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Is alcoholism a disease?

Managing alcoholism as a disease

By Thomas R. Hobbs, Ph.D., M.D., Physician's News Digest

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 Due to public outcry, prohibition was repealed in 1933.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.

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.

  Physician's News Digest Feb 1998

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NOTE by AddictionInfo editor: Classifying alcohol and drug problems as a medical "disease" is being disputed by many experts - see these articles, among many others on this site:

Why hasn't alcohol rehab worked for Lindsay Lohan and 93% of the problem drinkers in the US?

Addiction as a Disease: Birth of a Concept

Also see videos by Stanton Peele - including Alcoholism Is Not a Disease