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| | From:  Silken2004 (Original Message) | Sent: 6/29/2006 11:10 PM |
Most are aware that drugs are a major factor in our biggest social problems: violence, crime, poverty, AIDS, family disintegration " but many do not think of alcohol as a drug at all, only as a social beverage. We shall see that alcohol causes immense problems, of which alcoholism is only one. (The other drugs are dealt with in Chapters 2 and 5.) The facts about alcohol are distorted by our emotionally charged attitudes toward drinking, drunkenness, and alcoholism. Those attitudes are the result of many factors: family situation, sociocultural experience, biological differences, prohibition, differing religious beliefs, and political, economic, and personal feelings unique to each individual. Obvious as they may seem, we must spell out some distinctions that are ignored in most arguments on the subject. Drinking. Abstinence from alcohol is the opposite of drinking. Technically anyone who drinks alcoholic beverages, however rarely and moderately, is a drinker. About 60 percent of Americans over eighteen drink at least occasionally (down from 71 percent a dozen years ago); most are neither drunkards nor alcoholics. In fact, about 11 percent of drinkers consume 68 percent of our beverage alcohol, whereas many of those technically classed as drinkers have only a New Year's toast or the like. Less than half of American "drinkers" use alcohol more than once a month. Drunkenness. Temperance is the opposite of drunkenness. In Chapter 3 we shall see how the prohibitionists created untold confusion by assuming that everyone who drinks is a drunkard. Actually, anybody can get drunk on a given occasion; they might not even be a drinker in the usual sense of the term. To the na茂ve guest at a wedding reception or the person honored at a retirement banquet, the champagne seems much like ginger ale; a subsequent arrest for driving while intoxicated is not presumptive of alcoholism. However, intoxication even by nonalcoholics is a major source of both civil and criminal problems: battered spouses and children, rape, fights, homicides, unwanted pregnancies, poor health, suicides, lawsuits, family disruptions, job loss, and a sizable share of accidents " not only traffic but also home, boat, small plane, and industrial. The degree of intoxication need not be that required to be legally drunk, as we shall see in Chapter 4, Section B. Alcoholism. Alcoholism is the state of a person whose excessive use of alcohol creates serious life problems. An alcoholic may never get drunk, as in the Delta type (maintenance drinker) common in France and described in Chapter 6. They may not even drink, as in the case of the 2 million or so recovered alcoholics who still identify themselves as such (Chapter 8). Alcoholics In most minds, the word alcoholic conjures up an image of a skid-road bum. Yet only about 3 percent of alcoholics are on skid road. (Incidentally, Skid Road is the original term, named for Yesler Way in Seattle, where logs were skidded down to Yesler's mill; skid row is a later version, by analogy with Cannery Row.) What kinds of people are alcoholics? Alcoholics may be young or old, male or female, black or white, banker or bum, genius or mentally retarded. A large body of research data has accumulated on this subject, and there have been intensive educational efforts to make these facts known to the public. Yet the old stereotypes persist and must be dealt with before any meaningful discussion of alcoholism can occur. Skid Road? It is essential to eradicate right now the stereotype of the alcoholic as a skid-road, old, male, weak-willed, inferior derelict. If 3 percent of alcoholics are on skid road, the other 97 percent of American alcoholics have jobs, homes, and families. About 45 percent of alcoholics are in professional and managerial positions, 25 percent are white-collar workers, and 30 percent are manual laborers. Over half have attended college; only 13 percent have not finished high school. No suggestion of skid road there. Physicians, brokers, attorneys, judges, dentists, and clergymen all have a high incidence of alcohol problems. Instead of being inferior, the average intelligence of alcoholics is slightly above that of comparable groups " for example, compared with other employees in their company. Alcoholics also appear to be superior in talent and sensitivity. Hence it is not mere emotional loyalty that prompts a spouse or foreman to assert that their alcoholic is "the finest" when not drinking. That is important, because both alcoholic and spouse tend to deny the problem by saying that the person is too intelligent to be an alcoholic. Weak Will? Anyone with experience in the field can testify that when an alcoholic needs a drink there is no one on earth with a stronger will: They will get a drink come hell, high water, or prohibition. The notion of weak-willed moral depravity rather than a compulsive disorder stems from the days before alcoholism was accepted as a disease by the World Health Organization and important national professional associations. Mentally Ill? The notion that a typical alcoholic is a person who drinks to escape from some inner conflict raises a complex question that is addressed in Chapters 7 and 8. Suffice it to say here that research now shows that about 80 percent of alcoholics are normal personalities who began drinking for the same reasons as anybody else: custom, sociability, relaxation, or just to feel good. Male? The ratio of men to women alcoholics is often still reported as four or five to one. That is probably due to the double standard in our society regarding women and drunkenness. Women alcoholics are often better able to hide their drinking at home (though in the business world they may be more exposed than men) and, in any case, are not as likely to be counted by the fact-gatherers. Even when they die of alcoholism, the diagnosis is written as a total liver failure or something similar, because the doctor is a gentleman and it's not ladylike to be an alcoholic. Hence the statistics are questionable. If the truth were known, the ratio of male to female alcoholics in this country is probably fifty-fifty, an opinion shared by such national authorities as M. Block, L. Cloud, R. G. Bell, R. Fox, M. Mann, M. Nellis, and M. Chafetz. (Since English just does not have a suitable pronoun for the clumsy he/she or her/his, our use of pronouns in this book is not taken as sexist but is simply due to the inadequacy of our language.) Old? One does not have to drink heavily for thirty or forty years in order to develop alcoholism. More than a million American teenagers have serious alcohol problems. There are full-blown alcoholics who are eight or nine years old. A visitor at open AA meetings will frequently hear, "I was an alcoholic at the time I took my first drink." Although this evidence is subjective, it is in accord with scientific findings that up to 60 percent of alcoholics are such from the onset of drinking. Alcohol as a Drug We reject the phrase "alcohol and drugs" because it implies that alcohol is not a drug. We insist on "alcohol and other drugs." Is alcohol really a drug? Yes, in every sense of the word. Alcohol can produce all the classic signs of addiction: changes in tolerance (the need of more alcohol to get the same effect), cellular adaptation or tissue change, and withdrawal. Chemically very similar to ether and chloroform, alcohol is a sedative, a hypnotic, a tranquilizer, a narcotic, and sometimes a hallucinogenic. For centuries it was our only anesthetic, although for practical reasons a very poor one. If it were not dangerously addictive, it would be hailed as the world's greatest tranquilizer. It is most like the barbiturates, except for three important differences: -
Stimulant or depressant? Both. Alcohol is perhaps the only common drug that gives a lift or stimulates before acting as a sedative or depressant. Some of the latter results from the depression of inhibitory centers in the brain. But the initial effect of alcohol on tissue is to irritate or agitate or stimulate, as well as to provide quick caloric energy. Some research evidence indicates that this is more true for alcoholics than for others, perhaps right from the beginning of their drinking careers; and it is this initial stimulation that many beginning alcoholics seem to look for rather than the later sedative effect. (See Chapter 4, Section B.) -
Selective addiction. The reason why alcohol is often not thought of as a drug is that, in contrast to other drugs, it becomes addictive to only one in ten of its users. Most people drink moderately all their lives, with perhaps an occasional drunk. Why only some drinkers become addicted to alcohol is not known for certain; we shall examine this question when we deal with causality. The fact that alcohol seems safe for most people makes it harder to accept that it is a dangerous drug for a minority of 10 million to 12 million, making alcohol by far the biggest problem drug in America. The important thing here is that people differ in their reaction to alcohol. -
Socially acceptable. One is tempted to call alcoholism a respectable addiction. Millions of people casually invite friends in for a drink who would be horrified at hearing "Come over tonight and we'll shoot a little heroin, or drop a few barbs." Even when there is misuse, we pass it off lightly or with minor embarrassment, perhaps with the remark that everybody has a few too many once in a while. How often do we think of drunkenness as a drug overdose? Do we think alcoholic beverages should be in childproof bottles? Serving drinks is a mark of hospitality, and failure to do so smacks of puritanical repressiveness. As a result of such attitudes, even when a friend is in serious trouble with alcohol there is a tendency to minimize or excuse the behavior rather than face the issue of debilitating and even terminal illness. Society feeds the denial of the alcoholic by implying that heroin and cocaine may be dangerous, but not alcohol. Until MADD (Mothers Against Drunk Driving) influenced public opinion, manslaughter by a drinking driver was almost a socially accepted form of homicide. SCROLL DOWN... THERE'S MORE.... |
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The Definition of Alcoholism: There are nearly as many definitions of alcoholism as there are those who write or lecture on the subject. Why bother to define? There are many reasons. The alcoholism worker must have a definition that will stand up in court under cross-examination, whether alcoholism is being used as a defense or as grounds for involuntary commitment. The counselor must be able to proffer a definition that will induce the client to accept treatment and that will be neither so loose nor so rigid that clients can say in their denial, "That doesn't apply to me!" (In this vein, an alcoholic is said to define alcoholism as a disease that others get.) If insurance companies are going to pay health benefits for treatment, they are going to demand a strict definition of the object of their dollars. Physicians need solid criteria for making a diagnosis. Some of the fallacies occurring in the controversy about conditioning alcoholics to drink socially stem from dubious definitions of who is an alcoholic. Industrial alcoholism programs need to be precise in order to protect the rights of both labor and management. Defining alcoholism as a disease has moved it from the criminal justice system and the jail drunk tank to the health care system and treatment centers. It is crucial to any prevention campaign. Problems in Definition A good definition must be coterminous with what is being defined. A definition of alcoholism as "a horrible disease that affects the whole person" is unacceptable, because it is so broad it can apply to cancer or schizophrenia. Conversely, to define alcoholism in terms of one type of alcoholic is likewise unsatisfactory, because it misses many other types of alcoholics. Alcoholics cannot be defined as those who get drunk every time they drink, nor as those with a prolonged history of drinking, nor as those who crave alcohol, nor as those with any other single symptom. A common fallacy is to define alcoholism by the amount or the beverage consumed. "He only drinks beer" ignores the fact that the same alcohol is present in the most expensive liquor and in the cheapest beer or wine. At an upper-class hospital for alcoholics 15 percent of the patients have never drunk anything but beer. People in Australia, New Zealand, and other countries with an incidence of alcoholism as high as that in America drink beer ("grog") as their primary source of alcohol. Yet our laws and our advertising still imply a difference. The amount of alcohol drunk combined with the frequency of drinking (quantity/frequency index) is also a misleading way to define alcoholism. Because of individual differences some alcoholics might actually drink less than some nonalcoholics. Average consumption per week or month means nothing. An Italian might spread out fourteen ounces of absolute alcohol per week as wine and not be alcoholic, while an American alcoholic might consume the same amount of absolute alcohol in the form of a quart of 86 proof whiskey each Saturday night with total intoxication. More important than how much one drinks is the question of how one drinks. Moreover, alcoholics either lie about the amount they drink or just don't remember. Some define an alcoholic as one who cannot predict what will happen after one drink. But one can think of many alcoholics who can predict exactly what will happen. (True, most alcoholics cannot predict consistently or accurately.) Some define alcoholism as drinking alcoholic beverages in excess of customary dietary usage or social use of the community. This confuses average with normal. In a "dry" Southern town one beer on a hot day would exceed custom, but that is hardly alcoholism. In a north Alaska village, where every adult male gets drunk every weekend, the mere fact that this is customary usage does not preclude the presence of alcoholism. A Working Definition We define alcoholism as a chronic primary illness or disorder characterized by some loss of control over drinking, with habituation or addiction to the drug alcohol, or causing interference in any major life function, for example: health, job, family, friends, legal or spiritual. -
Some loss of control is involved, but it need not be total. Most alcoholics can take one or two drinks under certain circumstances without getting drunk, but that does not prove they are not alcoholic. Sooner or later they are in trouble again. Total loss of control is usually seen only in latestage, deteriorated alcoholics. Loss of consistent control is sufficient for diagnosis. The loss can be over how much they drink, or over when they drink, or both. One may not get drunk, but drinking more than one intends or drinking at inappropriate times would indicate alcoholism. -
Dependence or need can be either psychological or physiological. Psychological dependence or need is habituation (discussed in Chapters 4 and 7). As the poster slogan says, "If you have to drink to be social, that's not social drinking." Discomfort if deprived of alcohol and inability to quit on one's own are symptoms, even if no physical need is apparent. Physiological dependence or need is addiction, with its familiar signs of increased tolerance initially, cellular adaption, and withdrawal symptoms. One physically needs a drink to function. DSM-III-R distinguished abuse from alcoholism largely by using the notion of dependence. The tendency in America is to focus on addiction and to dismiss habituation as "only" psychological need. Yet in every respect except the physical dangers of withdrawal, psychological dependence can be more devastating. To appreciate this one has only to look at the way compulsive gambling can destroy a family. Cocaine causes no physical withdrawal, yet it fulfills all the other parts of the definition; nobody would deny it is very addictive. And marijuana users are coming to treatment centers in increasing numbers, saying that they want to quit and can't " obviously addiction. -
Interference with normal functioning. The interference must be notable or habitual, to exclude the case of the turned ankle from one drink. This is the least subjective criterion and closest to an operational or behavioral definition. It can be quantified for research purposes, which is why it is the major factor in DSM-IV, 303.90 (American Psychiatric Association, 1994). For example, anybody can be arrested for drunk driving once, but three DUIs (Driving Under the Influence) in the same year suggest alcoholism. Likewise if drinking is involved in more than one fight where there is serious injury or a lethal weapon is used. Social disruption and health damage may be very different measures, but both are valid. This last element complements the earlier parts of the definition, because the fact that one continues to drink after he has been told his health or marriage or job is endangered would indicate dependence and some loss of control; otherwise why continue? "Chronic" means enduring, something that can be arrested but not cured. The complex physical, psychosocial, and spiritual nature of this illness will be explored in Chapters 7 and 8. At least it seems that continuing to drink in spite of such unwanted consequences is sick behavior. Our definition seems quite congruent with that developed by a joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine (NCADD/ASAM Joint Committee, 1992), which, like that in DSM-IV, is more a clinically useful description than a strict definition. Leaving detailed symptoms to Chapter 6, let us round out our definition by noting three common errors in diagnosis: -
Joe can drink anybody under the table. He is not safe, but rather in serious danger. Increased tolerance, the ability to function with higher than average amounts of alcohol in the bloodstream, is the first sign of physical addiction. -
Cutting down or quitting drink for a period of time (going on the water wagon) is not proof that one has it under control. Most do not realize that this is a classic symptom of alcoholism. The true social drinker does not need to play games of control. -
The assertion, "I can take it or leave it alone," especially when made often or with vehemence, is usually indicative of denial and betrays the alcoholic. The social drinker doesn't feel compelled to say such things. This subtle self-deception is so characteristic that we have long defined an alcoholic as "one who says I can quit any time I want to." Primary Versus Secondary Alcoholism The terms primary and secondary have acquired ambiguous and even contrary or reversed meanings. Some old medical literature even uses the term "acute alcoholism" to refer to any severe intoxication. In this book we shall use primary when the alcoholism is the basic pathology, regardless of cause ("essential alcoholism"), and secondary to refer to alcoholism as a symptom of some other disorder ("reactive alcoholism"). Remove the alcohol, and you will find anything: normal people, neurotics, sociopaths, mentally retarded, psychotics. Any psychopathology may then be either the cause of the alcoholism or the effect of the alcoholic drinking on the brain. |
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