Disease theory of alcoholism

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The Disease theory of alcoholism is a theory based on the concept that alcoholism is a disease process. The disease theory is generally accepted by the medical community, which argues that genetic, neurological and behavioral studies distinguish those with alcohol dependence from problem drinkers.^[1]

Contents 1 Theory 2 History 3 Legal considerations 4 Current acceptance 4.1 Opponents 5 Miscellanea 6 See also 7 References 8 External links

[edit] Theory

The term "disease" refers to a disorder of structure or function. The term can refer to a physical disorder, such as diabetes, or to a mental disorder, such as schizophrenia. Diseases can be short-lived, such as the common cold, or life-long, as in sickle cell anemia.

It is not clear whether the proponents of the "disease" theory of alcoholism were basing their conclusions on the notion of a physical disorder, or on the not uncommon notion of "disease" being a discomfort or anxiety, i.e. dis-ease. Both interpretations, still noted in modern dictionaries, were in common use at the time of the early studies on alcoholism.

In the case of alcoholism, research has demonstrated both genetic and environmental contributors to the development of a condition that carries significant physical morbidity. Such factors as a typical course and well-described epidemiology (the incidence and prevalence of the condition) also contribute to the establishment of a disease entity.

In a review in 2001, McLellan et al. compared the diagnoses, heritability, etiology (genetic and environmental factors), pathophysiology, and response to treatments (adherence and relapse) of drug dependence vs type 2 diabetes mellitus, hypertension, and asthma. They found that genetic heritability, personal choice, and environmental factors are comparably involved in the etiology and course of all of these disorders, providing evidence that drug (including alcohol) dependence is a chronic medical illness.^[2]

[edit] History

The Scottish physician Thomas Trotter (1760-1832), was the first to characterize excessive drinking as a disease, or medical condition.^[3]

The American physician Benjamin Rush (1745-1813), a signer of the United States Declaration of Independence -- who understood drunkenness to be what we would now call a "loss of control" -- was, perhaps, the first to use the term "addiction" in this sort of meaning.^[4]

My observations authorize me to say, that persons who have been addicted to them, should abstain from them suddenly and entirely. 'Taste not, handle not, touch not' should be inscribed upon every vessel that contains spirits in the house of a man, who wishes to be cured of habits of intemperance.^[5]

Rush argued that "habitual drunkenness should be regarded not as a bad habit but as a disease" -- essentially a disturbed, distressed, and uncomfortably destabilized condition (i.e., dys-ease) rather than an actual illness -- describing it as "a palsy of the will".^[6] They are briefly described in both by Levine^[7] and by Valverde^[8]

Rush’s contribution to a new model of habitual drunkenness was fourfold: First, he identified the causal agent—spiritous liquors; second, he clearly described the drunkard’s condition as a loss of control over drinking behavior—as compulsive activity; third, he declared the condition to be a disease; and fourth, he prescribed total abstinence as the only way to cure the drunkard.

The modern theory of alcoholism as a disease was put forth by E. Morton Jellinek.^[9] The American Medical Association declared that alcoholism was an illness in 1956.^[10]

The first major empirical challenge to the disease model came in 1962 with the publication of Dr. D. L. Davies' follow-up of seven alcohol abusers which found that some of them were able to return to "controlled drinking".^[11] Other research also reported that some alcoholics could drink in moderation.^{[12][13][14][15][16][17][18][19][20]} However, a subsequent follow-up of the 7 cases studied by Davies suggested that he "had been substantially mislead, and the paradox exists that a widely influential paper which did much to stimulate new thinking was based on faulty data."^[21]

In 1978, what is commonly referred to as the RAND report published extensive evidence that alcoholics could learn to consume alcohol in moderation.^[22] The publication of the book caused strong controversy in its findings that people suffering a disease which reputedly leads to uncontrollable drinking could manage to drink controllably. Subsequent studies also found that many alcoholics can drink in moderation.^[23] Indeed, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), about one of every six (17.7%) of alcohol dependent adults in the U.S. whose dependence began over one year previously had become low-risk drinkers.^[24]

In 1980, the American Medical Association's Council on Scientific Affairs (now the Council on Science and Public Health) noted that "alcoholism is in and of itself a disabling and handicapping condition". Between 1980 and 1991, medical organizations, including the AMA, worked together to establish policies regarding their positions on the disease theory. These policies were developed in 1987 in part due to the fact that third-party reimbursement for treatment was difficult or impossible unless alcoholism were categorized as a disease. The policies of the AMA, formed through consensus of the federation of state and specialty medical societies within their House of Delegates, state, in part:

"The AMA endorses the proposition that drug dependencies, including alcoholism, are diseases and that their treatment is a legitimate part of medical practice."

In 1991, The AMA further endorsed the dual classification of alcoholism by the International Classification of Diseases under both psychiatric and medical sections.

[edit] Legal considerations

In 1988, the US Supreme Court upheld a regulation whereby the Veterans' Administration was able to avoid paying benefits by presuming that primary alcoholism is always the result of the veteran's "own willful misconduct." The majority opinion written by Justice Byron R. White echoed the District of Columbia Circuit's finding that there exists "a substantial body of medical literature that even contests the proposition that alcoholism is a disease, much less that it is a disease for which the victim bears no responsibility".^[25] He also wrote: "Indeed, even among many who consider alcoholism a "disease" to which its victims are genetically predisposed, the consumption of alcohol is not regarded as wholly involuntary." However, the majority opinion stated in conclusion that "this litigation does not require the Court to decide whether alcoholism is a disease whose course its victims cannot control. It is not our role to resolve this medical issue on which the authorities remain sharply divided." The dissenting opinion noted that "despite much comment in the popular press, these cases are not concerned with whether alcoholism, simplistically, is or is not a "disease.""^[26]

The American Bar Association "affirms the principle that dependence on alcohol or other drugs is a disease."^[27]

[edit] Current acceptance

The current mainstream scientific and medical view is that alcoholism is a disease, although some debate on this topic still occurs.^[28][29]

The American Society of Addiction Medicine and the American Medical Association both maintain extensive policy regarding alcoholism. The American Psychiatric Association recognizes the existence of "alcoholism" as the equivalent of alcohol dependence. The American Hospital Association, the American Public Health Association, the National Association of Social Workers, and the American concerned with College of Physicians classify "alcoholism" as a disease.

In the US, the National Institutes of Health has a specific institute, the National Institute on Alcohol Abuse and Alcoholism (NIAAA), concerned with the support and conduct of biomedical and behavioral research on the causes, consequences, treatment, and prevention of alcoholism and alcohol-related problems. It funds approximately 90 percent of all such research in the United States. The official NIAAA position is that "alcoholism is a disease. The craving that an alcoholic feels for alcohol can be as strong as the need for food or water. An alcoholic will continue to drink despite serious family, health, or legal problems. Like many other diseases, alcoholism is chronic, meaning that it lasts a person's lifetime; it usually follows a predictable course; and it has symptoms. The risk for developing alcoholism is influenced both by a person's genes and by his or her lifestyle."^[30]

Current evidence indicates that in both men and women, alcoholism is 50-60% genetically determined, leaving 40-50% for environmental influences.^[31]

[edit] Opponents

Critics such as psychotherapist Dr. Stanton Peele, psychologist Dr. Jeffrey A. Schaler and Dr. Thomas Szasz reject the disease model.^[32]

[edit] Miscellanea

Many doctors "loath to prescribe drugs to treat alcoholism, sometimes because of the belief that alcoholism is a moral disorder rather than a disease", according to Dr. Bankole Johnson, Chairman of the Department of Psychiatry at the University of Virginia.^[33] Dr Johnson's own pioneering work has made important contributions to the understanding of alcoholism as a disease.^[34]

Certain medications including opioid antagonists such as naltrexone have been shown to be effective in the treatment of alcoholism, although research has not yet demonstrated long-term efficacy.^[35]

Frequency and quantity of alcohol use are not related to the presence of the condition that is, people can drink a great deal without necessarily being alcoholic and alcoholics may drink minimally or infrequently.^[36]

A greater belief in the disease theory of alcoholism and higher commitment to total abstinence were found to be factors correlated with increased likelihood that an alcoholic would have a full-blown relapse (substantial continued use) following an initial lapse (single use).^[37] However, the authors noted that "the direction of causality cannot be determined from these data. It is possible that belief in alcoholism as a loss-of-control disease predisposes clients to relapse, or that repeated relapses reinforce clients' beliefs in the disease model."

[edit] See also

• Disease model of addiction

[edit] References

[edit] External links

• American Public Health Association - APHA