ADDICTION & RECOVERY

Mark Lender

Alcohol is legal and popular in America, but it's a powerful, often addictive drug that kills 100,000 people a year and costs the country $166 billion every year.
The romantic, devil-may-care aura surrounding this significant component of our culture is overshadowed by the fact that alcohol is a primary cause of 100,000 deaths a year in the United States, about one-fourth of all hospital admissions, and $166 billion in annual economic losses.
Although a majority of Americans enjoy drinking and successive generations have incorporated some degree of alcohol use into their lives, many have found it to also be a source of health problems, addiction, social disruption, and personal tragedy. Today, perhaps 14 million Americans (about 1 in every 13 adults) have some magnitude of a drinking problem, and around 8 million are actual full-blown alcoholics.
According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), part of the National Institutes of Health, over half of the U.S. population has family members or close relatives with drinking problems.
Alcoholism defies easy definition. In the 1990s the U.S. lost billions of dollars in lost productivity.considered it a disease and, while not using the term, an addiction. The classic statement on the subject was An Inquiry Into the Effects of Ardent Spirits on the Human Mind and Body (1784), by Benjamin Rush of Philadelphia. Rush was perhaps America's foremost physician, and he had no quarrel with beers and wines, which he believed healthful in moderation, but he argued that "ardent spirits" (distilled liquor) could eventually cause illness and death.
He called chronic drunkenness a disease that led drinkers through an addiction process, and he identified alcohol as the addictive agent. Once an "appetite" for spirits had become fixed, Rush claimed, drunkenness was not a vice, for the imbiber had lost control over drinking. Instead, the alcohol controlled the drinker. With differences in detail, this disease conception has survived into the present. The modern definition of alcoholism also includes four key components.
One is physical dependence, characterized by withdrawal symptoms following episodes of heavy drinking. When he stops drinking, the alcoholic can suffer from shakes, nausea, agitation, sweating, or combinations of these symptoms.
Another element is craving (Rush's "appetite"), the compulsion to drink.
This is coupled with loss of control, the inability of a drinker to stop drinking once started. Finally, tolerance is the alcoholic's need for larger quantities of alcohol in order to feel its effects.
In the current definition of alcoholism--as in Rush's formulation--the inability to control the need for alcohol is the crucial factor. Willpower has little chance in the face of craving or loss of control.
Yet most problem drinkers are not alcoholics. They may drive while under the influence, miss work or lose friends because of their drinking, or experience alcohol-related health or other difficulties. These are serious matters; if drinking behavior involves any of them within a single year, some authorities define it as alcohol abuse, which has created as much concern as alcoholism.
In the nineteenth century, many business managers became temperance advocates
Alcohol abuse can involve some signs of tolerance. But without craving, loss of control, and dependence, problem drinking-as dangerous as it may be-is not actual alcoholism.
Henry Ford, a prohibitionist at one point in his career, did not believe that drinking could coexist with operating automobiles. Indeed, the public safety aspect of alcohol abuse remains an important issue quite apart from the matter of alcoholism; witness the modern activities of Mothers Against Drunk Driving.
Alcohol abuse can involve some signs of tolerance. But without craving, loss of control, and dependence, problem drinking--as dangerous as it may be--is not actual alcoholism.

CAUSES OF ALCOHOLISM

At some point, an alcoholic simply loses the ability to stop drinking. But why? Aside from moralistic explanations popular among early reformers, the chief focus of many researchers has been heredity.
Since at least the nineteenth century, many writers noted that alcohol problems seemed to run in families. In the late 1800s, the Association for the Study and Cure of Inebriety, comprising mostly doctors and asylum managers, believed that alcohol changed human cell structure, which initiated craving and the transmission of the addiction to future generations. The science and its conclusions were wrong, but such early theories at least helped put alcoholism on the scientific agenda.
The modern alcohol research movement began in the early 1930s, with achievements in biotechnology and genetics allowing some of the most interesting advances in the last two decades. Genetic studies have indicated that there is a hereditary element in alcoholism. Perhaps 40 to 60 percent of alcoholism is due to genetic predisposition.
While genetics may explain why certain individuals are especially vulnerable to alcoholism, it is not an absolute predictor. Environmental factors, including demographic, religious, social, and cultural influences, play a role. The drinking behavior of family, friends, or religious or ethnic groups and the availability and price of alcohol can affect individual drinking patterns as well as local rates of alcoholism and alcohol abuse.
As of the late 1990s, two-thirds of the population used alcoholic beverages in some form. Annual per capita consumption now averages about 2.18 gallons (a figure that measures consumption of actual ethyl alcohol, the psychoactive chemical present in alcoholic beverages, excluding water and other ingredients.) Of the drinkers, however, about 10 percent consume half the alcohol, meaning that a sizable minority of Americans drink heavily. This consumption level represents a modest decline from earlier in the 1990s and is one of the lowest levels in the last four decades. In the 1790s, per capita consumption was probably around 5.8 gallons and climbed to just over 7 gallons by 1830. This was serious drinking, and many contemporaries expressed alarm over what they saw as a socially damaging national binge.
The temperance response to heavy drinking patterns helped moderate consumption over the mid-nineteenth and early twentieth centuries. For the only time in American history, national Prohibition (1920 to 1933) helped reduce the consumption level below one gallon per capita, and most drinking-related social and health problems (including alcoholism) declined as well. But as public antipathy to compulsory temperance grew, so did illegal drinking. After repeal, consumption quickly reached levels roughly similar to those of today.

THE IMPACT OF PROBLEM DRINKING

Abusive drinking can harm almost every bodily system: It increases the risk of heart disease and cancer, especially in the mouth, throat, and upper digestive tract. It reduces the efficiency of the immune system, leaving problem drinkers more vulnerable to infectious diseases, and it is the leading cause of liver diseases, particularly cirrhosis. Alcohol is also a threat to the unborn: between 4,000 and 12,000 babies are born every year with symptoms of fetal alcohol syndrome.
Alcohol can be a killer. Problem drinking and alcoholism, according to the NIAAA, are primary factors in some 100,000 deaths each year. The NIAAA says that, by the mid-1990s, the annual economic costs of alcohol abuse and alcoholism were in the order of $166.5 billion. Alcohol ranks behind only tobacco and high-risk activities as the leading cause of preventable mortality, also accounting for about one-fourth of general hospital admissions every year. The health toll of drinking, then, is huge.
The NIAAA says that, by the mid-1990s, the annual economic costs of alcohol abuse and alcoholism were on the order of $166.5 billion. Over 66 percent of these costs derived from lost productivity due to alcohol-related deaths and illnesses, with another 13 percent stemming from alcoholism treatment and other alcohol-related medical expenditures. Remaining costs were linked to vehicle accidents (about 9 percent) and drinking-related crime (just over 8 percent).
The impact of alcohol on families has been a long-standing concern. Over the late nineteenth and early twentieth centuries, for instance, the Women's Christian Temperance Union campaigned under the banner of "home protection," which struck a chord with thousands who had seen the drinking of breadwinners impoverish families or destroy them through alcohol-related domestic violence. Current estimates indicate that over 1.5 million children have an alcoholic parent. For the vast majority of alcoholics, the safest course is abstinence, which is the goal of most treatment efforts. In general, alcoholism seems to respond to treatment about as well as most chronic health disorders.
Once withdrawn from alcohol, and with proper social support, alcoholics can stay sober for years--indefinitely, if they remain abstinent. (Though there have been cases of diagnosed alcoholics returning to nonabusive drinking, treatments based on controlled drinking or other nonabstinence goals remain controversial.) Most treatment takes place on an outpatient basis, but serious cases can require an institutional setting. After prolonged drinking, treatment usually involves detoxification, the process of ridding the body of alcohol. A number of drugs, notably disulfiram (marketed as Antabuse) and naltrexone (trademarked as ReVia), can help some alcoholics avoid relapsing. Virtually all treatment efforts involve some form of counseling to help alcoholics cope with their condition.

ALCOHOLICS ANONYMOUS

Most treatment programs include participation in Alcoholics Anonymous (AA). Since its founding in 1935, the program has helped hundreds of thousands of alcoholics reach and maintain sobriety. AA calls itself a "worldwide fellowship of men and women who help each other to stay sober," and membership is open to all on a nonsectarian basis.
From the beginning, anonymity was the key to upholding the ideals embodied in the Twelve Steps, which offer participants a guide to coping with their own drinking and helping others. In AA's view, anonymity subordinated personalities to principles and avoided outside interference in the group's concerns. Regular meetings of local fellowships, which featured the personal stories of member alcoholics, served to assist participants in the practical application of the Twelve Steps.
AA's self-help idea was not new. As early as the 1840s, and continuing into the early 1900s, members of the Washington Temperance Society (usually called the "Washingtonians"), various reform clubs, and dry fraternal lodges (such as the Sons of Temperance) also used a mutual-assistance approach to sobriety. Like AA, these groups offered drinkers social stability, a common understanding of their powerlessness in the face of alcohol, group meetings, and assistance if they relapsed.
For all its accomplishments, however, AA has its critics. Its strong spiritual emphasis is not for everyone, and its insistence on abstinence has drawn fire as well. Still other critics want the fellowship to drop its anonymity, arguing that AA members cannot serve as role models for recovery unless they are publicly visible. Early in its history, there were complaints that the group was oriented narrowly toward white, middle-class drinkers. In response, AA can justifiably say that it never claimed that its approach was for everyone. Moreover, it would make little sense to give up anonymity: It has been one of AA's strongest attractions, and abandoning it for any reason would risk putting off many who otherwise would benefit from the organization. If the public needs role models, there are plenty of celebrity alcoholics who regularly bring their stories to the media. AA also has demonstrated an ability to broaden its base and now functions well among black, Hispanic, and other minority groups. Over time, it has consistently produced more impressive results than any other alcoholism treatment program, although it seems to work best in conjunction with other medical and counseling efforts.

PREVENTION

Modern prevention efforts are varied, incorporating legal initiatives, such as stricter DUI (driving under the influence) laws and requiring warning labels on liquor bottles, as well as educational measures, including alcohol education in the schools. But prevention efforts, especially education, seldom work quickly.
Raising the minimum drinking age to 21 has substantially reduced traffic fatalities. Various alcohol education programs have aimed to help students delay taking up drinking. This delay is critical, as research indicates that most individuals who escape drinking problems before 21 will likely never experience them.
Mark Lender is professor of history and associate dean of the Nathan Weiss College of Graduate Studies at Kean University in Union, New Jersey.
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