Sunday, November 23, 2014

Alcoholism vs Heavy Drinking: Who's On First?

Individuals and families come to me all the time seeking guidance and answers about their loved ones (or themselves) who have drinking problems.  There is no problem finding treatment providers who have the answers – except that there are many different, sometimes conflicting answers to be found.  Some are based on personal experience.  Others are based on studies – but studies vary a great deal in what they find (and in what they emphasize and how they are designed).

Then there is our own national ambivalence about drinking.  A major film fan, I decided to catch a glimpse of the Hollywood Film Awards recently televised for the first time on CBS.  On hand for commentary were two of the 3 newscasters from CBS This Morning, the only major morning news program that actually emphasizes news.  Yet on this occasion they not only seemed to be auditioning for Entertainment Tonight (does that still exist?) but to join in the frequently mentioned advice to the audience to be sure to drink a lot.  Drinking is apparently the major appeal of these awards, as exemplified by Johnny Depp, who was either very drunk or convincingly acting  very drunk, for our viewing pleasure.  One week later, the same CBS This Morning crew interviewed Dr. Holly Phillips as she noted that heavy drinking, while not equivalent to alcoholism, is dangerous to multiple organ systems in the human body.  No wonder so many people are confused.  I’m confused, and I’ve been working in alcoholism treatment for decades.

On top of that, there’s a new diagnostic manual in town, the DSM 5.  (The criteria used I the CDC study came from the DSM IV, as it was known – Roman numerals are so last year.)  In the DSM 5, the whole distinction between Alcohol Abuse and Alcohol Dependence has been replaced by one diagnosis, “Alcohol Use Disorder,” which can vary in severity.  Well, we’ll see where that goes, but it kind of undercuts the thrust of this study.

The fact is that there seem to be many genes and biological traits that contribute (along with many psychological, life history, and environmental factors) to a person’s problems with alcohol consumption, so that in a sense no two cases are identical.  (Yet one has only to attend a self-help group meeting to realize how much people who self-diagnose as alcoholic do have in common.) 

Perhaps the most crucial feature of those who have been designated alcoholic or alcohol dependent is known as “loss of control.”  The term does not refer to uncontrolled drunken behavior, but rather to the ability to regulate consumption, which most of us do in a relatively automatic way.  Those deemed alcoholic are often unable to do so – once they get 2 or 3 drinks in their systems, they are “off and rolling;” there seems to be no internal feedback loop to shut off alcohol consumption after a certain blood alcohol level is reached.  Although remaining very self-aware may enable a person to override loss of control (that is, to regulate cognitively rather than systemically), it’s not easy and that approach tends to fail over time.  For that reason, many individuals with loss of control over drinking ultimately choose abstinence as the only stable, reliable goal.  Heavy drinkers without signs of loss of control may have a better chance of learning new, less problematic patterns of drinking.

One thing the CDC study seems to be pointing out is that there are many, many people who don’t have loss of control (other other criteria such as tolerance or a pattern of proximate negative consequences of drinking) but drink a lot, enough to be considered “binge drinking” (now defined as more than 4 drinks per occasion for men or more than 3 for women) – and that heavy drinkers, even if not alcoholic, are just as susceptible to the many medical problems associated with too much exposure to alcohol.  These conditions include: 
  •  Liver disease (you knew about that one)
  • Lowered resistance to infection
  • Heart disease and stroke
  • Osteoporosis
  • Breast cancer (a more modest connection)
  • Brain damage (including to the white matter -- new study from Harvard Med School)
For the individual who comes to the office of an addiction professional, the question often boils down to:  I’ve run into trouble with my drinking, but I like to drink; what are my options, what should I do, and how?  This study suggests that it’s not only alcoholics who need to ask themselves those questions.  Answering them often involves another kind of research – the kind you do on yourself, perhaps with a therapist as your co-investigator.