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Alcoholism
Laura Huckaby Advisor: Dr. Albert Sattin University of California, Los Angeles
Abstract This article attempts to provide the reader with a better understanding of the disease of alcoholism. In addition to reviewing the health consequences and social implications of the disease, this review examines the development of the disease theory of alcoholism, the paradigm shift in Western culture’s understanding and treatment of the disease, and highlights the treatment and recovery options available today to the alcoholic seeking help. Section One generally describes the disease of alcoholism, the physical effects of alcohol, the development and progression of alcohol dependence, suggested causes of alcoholism, and health consequences associated with heavy drinking. Section Two discusses the prevalence of alcoholism and its social effects. Section Three describes the development of the disease theory of alcoholism and discusses the change over time in social attitudes and perspectives towards this disease. Section Four describes genetic research currently being conducted in the field of alcoholism study and considers the implications of the findings that this research provides. Section Five discusses different treatment approaches to the disease of alcoholism and various recovery options that are available to an alcoholic seeking help.
Alcoholism A
GENERAL OVERVIEW OF ALCOHOLISM AND VARIOUS IMPLICATIONS Alcoholism
is a common, chronic, often progressive disorder that has serious negative
consequences not only for the affected individual, but also for society.
Alcoholism has serious health consequences and is responsible
annually for a large number of deaths from alcohol-related diseases,
accidents, and homicides. Current
research suggests that nearly 100,000 Americans die annually as a result
of alcohol abuse (Vogin, 2002). Alcohol
abuse is also a significant factor in a number of social problems
including criminal behavior. Estimates indicate alcohol as a factor in
more than half of the country’s traffic accidents, homicides and
suicides (Vogin). People who
suffer from this illness are known as alcoholics.
They cannot control their drinking even when it becomes the
underlying cause of serious harm, including medical disorders, marital
difficulties, job loss, or automobile crashes.
Medical science has yet to identify the exact cause of alcoholism,
but research suggests that it has a genetic basis and that psychological,
social, and environmental factors influence its development (Vogin).
Alcoholism cannot be cured yet, but various treatment options can
help an alcoholic avoid drinking and regain a healthy life.
Alcohol
dependence develops differently in each individual, but is characterized
by certain common symptoms that separate alcoholics from “normal
drinkers,” according to the National Institute on Alcohol Abuse and
Alcoholism (NIAAA), a United States government agency that is part of the
National Institutes of Health. Alcoholics
develop a craving, or a strong urge, to drink despite awareness that
drinking is creating problems in their lives.
As their tolerance increases, they need to drink increasing amounts
of alcohol in order to reach intoxication.
In addition, they suffer from impaired control, an inability to
stop drinking once they have begun. Their
physical dependence upon alcohol is such that when they stop drinking
after a period of heavy alcohol use, they suffer withdrawal symptoms,
which include nausea, sweating, shakiness, anxiety, delirium, grand mal
seizures, and even death. The
World Health Organization (WHO) notes that other behaviors common in
people who are alcohol dependent include their seeking out opportunities
to drink alcoholic beverages (often to the exclusion of other activities)
and rapid return to their former drinking patterns following periods of
abstinence. These features of
drinking patterns and reactions in such individuals are what distinguish
alcoholics from non-alcoholics and have led medical scientists to believe
that alcoholism is a progressive and often fatal disease. Physical
Effects of Alcohol
Ethyl
alcohol, or ethanol, is present in varying amounts in different alcoholic
beverages from beer or wine to distilled liquors such as whiskey, gin, and
rum. When a person consumes
alcohol, it is rapidly absorbed into the bloodstream, travels throughout
the entire body, and affects nearly every tissue.
Moderate and high doses of alcohol impair the functions of the
central nervous system. The
higher the alcohol level is in the blood, the greater the impairment.
As the blood passes through the liver, enzymes break down the
alcohol into harmless byproducts, which are eliminated from the body six
to eight hours later. In
alcoholics, oftentimes the rate of ingestion exceeds the rate of
elimination, thus raising the blood alcohol level and resulting in
intoxication (Hewitt & Gordis, 2001).
While
small amounts of alcohol may relieve tension or fatigue, increase
appetite, or produce an anesthetic effect, larger quantities inhibit or
impair higher thought processes, often producing euphoria, and reducing
inhibition, anxiety, and guilt. As
a person becomes intoxicated, their inhibitions become lessened and, as
drinking progresses, their speech may become loud and slurred.
Impaired judgment may lead to incautious behavior, and physical
reflexes and muscular coordination may become noticeably affected.
Non-alcoholics may experience dysphoria (i.e., unpleasant feelings)
and stop drinking at this point. Alcoholic
individuals, however, may continue to drink in spite of such feelings (Peele,
in D.A. Ward (Ed.), 1990). If
drinking continues, complete loss of physical control follows, ending in
stupor, and possibly death. One
paradox with an alcoholic’s drinking patterns as a response to relieve
anxiety, depression or other emotional distress is that they continue to
show these problems after drinking, often in quite severe form.
Studies have indicated that alcoholics who drink in response to
depression and anxiety actually show greater anxiety and depression after
drinking (Peele, 1990). Here
we see that while drinking to relieve emotional stress may provide acute
relief for the drinker, it may also result in the possible development of
more severe emotional disabilities that perpetuate the individual’s
alcohol dependence. It seems that drinking creates a vicious cycle for these
alcoholics, which reinforces and potentially exacerbates their drinking
and emotional problems (Peele, 1990).
The
Development of Alcohol Dependence Once
begun, alcoholism typically progresses over 10-20 years (Blondelle,
Frierson & Lippmann, 1996). Health
professionals typically describe three general stages to characterize this
progression. Each stage is
defined by a set of symptoms that can be used by the treating physician in
early diagnosis and treatment of alcoholism.
These stages are: (1) social drinking, (2) problem drinking and (3)
alcohol dependence. Most
individuals who drink alcohol never progress beyond Stage One, and are
commonly known as “social drinkers.”
In this stage, individuals drink alcohol primarily as an
accompaniment to social situations and alcohol consumption is not the
central focus of their activities (Hewitt & Gordis, 2001).
A
small percentage of social drinkers may progress to Stage Two.
During this stage, drinking begins to cause problems that may
increase in severity over time with continued heavy drinking, although
they may not show any signs of physical illness.
Signs of Stage Two progression usually include an increase in
alcohol consumption that begins to interfere with other activities.
As problem drinking progresses, the alcoholic's intoxicated
behavior may become disagreeable and antisocial.
Such a person may resort to drinking to relieve the physical
discomfort of withdrawal symptoms. During
this phase, one may take up “morning drinking” in an attempt to offset
uncomfortable symptoms of a “hangover” that may have developed after
heavy drinking the night before (Hewitt & Gordis, 2001).
During
Stage Two, one may or may not be alcohol dependent, as dependence is
subtle, slow and progressive. As
alcohol dependence develops, the person is often unable to acknowledge
that drinking and intoxication have become goals in and of themselves. Drinking may become a coping mechanism for dealing with
problems, and hence, justifiable to the user (although many of such
problems may have been brought about by the heavy alcohol use in the first
place). In addition, these
heavy drinkers may neglect familial responsibilities and decline in their
productivity at work. Many
alcoholics develop a psychological condition known as denial, where they
are unable to acknowledge that alcohol use lies at the root of many of
their problems, which furthers the progression of the disease.
Denial was long thought to be a personality trait shared by all
persons who suffer from alcohol-use disorders.
Despite their claim that they can quit drinking at their own
discretion, in actuality, many problem drinkers find it increasingly
difficult to moderate their alcohol consumption as time progresses,
despite their illusion of control (Hewitt & Gordis, 2001).
These
factors over time lead to stage three, the ultimate stage of alcohol
dependence. In addition to
suffering from many of the problems experienced by individuals in stage
two, an individual who has progressed to stage three can no longer control
his or her drinking. This
impaired control, in which the compulsion to drink is further exacerbated,
is the primary means by which health professionals may diagnose people who
have progressed to alcohol dependence (Hewitt & Gordis, 2001). Causes
The etiology of alcoholism is unknown, but strong evidence exists for a genetic origin (Devor & Cloninger, 1989), although clearly psychological, social, and environmental factors influence its expression and may perpetuate its development as well (Hewitt & Gordis, 2001). Environmental factors and social factors that may affect the development of the disease include personal behavioral skills, peer influences early in life, parental behavior, social and cultural attitudes toward alcohol use, stress, and availability of alcoholic beverages. Once a person has established a drinking pattern, social and environmental factors combined with physical and psychological changes induced by heavy drinking may perpetuate the continued use of alcohol among alcoholic individuals (Hewitt & Gordis, 2001). Health
Consequences
While
some studies have found that moderate use of alcohol has beneficial health
effects, including protection from coronary heart disease, heavy and
prolonged intake of alcohol can seriously disturb body chemistry.
Heavy drinkers lose their appetite and tend to obtain calories from
alcohol rather than from ordinary foods.
While alcohol is rich in calories and can provide substantial
amounts of energy, if it constitutes the primary source of calories in
place of food, the body will lack vitamins, minerals, and other essential
nutrients (Hewitt & Gordis, 2001).
In
addition, prolonged use of large amounts of alcohol may cause serious
liver damage. In the first
stage of liver disease, usually caused by excessive alcohol consumption,
fat accumulates in the liver (also known as “fatty liver”) whereby
complications leading to hepatitis or cirrhosis may develop.
Such heavy drinking may also damage heart muscle as nearly half of
all cases of cardiomyopathy, a potentially fatal heart disease, are caused
by alcohol abuse. Alcoholics
also tend to have higher levels of the hormone epinephrine in the blood
along with deficiencies of the mineral magnesium.
This combination produces severe arrhythmias, or heartbeat
irregularities, a common cause of sudden death in heavy drinkers.
In addition, chronic drinkers typically develop hypertension, a
leading cause of stroke. A
particularly common feature of alcoholism is “blackout” drinking,
where the person cannot consciously recall events or his behavior during
such a blackout state of intoxication.
Some such blackouts may last for a period of several hours or up to
several days (Hewitt & Gordis, 2001).
Clinical
psychologist J.R. Milam (1992) suggests, three phases of progressive brain
impairments that participate in personal and character transformation in
the alcoholic that augment the strength of their emotions and of their
addiction. These phases are
briefly described as follows: (1)
Between drinking episodes, all brain cells are in a toxic, malnourished
state. Their detoxification and stabilization takes several weeks of
total abstinence from alcohol and all other drugs. If heavy drinking continues, (2) billions of brain cells are
damaged, such that repair and healing takes several months of abstinence.
Chronic alcoholics often reach the point where (3) many millions of
brain cells die. The loss is
permanent, but during a period of some four years of total abstinence,
surviving brain cells compensate for those that are lost (Milam).
The
strong physical component of alcohol addiction becomes even more evident
when the alcoholic tries to stop drinking.
In some cases, alcohol withdrawal may lead to delirium tremens
(DTs), which produce confusion, sleeplessness, depression, and terrifying
hallucinations. As the
delirium progresses, a persistent and uncontrollable shaking develop,
beginning with the hands that may extend to the head and body (Hewitt
& Gordis, 2001).
PREVALENCE
OF ALCOHOLISM AND ITS SOCIAL EFFECTS Alcohol
dependence affects a broad cross section of society around the world.
Scientists have not identified a typical alcoholic personality, and they
cannot predict with absolute certainty which drinkers will progress to
alcohol dependence. While
alcohol use disorders develop in a predictable pattern, some studies show
that alcohol problems and their solutions differ significantly according
to the age, sex and ethnicity of the individual (Seale & Muramoto,
1993). The prevalence of the illness varies in different countries.
At a cultural level, addiction to a substance such as alcohol
varies according to historical events and social attitudes (Blum &
Blum, 1969; McClelland et al., 1972; Zinberg & Harding, 1979).
Cultural variations in alcoholism rates are related to the way in
which drinking is perceived of in different cultural settings.
In some cultures, problem drinking is practically unknown.
In rural Mediterranean societies, for example, drinking does not
lead to the destructive and antisocial behavior (such as fighting,
reckless driving, blackout, sexual aggression) that seems to define
alcoholism in American culture (Blum & Blum).
Moderate drinking is notable in ethnic and cultural groups such as
the Chinese (Barnett, 1955), the Greeks (Blum & Blum), the Jews (Glassner
& Berg, 1980), and the Italians (Lolli, Serianni, Golder &
Luzzato-Fegiz, 1958).
The
WHO estimates that nearly 62 million people worldwide suffer from alcohol
dependence, and studies estimate
there are more than 15 million alcoholics in America who require treatment
(Hackler, 1983). In August
1982, a Gallup poll (Alcohol Abuse, 1982) found that one-third of American
families has had a problem with alcohol, a figure that had doubled over
the previous 51.5 years (Peele, 1984).
Although its exact prevalence has not been established,
in the United States, alcoholism affects approximately 5-10% of the
general population, 10-20% of ambulatory patients, and 20-40% of patients
in hospital settings (Maly, 1993; Moore et al., 1989).
In the United States, research shows that nearly 15 million people
experience problems related to their use of alcohol.
Of these, actual alcohol dependence affects about 8.1 million men
and women – almost 3 percent of the population.
Other research studies indicate that men are three times more
likely than women to become alcoholics, while people aged 65 and older
have the lowest rates of alcohol dependence (Hewitt & Gordis, 2001). In
the United States, people who consume alcohol at an early age are at a
higher risk for developing alcohol dependence later in life.
Estimates indicate that 40 percent of people who begin to drink
before age 15 will become alcohol dependent at some point in their lives,
and that such individuals are four times more likely to become alcohol
dependent than those who delay drinking until age 21 (Hewitt & Gordis).
Today
experts characterize alcohol-use disorders as forms of illness that are so
widespread that they constitute a major public health problem.
According to the WHO, alcohol dependence and other alcohol-use
disorders undermine global health, and account for 3.5 percent of the
total cases of disease worldwide. In
the United States alone, the NIAAA estimates that alcoholism causes losses
of more than $185 billion a year in lost productivity, illness, and
premature death. In addition,
women who drink excessive amounts of alcohol while pregnant run a high
risk of having a baby born with fetal alcohol syndrome (FAS), the leading
known cause of birth defects, which results in a combination of mental and
physical defects that may have dramatic or subtle expression in the
individual (Hewitt & Gordis, 2001).
There are costly links between addiction/alcoholism and our criminal justice system as well. The vast majority of all prison inmates are incarcerated for crimes secondary to drug and alcohol addiction. The annual cost to society of tending to the multiple effects of alcoholism and addiction, including rampant “psychiatric” problems, family neglect and abuse, poverty, violence, and other crimes, illness, and organ and system failures, accidental injuries and deaths, is in the hundreds of billions of dollars (Milam, 1992). Clearly, the disease of alcoholism is not only a problem for the individual, but a problem with enormous consequences for society as well. THE
DEVELOPMENT OF DISEASE THEORY AND CHANGE IN SOCIAL ATTITUDES Complications
from heavy alcohol consumption have been recorded throughout history
around the world. Physicians
have played a role in the treatment of alcoholism since the age of
Antiquity. A large amount of
treatment by physicians has been well meaning, but misinformed and
characterizes the complexity of understanding the disease of alcoholism.
With the exception of a few physicians ahead of their time, most of
society has viewed people who drink excessively as irresponsible, immoral,
and of weak character. The
commonplace view for centuries (and still among many of the uninformed
today) held that taking or rejecting a drink was a matter of personal
decision, thus all excessive drinking was considered a voluntary act and
the individual, therefore, should be held responsible for his or her
behavior. Thus, punishment
and incarceration of drunkards was considered necessary to protect the
community, an issue that we are still grappling with today. It is only within the last two centuries that research
findings have determined that alcoholism is, indeed, a disease with real,
neurophysiological components; these effects may render the alcoholic
incapable of exercising discretion or control regarding alcohol or drug
ingestion.
One
of the earliest versions of the disease theory of alcoholism originated
with physician Benjamin Rush, who published An Inquiry into the Effects
of Ardent Spirits on the Human Mind and Body in 1784.
Therein he chronicles the progression of alcoholism with the same
level of understanding that we maintain today:
“Drunkenness
is the result of a loss of willpower.
Initially drinking is purely a matter of choice.
It becomes a habit, and then a necessity.”
He also identified alcoholism as a primary disease and not a
symptom of some other malady. Rush
considered cold baths and total abstinence necessary treatments to effect
a cure for alcoholism, but found that such treatment methods yielded
disappointing results. Since it proved almost impossible for Rush to impose his
radical therapy in everyday surroundings, he proposed the construction of
detoxification establishments, and asylums to provide sober housing for
chronic abusers until cured (Levine, 1978).
Perhaps
the greatest advances in our understanding of alcoholism as a disease came
about in the 19th and 20th Centuries.
At the turn of the 19th Century, English physician, Dr.
Thomas Trotter was one of the first medical professionals to relate
alcoholism to the increasing numbers of patients in the emerging,
specialized mental hospitals, and among the first medical professionals to
articulate a conception of alcoholism similar to the disease theory we
have today. He wrote,
“drunkenness is an illness of unknown cause which upsets the healthy
equilibrium of the body.” His
deduction quickly caught on. In
1841, the first English life assurance company offered lower premiums to
those who abstain from alcohol, thus we see the emergence of a growing
awareness of the link between longevity and alcohol consumption.
Doctors in English sanitariums were also quick to draw such links.
In 1850, Forbes Wilson mentioned that 4 out of 5 inmates were in
the asylum through overindulgence in distilled liquor (Sournia, 2000).
Throughout
other parts of Western Europe during this century, respected physicians
were gradually becoming convinced that alcoholism was indeed an illness.
The reputable Bruhl-Cramer, a German physician, also considered
heavy drinking to be a disease and used the psychiatric term
‘dipsomania’ to describe the disorder.
He wrote: “Those affected have an abnormal, all-consuming and
elemental need for alcohol.” He
believed that the destruction of their moral judgment was a consequence
and not the cause of their sickness, and that will power alone could
provide a cure. Austrian Dr.
Lippich produced the first statistical evidence connecting negative health
consequences as the effects of heavy alcohol consumption.
He followed up two hundred drinkers for four years and established
that their lives were shorter and that they had fewer children who were
more prone to illness than those patients who did not drink (Sournia,
2000).
Concurrently,
in America, people were also increasingly coming to view alcohol as
“demon rum” and regarded uncontrolled drunkenness as an inevitable
consequence of frequent, heavy drinking.
The solution they proposed was national abstinence.
Temperance
societies in the 19th and 20th centuries pushed for laws ranging from
arrest and jail sentences for public drunkenness to prohibition of the
manufacture, distribution, and consumption of alcoholic beverages.
In 1920, at a point when
drinking patterns had moderated substantially, national prohibition was
enacted. When it was repealed
in 1933, the goal of universal abstinence died with it.
The disease theory became transmuted at this time to the view that
chronic drunkenness was not an inherent property of alcohol, but was
rather a characteristic of a small group of people with an inbred
susceptibility to alcoholism (Beauchamp, 1980).
Medical
Doctor Thomas L. Haynes (1988) suggests that the most notable treatments
for alcoholism developed in the 19th and 20th
Centuries beginning with Sigmund Freud.
Although Freudian psychoanalytic theories about why people drink
uncontrollably were insightful, his therapies seemed unable to keep people
sober for long. Against the
setting of temperance movements gaining swift momentum, he and other
physicians were just becoming aware of chemical dependency as a disease
and were gradually discovering more about various physical and mental
complications related to heavy drinking (Haynes).
Dr.
Carl Jung, one of Freud’s students, is said to be instrumental in our
current understanding of alcohol dependence as a disease.
He concluded, after working with many alcoholics, that alcoholism
was a hopeless condition from which one could not recover without some
type of spiritual conversion experience.
Dr. William Silkworth coined the description of alcoholism that was
adopted by Alcoholics Anonymous in 1935 as “an obsession of the mind
that condemns one to drink and an allergy of the body that condemns one to
die.” He estimated that his success rate with alcoholics was
approximately 2% before the recovery of Bill Wilson and the founding of
Alcoholics Anonymous (Haynes, 1988).
Dr.
E.M. Jellinek is recognized as the premier researcher in the field of
alcoholism and was strongly influential of the disease model of alcoholism
that we maintain today. Dr.
Haynes maintains that Jellinek’s writings and descriptions “did more
for the acceptance of the disease concept of alcoholism and of A.A. as a
respectable therapeutic modality than any other medical force of the
time” (Haynes, 1988).
Up
until these advances mid-20th century, social attitudes about alcoholism
were ambivalent, as there was no strong correlative evidence that
alcoholic drinking and behaviors (and all of the consequences entailed)
were not just a matter of personal choice.
As noted earlier, the typical picture of the alcoholic was of
someone without steady employment, unable to sustain family relationships
and most likely in desperate financial straits, because of poor choices
and hedonistic indulgences in alcohol.
This stereotype was slowly dispelled as new medical findings
emerged and as highly respected people publicly admitted their alcohol
dependence and shared their successful (although often more apparent than
real) recovery stories. Particularly
critical in changing the way Americans view alcohol-use disorders were New
York broker William Griffith Wilson (more familiarly known as Bill W.) and
Ohio physician Robert Holbrook Smith (Dr. Bob).
In 1935, these two recovered alcoholics developed a program to
promote their successful philosophy for recovering from alcohol
dependence. The program,
which became known as Alcoholics Anonymous, has spread around the world,
helping millions of members to avoid alcohol use and rebuild their lives
(Haynes, 1988).
The
American Medial Association is widely believed to have first accepted
alcoholism as a disease in 1956, although the original resolution was not
officially ratified until ten years later.
In February of 1987, Dr. Smith introduced a motion that the AMA
include all mood-altering drugs in the disease of chemical dependence, and
the American Medical Society on Alcoholism and Other Drug Dependencies
introduced the same motion in June of 1987.
The AMA then passed a resolution that all drug addictions are one
disease (Haynes, 1988).
During
the early 1980s, the National Institute on Alcohol Abuse and Alcoholism
and the National Institute on Drug Abuse shifted their funding emphasis to
support research in the biology of addiction.
In 1986, Harvard, Dartmouth, and Johns Hopkins broke with
academic tradition and announced they were going to inaugurate courses in
alcoholism in their medical schools (Milam,
1992). Other medical associations involved in expanding
knowledge about alcoholism and drug dependency include: the International
Doctors in Alcoholics Anonymous, the American Medical Society on
Alcoholism, the California Society for the Treatment of Alcoholism and
Other Drug Dependencies, the American Academy of Addictionology, the
Association for Medical Education and Research, Substance Abuse (AMERSA),
the National Institute on Alcoholism and Alcohol Abuse (NIAA) and the
National Institute of Drug Abuse (NIDA).
Today, the American Society of Addiction Medicine (ASAM) is the
national organization that was given the task of unifying the physicians
from around the country whose focus includes all forms of chemical
dependence. Since its
coagulation, ASAM has taken on the task of developing and administering a
certification examination for physicians in the treatment of addictive
diseases. With 1275 certified
physicians, the latter half of this century has seen the emergence of the
new medical specialty of addiction medicine, although residency-training
programs in addiction medicine have yet to be fully instantiated (Haynes,
1988).
GENETIC
RESEARCH The
biological or “disease theory” model as it is articulated today
recognizes that alcoholism is a primary addictive response to alcohol in a
biologically susceptible drinker, regardless of character personality.
Both animal and human studies have shown repeatedly that alcohol
addiction is hereditary and indicate a number of in-born, pre-drinking
biological differences in alcoholics – such as initial and progressive
differences in their biological responses to alcohol, including alcohol
metabolism, and in the effect of alcohol on performance, mood, and mental
abilities (Milam, 1992). Despite
the opposing belief that alcoholism is not a disease, but rather a
conditioned response to psychosocial stress, the majority of the medical
community today accepts the disease theory and focuses their research
efforts on this model and its implications (Hewitt & Gordis, 2001).
Most
of the support for the popularity of the disease model of alcoholism is
based on genetic research that gives scientists positive indicators that
alcoholism is inherited. Studies
in the 1970’s have shown that alcoholism runs in families—alcoholics
are six times more likely than non-alcoholics to have blood relatives who
are alcohol dependent (Goodwin et al., 1974; Cotton, 1979).
Researchers have long sought to determine whether these familial
patterns result from genetics, from a common home environment (which often
includes alcoholic parents), or both.
In their research, scientists investigate the possible genetic
components of alcoholism by studying populations and families as well as
genetic, biochemical and neurobehavioral characteristics (Cloninger &
Begleiter, 1990).
Proponents
of the biological model or “disease” approach to understanding
alcoholism, support genetic research because the discovery of a specific
genetic effect on the development of alcoholism would be beneficial for
three general reasons: 1.)
It could lead to the identification of some people at risk who
could act to avoid developing alcohol related problems (Goodwin, 1989.
Goodwin, in WM Cox (Ed.), 1990). 2.)
Genetic research may help us
to understand the role of environmental factors that are critical in the
development of alcoholism (Cloninger et al., 1981). 3.)
Genetic research may lead to
better treatments, based on new understandings of the physiological
mechanisms of alcoholism (Crabbe & Harris, 1991).
Three general research methods that scientists employ to learn more about the genetics of alcoholism include genetic marker studies, animal studies and twin/adoption studies. Each will be briefly described herein. Genetic
Marker Studies Different
models for the way in which alcoholism runs in families have been
suggested by a limited number of family studies.
Interpretation of these studies has been complicated by the
likelihood that alcoholism is a heterogeneous condition (i.e., a
collection of different conditions that look similar, but whose mechanisms
and modes of inheritance may differ).
Additional studies are needed to sort out the mechanisms of
transmission (Hill, 1992; Gilligan, Reich & Cloninger, 1987).
To search the human genome for specific genes related to alcoholism, researchers may employ different methods of experimentation. These methods include DNA scanning, the candidate gene approach, and genetic marker studies. In DNA scanning, scientists scan the human genome which involves characterizing the entire length of DNA and finding genes that relate to alcoholism without proposing candidate genes (genes that are hypothesized to be connected with the expression of alcoholism). Genetic marker studies and the candidate gene approach test particular genes that are hypothesized to be related to the physiology of alcoholism. If certain genes are related to alcoholism, then genes lying close to them on the same chromosome – and the traits they determine – may be inherited at the same time that the risk of alcoholism is inherited. This phenomenon is called linkage. Assortments of genes hypothesized to be linked to alcoholism have been examined, but none have passed a rigorous test for linkage (Cook & Gurling in Cloninger & Begleiter, 1990; Goldman in Galanter, 1988). Animal Studies
Another research method used in
studying the genetics of alcoholism includes using animal models.
These models have several advantages over human subjects insofar as
researchers can study larger numbers and more generations of subjects, can
arrange informative matings, can better manipulate the environment, and
can make measurements that would not be possible on humans.
Using the powerful genetic methods available through animal
studies, investigators are beginning to map genes that may be responsible
for some of the animals' alcohol-related behaviors (Nadeau, 1990).
The main limitation of using animal research methods to study alcoholism
is that there is no animal model of alcoholism that encompasses the whole
spectrum of alcoholic behaviors in humans.
Researchers have, nevertheless, studied alcohol-related behaviors
in animals that are believed to resemble aspects of human alcoholism, and
have succeeded in breeding lines of rodents with high or low measures of
most of these traits. This success demonstrates that such traits are substantially
genetically determined in rodents and could be genetically determined in
humans as well (Phillips & Crabbe, in Crabbe & Harris, 1991). Twin
Studies and Adoption Studies Two
major methods of investigating the inheritance of alcoholism involving
humans are studies of twins and adoptees.
Further support for the idea of genetic transmission of alcoholism
has been confirmed by such studies. Research
findings indicate greater concordance rates in alcoholism for identical
versus fraternal twins, and on the greater influence of the biologic
versus the adoptive family in the development of alcoholism among adoptees.
Pickens and co-workers (1991) studied 169 same-sex pairs of twins,
both males and females, at least one of which sought treatment for
alcoholism. They found a
greater concordance of alcohol dependence in identical twins than in
fraternal twins. In studying
902 male Finnish twins, Partanen and co-workers (1966) found that less
severe drinking patterns were less heritable and more severe drinking
patterns were more heritable.
Goodwin
et al. (1973) found that male adoptees with alcoholic parents were four
times more likely to become alcoholics than those without, although there
was no alcohol abuse in the sets of adoptive parents.
Cloninger and his fellow
researchers subsequently performed a series of much larger studies of
adoptees, which also revealed these trends (Cloninger, Bohman &
Sigvardsson, 1981). Studies
conducted by Schuckit et al. (1972) discovered that half-siblings with at
least one alcoholic-biologic parent were far more likely to develop
alcoholism than those without such a parent, no matter by whom they were
raised.
There
is still some debate within the medical community as to what sort of a
role genetic influences have on a person’s susceptibility to inheriting
and expressing traits of alcoholism.
Genes might play a direct role in the development of alcoholism, as
in affecting the body’s metabolism of alcohol; or they might play a less
direct role, such as influencing a person’s temperament or personality
in such a way that the person becomes vulnerable to alcoholism.
The extent of the influence of genetic factors on the development
of alcoholism is still pending further research, but enough studies seem
to have confirmed that there is a genetic link (Hewitt & Gordis,
2001). PREVENTION,
TREATMENT APPROACHES AND RECOVERY Physicians
can play an important role in treatment by educating patients to prevent
the addictive cycle from starting, by being alert to risk factors,
recognizing signs of alcoholism (particularly during its early stages),
and initiating interventions designed to halt progression of this disease.
The physician’s prominent role in preventative treatment for
alcohol dependency can be roughly divided into three categories: primary,
secondary and tertiary prevention. Each
phase of treatment entails an assessment of different factors, which will
be briefly discussed herein.
Primary
Prevention The
goal of primary prevention is to identify those patients at risk for
alcohol abuse and to educate them in order to stop the disease before it
starts. The intensity of the
steps taken during primary prevention will depend on whether the patient
is considered a high-risk candidate for alcoholism or a low-risk
candidate. Low-risk candidates who drink at all should be told to drink
only in moderation (meaning no more than two standard-sized drinks per
day) and never at work, before driving or when operating machinery.
High-risk candidates (e.g., those with a strong family history of
alcohol problems) are recommended to consider total abstinence as the best
way to prevent alcoholism. They should also be encouraged to learn more about alcoholism
by attending AA meetings as an observer and by reading AA literature or
similar publications. Similarly,
total abstinence is recommended for adolescents, persons with
alcohol-sensitive conditions, recovering alcoholics, and patients with
past alcohol-related problems (Blondell, Frierson & Lippman, 1996).
Secondary
Prevention Secondary
prevention aims to identify patients with early signs of the disease and
halt its further progression. In
its early stages, alcoholism has few specific signs or symptoms, but
clinicians can prevent its further progression if they recognize them and
intervene. Combinations of
certain conditions may be suggestive of alcoholism.
They include the following four general categories: (1) Recognition
by the patient of excessive consumption of alcohol or the need to
“control” their drinking. (2)
Negative effects on others when or because of drinking (or lack of
drinking). (3) Adverse
personal consequences when or because of drinking (or lack of drinking).
(4) Evidence of tolerance, actual chemical dependence or the need
to manage a withdrawal syndrome. More
specific symptoms may include anxiety, depressed mood, drunk driving
arrests, blackouts, dysphoria, dyspepsia, gastritis, elevated liver enzyme
levels, hypertension, vague abdominal complaints, sleep disturbance,
frequent job changes, marital/family problems, and myriad of other
possible physical and psychological manifestations of this disease.
During secondary prevention, the patient must be confronted, as
decisive action is necessary to overcome any onset of denial, the main
defense mechanism against recognition of the problem and acceptance of
treatment (Blondell, Frierson & Lippman, 1996).
A
treatment strategy is also recommended at this phase of prevention (i.e.,
attendance at Alcoholics Anonymous meetings, attempts at controlled
drinking, etc.). If these
measures show no improvement, further steps such as formal intervention,
counseling, or commitment to an inpatient treatment center may be
necessary (Blondell, Frierson & Lippman, 1996).
Tertiary
Prevention The
goal of tertiary prevention is to treat and rehabilitate patients with
chronic alcoholism to prevent a potentially fatal disease progression. Typically, 10 to 20 years of active drinking are needed to
reach this stage, although in some individuals alcoholism proceeds more
rapidly. Patients often
require hospitalization for an acute medical problem, related or unrelated
to alcohol. Tertiary
prevention includes the following measures: (1) The assessment of risk for
a withdrawal syndrome by obtaining information about the quantity and
frequency of alcohol consumption. (2)
Treating withdrawal syndrome and detoxification, as well as other possible
complications (e.g., malnutrition), pharmacologically as needed.
(3) Planning for rehabilitation after the patient stabilizes (Blondell,
Frierson & Lippman, 1996).
Treatment
Approaches A
positive, public health approach that integrates medical, psychological,
and social therapies can lead to improved outcomes for patients who are
addicted to alcohol and/or other substances.
There have been several recent
changes in the areas of treatment and recovery for alcoholism.
Private treatment for alcoholism and drug abuse greatly expanded
beginning in the late 1970’s. Federal
financing for the treatment shifted to service contracts and third-party
payments, and as a result, the primary locus for treatment changed from
public institutions to private facilities and contractors (Peele, 1984).
Between 1978 and 1984, the number of beds in private alcoholism
treatment centers more than quadrupled.
In the 80’s hospitalization of adolescents in private psychiatric
facilities mainly for drug and alcohol abuse, jumped 450% (Peele, 1991). Some
research indicates that treatment does indeed have a dramatic impact in
positively changing an individual’s behavior.
A recently completed 5-year study by the Center for Substance Abuse
Treatment (CSAT) which involved thousands of clients in hundreds of
alcohol and drug treatment centers, indicated that treatment dramatically
reduces criminal behavior, reduces arrests by nearly 60%, and cut illicit,
violent and risky sexual behaviors in half (Lucas, 1999).
There
are, however, skeptics as to whether or not treatment centers are
efficacious in and of their own right.
One prominent skeptic is
Enoch Gordis, M.D., the director of the National Institute on Alcohol
Abuse and Alcoholism (NIAA). After
studying a large hospital program that he himself administered, Gordis
concluded, “contemporary alcoholism treatment is, at best, of limited
effectiveness” (Peele, 1991). George
Vaillant, a supporter of the disease theory of alcoholism, recently
completed a research study of methods of treating alcoholism that included
hospital detoxification, compulsory AA attendance, and a counseling
program. Contrary to what one
might expect, his findings indicated that his patients, who participated
in the treatment programs fared no better after 8 years than alcoholics
who did not participate in such recovery programs.
He reflected that perhaps the best that can be said concerning the
current methods of treatment is, at least, that they do not interfere with
the natural recovery process (Vaillant, 1983).
Another
important factor to acknowledge when considering whether or not people
succeed in overcoming an addiction may not only be determined by the type
of treatment they receive. Based
on his research findings, Vaillant remarked, “the most important single
prognostic variable associated with remission among alcoholics who attend
alcohol clinics is having something to lose if they continue to abuse
alcohol.” Among
Vaillant’s own patients at an urban municipal hospital, many had little
to lose, as 95% relapsed at some point after treatment (Peele, 1991).
A study of an inner-city hospital alcoholism ward by John Helzer
and his colleagues found that 93% of the patients were either dead or
still abusing alcohol 5-7 years after treatment.
It has been suggested that private treatment centers ordinarily
show better outcomes, partly because their clients are more likely to have
families, jobs, and incomes (Peele, 1991).
Treatment
Methods Treatment
methods of alcohol dependency vary depending upon an individual's medical
and personal needs. Some
heavy drinkers who recognize their problem appear to recover on their own.
Others recover through participation in the programs of Alcoholics
Anonymous or other self-help groups.
Some alcoholics require long-term individual or group therapy,
which may include hospitalization (Hewitt & Gordis, 2001).
Numerous
studies indicate that simple, brief interventions can be effective in
changing drinking behavior in those who are not severely alcohol
dependent. In brief
interventions, a problem drinker meets with a health professional for one
to four sessions, with each session lasting from a few minutes to an hour.
During these meetings, the health professional makes the person
aware that his or her current drinking patterns or medical problems are
related to alcohol abuse and could progress to alcohol dependence (Hewitt
& Gordis, 2001).
For
some alcoholics, treatment begins with detoxification, which normally
requires less than a week, during which time patients usually stay in a
specialized residential treatment facility or a separate unit within a
general or psychiatric hospital. These
facilities also offer extended treatment programs to help alcoholics in
their recovery (Hewitt & Gordis, 2001).
Treatment
may also involve individual counseling and group therapy to help a person
who is alcohol dependent adapt to a new way of life that is not driven by
alcohol. Throughout the
United States, public outpatient and inpatient clinics offer a variety of
treatments for alcoholics. Many
public mental hospitals and Veterans Administration hospitals, as well as
private clinics and hospitals, treat alcohol dependence (Hewitt &
Gordis, 2001).
Physicians
may prescribe medications to help prevent alcoholics from returning to
drinking once they have stopped. The
drug disulfiram (sold under the trade name Antabuse), interferes
with the way the body processes alcohol, producing extremely unpleasant
reactions when alcohol is ingested, but shows no noticeable effect unless
a person drinks alcohol (Fuller et al., 1986).
Naltrexone (ReVia) is a narcotic approved for use in alcohol
treatment in 1995. Although
scientists are not certain how this medication works in the brain, it
reduces an alcoholic's craving for alcohol, most likely by blocking the
positive effects the individual gets from drinking alcohol.
Indications are that Naltrexone is most effective when it is used
in combination with counseling programs such as individual and social
therapies (Voipicelli et al., 1992; O’Malley, 1995).
Recovery Since there is no cure for alcoholism, even sober alcoholics are said to be “in recovery,” a lifelong process. Total abstinence from alcohol and other sedatives (including prescription drugs) is said to be the cornerstone of managing recovery. Relapses are a common part of the recovery process as well and should be expected and planned for. Discussion of temptations, means of coping, support systems and a non-drinking, healthful lifestyle (i.e., diet and exercise) is often helpful. Follow-up aftercare programs may assist in helping a recovering alcoholic maintain sobriety. Such programs may include group therapy, individual psychotherapy, employer-mandated monitoring programs, and self-help groups such as Alcoholics Anonymous (Blondell, Frierson & Lippmann, 1996).
Alcoholics
Anonymous Until
the mid-1930s, alcohol-dependent individuals who could not afford a
private sanitarium or psychiatrist could find help only at state
hospitals, in jails, or through street ministries. The formation of
Alcoholics Anonymous (A.A.) in 1935 marked the first non-medical approach
that made sustained recovery from alcohol dependence possible for many
individuals. Today nearly 2
million people worldwide claim membership in A.A.
Its rapid growth and wide
acceptance were due to the melding of its strong ethnoreligious support
with its backing as medical dogma. In
no other Western country have A.A. and the recovering alcoholic attained
such a central role in the formulation of alcoholism policy and alcoholism
treatment as in the United States (Peele, 1984).
The
A.A. program promotes psychological principles that help people live a
healthy, stress-free lifestyle where the individual learns that he or she
suffers from a disease and gains support and encouragement to stay sober
through group interaction and help from his or her own conception of a
“higher power.” The
organization functions through local groups that have no constitutions,
officers, or dues. Anyone who
has a drinking problem may become a member, provided he or she is willing
to abstain from alcohol and make an honest attempt to live by the
principles outlined by the organization (Alcoholics Anonymous, 1935). Other
Recovery Approaches While
Alcoholics Anonymous is widely recognized as an effective source of
support, not everyone responds to the group's spiritual bent.
Other recovery approaches include Rational Recovery, an
organization that promotes lifelong abstinence from alcohol and teaches
people how to recognize psychological “triggers” to combat the urge to
drink. Another non-A.A. organization is the Secular Organizations
for Sobriety/Save Our Selves (SOS), which endorses a program that
separates recovery from spirituality whereby individuals are encouraged to
rely on themselves and others in the group – not a spiritual power –
to gain sobriety (Hewitt & Gordis, 2001).
Concluding
Remarks The
disease of alcoholism is vast and all encompassing, and affects many, if
not all areas of the alcoholic’s life.
The effect of this disease on social institutions and its impact
upon the medical field has been magnanimous.
Research efforts regarding the biological components of this
disease have just begun, and are far from being exhausted.
While there is much left to be resolved regarding our understanding
of the nature of this disease and its various implications on both the
individual and societal level as well, this paper is expected to have been
successful in at least establishing the following summary points with
respect to our current understanding of alcoholism: 1.)
That
alcoholism is a progressive, often fatal disease having genetic origin,
influenced by social, psychological and environmental factors, and should
be distinguished from heavy drinking. 2.)
The
disease of alcoholism has a drastic negative impact on both the individual
and on society. 3.)
Genetic
research is discovering more and more evidence in support of the disease
theory of alcoholism, although many advancements have yet to be made. 4.)
Physicians
can take active steps in preventative treatment of alcoholism. 5.)
Treatment
approaches may or may not be effective, but do not seem to be interfering
with the recovery process. 6.)
There
are a variety of treatment approaches and recovery options available to
the individual seeking help. Clearly,
we are still lacking scientific answers to many key questions about
alcoholism; including: why alcoholism is transmitted, how it affects
complex neurobehavioral systems, whether or not such genetic transmission
can be prevented, and whether or not we can design medication to stop the
addictive cycle before it becomes destructive, if one is found to have
such a genetic susceptibility. Only
time and scientific efforts will provide such answers.
In the meantime, the paradigmatic shift from understanding
alcoholism as a psychological response to our current understanding of
alcoholism as a biological response has greatly affected treatment
programs, research methods and social attitudes regarding our perception
of alcoholism and of alcoholic individuals.
We can only hope that as scientific research methods are refined
and as we learn more about the human genome, that we will be able to
discover more about this genetic susceptibility that is expressed in
multitude of aspects that differentiate the alcoholic from the
non-alcoholic. Such findings
would not only provide us with a better understanding of the disease of
alcoholism and the alcoholic, but a better understanding of ourselves as
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