has continued for over 200 years. In the United States, Benjamin Rush, MD, has been credited with first identifying alcoholism as a "disease" in 1784. He asserted that alcohol was the causal agent, loss of control over drinking behavior being the characteristic symptom, and total abstinence the only effective cure. His belief in this concept was so strong that he spearheaded a public education campaign in the United States to reduce public drunkenness.

The 1800s gave rise to the temperance movement in the United States. Alcohol was perceived as evil, the root cause of America’s problems. Accepting the disease concept of alcoholism, people believed that liquor could enslave a person against his or her will. Temperance proponents propagated the view that drinking was so dangerous that people should not even sample liquor or else they would likely embark on the path toward alcoholism. This ideology maintained that alcohol is inevitably dangerous and inexorably addictive for everyone. Today, we know that strong genetic influences exist, but not everyone becomes addicted to alcohol.

The temperance movement picked up steam in the late 1800s and evolved into a movement advocating the prohibition of alcohol nationally. Banning alcohol would preserve the family and eliminate sloth and moral dissolution in the United States, according to supporters. Backed by strong political forces, legislation was passed and prohibition went into effect in 1920. Paradoxically, the era of prohibition also marked the death of Victorian standards. According to A. Sinclair in his book, Prohibition: The Era of Excess, a code of liberated personal behavior grew and with it the idea that drinking should accompany a full life. Drunkenness represented personal freedom. Due to public outcry, prohibition was repealed in 1933.

Soon after prohibition ended, Alcoholics Anonymous (AA) was born. Formed in 1935 by stockbroker Bill Wilson and a physician, Robert Smith, AA supported the proposition that an alcoholic is unable to control his or her drinking and recovery is possible only with total abstinence and peer support. The chief innovation in the AA philosophy was that it proposed a biological explanation for alcoholism. Alcoholics constituted a special group who are unable to control their drinking from birth. Initially, AA described this as "an allergy to alcohol."

Although AA was instrumental in again emphasizing the "disease concept" of alcoholism, the defining work was done by Elvin Jellinek, M.D., of the Yale Center of Alcohol Studies. In his book, The Disease Concept of Alcoholism, published in 1960, Jellinek described alcoholics as individuals with tolerance, withdrawal symptoms, and either "loss of control" or "inability to abstain" from alcohol. He asserted that these individuals could not drink in moderation, and, with continued drinking, the disease was progressive and life-threatening. Jellinek also recognized that some features of the disease (e.g., inability to abstain and loss of control) were shaped by cultural factors.

During the past 35 years, numerous studies by behavioral and social scientists have supported Jellinek’s contentions about alcoholism as a disease. The American Medical Association endorsed the concept in 1957. The American Psychiatric Association, the American Hospital Association, the American Public Health Association, the National Association of Social Workers, the World Health Organization and the American College of Physicians have also classified alcoholism as a disease. In addition, the findings of investigators in the late 1970s led to explicit criteria for an "alcohol dependence syndrome" which are now listed in the DSM IIR, DSM IV, and the ICD manual. In a 1992 JAMA article, the Joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine published this definition for alcoholism: "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 impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, mostly denial. Each of these symptoms may be continuous or periodic."

Despite the numerous studies validating the disease model of alcoholism, controversy still exists. In his 1989 book, Diseasing of America, social psychologist Stanton Peele, Ph.D., argues that AA and for-profit alcohol treatment centers promote the "myth" of alcoholism as a lifelong disease. He contends that the disease concept "excuses alcoholics for their past, present, and future irresponsibility" and points out that most people can overcome addiction on their own. He concludes that the only effective response to alcoholism and other addictions is "to recreate living communities that nurture the human capacity to lead constructive lives."

Surprisingly, Dr. Peele’s view that alcoholism is a personal conduct problem, rather than a disease, seems to be more prevalent among medical practitioners than among the public. A recent Gallop poll found that almost 90 percent of Americans believe that alcoholism is a disease. In contrast, physicians’ views of alcoholism were reviewed at an August 1997 conference held by the International Doctors of Alcoholics Anonymous (IDAA). A survey of physicians reported at that conference found that 80 percent of responding doctors perceived alcoholism as simply bad behavior.

Dr. Raoul Walsh in an article published in the November 1995 issue of Lancet supports the contention that physicians have negative views about alcoholics. He cites empirical data showing physicians continue to have stereotypical attitudes about alcoholics and that non-psychiatrists tend to view alcohol problems as principally the concern of psychiatrists. He also contends that many doctors have negative attitudes towards patients with alcohol problems because the bulk of their clinical exposure is with late-stage alcohol dependence.

Based on my experiences working in the addiction field for the past 10 years, I believe many, if not most, health professionals still view alcohol addiction as a willpower or conduct problem and are resistant to look at it as a disease. Part of the problem is that medical schools provide little time to study alcoholism or addiction and post-graduate training usually deals only with the end result of addiction or alcohol/drug-related diseases. Several studies conducted in the late 1980s give evidence that medical students and practitioners have inadequate knowledge about alcohol and alcohol problems. Also, recent studies published in the Journal of Studies on Alcoholism indicate that physicians perform poorly in the detection, prevention and treatment of alcohol abuse.

The single most important step to overcoming these obstacles is education. Education must begin at the undergraduate level and continue throughout the training of most if not all specialties. This is especially true for those in primary care where most problems of alcoholism will first be seen. In recent years, promotion of alcohol education programs in medical schools and at the post graduate level has improved. In Pennsylvania, for example, several medical schools now offer at least one curriculum block on substance abuse. Medical specialty organizations, such as the American Society of Addiction Medicine, are focusing on increasing addiction training programs for residents, practicing physicians and students.

Also, an increasing number of hospitals have an addiction medicine specialist on staff who is available for student and resident teaching, as well as being available for in-house consultations.

The American Medical Association estimates that 25-40 percent of patients occupying general hospital beds are there for treatment of ailments that result from alcoholism. In the United States, the economic costs of alcohol abuse exceed $115 billion a year. Physicians in general practice, hospitals and specialty medicine have considerable potential to reduce the large burden of illness associated with alcohol abuse. For example, several randomized, controlled trials conducted in recent years demonstrate that brief interventions by physicians can significantly reduce the proportion of patients drinking at hazardous levels. But first, we as physicians must adjust our attitudes.

Alcoholism should not be judged as a problem of willpower, misconduct, or any other unscientific diagnosis. The problem must be accepted for what it is—a biopsychosocial disease with a strong genetic influence, obvious signs and symptoms, a natural progression and a fatal outcome if not treated. In the past 10 years, the medical profession’s and the public’s acceptance of smoking as an addictive disease has resulted in reducing nicotine use in the United States. I feel that similar strides can be made with alcohol abuse. We must begin, as we did with nicotine, by educating and convincing our own colleagues that alcoholism is a disease. We must also emphasize that physicians have played a significant role in reducing the mortality and morbidity from nicotine use through patient education. Through strong physician intervention, I believe that we can achieve similar results with alcohol abuse.

Just a couple of corrections (or perhaps updates):

The American Psychiatric Association classifies alcohol abuse/alcoholism as a mental health disorder. Meanwhile the National Institute on Alcohol Abuse and Alcoholism (NIAA), under the auspices of the U.S. Dept of Health & Human Resources, recognises two separate 'alcohol use disorders', abuse and dependence, no use of the term 'disease' in reference to either, a view endorsed by the American Medical Association, according their website.

Within the membership of any of these organisations there is liable to be a broad range of individual opinions. But if you don't believe in statistics, then it doesn't matter how many experts endorse the disease model and how many do not.

But as you said in another thread, it hardly matters what you call it. The term 'disease' itself is quite imprecise in any case, having at least three commonly accepted meanings.

[sabaijai]

from the American Society of Addiction Medicine (ASAM) website, diagnosis-related:

FACTS about ALCOHOL DISORDERS and ALCOHOL PROBLEMS

What is alcohol dependence (alcoholism)?

Clinicians recognize two disorders related to alcohol use. The more severe disorder, known as alcohol dependence (commonly called alcoholism or alcohol addiction), is characterized by impaired control over intake, physical dependence (evident from withdrawal symptoms when alcohol is stopped after a period of heavy drinking), and tolerance (the need for increasing amounts of alcohol to achieve a desired effect).

How is alcohol dependence different from alcohol abuse?

Alcohol abuse, a less severe clinical disorder, differs from alcohol dependence in that it does not include loss of control or physical dependence. In addition, alcohol abuse is less likely than alcohol dependence to include tolerance. Rather, alcohol abuse is a pattern of chronic alcohol misuse that causes life problems but stops short of physiological addiction and dependence.

Does alcohol cause other problems?

The terms risky drinking, problem drinking, and alcohol misuse may apply to persons with clinical alcohol disorders but also apply to any drinking that exceeds moderation or causes problems.

Alcohol problems occur in individuals (trauma and injuries, health, legal, or financial problem s) and society (health care, criminal justice, and economic problems) as a result of drinking by persons with and without clinical diagnoses.

Chronic heavy drinkers are prone to health problems including liver diseases such as cirrhosis (the tenth leading cause of death), brain damage, cardiovascular damage, pancreatic disease, certain cancers, traumatic injury, suicide, and increased overall mortality.

Alcohol problems account for more economic and social damage than any other public health problem. The economic cost to society was estimated to be $185 billion in 1998. More than two-thirds of these costs are from lost productivity due to excess morbidity (45.3 percent) and premature mortality (21.0 percent) attributed to alcohol use. Most of the remainder of the costs are for treating alcohol disorders and the medical consequences of alcohol consumption (13.5 percent), property and administrative costs of automobile crashes (9.1 percent), and additional costs of alcohol-related crime (9.6 percent).

Who is affected by alcohol disorders?

In 1992, nearly 14 million adult Americans met diagnostic criteria for alcohol dependence (8,132,000 people, or 4.4 percent of adults) or alcohol abuse (5,628,000 people, or 3.0 percent of adults).

At some time during their lives, about 18 percent of Americans experience one or the other disorder. Thirteen percent experience alcohol dependence (alcoholism), and more than 5 percent experience alcohol abuse.

More than 50 percent of Americans have direct family experience with alcohol disorders.

What are the causes of alcohol disorders?

Alcohol abuse and alcohol dependence are caused by a combination of genetic and environmental factors. Researchers recently identified chromosomal regions believed to contain genes that either increase or decrease the risk for alcohol dependence. They expect soon to identify the actual genes, paving the way for new medications that precisely target alcoholism risk. Research also is underway to precisely define environmental risk factors.

In addition, researchers are beginning to understand the role of neurochemical factors, some of which are genetically determined, in the development and maintenance alcoholism. A focus of current research is developing medications that target the hallmark features of alcoholism: impaired control over drinking, craving, tolerance, and physical dependence.

[Neeranam]

Just a couple of corrections (or perhaps updates):

The American Psychiatric Association classifies alcohol abuse/alcoholism as a mental health disorder. Meanwhile the National Institute on Alcohol Abuse and Alcoholism (NIAA), under the auspices of the U.S. Dept of Health & Human Resources, recognises two separate 'alcohol use disorders', abuse and dependence, no use of the term 'disease' in reference to either, a view endorsed by the American Medical Association, according their website.

Sorry Sabajai, I beg to differ - these associations DO state that:

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.

Don't you think that Thomas R. Hobbs, Ph.D., M.D., is medical director of the Physicians’ Health Programs (PHP) might know more than you on this subject?

Also the AMERICAN SOCIETY OF ADDICTION MEDICINE say exactly the same thing.

Edited September 15, 2006 by Neeranam

[robitusson]

It's not a question of a particular poster or another here knowing "more" than anyother purported expert or anyone else. The fact is at the very least the disease theory is highly contested and the opposing view is both reasoned and verifiable. The supreme court think they know better than Thomas R. Hobbs PhD.

The Supreme Court recently ruled that the alcoholism of veterans is caused by "willful misconduct," not necessarily disease, but debate among alcoholism researchers continues. Their ranks will be further stirred by Heavy Drinking: The Myth of Alcoholism as a Disease (University of California Press, $16.95), in which addiction specialist Herbert Fingarette asserts that the "disease concept" of alcoholism is little more than a hoax perpetrated by various medical, political and economic special interests. Rather, he argues, the notion of alcoholism as a disease is belied by the bulk of scientific evidence.

http://www.findarticles.com/p/articles/mi_..._v22/ai_6703167

Besides, the disease model that the medical world occasionally uses is not the same concept as the AA version.

The AA disease model relates directly to belief in a HP to alleviate the supposed disease/ allergy. Find one single scrap of evidence whatsoever that the contested disease model mentioned here is somehow alleviated by belief in a God or practice of religion and then post that here.

There's no link between the contested medical and psyhciatric studies which are being posted here and the AA concept of disease as powerlessness alleviated by belief in a God. None.

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http://www.druglibrary.org/special/davies/myth4.htm

The most problematic concept in the addiction area is 'disease'; and despite repeated and consistent assertions in the recent literature that the disease notion has either (a) a highly qualified and constrained application in this area (cf. the Alcohol Dependence Syndrome), or ( has no applicability whatsoever (cf. Heather and Roberston's account of controlled drinking), it remains a notable fact of life that the idea of addiction-as-disease is alive and well amongst many drug and alcohol misusers and their families, and in many treatment agencies. It will not go away for one simple reason. Namely, it is highly functional.

This functionalism will become the main theme of the present book in later chapters, but for the time being we must content ourselves with observing that as a general rule, where a disease interferes with behaviour it replaces something purposive and coordinated with something chaotic (for example, Parkinsons disease, Huntingdon's chorea, peripheral neuritis). Commonsense suggests that the disease definition should indeed normally make reference to something which disrupts or is inimical to integrated and purposive behaviour patterns. It does not make sense as a category description for the replacement of one behaviour with a new, equally integrated, coordinated and purposive pattern. If we postulate a disease which has the direct capacity to force people to steal, to lift up glasses, or to stick needles in their arms when they are actually trying not to, and furthermore to execute long strings of appetitive goal-directed behaviour as precursors to these actions, we have to accept the possibility that any integrated chain of goal directed behaviour in any realm might be nothing more than a disease symptom.

The fact that the short and longer-term disruptions of behaviour which sometimes result from taking drugs can become the occasion for postulating drug taking as a disease manifestation shows a familiar confusion; namely the confusion of intentions with outcomes. For example, during the late 19th and early 20th centuries, missionaries went to Africa where many of them caught malaria and died. The disease was malaria; not the decision to go to Africa. Furthermore, whilst a doctor can in principle treat the malaria, he can only advise people not to go to Africa, on the basis of his own beliefs and opinions about Africa. In a similar way, damage to health caused by drugs does not imply that the decision to take them is pathological, any more than deciding to go to Africa is pathological.

________________________________________________________________________________

"Our real purpose is to fit ourselves to be of maximum service to God and the people about us."

-- William Griffith Wilson, "Into Action", pp. 77 Alcoholics Anonymous

Why "Mythology" Is A Better Term Than "Theory"

A myth within the context of this article is "any fictitious story, or unscientific account, theory, belief, etc." When one actually compares and contrasts A.A. simplistic definition of disease with far more authoritative work upon that subject the "disease theory" immediately crumbles into the mythology that it is. Myths, such as loss of control and mental blank spots do not exist within the context of the pursuit of inebriation. In fact when one chooses to drink one is fully aware of what one is doing from the moment the drinker thinks of the idea of alcohol consumption right on down to the actual action involving their own skeletal and facial muscles to place that intoxicant within their own body.

As proven above there is NOTHING proving that Alcoholism is a disease. Terms such as "disease concept" or "disease theory" in relation to Alcoholism and the identical mythology of "addiction disease" in general are just simply wrong. A more accurate phrase describing this nonsense is "disease mythology". Words, such as concept or theory imply that there is a shred of academic or empirical evidence backing the claim. The more accurate terms, myth and mythology, tell it exactly the way it is in regards to the lack of substance behind the claims that are made.

Edited September 15, 2006 by robitusson

[Neeranam]

It's not a question of a particular poster or another here knowing "more" than anyother purported expert or anyone else. The fact is at the very least the disease theory is highly contested and the opposing view is both reasoned and verifiable. The disease model that the medical world occasionally uses is not the same concept as the AA version. Come on they don't use it occassionally - it's the most common usage.

The AA disease model relates directly to belief in a HP to alleviate the supposed disease/ allergy. Find one single scrap of evidence whatsoever that the contested disease model mentioned here is somehow alleviated by belief in a God or practice of religion and then post that here. I'm not saying it is!

There's no link between the contested medical and physciatric studies which are being posted here and the AA concept of disease as powerlessness alleviated by belief in a God. None.

The medical experts that I quoted are nothing to do with AA. My personal beliefs are NOT the same as AA. Let's forget what AA say.

I understand your, and Mr.Sabaijai's opinion on this matter, possibly due to your ardent following of an Eastern religion, and respect that, but let's look at it unblinkered and stick to the facts, which are MOST medical experts think alcoholism is a disease. If you don't believe it, look at the statistics. It ain't rocket science.

[robitusson]

The medical experts that I quoted are nothing to do with AA. My personal beliefs are NOT the same as AA. Let's forget what AA say.

I understand your, and Mr.Sabaijai's opinion on this matter, possibly due to your ardent following of an Eastern religion, and respect that, but let's look at it unblinkered and stick to the facts, which are MOST medical experts think alcoholism is a disease. If you don't believe it, look at the statistics. It ain't rocket science.

Glad to hear you recognise the disparity between AA's disease model and what you're posting here.

Ok. Let's look at the facts. Where did you get the most medical experts think alcoholism is a disease? And, while doctors and professionals may use the model for its practical applicability, there is no evidence for an alcoholism disease. How does a doctor make a prognosis? If it's an allergy, how is an allergy test done?

I've offered the middle-ground in the last post by saying that, at best the disease model is highly contested. Personally I think the evidence is evolving in the direction away from the disease theory as time goes by. It was a fairly uncontested idea when it entered the mainstream last century, but the concept is becoming marginalised. It's not taken as seriously at all outside of America, where the culture doesn't support this kind of thinking so much.

What are you on about being an ardent follower of "an Eastern religion"? What's this got to do with anything?

Edited September 15, 2006 by robitusson

[Neeranam]

Ok. Let's look at the facts. Where did you get the most medical experts think alcoholism is a disease? And, while doctors and professionals may use the model for its practical applicability, there is no evidence for an alcoholism disease. How does a doctor make a prognosis? If it's an allergy, how is an allergy test done?

I've offered the middle-ground in the last post by saying that, at best the disease model is highly contested. Personally I think the evidence is evolving in the direction away from the disease theory as time goes by. It was a fairly uncontested idea when it entered the mainstream last century, but the concept is becoming marginalised. It's not taken as seriously at all outside of America, where the culture doesn't support this kind of thinking so much.

I look at the WHO, American Addiction Council, etc etc. There must be some evidence, why would they all say it's a disease if there weren't?

You are correct - it is contested, but highly?

I think America is pretty screwed up with their 12 step recovery programs. 90% of American people think that alcoholism is a disease.

What are you on about being an ardent follower of "an Eastern religion"? What's this got to do with anything?

Just kidding

[AlexLah]

Hi all,

I think that when you are an alcohol drinker and cause problems for others or yourself then it is a problem. During my time working in East Europe I have seen people that could drink a liter of wodka in the evening (every night) and where fresh in the morning.

Are they alcoholics? I think so as the effects of this heavy drinking will for sure do something with their health.

But who am I to tell someone he/she is destroying their body?

It is up to them as long they not bother me with their health problems caused by excesive drinking.

AA is a good organisation to those who feel they have problems in daily life caused by drinking alcohol and need others to help them stop.

My father who passed away a few years ago had an alcohol problem. It went that far that my mother told him if he did not stop she would diforce him (they where together more then 30 years).

He decided it was beter to stay with my mother and from the next day he never drinked again.

If you want to stop drinking alcohol it is all in your mind.

If you really want, you can do it. Some need help some others not.

Good luck to all of you!

Alex

[sabaijai]

Don't you think that Thomas R. Hobbs, Ph.D., M.D., is medical director of the Physicians’ Health Programs (PHP) might know more than you on this subject?

It wasn't my knowledge that I offered, rather direct citations from the AMA, APA, NIAA, and SAMA, where 'disorder' has become the more accepted terminology.

As I wrote earlier, within each there is bound to be plenty of variation in views and explanations so I'm sure we can both find plenty of citations to bolster our views. You can call alcohol abuse and alcohol dependence anything you want, I'll stick with the use of 'alcohol disorders' by these organisations.

Neeranam, I don't see how discussing the terminology has anything whatsoever to do with my being interested in Buddhism. If motivation goes to the point of discussing terminology, then I think we should look at who among is an AA functionary.

[robitusson]

I look at the WHO, American Addiction Council, etc etc. There must be some evidence, why would they all say it's a disease if there weren't?

You'd think so. It used as a model for treatment purposes in my understanding. One of the main contentions with the disease model is the lack of discernable symptoms or evidence for a disease.

You are correct - it is contested, but highly?

If you need long and potentially boring posts of evidence that it is highly contested, I would be happy to provide it.

[AlexLah]

Hi all,

I do not understand why some of you need to see a medical explanation or whatever scientifically approved explanation on alcoholism.

You know that you are drinking on a regular base. The question is: why?

Why are you drinking alcohol?

Is it because you wanna escape reality?

What is it you alcohol drinkers that you drink in excessive amounts I mean.

Yep that means you drink untill you get drunk.

Why?

If you find the answer you know how to solve it.

There is a reason why you do that, please find out and accept it and find a solution.

Take care all,

Alex

[sbk]

Good points alex but the problem lies in the fact that many alcoholics refuse to face their problems. Heck, even non-alcoholics can have difficulty with that!

So, get a person who is drinking too much and it is causing problems with their relationships, work etc and they tend to blame outside factors. "My girlfriend/wife is a nag, my boss is a slavedriver". The alcoholic (and lots of other people too, it is not a trait that is exclusive to addicts) tends to not take responsibility for their own behavior, hence the difficulty in assessing the situation.

So, although there seems to be a simple solution, alexlah, often it is not as simple as it appears.

[sabaijai]

Good points alex but the problem lies in the fact that many alcoholics refuse to face their problems. Heck, even non-alcoholics can have difficulty with that!

So, get a person who is drinking too much and it is causing problems with their relationships, work etc and they tend to blame outside factors. "My girlfriend/wife is a nag, my boss is a slavedriver". The alcoholic (and lots of other people too, it is not a trait that is exclusive to addicts) tends to not take responsibility for their own behavior, hence the difficulty in assessing the situation.

So, although there seems to be a simple solution, alexlah, often it is not as simple as it appears.

Yes many factors are involved, probably different for every individual. I think it sometimes looks simple to the non-drinker/non-drunk. In many cases I think you have to treat the symptoms first--get medical intervention, detox, join AA or the like, etc, and then examine the causes while recovering.