Recovery   

Recovery is the official newsletter of the American Council on Alcoholism published quarterly. Featured articles are posted on this page. To receive the full edition of Recovery, become an ACA member.

Alcohol is not the problem with alcoholism
by Chuck Peña, ACA Executive Director

There seem to be quite a few people who want to blame alcohol for the problem of alcoholism. Their view and solution is simple: get rid of (or severely restrict access to) alcohol, and alcoholism will simply go away. To many who hold this view, alcohol in and of itself is an evil and alcoholism is simply a product of this evil. And it is all too easy to then blame many other of society’s problems on alcohol and drinking.

Such a simplistic view, however, ignores the fact that our bodies produce alcohol naturally and that alcohol has known health benefits. For example, studies have shown that moderate alcohol consumption is associated with a 40% reduction in the incidence of heart attacks in persons over 50 and outweighs the risk of death from other causes, including cancer and liver disease.

Alcoholism is a disease. But it is not caused by alcohol. Not everyone who drinks alcohol is or will become an alcoholic (just as not everyone who eats sugar is or will become a diabetic - surely no one would claim that sugar is the cause of diabetes!) 

It is also important to note that one doesn’t always have to drink excessively to be an alcoholic. If all you can think about is how and when you’ll get your next drink - even if it’s only one - and getting that drink rules your life, then it’s likely that you suffer from alcoholism.

The other view that seems to have a lot of support is that alcoholism is the fault of the alcoholic; that such persons are responsible for their own condition because they suffer from weak moral character. In other words, alcoholics choose to be alcoholics because they choose to drink.  Curing alcoholism, then, should simply be a matter of willpower. And while AA and the 12-step program have been tremendously successful in helping alcoholics stay sober, AA doesn’t work for everyone afflicted by alcoholism.

The fact of the matter is that alcoholics don’t choose to be alcoholics - they just are. Unfortunately, it’s almost impossible to know if someone is an alcoholic until they start drinking. It’s kind of like not knowing you’re allergic to something until you are exposed to it. As long as we continue to demonize alcohol and alcoholics, we will not make any meaningful progress towards solving the problem of alcoholism. That is why the Substance Abuse Treatment Parity Act sponsored by U.S. Representative Jim Ramstad (R-MN) and U.S. Senator Paul Wellstone (D-MN) has great significance. This legislation would require private health insurance plans that already cover substance abuse (i.e., alcoholism) treatment to do so the same as they would for other major illnesses. As such, the Parity Act recognizes alcoholism for what it truly is: a disease that responds to treatment.

Clearly, there are employer costs and health insurance premium implications, as well as other issues, that need to be understood and resolved. And while we have to be concerned with the potential costs of providing treatment, we also have to be concerned with costs of not providing treatment - dollar costs, both individually and for society as a whole, as well as the real human costs.

It’s also important to know and understand that there are a wide range of alcoholism treatment programs. Most people are familiar with places such as the Betty Ford Center, Hazelden, and the Caron Foundation - all reputable treatment centers, but also relatively costly. But a lot of people don’t know that there are other lower-cost alternatives that are also successful in treating alcoholism. For example, naltrexone (marketed under the brand name REVIA by DuPont) has been shown to be effective and safe for people with alcohol dependence. Combined with other alcoholism treatment (counseling, support groups), naltrexone is a relatively low-cost option with a remarkable success record.

There is no “magic pill” for alcoholism. Neither AA nor naltrexone will necessarily work for everyone. And graduates have been known to return to the Betty Ford Center. But we need to start taking alcoholism seriously and treating it seriously. And we have to stop blaming alcohol and the alcoholic.

AIDS used to be viewed as a disease that was the result of homosexuality and so-called “lifestyle choices”. Alcoholism is viewed similarly. AIDS “came out of the closet” and is now considered a
“mainstream” disease, usually covered by health insurance. It’s time for alcoholism to come out of the closet. Not to take anything away from the success of AA, but alcoholism is not an anonymous disease. It affects real people with names and faces, families, friends, and jobs. Unlike AIDS, it’s not a question of finding a cure for alcoholism. It’s a question of recognizing that alcoholism is a disease that afflicts people. And knowing that people can be successfully treated. And then making that treatment available to the people who need it.

One of AA’s mottoes is: One day at a time. I think we also have to realize that helping people recover also means treating alcoholics “one person at a time”. As such, there is no “one size fits all” treatment for alcoholism. And while treatment is no guarantee that an alcoholic will recover, without treatment, an alcoholic is destined to live the rest of his or her life out of a bottle.

The Treatment of Alcoholism        
by Percy Menzies, ACA Board Member

Alcoholism by any standard is one of the biggest public health issues in this country. Alcoholism wrecks havoc on society -- ruthlessly and indiscriminately. It affects men and women, the young and the old, the rich and the poor, the educated and the illiterate, the employed and the unemployed. The statistics are staggering. Over 100,000 deaths attributed directly or indirectly to alcohol. Up to 40 percent of medical and surgical patients have alcohol problems and alcohol use consumes about 15 percent of the health care cost. Alcohol is involved in automobile accidents, child and spouse abuse, divorces, homicides, suicides and the list goes on and on. Heavy drinking also increases the risk heart disease, stroke, cancer long before people have to worry about liver and brain damage. The National Institute of Alcoholism and Alcohol Abuse estimates the direct and indirect cost at over $130 billion a year. In addition to this staggering cost, many experts contend that alcohol is often the "gateway" to other drug abuse and high-risk sexual behavior.

If alcoholism and alcohol abuse is such a huge problem why does this public health issue rarely attains national prominence like cigarette smoking, handguns and drugs? The answer lies within the complexity of the social, political and moral history of this disease and the policies of the past to mitigate this problem (we hardly need to be reminded on the disastrous policy of prohibition). Unfortunately, in spite of all the advances made in the in the fields of neurosciences and behavioral sciences, alcoholism continues to be stubbornly viewed as a non-medical problem involving moral and character weaknesses brought upon oneself by irresponsible behavior. Society’s response, has been a harsh condemnation of these "morally weak" people not deserving any sympathy, and punishment being the preferred mode of treatment.

Alcoholism, like other addictions, has three components: A genetic predisposition towards the disease, a neurobiological component, and a socio-environmental component. Although scientists have not been able to identify the specific causative gene, alcoholics produce lower levels of certain neurochemicals involved in mediating the pain/pleasure receptors. When alcohol is ingested a series of complex and varied neurochemicals reactions unfold resulting in the classic effects: the "high"; sedation, lack of "inhibition", impaired of motor functions etc. Familial and social environment conducive to drinking completes the triad.

Nothing about alcoholism is straightforward. The pharmacology of alcohol is complex and so is the definition of the disease. We have heard about the social drinker, binge drinker, problem drinker and finally the classic alcoholic. How do we define each of these groups? Who should seek treatment and when? What should be the goal of therapy? How should success be defined? Should abstinence be the only definition of cure? Different groups hold strong and passionate answers to these questions based on their respective experiences and beliefs, making any kind of consensus nearly impossible. The differences also extend to the treatment modalities which each group zealously sticking to its approach.

How can we make progress towards meaningful and successful treatment? We have to recognize and accept that alcoholism is a chronic medical disease like diabetes or asthma, exacerbated by social conditions. It is very unlikely that, given the complex nature of alcoholism, a single medication to treat the disease will be discovered. In the past fifty years, only two medications have been approved by the FDA to treat alcoholism. Disulfram, better known as Antabuse, was approved in the 1950s and Naltrexone, an opioid antagonist was approved in 1994. Acamprosate has been used in Europe and may be approved in the US in the next year or two. None of the drugs have been used extensively because the preferred treatment for alcoholism continues to be non-medical.

The most common reason cited for not using medications is poor compliance. This is a poor argument, because poor compliance is a problem in treating all chronic diseases. Indeed, compliance levels of 40% are considered a success for treating other diseases, but such percentages not acceptable for drug and alcohol treatment. Why the double standard?

The reluctance, and in some instances the refusal, to use medications is a strong disincentive to the development of newer and more effective drugs. The private drug companies have very little interest in discovering and developing drugs for the treatment of addictions which includes alcoholism, preferring to concentrate on other chronic diseases where the medical approach is an accepted standard. Federal research agencies spend billions of dollars each year in research grants and they too are no closer to discovering a "magic bullet" and even if one is found it is likely to rejected.

If we are serious about tackling one of the most serious public health issues, all concerned will have to accept that alcoholism is a complex chronic medical disease and approach the treatment accordingly, combined with comprehensive programs to help people freed from the disease to establish a new life.

Back to school and binge drinking on campuses
by John A. Carpenter, Ph.D., ACA Board Member

It is fall and students have returned to college.  Because of several widely publicized incidents, one of the growing concerns on college campuses is so-called "binge drinking".

As with so many other words, the term "binge" has, over a period of time, been massaged into meaning something other than its original definition.  This change in meaning has created a potential source of confusion.

Marc Schuckit, editor of the Journal of Studies on Alcohol, has issued a "guide to his editorial staff, and hence to authors, in which he affirms the historical use of the term "binge".  The Schuckit statement, without alteration, is provided below with his permission.  It's original title is "Guidance for authors on the policy of the Journal of Studies on Alcohol regarding the appropriate use of the term "binge".  ACA agrees with Dr. Schuckit's statement on the definition of binge, and further support for his position appears in the September 1998 issue of JSA (p.621) in a letter to the editor from Dr. Sheila B. Blume.

In recent years it has become increasingly apparent that the clinicians and researcher who submit to the Journal of Studies on Alcohol have been using the term "binge" or "binge drinking" to describe quite a different phenomena.  For instance, while some contributors have simply used a set number of drinks per drinking occasion to define a binge (e.g., 5 drinks in a row for men and 4 drinks in a row for women), others feel that the term "binge" should only be used to describe an extended bout of drinking or other substance abuse (often operationalized as at least 2 days) in which the person neglects other activities in order to drink.

In order to avoid the confusion that can potentially arise when different clinical phenomena are being described by the same name, the Journal has now adopted a policy that requires the term "binge" to be used in a specific way in accepted manuscripts.  According to the policy, the term "binge" should only be used to describe an extended period of time (usually two or more days) during which a person repeatedly administers alcohol or another substance to the point of intoxication and gives up his/her usual activities in order to use the substance [emphasis added].  It is the combination of prolonged use and the giving up of usual activities that forms the core of the definition of a "binge".

If authors are using the word "binge" to mean something other than the extended period of intoxication with concomitant neglect of activities/obligations as described above, we ask that they change their terminology.  Alternative terms for the word "binge" include "heavy drinking/heavy use" or "heavy episodic drinking/heavy episodic use".

Authors who retain the term "binge" in their manuscripts must clearly show in the methods sections to their papers that what they are actually measuring is a "binge" as described above (i.e., the several days of extended intoxication with interference in usual obligations and activities.

For more information on the Journal's definition of this or other terms, authors should contact either the editor or the associate editor assigned to handle their manuscripts.

Journal of Studies on Alcohol
Editorial Office
Center of Alcohol Studies
Rutgers, The State University of New Jersey
607 Allison Road
Piscataway, NJ 08854-8001

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This page was last updated on 7-23-2003.