Alcohol and Alcohol Problems
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 naïve 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).
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:
1. 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.)
2. 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.
3. 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.
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.
1. 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.
2. 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.
3. 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:
1. 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.
2. 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.
3. 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.
Alcoholic Versus Problem Drinker
Scientific researchers like W. Madsen, D. Cahalan, and S. Bacon rightly insist that to gather meaningful and comparable data one must have an operational, quantifiable definition that guarantees consistency as to which cases are counted as alcoholics and which are not. But clinicians and field workers often find it advantageous to ignore such precision and not to allow themselves to get trapped into games of labeling or arguments about whether a client is or is not an alcoholic. There is a general tendency to use the term alcoholic when loss of control and dependence are stressed, and problem drinker when the emphasis is on consequences. There is no standard or sacrosanct terminology here. One could argue the pros and cons of even dropping the term alcoholic entirely:
Con. In view of the great progress that has been made in the last few decades to eliminate the social stigma attached to alcoholism, it would seem a strategic mistake to reverse the trend. Dropping the term would cause the alcoholism movement, after having espoused the term, to lose face before the medical profession, the courts, and the insurance companies. There would be a loss in continuity of research. It might feed the denial system of some alcoholics, encouraging them to delude themselves into attempts at social drinking. It would take the focus off alcohol as our major drug: The alcoholic beverage industry would be delighted to have NCADD change its name to "National Council on Chemical Dependency." A major loss would be the sense of identity that people feel within the fellowship of Alcoholics Anonymous.
Pro. Yet dropping the term would have its advantages. In spite of progress, alcoholism is still odious in the minds of many. Some wish to name it Jellinek's disease, as we now call leprosy Hansen's disease. The stereotype of the skidroad derelict or the "fallen woman" prostitute and the suggestion of insanity still cling to the word, making early detection more difficult and fostering a defeatism or sense of hopelessness not warranted by current success rates in rehabilitation.
For alcoholics in the denial stage the term raises their defenses, and many an initial interview goes smoother if there is no attempt to hang the label "alcoholic" on a new client but just an effort to explore calmly together whether drink is causing some problems. If the client later wishes to label himself, perhaps in an AA meeting, the victory was well worth the tactic. (AA members working in the field too often take for granted the ease with which the word is used among them now and forget how defensive they were in the denial phase, or how painful it was the first time to say "I am an alcoholic.")
Dropping the term might make it easier to sell a program to industry and might lessen the denial or defensiveness of the spouse and family by making them less self-conscious. Alcohol education would be easier and more positive, with less scare tactics centered around alcoholism. Traffic problems and court referrals might be handled more easily if alcoholism were brought into the picture under a different name.
The change might even stimulate a fresh, innovative approach to research. Alcoholism is not a single disease entity like TB or malaria, and cross-cultural differences further confuse the issue. Data might be more objectively gathered from emergency hospitals and police stations if not contaminated by subjective perceptions of alcoholism, as in one study where the physician missed the diagnosis half the time if the patient was well-dressed and not unkempt. Last and perhaps most important, the connotations of the term alcoholic prevent many women from being properly diagnosed, which not only yields misleading statistics but keeps those women from getting the help they need.
What to do? As in many aspects of this field, there is no clear answer. We reject outright the term substance abuse, because it suggests behavioral choice rather than compulsive disease. This is not just "political correctness" but avoids putting those recovering from a disease in the same category with child abusers or sexual abusers. Both DSM-IV and the title of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) distinguish between abuse and alcoholism. Chemical dependency is better, but like "substance" it detracts from the fact that alcohol is our biggest drug problem. We prefer alcohol and other drug addiction.
Extent of Alcohol Problems
(For fuller discussion of this topic see Royce, Alcohol Problems and Alcoholism, Chapter 2 and references therein.)
Alcohol causes more significant problems than all other drugs combined. Alcohol kills over five times more people each year than all illegal drugs together (JAMA, 1993, 270: 2207-12). We now know that a great number of deaths once attributed to accidents and to physical illnesses such as heart or liver failure, acute pancreatitis, internal hemorrhaging, and the like should really be counted as alcohol deaths. And there is clear evidence that alcohol contributes to the causality of cancer. Yet even reasonably well-informed people do not realize the extent to which alcohol use and misuse pervade every aspect of American life: social, economic, political, medical, legal, historical, moral, and emotional. Smoking is now considered our number-one cause of death, but smoking rarely causes one to cross the highway center line to wipe out a carload of innocent people, or a man to beat up his wife. So alcohol can still be ranked as our number one public health problem drug.
Estimating Is Difficult. Lengthy treatises -- to some more boring than the statistics themselves -- have been written about the problems involved in trying to compile accurate figures on alcoholism. Vagueness of definition and a lack of standard criteria for alcoholism are complicated by our society's emotional attitudes toward the misuse of alcohol and consequent tendencies to gloss over it. Some apparent increases in the estimates of the numbers of alcoholics are no doubt merely a reflection of better methods of case finding and reporting, along with the new willingness to face alcohol problems openly and without disguise, especially among women.
Estimates of the extent of alcohol abuse based on arrests and court convictions can be misleadingly low. Arresting officers will often settle for lesser charges, such as reckless driving, because there is a better chance of proving the charge in court. More severe penalties tend to predispose a jury toward acquittal. In 1984 three groups of Midwest pathologists claimed that their autopsies showed 91 percent of auto deaths were alcohol-related.
Often neglected in such discussions are the figures from the National Safety Council and other sources on the role of alcohol in death and injury other than by automobile. Other types of alcohol-related accidents should not be ignored: home, boat, fire, drownings, suicides, and a high percentage of fatal crashes in airplanes other than commercial or military. Thus one-third of industrial and home accidents, 25 percent of ski accidents, 19 percent of bicycle accidents, and an estimated 75 percent of boat and small plane deaths and injuries occur after drinking. Commercial pilots are rigidly monitored, but the Federal Aviation Administration (FAA) has no effective means of checking private planes. People who are used to boats and are around them all the time don't fall off and drown in the wee hours because they have been drinking milk all Saturday night. Not drunk nor an alcoholic, the man who has a few beers before climbing the ladder to paint his house may dull his sense of balance just enough to cause a broken neck, but it will not be reported as alcohol-related.
Rates on per capita consumption of alcohol do not necessarily reveal rates of alcoholism. Orthodox Jews, Greeks, and wine-drinking southern Italians have low rates of alcoholism (not zero, as is mistakenly thought) but relatively high rates of alcohol consumption. Some Scandinavian and other northern countries have high rates of alcoholism without overall per capita consumption of alcohol ranking equally high. High consumption rates for convention and vacation cities do not necessarily mean high alcoholism rates for the local citizens.
Another irritation is that statistics on rates of alcoholism among adults do not use a uniform age base. Some figures are based on all people over twenty-one, others on those over twenty, and some on those over eighteen or even fifteen -- making comparisons difficult. Lastly, since research takes time to compile and this is a rapidly changing field, the latest figures are bound to be obsolete before the ink is dry.
Methods of Estimating. One method of estimating the percentage of alcoholics in a given population was the formula developed by E. M. Jellinek (Haggard and Jellinek, 1942) based on deaths from cirrhosis of the liver. Jellinek (1959) himself repudiated the formula. Polling physicians, social workers, and clergymen regarding the prevalence of alcoholism in their clientele may not be very reliable, but it is useful to uncover those who do not get counted in data from agencies explicitly designated as serving alcoholics. Sociological surveys of drinking practices and alcohol problems, using methods like those of Cahalan, Room, and associates, are perhaps the most realistic approach. Community surveys, especially longitudinal studies that follow a group over a long period of time (e.g., Fillmore, 1988; Vaillant, 1983), are the most expensive but the best source of data when properly designed and administered. Even here, getting a representative cross-section for one's sample and standardizing criteria for comparison with other groups present nearly insurmountable problems, while adequate follow-up may require dogged (and expensive) detective work.
With all the above cautions in mind, we shall summarize the literature to substantiate our assertion that alcohol is a large factor in American life and a major cause of problems. For the reasons given, very few statistics here are more than estimates, but the expertise of social scientists is such that they are on guard against pitfalls and skilled in acquiring the most accurate data possible. It is better to lean toward the conservative side, lest we lose credibility. We must resist the temptation to inflate figures in order to impress either the public or legislators, though this becomes a crucial issue when funds are being allotted. Youngsters especially may not believe us on anything if they catch us in even one exaggerated statement.
Number of Alcoholics
In 1993 NCADD put the figure at 12.1 million. Using our working definition but applying it conservatively, one can say as a rule of thumb that alcoholics constitute 4 percent of the general population. In an adult population where at least three-fourths are drinkers, about 6 percent of the total group are probably alcoholic. In groups where practically all are drinkers, as in certain professions or types of work, the alcoholism rate may run about 8 percent, or one in twelve. If we include alcohol abusers as well as alcoholics, the best estimate is 10.5 percent of working Americans.
Those percentages vary markedly by locality and ethnic background, so the chances of developing alcoholism if you drink are not always one in twelve. They may be 1 percent for some and 90 percent for others. These are averages, which can be very misleading when applied to individuals, just as the concept of average temperature is meaningless if we talk about a man with his head in the refrigerator and his feet in the stove.
Among Americans, Eskimos and then other Native Americans seem to rank highest, followed by blacks, Irish, Poles, and those of Scandinavian origin. But again, generalizations are unwarranted. For example, up