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The Debate

Conversations on the subject of alcoholism are interesting because it is a rare subject matter in which we all have first-hand experience. I don’t just mean we know alcoholics. I mean virtually all of us have consumed alcohol. When we discuss subjects like healthcare or capital punishment, we approach these matters in an abstract, intellectual way. Sure, we deal with health issues and the judicial system to some extent, but these are issues that we do not have such an intimate and direct relationship with. But, when we drink alcohol and see how it affects our own lives, we become intimately familiar with the results. Alcohol is different in this way. Understandably, we take our individual experiences with alcohol and drugs and create our own philosophies around it that make sense. What is true for me must be–in many ways–true for you. 

Chemical Abuse vs. Chemical Dependence

We should first clarify what neuroscientists and others in the medical community are calling the difference between chemical abuse and chemical dependence. The term “addiction” is a vague one and for many, it serves no clinical purpose. This may sound like a game of semantics but when we constantly say things like “I’m addicted to coffee” or “I’m addicted to Candy Crush” we create a paradigm that groups all potential addictions together. Addiction is thus reduced to doing something an unhealthy amount of times. There’s just no way I’m addicted to hot tubs in the same way I was addicted to alcohol. While the DSM uses the term “substance abuse disorder,” I’m going to use what research scientist Carlton K. Erikson perfers–chemical abuse and chemical dependence. 

Chemical Abuse is intentional overuse or misuse (think college kids) where the main trait is that people will moderate or stop abusive drinking when they decide the consequences are worse than the desirable effects. This category doesn’t mean bad things don’t result from the drinking or drugs. People who abuse alcohol/drugs can be hospitalized, get DUIs, and ruin relationships. These are the “heavy drinkers” but often times these are the people who go nuts on the weekend, feel crappy on Sunday, and get it together for work on Monday. Alcohol abuse does not necessarily lead to alcohol dependence. One study (Schuckit, Smith, Danko, Bucholz, Reich, et al 2001) found that of alcohol abusers only about 3% of abusers had become dependent after 5 years. Other statistics (10-15% will become substance dependent) may relate to those who use for greater periods of time (longer than 5 years). 

Chemical Dependence relates to a chronic condition driven by a loss of control over drinking characterized by an inability to moderate or stay abstinent even under adverse consequences. It is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving (Savage, Joranson, & Covington, 2003). We will get into how dependence relates to elements like genetics and environment so hold that thought. 

The Divide

I believe this issue (the difference between abuse and dependence) is at the heart of public misunderstanding. It is also at the heart of much of the current scientific research. Many of us have wondered if we drink too much. Maybe when you were 22 you thought your partying was affecting your life so you stopped or cut back. You “get” that alcohol can be tempting but because you could stop, so should others. So the million-dollar question looms: is there any real evidence that suggests that this isn’t just a matter of will-power? The answer it seems, may be,  yes.

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Is “Alcoholism” a Disease?

If you Google “Is Alcoholism a Disease?” you’ll get over 18 million hits. Many of the articles and links that argue it is not, use concepts and research from the 1970s. But excellent scientific research in genetics, neurobiology, and pharmacology in the past 20 years now clearly suggests that chemical dependence is a chronic, medical brain disease, driven significantly by genetic vulnerability (Leshner, 1997). The site of this disease lies in the mesolimbic dopamine system, or “pleasure pathway” or “reward system.” Neuroscientists believe that the function of MDS neurotransmitter systems is disrupted, due to genetic “miswiring” long-term exposure to a drug or more likely, a combination of genetic heritability, drug exposure, and environmental influences. This combination–genetics, exposure, and environment–are the key components in predicting possible chemical dependence. One theory of synaptic plasticity suggests that the repeated use of alcohol in some people create these faulty wirings and over time, this produces real brain-wiring changes. The belief that the mind is a static entity is an old one and if you’ve read anything about the effects of meditation, you’re probably aware of this concept of the changing brain.

When you discuss things like genes, culture, and environment, we’re speaking in terms of probability. Unlike what I thought for a while–that maybe they’d uncover some “alcoholic” gene–genetics don’t work like this. We all have, more or less, the same amount of genes but we have genetic variability that makes us unique. This means there is not going to be a gene that will be isolated that will prove to be the single, all-causing agent in chemical dependence. Instead, we speak in terms of a ‘vulnerability’ to becoming chemically dependent. Still, there may be some gene sequences that greatly enhance risks. Geneticists have put an estimation of 60% of this probability—or susceptibility to chemical dependence—on genes. These genes are believed to affect some physiological component of the brain (probably neurotransmitter receptors) that are associated with the production of “impaired control”– the hallmark of alcohol dependence (Erickson). Genes are related to alcohol dependence because genes form proteins in the brain and in the brain’s neurotransmitter systems, proteins and enzymes (specialized proteins) are involved in the manufacture, release, and metabolism of chemicals that allow brain cells to communicate with one another. When this communication is disrupted between nerve cells in the “pleasure pathway,” dependence on alcohol can occur. This is probably caused by an abnormal gene regulation of protein function (Erickson, 2007). COMBINE this 60% vulnerability with unknown environmental factors, plus exposure to alcohol, you may have the necessary– but unfortunate–recipe to become alcoholic. New research has found that genes for two neurotransmitter receptors are probably heavily involved in all of these. These two receptors, GABA-A and a form of the gene that codes for the serotonin transporter (sounds like a great movie title: The Serotonin Transporter) may produce abnormalities in the mesolimbic dopamine system that cause people to be unable to stop drinking. Another study done by Bowirrat & Oscar-Berman (2005) indicates that people with a variant of the DRD2 gene (a gene associated with dopamine function in the brain) may be more prone to receive pleasure from drinking. Nevertheless, that finding doesn’t point to dependence and there’s no evidence suggesting that people who find more pleasure in drinking end up more likely to become alcoholics.

It Still Doesn’t Seem Right!

Most of us feel that we have an intuitive idea of what constitutes a disease. Nevertheless, it’s not a easy term to nail down. We just know it when we see it. And for a lot of people–myself included–alcoholism just does not seem to fit the criteria of a disease. I believe there is a genetic thing going on…I know people choose to drink…and I get that the environment can impact people but still! Just think about some other diseases. As McLellan and colleagues (2000) point out, type II diabetes mellitus, hypertension, and asthma all include “genetic heritability, personal choice, and environmental factors.” I will admit, I do not hesitate when I call asthma a chronic disease. 

Still, you have people actively putting a substance in their bodies. They are causing all of the problems by their choice. I wouldn’t argue this. You can’t argue it. The difficult thing then is to determine at what point did someone’s alcohol abuse TURN INTO alcohol dependence. If I had that answer, I’d own so many hot tubs. I will say this: I don’t really  care if it’s called a disease, a condition, or a disorder. If there was a spectrum of belief and will-power/morally deficient is on one side of the spectrum and full-blown disease is on the other, my views fall somewhere in the middle. 

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The “Molecular Switch” and Data

Some believe that irreversible changes of behavior due to chronic drug use must have foundations at the molecular and/or structural level and yet this “molecular switch” (going from abuse to dependence) has so far, not been identified (Spangle & Heilig 2005). Also, where in the brain does “craving” for alcohol arise? I can tell you from experience that this phenomenon of craving exists. If I wanted to drink in a given moment, there wasn’t anyone or anything that was going to talk me out of it. No one knows for sure where this insane behavior stems from but one study (Pelchat, 2002) suggests that it arises in the orbitofrontal cortex, a part of the brain behind the forehead.

I touched my forehead and couldn’t find it, so I think I’m cured, guys.  

New brain-scan research is showing that alcohol affects decision-making and judgment (the executive functions of the brain) by reducing activity in the frontal lobes, where such functions reside. It appears that preexisting (or alcohol-induced) impaired function of these same brain areas leads to the disease of alcohol dependence, making it impossible for the person to exert conscious will over drinking behaviors (Erickson, 2007). There’s a lot more research on the brain’s response to drugs and alcohol and if I were getting paid, I’d provide some sources below. I will not. Google the names in parentheses. 

I would like to make clear that there can be some real damage done with semantic games and medical jargon. Some fear that pushing a “disease” agenda leads to making victims out of alcoholics and drug addicts. A counselor I know said that he’s not supposed to use the term “addicts” anymore because of it’s negative connotation and stigma. I think these measures do more harm than good. The effects of words in recovery could be a whole new topic for another day. I’m just curious about what we are learning about addiction and how it works. What is actually happening with people? Why did I almost end my life because of a pursuit for vodka? What actually changed in me that helped me get better? These are questions I sometimes think about, but not too much now, because I haven’t soaked in a while and that’s priority #1. 

There are many questions that continue to plague the medical community.

  • Why do a number of “addicted” individuals spontaneously recover from drug dependence defined by the DSM without formal treatment? (Dawson et al. 2005)
  • Anecdotally, many claim they were “instantly hooked” on drugs or alcohol. Is this false-reporting or does this undermine the research suggesting that brain-wiring changes over time?

There are many more questions to ask and many that I have not answered or addressed. I hope this has been useful for you and if you have further questions or have issues with anything presented, comment on the Facebook thread. I did my best presenting what I have learned and can always benefit from others’ thoughts and insights. This week I’ll begin to explore perhaps the most important and relevant topic for people: recovery. What treatments are available and if this is a truly a disease, what is the best way to approach it individually, and collectively, as a society.