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Clinical Aspects Regarding Alcoholism As An Addiction Back to Course Index

addiction

Clinical Aspects Regarding Alcoholism As An Addiction

“Disease of Addiction”

 

 

 

Introduction

 

Is alcoholism/addiction a disease or a consequence of a series of bad choices?  This question has been one of the most debated topics related to the field of substance abuse since the Disease Concept was introduced by E.M. Jellinek in 1960.  The objective of this course is to look specifically at alcoholism and explore both the concept of its a disease and its a learned behavior.  I will initially describe the disease model of addiction followed by the phases of alcohol use and then present a time line for the progression through the phases.  I will then offer arguments supporting the disease concept followed by arguments in opposition to the disease concept.  The final section will present a unifying approach that may offer both camps an understanding of the others view.

 

 

Disease Model

 

The NAADAC Desk Reference and Study Guide on Addiction Counseling describes the disease model of addictions as follows, Alcoholism is considered by most to be a primary disease and not a symptom of a primary psychiatric disorder.  It is also considered to be a chronic and progressive disease and potentially fatal if left untreated.  Most substance abuse counselors agree that a biogenetic predisposition to the disease can be shown to exist through observation (working with addicted individuals) and research.  The following attributes are generally accepted as items that can influence a susceptibility to alcoholism.

  • Children of alcoholics are twice as likely to experience alcoholism as offspring of non-alcoholics.
  • Adoption studies indicate that adopted offspring of alcoholics are approximately four times more likely to develop alcoholism than adopted offspring of non-alcoholics.  Other adoption  studies suggest this risk factor may be as high as nine times.
  • Brain chemistry of alcoholics may be permanently altered. 

Elevated levels of tetrahydorpaverolines (THP) have been noted.  The THP interacts and results in tetrahydroisoquinolines (THIQ).  Researchers have shown that higher levels of THIQ result in animals having a preference for alcohol.

 

There is also evidence that supports a physical component to addiction.  The most significant observation that supports the physical component is the fact that when an increased amount of a drug is used, the more of the drug the body will demand to obtain the same euphoria level as previously obtained.  This phenomenon is generally referred to as tolerance that in turn reflects the bodys effort to adjust to the presence of a drug.

 

There also appears to be a psychological component to addiction.  The psychological component may precede physical addiction and may continue after the drug has been eliminated from the body.  The observations that support the psychological component are:

  • The use of the drug is psychologically necessary (needed to feel normal).  The use of the drug takes precedence over the best interests of self, relationships, job, health and family.
  • The individual develops a relationship with the drug.  The individual may feel that life without the drug would be boring and meaningless.
  • The individual perceives an inability to stop using.  They may have attempted to quit several times.  There are several physical and psychological factors that contribute to this emotional state:

        – Intense desire to use; physical cravings

        – Fear of withdrawal; avoid pain or discomfort associated with abstinence

        – Inability to control amount of drug used per episode; binge drinking

        – Preoccupation with drugs-thoughts dominated by desire to use

        – Recall of prior episodes (mind may actually embellish episode

         to a greater euphoric level than was originally experienced.)

        – Emotional turmoil (frustration, anxiety, depression, irritability, fearful)

        -Behavioral changes-dependent individual may feel fear, guilt, shame and confusion

 

This behavioral pattern may cause conflict with family, community, work and internally with the individuals own value system.

 

Dependency is progressive and chronic.  It has distinctive signs and symptoms and progresses in a predictable pattern.  The denial process is common in dependent individuals and typically manifests itself in the following ways: 

 

Denial is the way an individual protects himself or herself from the reality of chemical dependency.  The individual may create his/her own world and that world may be very different from reality.

 

The individual may protect himself or herself by repressing certain emotions.

 

Blackouts are an example of alcohol-induced amnesia.  The individual remains conscious but is unable to recall part or all of what occurred.

 

The addicted individual may experience euphoric recall, which means they recall prior episodes of drug use.

 

Misrepresentation to self and others about the amounts and frequency of drug use can be described as simple denial.

 

The individual attempts a logical excuse (rationalization) for illogical behavior.

 

Minimizing can occur by the user comparing their use to someone elses.  I dont have a problem like Tony.  I only drink beer.

 

Blaming others for their problem occurs (i.e., if things were not so bad at work, I wouldnt need to use).  This projection is common in addicted individuals.  These individuals also have a tendency to project negative feelings they have about themselves onto others.

 

Intellectualizing occurs as the individual avoids pain by denying or ignoring feelings and thinking about life from an intellectual point of view.  An example of this is when someone frequently attempts to present information to support the stance that marijuana should be legal because it is not as bad for you as alcohol.

 

The Stages of Drug Use

The commonly accepted phases of alcohol and other drug uses are as follows:

 

Experimental/Recreational Phase

     > Person experiments with drugs to satisfy curiosity and to fit in.

     > Drugs are used to alter mood in social settings.

 

Regular Use/Abuse Phase

     > Drugs are used on a regular basis over a period of time.  The

        person drinks to intoxication on occasion.

     > Drug use can be situational.  Binge drinking may begin.

 

Compulsive/Dependent Use Phase

     > Time, energy and money are focused on securing and using  drugs.

     > Preoccupation with drugs

     > Physical and psychological degradation is apparent to others

     > Functioning is impaired

     > Responsibilities such as job and family are neglected

     > Relationships with others may become strained and stressful

     > Family members may make excuses for drug users.

     > Many heavy users are in denial (they do not consider themselves addicted).

     > Uses to avoid withdrawal symptoms

     > Individuals main focus in life is when and where will I get my next fix.

 

The preceding stages and description of the disease concept correlate with the criteria presented in the DSM-IV for alcohol abuse and dependence.  The DSM-IV criteria are as follows:

 

Alcohol Abuser: 

An individual who continues to use despite recurrent social, interpersonal and legal difficulties as a result of alcohol use.  Harmful use implies use that results in physical, legal or mental damage.

 

Alcohol Dependence:

Those who are alcohol dependent meet all of the criteria of alcohol abuse and they will also exhibit some or all of the following:

  • Typically drinking only one type of alcoholic beverage
  • Attending only social events that include drinking; for example if invited to a wedding the first question asked is is there an  open bar?
  • Avoids rejection by hanging out with using buddies.
  • Increased tolerance (having to drink larger amounts to achieve previous effects).
  • Drinks to avoid withdrawal symptoms (getting physical symptoms after going a short period without using).
  • Drinking to relieve withdrawal symptoms (drinking to stop the shakes or cure a hangover).
  • Subjective awareness of the compulsion to drink or craving for alcohol (whether they admit it to others or not).
  • Pattern of relapses (return to using after a period of
  • abstinence)

Typically, those drinkers who are diagnosed as only alcohol abusers can be helped with substance abuse counseling.  The counseling may focus on education concerning the health risks, family/job issues that may be encountered and the dangers of binge drinking and alcohol poisoning. 

 

Those who have become alcohol dependent generally require treatment to stop drinking, which may include detoxification, medical treatment, counseling and/or self-help support.

 

 

Progression/Time Line

 

When describing the phases of alcohol use a factor that is often overlooked or under evaluated is the timeline for each phase and the cumulative time it typically takes for an individual to progress through the phases and to become dependent on alcohol.  As a suggestion, perhaps even the dependency phase is not absolute individuals in the early stage may very well have the ability to control their use if they are sufficiently motivated (spouse may require them to choose between alcohol and his or her family).  Unfortunately, in so many cases, when an individual progresses to the latter stages of the dependence phase there is little chance of the individual being able to control their use without professional help.

 

Figure 1 depicts the approximate time frame for each phase.  As can be seen, an individual may remain in experimental/recreational use for 10 to 15 years prior to progressing to the regular use/abuse phase.  Typically, the regular use/abuse phase is shorter than either of the other phases.

 

It appears the increased situational use (seeking out drinking functions), as well as psychological factors (need drug to feel normal) helps to accelerate individuals through this stage rather quickly.  Also, during the use/abuse phase, alcohol is often used as a crutch to help cope with all stressful situations and to enhance joy associated with celebratory occasions.  Also, alcohol becomes the primary self-administered medication for all ills and situations.  Consequently, it becomes progressively more important to the individual; again this tendency is to accelerate an individual through the use/abuse phase.  As can be seen on Figure 1, The time frame for phase 2 is from three to five years.

 

The final phase is the dependency phase.  It is helpful for illustration to divide this phase into three stages and look at the characteristics of each stage independently.  In each case, the point to focus on is that alcohol is becoming more important to the individual and he/she is making more concessions to alcohol in terms of withdrawing from family, work and community responsibilities.  Typically, early in phase 3 an individual can stop drinking.  It typically takes a catastrophic life incident (serious illness, accident, loss of family/family member) for the individual to revert to abstinence on his/her own.  Through my years of counseling I have seen approximately 5 to 10% of early phase 3 alcoholics undergo a successful recovery program motivated internally.  The middle and late phase 3 are a different story.  The most significant characteristics of an individual in these stags are that the most important item on their minds is when and with whom they will get their next drink.  I have met phase 3 alcoholics that would lie, steal, cheat or do almost anything to obtain alcohol.  Unfortunately, few stage 2/3 alcoholics have the physiological and psychological under pinning to get into recovery themselves.

 

Phase 3 typically extends for several years.  The early stage of phase 3 typically does not extend beyond 5 years.  The second stage is characterized by a worsening of stage 1 and can typically last up to five additional years.  The final stage is characterized by total emersion into a drug related lifestyle and will generally last until either recovery starts or death.

 

Arguments for the Disease Concept

 

The concept of the disease of alcoholism has been around from the nineteenth century and even ancient Romans recognized that some individuals drank to excess by choice and others could not control their intake of alcohol.  Fast forward to around 1785 when Dr. B. Rush explained habitual consumption of alcohol as an involuntary condition.

 

The first and probably the most significant happening was that Alcoholics Anonymous embraced the disease concept.  As noted previously, the research done by E.M. Jellinek brought the total concept into focus.  Regardless of the scientific validity of his work, he developed a model of alcoholism that has brought most of the fringe concepts into a single, unified concept.  Other advocates such as Mary Mann, who was the first woman to achieve sobriety through AA founded the organization now known as the National Council of Alcoholism and Drug Dependence.  The NCADD has helped many individuals to understand that alcoholism is a preventable and treatable disease.

 

Most researchers have concluded its highly likely there is a link between genetic predisposition, brain and body chemistry, and social and environmental factors to alcoholism/addiction.  Probably the most accepted study is that which studied offspring of alcoholic parents.  As mentioned earlier, this study indicates there is an approximately four times greater risk of becoming an alcoholic in this subpopulation than in the general population.  Several studies have been conducted over several years and the conclusions are fairly consistent from study to study.

 

Current organizations that promote policies and programs based on the disease concept include the American Medical Association and the U.S. Department of Health and Human Services.

 

The net of the pro disease concept is that alcoholism is a primary, chronic disease with genetic, psychosocial and environmental factors influencing its development and manifestations.  The disease is also progressive and often fatal is left untreated.  It is also generally accepted that it has a relapsing component and is characterized by continuous:  impaired ability to control drinking, preoccupation with alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial.  Most counselors may recognize the similarity of this wording to the Diagnostic and Statistical Manual (DSM-IV) for disorders associated with alcohol abuse and addiction.

 

The Journal of the American Medical Association published an article in 1992 that further defined alcoholism in greater detail.  In essence, this article defined alcoholism as repeated use that causes trouble in the drinkers personal, professional, family or social life.  The basis for the broadening of the definition is that typically when alcoholics drink, they cant always predict how much they will drink and how long the episode will last or what the consequences of their drinking will be.  Most alcoholics adopt a binge-drinking pattern and may drink continuously for several days or weeks and often stop only after their supply is depleted.  One of the most common characteristics of an alcoholic is one of denial of the negative consequences of alcohol in their lives.  As I have stated before, the biggest challenge in treatment of alcoholics is the breakdown of denial.

 

A common attribute that alcoholism has with other diseases is the interaction between individual (who gets the disease and his/her genetic and biological makeup), the agent (alcohol) and the environment.  In essence, alcoholism is a complex disease that is influenced and impacted by personal choices, genetic predisposition, family, environmental risk factors and probably many other items, which we have not yet discovered.

 

There is no known cure for alcoholism.  The disease can be arrested by complete abstinence from alcohol and other mind-altering drugs.  Once abstinent, most alcoholics recover from the damage caused by excessive use.  Millions of Americans are currently recovering from alcoholism.  The ones that are most successful recognize that their bodies are sensitive (allergic) to alcohol due to a unique chemical composition; consequently, they accept themselves as being unique and also accept their inability to handle alcohol.  I am reminded of the story of the young boy and the green apples.  The boy found an apple tree and ate several apples.  Subsequently he became very ill (vomiting, rash, high fever, etc.) His parents took him to a doctor and they discussed what the boy had done.  The doctor treated the symptoms and the boy recovered quickly.  A few days later the boy again visited the apple tree.  Again he got sick and went to the doctor.  They went through the same process and the doctor recognized the boy was allergic or chemically sensitive to green apples.  They were instructed that the boy should discontinue eating green apples.  The boy and his parents agreed and followed the doctors instructions. The message of this story is simple yet sublime.  If alcoholics could accept their sensitivity and walk away from alcohol once it has been determined they are sensitive or allergic, the disease of alcoholism could be significantly reduced or even eradicated.  The difficulty lies in carrying through with what we know is best for us.  As we continue to educate those at higher risk for alcoholism and as the public becomes better informed, collectively we are able to help the alcoholic manage his/her life and prevent or reduce many of the harmful outcomes associated with the disease of alcoholism.

 

 

Arguments Against the Disease Concept

 

One of the strongest arguments against the disease concept has been directed at Jellineks research.  This research was the basis for him concluding and presenting the Disease Concept of Alcoholism.

 

It has been widely reported that he sent questionnaires to Alcoholics Anonymous (AA) members though his newsletter, The GrapeVine.  He received approximately 160 responses and approximately 60 of these were rejected (respondents had pooled data).  He chose to use only questionnaires completed by males.  This information coupled with the fact that he acknowledges his data was sparse leads one to suspect that he may have arrived at a conclusion and selected data that supports that concept.

 

There are other arguments against the disease concept, as well.  One additional argument is the propagation of the concept into other disciplines.  It has been said that eventually everyone will have at least one disease of something.  The final argument against the disease concept is that by everyones admission it is self-induced.  I think its fair to say if an individual abstains from alcohol throughout his/her life there is no risk of alcoholism regardless of the risk factors he/she may have been exposed to. 

 

One of the reasons many have reservations regarding the disease concept is that it gives a person with a drinking problem an easy excuse or a reason for them to continue to use.  Consequently, some individuals may never get the help they need to become and remain abstinent.  Also, the medical profession has yet to develop a cure, that is not to say there is no help for alcoholism from the medical or other helping professions, but there is no designed procedure one can undergo to receive a cure.  In essence, once an individual is diagnosed with a disease they may have a tendency to give up on traditional treatment programs and to become comfortable hiding behind a label.  In fact, most alcoholics can be helped through counseling and treatment if they seek help and follow the recommended program.  This also includes help from the medical profession by administration of medication such as Naltrexon (helps to relieve the desire to drink in many alcoholics) and anti-anxiety medications.

 

Additional information on this subject may be found on the Stanton-Peele Addiction website at www.peele.net or by researching the work done by Herbert Fingarette, Ph.D..

 

 

Unifying Concept

 

It is suggested, based on experience and observation obtained through years of working with individuals who have a history of use/abuse/dependency, that anyone can become an alcoholic if they continue to drink heavily over an extended period of time.  Individual who are exposed to multiple risk factors such as genetics, predisposition, environmental, social, family and others will (with other things being equal) be affected by alcohol earlier (shorter time frame) than a person who is not exposed to those risk factors.

 

One of the biggest issues with the disease concept is the misapplication of the concept.  Substance abuse counselors and other professionals often yield to labeling an individual an alcoholic when perhaps they belong in the use/abuse category.  Another element that leads to misapplication is a preconceived notion by some personnel in the Criminal Justice System that anyone with two alcohol related charges must be an alcoholic.  Certainly, multiple alcohol related charges suggests a problem and assuredly equates to a tendency to make poor choices and also to make high-risk decisions, but it does not in itself equate to alcoholism.  Unfortunately, we have not maintained a clear division between the phases of use and have had a tendency to treat everyone as if they are a hard core alcoholic.

 

 

In summary, the disease concept should only apply to individuals who are in the later stages of alcoholism and when they have repeatedly demonstrated an inability to control their use.  It follows we should be very slow to label anyone as having a disease of alcoholism unless he/she has truly lost the ability to control this or her usage.  Perhaps this more narrow application to the disease concept would eliminate most of te objectives to the concept.  Very few professionals would debate that an alcoholic in the later stage of phase 3 has lost the ability to control their use.  Normally, by that stage the ability to be concerned with the consequences of use have long been cast aside.  Said in a different manner, they are concerned and controlled by their compulsion to use. 

 

The final point is that the disease concept has been widely accepted in the substance abuse arena, as well as in other disciplines.  Whether an advocate of this concept or in disagreement with it most can see there have been benefits to it’s momentum.  The concept has opened doors to employer funded treatment programs that would not have otherwise been available.  I began my professional career in the 60’s and worked for a very conservative company.  Their position at that time was if anyone used in the workplace it was grounds for termination.  Individuals are now getting help that would otherwise be denied.