From: bagg@ellis.uchicago.edu (matthew john baggott)
Subject: Alcoholism as a Disease (was Re: <azagthoth>)
Reply-To: bagg@midway.uchicago.edu
Organization: University of Chicago
Date: Mon, 11 Jan 1993 21:13:16 GMT

In some article, cblanc@pomona.claremont.edu (Malevolessence) wrote:

>                                                              ...  For one
>thing, there is a genetic propensity toward alcoholism clearly measured by
>either scientific survey (I'm sure there is some literature on this somewhere,
>as I've read some of it, but never thought I'd encounter belligerent users 
>bent on denial, so threw it out) or commonsense observation -- the children of
>alcoholics follow their parents habit, even when removed from the home
>environment. 

You greatly exaggerate the strength of the evidence for a genetic propensity
towards alcoholism.

For example, the conclusion you seek to draw from your hypothetical study
of children of alcoholics ignores (a) the fact the children who are
removed from their parents homes are not randomly placed in other
environments and (b) the possibility that alcoholism might be a behavior 
caused by problems stemming from early childhood trauma or by other
environmental variables.  You might consider reading _Not in Our Genes_, 
co-written by the brilliant geneticist Dick Lewontin, which details the long 
history of flaws and outright fraud in this sort of study. 

(I've added some references from Medline to my queue of articles to look
up next time I'm in the library, so I may post about the current state
of knowledge about genetic factors in alcoholism soon.  No promises though.)

>              Second, there is a perceivable need in the alcoholic, much like
>the addiction of the caffeine user -- headaches, crankiness, etc. that comes
>only from being an alcoholic.  

The headaches and crankiness which caffeine users experience when they
haven't had their morning coffee are withdrawal symptoms.  They are
symptoms of physiological dependency (which is not the same thing as
addiction) and disappear after a while.  Withdrawal symptoms are different 
from the "craving" which addicts sometimes report.  I assume you wish
to claim that alcoholics have a craving for alcohol which is somehow
unique.  It is true that alcoholics have a craving for alcohol, however
"chronic drinkers" (using your definition) do as well.  This "craving"
seems to be (partially?) triggered by environmental and social cues which
remind the alcoholic of drinking.  In other words, they feel the need
to drink when in situations where they normally drink.  This may be
a simple conditioned response much like in the infamous dogs of Pavolv.
Some treatment programs try to weaken this conditioning by having
heroin addicts handle syringes without using them, etc.

>                              Here is where someone's point comes into play: 
>what is our definition of a disease?  In this case, mine is that it is a
>biological, genetically-transmitable propensity toward alcoholism that will
>flower into the full-blown condition if given the proper chance -- that is, if
>the person drinks heavily enough to engender the onset ("heavily enough" can 
>be "once" in many cases). 

Given your definition, you probably don't have enough evidence to justify
calling alcoholism a disease.  Furthermore, it seems to me that we _all_ fit
your definition of alcoholics.  

>                           Second point is that once an alcoholic, always an
>alcoholic -- you will still be addicted to the substance, but have the
>potential to regulate your behavior regarding it.  Some cases are too extreme
>for regulation except cold-turkey quitting and never touching the substance
>again.  These facts are verifiable with either a little observation,
>interviewing at a treatment center, or checking in a library.

You say that these facts are easily verified.  But what sort of data would
verify the claim that "once [you're] an alcoholic, [you're] always an
alcoholic?"  I submit that this statement isn't falsifiable/verifiable.

>                                                               Alcohol, like
>any drug, is a tool -- and there are some who should not touch it for the
>medical reasons described above.  There are others, the psychological addicts,
>who may have the "addictive personality" I hear a lot about or may just be
>desperately searching for escape, who will make _anything_ addictive by process
>of behavior.  I know people who are "addicted" to dope, even though dope is the
>most unaddictive thing I can think of.  I know people who are "addicted to
>alcohol" (via this syndrome) who will drink and get drunk whenever possible
>(but do not have the thirst of the alcoholic).

I'm very skepical about this "addictive personality type."  Animals are
more likely to self-administer drugs if you deprive them of social
contacts or environmental stimuli.  It is a common error in reductionist 
research strategies to incorrectly localize global or environmental 
influences within the system being studied.  Why call it a personality type 
rather than shitty circumstances?

Besides, even polydrug abusers have well defined preferences.  It's not
like they go for any high that comes along.

In any case, people can be said to be addicted to many things, you're 
right.  I just don't understand why you think that "true alcoholics" are
obviously not just a subset of these people.

>[Text deleted]                                          ...First, as I've
>mentioned above, you cannot "cure" alcoholism -- you can regulate the behavior. 

>Second, as mentioned in past messages, a  "positive experience" isn't going to
>change an alcoholic's need for his substance. 

The type of "positive experience" which advocates of psychedelic and
entactogenic therapy have in mind is not simply a good time but a peak
experience or spiritual awakening in which the person gains a new
understanding of his or her life.  Such an experience might be useful
for alcoholics, as well as other addicts, because it might help them
to rechannel their urge to drink into more constructive behaviors.

I am posting the abstract to an article which articulates this general
perspective below.

  McPeake JD; Kennedy BP; Gordon SM.
    Altered states of consciousness therapy. A missing component in alcohol
    and drug rehabilitation treatment.
  Journal of Substance Abuse Treatment, 1991, 8(1-2):75-82.
    (UI:  91269369)
    Pub type:  Journal Article; Review; Review, Tutorial.

Abstract: Attaining altered states of consciousness is described as a basic
  human motive. The substance dependent population is distinguished from
  other populations because they pursue these states destructively by
  inappropriate use of alcohol and drugs. Despite a body of literature
  supporting the benefits of altered states of consciousness, alcohol and
  drug rehabilitation treatment programs fail to address this motive because
  of social disapproval, means-end confusion, and inadequate staff training.
  The authors maintain that Alcoholics Anonymous directs its members toward
  an altered state of consciousness called a spiritual awakening, which
  replaces the self-destructive pursuit of substance induced "highs." Failure
  to address patients' need for alternative methods of achieving altered
  states of consciousness is presented as part of the reason for relapse. An
  Altered States of Consciousness Therapy (ASCT) program is described that
  can be used to teach patients to consciously manipulate affect and
  cognition to achieve a new consciousness.


>                                                Third, most of the alcohol
>abusers who aren't alcoholics are of the addictive personality type, which
>would lead them to become MDMA abusers, despite the high tolerance initiated
>with each trip ("abuse" comes in many forms, not just what has been the
>attempted stereotype here: massive consumption).

Unsupported speculation.  You'd be a lot more credible if you said "COULD
lead them" rather than "would lead them."

In a later post, cblanc@pomona.claremont.edu (Bucko Gizm) continued:

>        The distinction between "chronic drinker" and "alcoholic" seems
>to be the key issue.  I would define a chronic drinker as one who drinks
>a lot for emotional reasons, where as an alcoholic drinks as a matter of
>sustenance.  At this point the issue should be crystal clear:  chronic
>drinkers require no treatment beyond the psychological, for which
>administering MDMA, LSD, or even just floral arrangements could be an
>aid.  Alcoholics, on the other hand, either require some kind of blocker
>treatment (that is, to keep them from gaining anything from alcohol) or
>recognition of their disease followed by cold turkey quits.  

When you say "blocker treatment" do you mean a pharmacological
intervention?  If so, you are effectively hypothesizing that all the
alcoholics who have been successfully treated (whether by themselves
or others) without such intervention were not really alcoholics.
It seems to me that you're arbitrarily excluding many heavy drinkers
from your definition of alcoholism in your zeal to support your
particular pet theory about alcoholism.

There is something extremely dubious about making a distinction
between alcoholics and chronic drinkers based upon success of
treatment.  Treatment for all drug users is mediocre and success rates
are only slightly better than the chances of people controlling their
drug use on their own.  Treatment is not at all standardized and
the degree of treatment you get depends as much on where you go and
how much money you have as it does on anything about the drug user.

Your theory seems to be that alcoholics somehow drink because they
have to ("for sustenance").  You seek to distinguish this population
of drinkers from those who drink for psychological reasons.  From
this, I conclude that the "sustenance" that alocoholics allegedly
get from alcohol is, in your mind, physiological.  This sort of theory
has been proposed about addicts of other stripes in the past but has
been discarded because it didn't seem to be true.  One problem I have with 
this sort of physiological theory is that it is very difficult to make 
differences in metabolism explain differences in more global behaviors.  
What difference in metabolism or reaction to alcohol could there be that
was sufficient to cause someone to loose control of their drinking and 
become an alcoholic?  Just because I have less tolerance for alcohol or
it effects me more/less, why should I embark upon the highly complex
set of behaviors over time that would cause society to label me an
"alcoholic?"  Unless you can propose some possible mechanism on the
physiological level which could cause the cognitive and behavioral
aspects of alcoholism, then there seems no reason to place
the emphasis on the physiological level rather than a cognitive or
behavioral one.  So, I don't even see there being a plausible _type_ of
theory which could fill out your distinction.

The current thinking on addictions is that the object of addiction is not
just the drug, but, rather, it is the addicted person's experience of the
combined physical, emotional, and environmental elements that make up the
involvement for that person.  Your understanding of alcoholism, on the
other hand, would reduce the object of addiction to a simple physiological 
need.  I find that naive.

Don't get me wrong, I don't think that the disease model of alcoholism
is totally without merits.  On the other hand, it's just a model --at
best a way of organizing facts-- and it has its limits.  To take
the model for reality, as you do, causes systematic biases in the way
we understand the problem.  Most noticably, I think it causes its
proponents to become obsessed with finding genetic causes for
alcoholism (to the point where they become blind to environmental
explanations for "genetic" influences).  From the clinical point
of view, the biases may affect the rate of relapse through the
"abstinence violation effect," which is similar to the "I've already
blown my diet for today might as well eat this cake" thinking.
The diease model also has more broad implications for how one should
treat alcoholism. 

Others (like Brickman et al in _American Psychologist_ 37: 368-384, 1982)
have discussed the impact of assumptions about personal responsibility
on models of addiction.  I think that it is very important that we
articulate how our models hold people responsible for the causing or
curing of their problems.  We certainly don't want to turn a problem
best treated by doctors into one which is "treated" by priests or
police.  Disease models of addiction successfully avoid that.  However, they 
often go beyond the established evidence and hypothesize that the addict
is powerless in the face of the "disease."

>                                                             How do we
>know it is a disease?  Despite the elaboration posted in my last
>message, people are still doubting this, so I elaborate further:  ever
>hear about how most Native Amerikans/Indian reservations are plagued by
>alcohol problems, _years_ after the traders used rum for the purpose of
>cheating said individuals?  There seems to be proof there, as in the
>street speaks of many alcoholics. 

Of course, the alcohol problems on the reservations have nothing to do with 
the other social problems that oddly enough seem to correlate with
increased incidence of alcoholism in other parts of our country. 

You talk about the "street" knowledge of alcoholism.  Yet it was only a
few years ago that it was widely accepted by our culture that red heads
had firey tempers.  Let's face it, there are a lot of theories out there,
even among people with first-hand experience, that are totally worthless.
Paul and Patricia Churchland, Steven Stitch, and others have written
excellent critiques of the idea that our "folk psychology" (as they
call it) has much in it that will turn out to be scientifically
salvagable.

Finally, I would like to conclude this posting with a quote from
Griffith Edwards, Professor of Addiction Behavior in the University
of London and Director of the Addiction Research Unit of the Institute
of Psychiatry.

"Addiction is now defined as an illness because doctors have categorized
it thus... This was a process which had its origins in the last quarter
of the nineteenth century.  Disease entities were being established in
definitely recognizable physical conditions such as typhoid and cholera. 
The belief in scientific progress encouraged medical intervention in
less definable conditions.  The post-Darwinian revolution in scientific
thinking encouraged the re-classification of conditions with a large
social or economic element in them on strictly biological lines.  From
one point of view, diease theories were part of late Victorian 'progress,'
a step forward from the moral condemnation of opium eating to the
scientific elaboration of disease views.  But such views were never,
however, scientifically autonomous.  Their putative objectivity disguised
class and moral concerns which precluded a wider understanding of the
social and cultural roots of [drug] use." (from p. 150 of Virginia
Berridge and Griffith Edwards' _Opium and the People_) 

>Bucko Gizm

     --Matt


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