Disease theory of alcoholism

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^[1] which argues that genetic, neurological and behavioral studies distinguish those with alcohol dependence from problem drinkers.

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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.

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.

History

The disease theory of alcoholism was first proposed in 1784 by Dr. Benjamin Rush of Philadelphia, and independently by Thomas Trotter.^[2] The modern theory of alcoholism as a disease was put forth by E. Morton Jellinek. Controversy over Jellinek's claim that he received a doctoral degree has contributed to criticisms of the disease theory.^[3] In addition to the possibility of discrepancies regarding Jellineks's medical education or expertise, there are numerous other flaws with his work. The 1960 survey that he conducted that claimed alcoholism was a disease was comprised of Alcoholics Anonymous members and Jellinek removed all female subjects as well as many of the outliers that would have skewed the data and proven Jellinek's (and AA's) hypothesis incorrect. Jellinek himself admitted that his proposals lacked any demonstrated scientific foundation, and remarked that "for the time being this may suffice, but not indefinitely."

The first major empirical challenge to the disease model came in 1962 with the publication of Dr. D. L. Davies' ^[4] follow up of seven alcohol abusers which found that some of them were able to return to "controlled drinking." Other research also reported that some alcoholics could drink in moderation .^[5] In 1978, what is commonly referred to as the RAND report ^[6] published extensive evidence that alcoholics could learn to consume alcohol in moderation. 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.^[7] 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.^[8]

Between 1980 and 1991, medical organizations 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 American Medical Association, 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. In 1980, the AMA'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."

In a 1988 US Supreme Court decision on whether alcohol dependence is a condition for which the US Veterans Administration should provide benefits,^[9] Justice Byron R. White's statement echoed the District of Columbia Circuit's finding that "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." 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."^[9]

Current acceptance

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 College of Physicians classify "alcoholism" as a disease.

Many doctors are "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.^[10]

Opponents

There is much debate over whether or not alcoholism should be considered a disease. Opponents cite the inability to pin down the behavioral issues to a physical cause as a reason for avoiding classification^{[citation needed]}. Programs such as Rational Recovery and psychotherapist Dr. Stanton Peele,^[11] reject the "disease model" as do medical doctors such as Dr. Thomas Szasz and psychologists such as Dr. Jeffrey A. Schaler.

The US Social Security Administration no longer makes disability payments to individuals for whom substance use disorders are a material aspect of their disability.^[12]

Medical evidence

The results of medical research have been used both in support of and against the disease theory of alcoholism. Current scientific and medical opinions favour the concept that alcoholism is a disease; however, debate still remains on the subject.^[13][14]

Supporting evidence

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.^[15]

Current evidence indicates that in both men and women, alcoholism is 50-60% genetically determined, leaving 40-50% for environmental influences.^[16]

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 and/or infrequently.^[17]

See also

• Disease model of addiction

References