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Guidelines for new contributors
Welcome to alcoholism! To avoid common issues that have arisen in the past, please familiarize yourself with the following commonsense guidelines:
This article is for:
- facts about alcoholism
- facts about all conditions commonly called "alcoholism"
- all sides of alcoholism (biological, social, psychological, legal, etc.)
- standard terminology related to alcoholism
- historical perspectives on alcoholism
- modern perspectives on alcoholism
- a summary of the disease theory of alcoholism
This article is not for:
- unrelated facts about alcohol
- debating the "correct" definition of alcoholism
- opinions on alcohol or alcoholics
- creating new terminology
- advertising alcohol/alcoholism related websites
- debate over the disease theory of alcoholism
Things to keep in mind:
- Please base statements on reputable sources such as published studies and books.
- Whenever possible, cite original sources rather than secondary books/articles/websites.
- "Alcoholism" means different things to different people, if you say "alcoholism" or "alcoholic" make sure the definition you are referring to is apparent.
Forms of Alcoholism
There are at least two forms of alcoholism with no professional differentiation between them. Those who study one of them tend to insist that their form is the one and only true alcoholism, and this has resulted in a great deal of professional disagreement. The following few paragraphs are a description of these two forms based on research performed while writing this article. This should not be considered authoritative, and cannot go into the main article due to "original research" limitations, but I am presenting it here as a guide for those who wish to contribute to the article, to help them understand the considerations that have gone into it.
The first is the psychological/social addiction which comes about during a period of a person's life when alcohol consumption is of significant benefit to a person. This period may be a one time thing (like during college or after a divorce), or it may be a recurring thing (like that semi-annual girls night out or company party). This perception of benefit is often carried over for a considerable time after the benefit ceases to exist. This form of alcoholism can run rampant across the person's life until others help them realize that alcohol isn't providing benefit to match the problems it's causing.
The second form of alcoholism is a physiological condition in which the person's endorphin system convinces them that drinking alcohol is beneficial to them. It is essentially identical to a morphine or heroin addiction (endorphin being "endogenous morphine"), but is triggered by the consumption of alcohol (which releases endorphins into our system), and therefore alcohol consumption is the behavior that it reinforces. This form of alcoholism completely defies logic and sensibility, and often requires severely traumatic consequences to occur before the alcoholic is willing to admit that they have a problem. Even then they are often unable to quit drinking without assistance.
This results in several misperceptions of alcoholism. The most damaging one is due to differences in endorphin production and reception. Only about one sixth of the population is susceptible to the second form of alcoholism. This means that the majority of people who have suffered from the first type don't understand why the second type can't just quit.
In any case, the word Alcoholism does apply to both forms without differentiation, and therefore you will notice a few compromises in this article which are designed to reflect that unofficial duality.
Robert Rapplean 21:53, 28 September 2006 (UTC)
Maybe the form of addiction is related to the substance used? I have heard of no one who has died an alcoholic from drinking beer. All the alcoholics I have known or know of favor spirits. Can anyone contest this? —Preceding unsigned comment added by 24.201.169.149 (talk) 21:26, 3 September 2007 (UTC)
- Please remember to avoid stories about "all the alcoholics I have known" as this is original research and tends to lead to disputes that are difficult to resolve. --Elplatt 22:20, 3 September 2007 (UTC)
peer review/copy editing, October 2006
Originally finding edge into this article via it's Peer Review request, i've finally finished and even done a good deal of copyediting along the way. Some overall comments:
- This article needs forked articles; identification/diagnosis, effects and treatment are all too long & multifacited to not do so. I meant, this article is big, like 30k, and it gets a little tough to stick with the article when it's this daunting. It took me like a week to get through it myself for Peer Review/Copyedit.
- More cites. It isn't usually an NPOV thing, but alcoholism is a very studied condition, and there just isn't any excuse not to have a shit-ton of sources to this baby. Someone might also look around userpages for a substance abuse counselor or something to help with these.
- A lot of the sections seem sort of disconnected; i even caught a few repeats of something that had been said in a previous part of the article. Like a good essay, each needs to lead into each other to make a better flow.
- Stop using that damn word 'result'. ;) Getting 'results' is one thing, but having everything 'the result of this' and 'resulting in that' makes this article seem like a robot.
- As previously mentioned, more diagrams and images would better this article. Also, i know there is a ton of statistics out there, and it'd be great to have this article peppered in them.
Anyways, i've really enjoyed working on this baby, and i'll be around to help it out. JoeSmack Talk(p-review!) 17:55, 4 October 2006 (UTC)
- Thanks, Joe. Your input has been a great help. This article tends to get smacked around a lot by POV hacks, and it's good to get unbiased input on the content.
- Glad to help. :)
- BTW, there's a perfectly good excuse for not having a shit-ton of statistics. The majority of these statistics are performed by someone who's trying to prove their personal theory correct, and they often conflicting with other people's statistics. Reconciling those statistics is something that's of very little interest since there's no hard evidence one way or another and no money to be made by it. Because of this, any comparison of statistics has to be done on the fly, and gets labeled "original research". Not neccessarily a good reason, but a pretty damn good excuse. I'll keep working on it.
- Robert Rapplean 21:26, 4 October 2006 (UTC)
- You might put a little bit in about statistics being varied, and perhaps include a range of them a demonstration of such. Again, don't worry about 'original research' interpretations so much. I think you do a great job, be bold and see where it goes. :) JoeSmack Talk(p-review!) 17:05, 5 October 2006 (UTC)
genetic testing
At least one genetic test[3] exists for a predisposition to alcoholism and opiate addiction. Human dopamine receptor genes have a detectable variation referred to as the DRD2 TaqI polymporphism. Those who possess the A1 allele variation of this polymorphism have a small but significant predisposition towards addiction to opiates and endorphin releasing drugs like alcohol[4]. Although this allele is more common in alcoholics and opiate addicts, it is by itself inadequate to explain the full effect of, or be a reliable predictor of alcoholism.
Which would it be, the small yet significant predisposition, or inadequate to explain/be a predictor to alcoholism? If it isn't significant, the word significant could be removed and it'd be fine. If it is, I'd say how that plays into its role as an indentifier but not a predictor. The wording is just a little ambigious here (one of those wtf moments). JoeSmack Talk(p-review!) 15:51, 29 September 2006 (UTC)
- I think it's a usage issue. Maybe "small but statistically significant" is the proper phrase. It doesn't explain, predict, or identify an alcoholic. A person with this allele may be able to drink alcohol with no addictive results. However, this allele is slightly more common in those who have shown addiction to alcohol than in those who have shown the lack of this behavior. This suggests that, if all other things are equal the existence of the allele encourages people towards alcoholism, but that there are other factors and/or alleles that have a much stronger effect. Would you care to suggest an alternate phrasing that states this better? Robert Rapplean 19:07, 1 October 2006 (UTC)
-
- i find this a little less cloudy:
At least one genetic test[3] exists for an allele that is correlated to alcoholism and opiate addiction. Human dopamine receptor genes have a detectable variation referred to as the DRD2 TaqI polymporphism. Those who possess the A1 allele variation of this polymorphism have a small but significant tendancy towards addiction to opiates and endorphin releasing drugs like alcohol[4]. Although this allele is slightly more common in alcoholics and opiate addicts, it is not by itself an adequate predictor of alcoholism.
screening
i think that the screening section either should be the CAGE questionnaire and one more example, or they all need to be flushed out in more detail. right now it looks like a bunch of edits people crammed together. JoeSmack Talk(p-review!) 16:08, 29 September 2006 (UTC)
P.S. The DSM-IV diagnosis of alcohol dependence represents another approach to the definition of alcoholism, one more closely based on specifics than the 1992 committee definition. - wtf is the 1992 committee definition? not mentioned anywhere else. JoeSmack Talk(p-review!) 16:11, 29 September 2006 (UTC)
- You've done a very good job of fleshing this out. I think at this point we might want to resort to listing them (like in the terminology section) and making sure we provide them with equal coverage.
- The 1992 committee definition refers to something that was pulled out or moved away. Such statements that compare themselves favorably to other statements in the article were fairly common when we had many people contending for dominance on this article, and I haven't fully removed them all yet. This statement should be made to be more self-contained. Robert Rapplean 19:07, 1 October 2006 (UTC)
-
- The standard definition for alcoholism in the medical field is the 1992 committee definition that was here when that paragraph was written. The article, "The Definition of Alcoholism," was published in JAMA on 8/26/92 (Vol 268, #8, p1012) and was the result of work by the Joint Committee of the National Council on Alcoholism and the American Society of Addiction Medicine. The entire definition was part of this article originally and probably should be again: "Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions of thinking, most notably denial. Each of these symptoms may be continuous or periodic." The article goes on to define each term within the definition to a greater extent. For the past 14 years, this definition has been accepted by the medical community and provides the descriptive basis upon which physicians treat addictive disease, alcoholism in particular. Drgitlow 00:58, 18 October 2006 (UTC)
Ah, right. That was part of the introduction that we had such extensive disagreement about. For those who are new to this, you can find much of that argument in Archive 3. The short version is that a lot of it was replaced because it used categorizations that are not comprehensible to the average reader. It also resulted in the moving of the disease discussion to its own page. Robert Rapplean 17:04, 18 October 2006 (UTC)
I would like to suggest the addition of Internet-based alcohol screening resources available as a public service, as they can be very useful. One such resource is AlcoholScreening.org, devleoped by Boston University School of Public Health (full disclosure: I helped develop this website). This site provides screening results based on the AUDIT and U.S. Dietary guidelines for alcohol consumption. There is at least one such site in the United Kingdom based on its health service guidelines, one in Australia, and so on. There are a few such commercial services as well, although I am initially inclined to list only those Internet public service (free) screening sites which are sponsored by a credible source, i.e. a University, qualified health facility, or a governmental health agency. These tools do not exclusively screen for alcohol dependence (alcoholism) but also cover hazardously excessive consumption that may cause future problems or put one at risk for immediate consequences such as accidents. The best ones are nonjudgemental and non-labeling. I am quite willing to contribute this content, but I would appreciate guidance on where and how to do so. Should this be a new item under Screening? Should it go at the end under "see also?" Other suggestions? Eric Helmuth 02:39, 15 November 2006 (UTC)
- Hello and welcome, Eric. I looked through the screening on alcoholscreening.org and think that it's at least as valid as any other screening I've seen, and would be useful for people to confidentially understand how much of a problem their drinking is from an objective perspective. My view would be to just drop the content at the end of the Screening section, with an introductory sentence something like "Many free screening resources exist online...". It will likely be mulled over after that and may be reformatted. I'm not currently very happy with the "list quality" of that section, and would prefer a short paragraph describing the advantages and disadvantages of each screening type, but feel it's important enough to know that online confidential screening exists for this inclusion. Other opinions? Robert Rapplean 19:03, 15 November 2006 (UTC)
- Thanks for the warm welcome, Robert. I can't make the edit right now due to the protected status of the page, so others should feel free to add it if desired; otherwise I'll wait until my account clears. - Eric --WikkiTikkiTavi 02:18, 17 November 2006 (UTC)
-
- I'm now able to edit and have added some minimal information as suggested. Sugggestions for expansion and improvement are welcome. Eric Helmuth
Rationing section
Some programs attempt to help problem drinkers before they become dependents. These programs focus on harm reduction and reducing alcohol intake as opposed to abstinence-based approaches. Since one of the effects of alcohol is to reduce a person's judgement faculties, each drink makes it more difficult to decide that the next drink is a bad idea. As a result, rationing or other attempts to control use are increasingly ineffective if pathological attachment to the drug develops.
Nonetheless, this form of treatment is initially effective for some people, and it may avoid the physical, financial, and social costs that other treatments result in, particularly in the early phase of recovery. Professional help can be sought for this form of treatment from programs such as Moderation Management.
This section to me seems like a long-winded way of saying there are harm-reduction programs (i.e. non-zero-tolerance approaches). This is mentioned in the Treatments section that is short but done pithily. Anyone object to me removing this section? JoeSmack Talk(p-review!) 16:47, 2 October 2006 (UTC)
- 'Fraid so. Rationing is a viable treatment option that is significantly different from the others mentioned. This section provides a good overview of it, as it describes the advantages and disadvantages of this approach. However, We should seriously consider combining that with the "return to normal drinking" section, since they are functionally identical. Robert Rapplean 17:42, 2 October 2006 (UTC)
This section currently says "While most alcoholics are unable to limit their drinking in this way". Is it really most? Or some? Do we need a citation here? -Brian
- Hi, Brian. In reality, the argument tends to be whether the word should be "most" or "all." There's a plethora of evidence that suggests that moderation makes alcoholism worse for most people, and yet there are those for which it works. Some argue that those who can deal with their alcoholism with moderation aren't really alcoholics, but are just people who enjoy alcohol. Even Moderation Management, which leads the call for this form of treatment, insists that their members aren't alcoholics. We actually used to have a citation in here ( Pendery et al. Controlled drinking by alcoholics? New findings and a reevaluation of a major affirmative study. Science 1982 Jul 9;217 (4555):169-75) ) that states this, but I wouldn't want to further clutter the article by include it in that statement unless the consensus was that this statement was controversial.
- So what do we think? Is the statement "most alcoholics are unable to benefit from moderation" controversial? Robert Rapplean 22:23, 22 January 2007 (UTC)
-
- The question comes down to whether an "alcoholic" is anyone who abuses alcohol, or strictly someone with a physical dependence on alcohol. We should avoid the term "alcoholic" and refer directly to the meaning in context, such as "most abusers of alcohol" or "all sufferers of alcohol dependence". --Elplatt 22:36, 22 January 2007 (UTC)
- Um, neither. An alcoholic is someone who has extreme difficulty with not drinking, even when it's obviously harmful. People abuse alcohol all the time for perfectly valid social reasons. If it'll allow you to interact socially, or catch they eye of the girl you like, then it sometimes seems like a really good idea to drink until you're passed out in the bushes. Also, physical dependence suggests alcoholism, but it isn't the disease of alcoholism any more than a bunch of red spots are the disease of measles. It's just an effect that the disease causes.
- In this context, moderation would actually be a good idea for someone who just drinks too much and/or is physically dependent. It would back off of the physical dependence with less damage than detox, and would entirely eliminate excessive drinking. For an alcoholic, though, it increases the urge to drink and results in heavier drinking. -- Robert Rapplean 21:39, 1 February 2007 (UTC)
-
- "someone who has extreme difficulty with not drinking, even when it's obviously harmful" is the definition of abuse. This may be your definition of alcoholism, but some people use other definitions. Whenever possible, we should avoid using the ambiguous term "alcoholism" because things that are true for one definition may not be true for another. --Elplatt 23:37, 1 February 2007 (UTC)
- Please read the terminology section of this article, which has been hashed over rather thoroughly, before continuing this argument. I am more than a little aghast at your suggestion that we should avoid using the term "alcoholism" in the article about alcoholism. - Robert Rapplean 02:45, 2 February 2007 (UTC)
-
- I've read the terminology section. Abuse has a precise medical meaning (as I said). The term "alcoholism" is only defined in the intro, and that definition differs from the one used in many scientific papers. I can see how someone would disagree with the suggestion to avoid using the term "alcoholism" but if you are aghast, you should give the topic more thought. Since this subject is only tangentially related to rationing, I'll start a new subheading. --Elplatt 05:02, 2 February 2007 (UTC)
- Wikipedia is not a medical text. This is a good thing because the medical community is full of conflicting statements that are absolutely certain that their definition of alcoholism is the One True Definition(tm). As it currently stands, this article has suffered the ravages of a physician, a psychiatrist, a neurobiologist, and several AA enthusiasts all simultaneously insisting that their X++ years of education state that alcoholism must be this one thing. At times it's been extremely frustrating.
- Wikipedia attempts to reflect common usage, which includes how people in the non-medical community talk about alcoholism. The definition presented at the beginning of the article is a meticulously gathered consensus based on evidence presented from many perspectives that make use of the word, and represents the operational definition of alcoholism to be presumed throughout the article. Anything else would be nihilism. If you feel that this definition is in error, please review the conversations stored in the archives to identify which specific elements you feel were not adequately explored and present new evidence about them.
- In reference to this specific statement, regardless of the definition of alcoholism, we can UNCONDITIONALLY state that those who suffer from alcoholism are called "alcoholics". While it is, of course, bad style to use alcoholism in a self-referential way in the article (e.g., alcoholism is the problem that alcoholics have), providing characteristics of alcoholics is a fully qualified method of describing the characteristics of alcoholism itself. Therefore it is ludicrous to suggest that we should avoid making statements like "alcoholism is..." and "alcoholics are..." in an article about alcoholism. Robert Rapplean 20:33, 2 February 2007 (UTC)
-
- Stepping in here kind of late, MM's position in regards to rationing approaches is somewhat similar to this: If you are currently drinking, and can successfully use their approach to reduce the *harm* that drinking is doing to your life, it might be worth a shot to try MM. However, if you've been abstinent for a number of years, what is most likely to happen at an MM meeting is people congratulating you on your weekly "ration" of zero drinks, and encouraging you to keep at that level. Even Moderation Management, which leads the call for this form of treatment, insists that their members aren't alcoholics. is a tad misleading, as the general MM party line is that if someone *is* totally unable to modify their behavior, they aren't ready for MM approaches yet, as they simply cannot successfully ration their drinking behavior at all (by definition). In addition, the general MM media stance is that if somebody *is* a self-defined AA "alcoholic" (as compared to a peer defined), MM is not an easy excuse to start drinking again, and MM is probably not a choice that they should exercise. Summarized even further, If you truly match step one of the twelve steps, MM simply will not work. Ronabop 05:38, 28 February 2007 (UTC)
Naltrexone
There are currently two ways that naltrexone is used, and the two are strongly in contention. Naltrexone was ok'd by the FDA for use for alcoholism in 1995.
The FDA site suggests that people not drink when taking naltrexone. It is generally prescribed to alcoholics as a way of helping them maintain abstinance, for which it has a very small effect for some people. There is a great deal of research (see above) that suggests that, on the average, naltrexone has questionable value in maintaining abstinance. As a result most doctors will do one of three things: provide naltrexone with the instructions to avoid drinking, cocktail naltrexone with antabuse to specifically discourage drinking, or avoid naltrexone whatsoever.
Pharmacological extinction specifically requires the alcoholic to drink while on naltrexone, preferably where and when they normally drink. The FDA's standard instructions specifically prevent PE from occuring, and coctailing it with antabuse is even worse. PE has a success rate of about 87% for converting serious alcoholics into people who can forget alcohol exists from one day to the next, and have no problem with drinking socially.
Do you have a reference for this statistic? If true, you would think that the method would be widespread. Thanks.Desoto10 (talk) 06:04, 26 January 2008 (UTC)
Unfortunately, most people think that the drug IS the treatment, and as such the two treatments get confused, very much like what you did in your recent edit. This results in most people thinking that the "naltrexone to maintain abstinence" results reflect on the "naltrexone to cause extinction" treatment. It may take extra explaining to maintain the differentiation. Robert Rapplean 18:07, 2 October 2006 (UTC)
Sorry I screwed up. I hope you fixed whatever it was that I said. Which "recent edit"? Have you found any valid citations for this section?Desoto10 (talk) 22:18, 3 February 2008 (UTC)
genetic predisposition against alcoholism
i recently was leafing through a gigantic substance abuse manual, and found something pretty similar from what i see over at Effects of alcohol on the body article:
Some people, especially those of East Asian descent, have a genetic mutation in their acetaldehyde dehydrogenase gene, resulting in less potent acetaldehyde dehydrogenase. This leads to a buildup of acetaldehyde after alcohol consumption, causing the alcohol flush reaction with hangover-like symptoms such as flushing, nausea, and dizziness. These people are unable to drink much alcohol before feeling sick, and are therefore less susceptible to alcoholism. [1], [2] This adverse reaction can be artificially reproduced by drugs such as disulfiram, which are used to treat chronic alcoholism by inducing an acute sensitivity to alcohol.
i say this info should be injected into this article. what do we say? JoeSmack Talk(p-review!) 06:04, 12 November 2006 (UTC)
I'm inclined to say not. I'm aware of this particular genetic anomoly, and I'm also aware that another side effect is a slightly shorter life expectancy. My thoughts are that, while very interesting, groups who are not effected by alcoholism isn't as germain to the main topic of alcoholism as those who are and why. Also, a genetic anti-predisposition isn't very meaningful to those who are trying to understand the problem. Maybe we can start a branch with this information? Robert Rapplean 19:30, 12 November 2006 (UTC)
-
- I'm with Rob't on this one. The genetic issue isn't relevant to alcoholism directly, but rather to metabolism of alcohol itself. It therefore would fit nicely into the alcohol article (if it isn't already there). I'm not familiar with any studies, however, demonstrating a relationship between this genetic condition and alcoholism. One might speculate, as the person making the statement above did, that individuals with this gene are less susceptible to alcoholism. I suspect that's not the case, however, and would want to see cited studies supporting such a claim before making such a suggestion. Drgitlow 22:33, 29 November 2006 (UTC)
alcohol abuse costs
Im interested in more country to costs ratios, rather than just that snippet on uk, how about how much alcohol abuse costs other countries Portillo 04:31, 25 November 2006 (UTC)
Cultural and social causes of alcohol addiction
There's very little information here on the cultural and social causes of alcohol addiction. I'm not able to understand the contribution process once a topic has been closed, but the information page on alcohol addiction is pretty skimpy. It's evident that there are custodians of the topic here, but I'm not sure if this is the way to forward additional contributions.
Hoserjoe 09:06, 5 December 2006 (UTC)
Hi, Joe. The reason why there is very little on cultural and social causes is because this information is extremely subjective and as such couldn't be effectively summarized. There are a massive multitude of theories about which specific cultural elements contribute to alcoholism, but the only real consensus is that (a) alcohol availability contributes to alcoholism, and (b) attempts to limit alcohol availability only act to popularize its use. You may argue with this, and many have, but this many argue in a broad multitude of directions. This extremely broad argument makes this the subject of books, not encyclopedia articles. Robert Rapplean 18:12, 12 December 2006 (UTC)
- Joe, you raise an interesting point. Most of us live in societies where alcohol is available whether legally or not. This is a social structure. Without alcohol's availability, alcohol addiction wouldn't arise. One only needs to look at the US history of prohibition to see that although that process failed in many ways, it was an amazing success in terms of reducing the direct and indirect costs, morbidity, and mortality secondary to alcohol intake and addiction. So if you want to indicate that a society that promotes alcohol intake, as America's does through advertising and other measures, is likely to have a higher incidence (rate) of alcoholism than a society that does not promote alcohol use, I think that's a valid point. There are also significant cultural variations; there is a good quantity of literature looking at alcoholism in Jews, in Mormons, and in other groups, for the most part demonstrating significant differences. Part of that may well be genetic, but part may be cultural as well. I'm not sure I'd call these social and cultural issues "causes," but they are most definitely "contributors." Drgitlow 04:16, 19 December 2006 (UTC)
Hey, DG. Although I definitely won't argue about advertising and other forms of popularization increasing the use and secondary problems resulting from use, I can say with considerable authority that the US alcohol prohibion increased both of these instead of decreasing them. In 1918, alcohol use was very much on the decline, and in 1933 is was epidemic. By some estimates alcohol use increased more than ten fold in that time period, and there is nobody who suggests that it actually decreased. Robert Rapplean 18:24, 27 December 2006 (UTC)
- Hi, Robert. I'm afraid you're entirely incorrect. I refer you to the American Journal of Public Health, Feb 2006 issue, page 233-243, and JS Blocker's article, "Did prohibition really work? Alcohol prohibition as a public health innovation." I present here a short quote from the article:
- "Nevertheless, once Prohibition became the law of the land, many citizens decided to obey it. Referendum results in the immediate post-Volstead period showed widespread support, and the Supreme Court quickly fended off challenges to the new law. Death rates from cirrhosis and alcoholism, alcoholic psychosis hospital admissions, and drunkenness arrests all declined steeply during the latter years of the 1910s, when both the cultural and the legal climate were increasingly inhospitable to drink, and in the early years after National Prohibition went into effect. They rose after that, but generally did not reach the peaks recorded during the period 1900 to 1915. After Repeal, when tax data permit better-founded consumption estimates than we have for the Prohibition Era, per capita annual consumption stood at 1.2 US gallons (4.5 liters), less than half the level of the pre-Prohibition period."
- Robert, I've never seen any scientific estimates to indicate that alcohol use increased during prohibition. Everything that I found in a literature search of Medline indicates quite the opposite. Happy New Year! Drgitlow 00:50, 1 January 2007 (UTC)
The information that you're posting isn't an accurate measure of alcohol consumption because it's all based on the perception of the officials, and most of it represents the period immediately after prohibition started. The environment at the time was on the pro-prohibition swing if its 70 year cycle, and most areas of the country were already dry by order of local legislation. What prohibition did was put a blanket on all of the country, which largely prevented the dry areas from bringing alcohol in from the wet areas. In truth, the majority of the country really did support prohibition, and went into it with the best of intentions.
Unfortunately, a significant number of people went into it thinking that it would prevent other people from drinking, which was good, not thinking that it would prevent themselves from drinking, which would be bad. In the years previous to prohibition the writing was on the wall that it was on its way, and there was considerable stock piling of alcohol for personal use, kind of like the runs on supermarkets that happen before a blizzard. The black market on alcohol took a while to build up and establish, partially due to lack of demand and partially because it had to build itself up from scratch from close social connections.
There's no surprise that public drunkenness and hospital admissions decreased throughout the prohibition era. That's actually one of the primary health problems with the current war on drugs, that people are unwilling to call attention to their health problems if they're doing something illegal. People generally don't check themselves into a hospital until it's a choice between jail and death, and even then many cut it too close. Forensics weren't up to today's standards and most families were loath to tell the authorities that Uncle Joe drank himself to death, they just say he had a heart attack.
If you want to talk tax records, probably the most telling statistic comes from a count of the number of drinking establishments. In 1918 there were roughly 800 pubs, taverns, and saloons in New York city. In 1933 after prohibition ended, 20,000 speakeasies made an attempt to convert themselves into legitimate businesses. They almost all folded, however, for two reasons. With the legal restrictions removed an individual drinking establishment could be large and obvious, thus having considerable competitive advantage over small, cramped speakeasies. Second, when prohibition ended many people really did stop drinking. It stopped being as elicit and, after a few dozen celebratory drinks, stopped being exciting.
Unfortunately, the self-reported statistics don't tell a full story of what was going on at the time. A good book that you might want to pick up to help understand that time in history is Prohibition : America makes alcohol illegal by Daniel Cohen. Robert Rapplean 20:05, 11 January 2007 (UTC)
Costs of Abuse
I'm puzzled as to why the changes were made to the first paragraph as follows: "Estimates of the economic costs of alcohol abuse, collected by the World Health Organization, vary from one to six per cent of a country's GDP [1]. One Australian estimate pegged alcohol's social costs at 24 per cent of all drug abuse costs; a similar Canadian study concluded alcohol's share was 41 per cent[2]."
This is not an article about alcohol abuse, but rather an article about alcoholism (alcohol dependence or alcohol addiction are other names for the same entity). Alcohol abuse is a different animal with some similarities. It's sort of like having a reference to rhesus monkeys in an article about gorillas.
Any disagreements with moving these entries to a point later in the article and indicating the differences between abuse and alcoholism, or in removing these entries? Drgitlow 04:41, 11 January 2007 (UTC)
- Hi Drgitlow. The sentence in the first paragraph previously read:
- Alcoholism is one of the world's most costly drug use problems; with the exception of nicotine addiction, alcoholism is more costly to most countries than all other drug use problems combinedcitation needed.
- Seeing the tag, I went looking for a source for this statement, i.e. something about the costs of alcoholism to society. Hence the reason for the revision. The reason for the wording is simpler – was not aware of the distinction you point out.
- Am certainly not wedded to the term alcohol abuse, nor to the placement of the information. Why don't you change "alcohol abuse" to "alcoholism" (perhaps if you click on the reference and look at the terms used there you will be able to decide whether these studies are talking about alcoholism or alcohol abuse)? Or move it elsewhere, I don't mind. HMAccount 15:17, 11 January 2007 (UTC)
Hi, HM, and welcome. When I reviewed that edit, I agreed that filling it in with good statistical data was a good idea. OTOH, Dr. Gitlow does make an excellent point about the difference between alcohol addiction and alcohol abuse. The connection between alcoholism and alcohol abuse is somewhat complicated. Alcoholism wouldn't really be a problem if it didn't result in alcohol abuse, but by the same note alcohol abuse isn't just a result of alcholism. Some alcohol abusers are just people having a good time. I don't think that I've ever seen a statistic that calculates "alcohol abuse, but only by alcoholics", and I doubt I ever will. As a result, if we want to show a statistical demonstration of monetary social damages caused by alcoholism, it would need to be embodied as damages caused by alcohol abuse, with the disclamer that this is not a completely accurate measure, just the best available.
This just leaves the question of where we want to put it. The way the text sits, I have the feel that it's probably too much for the first paragraph. Summaries belong there, not full explanations. Can we move it down to Societal Impacts, and just leave a summary there? Robert Rapplean 20:36, 11 January 2007 (UTC)
I know I came late to the party, but here is the spectrum as I understand it: Use, Misuse, Abuse, Addiction, Dependancy, Death. Sometimes I see 'heavy use' in there between misuse and abuse, but definitions seem blury. Use is using at all, misuse is using at times that seem inhibitive, abuse is when it starts to infere with daily life/relationships/work, addiction is usually the embodiment of psychological yearnings/feelings of addiction (can be very intense), and dependency is physical addiction/dependence. Death is of course death. JoeSmack Talk 22:46, 11 January 2007 (UTC)
- Hi, Joe. You use those words as if they exist in a linear continuum, but they don't have the same properties. Misuse and abuse both tend to be subjective judgement calls on a person's behavior. Addiction refers to a psychological inability to not use it, and dependence refers to a condition that leads to negative consequences if a person doesn't use it. This is all layed out pretty well in the terminology section. Robert Rapplean 23:13, 15 January 2007 (UTC)
Criticism by FutharkRed
This may be the poorest article in Wikipedia, from beginning to end, and that is reflected in the discussion here.
One of the most glaring indicators is the decision to bury the most authoritative definition of alcoholism, that of the Diagnostic and Statistical Manual of Mental Disorders, in a spot 1/3 through the article--"The DSM-IV diagnosis of alcohol dependence represents another approach to the definition of alcoholism"--then asserting that the purpose of the definition is to enable clinical research! No, it is not 'another approach', it is that of the highest level of disease classification, by those specializing in the field, and its purpose is to best enable treating said disease. It is the diagnosis used by most in the field, is used in filing insurance claims for treatment, is what is meant, from a scientific point of view, by 'alcoholism'.
That definition is "...maladaptive alcohol use with clinically significant impairment as manifested by at least three of the following within any one-year period: tolerance; withdrawal; taken in greater amounts or over longer time course than intended; desire or unsuccessful attempts to cut down or control use; great deal of time spent obtaining, using, or recovering from use; social, occupational, or recreational activities given up or reduced; continued use despite knowledge of physical or psychological sequelae." That is alcoholism, not what has been tossed around either in this article or this discussion.
Alcoholism has been recognized for some time as a primary, progressive disease, involving addiction to alcohol (with both tolerance for and withdrawal from the alcohol as major defining features). The DSM-IV categorizes it, in fact, among the psychotic disorders. There is strong evidence for genetic factors in susceptibility to the addiction, as well as several distinctions in the ways that alcoholics process alcohol, metabolically and physiologically, compared to the general population.
Negative consequences of drinking are not diagnostic of the disease; inability to stop in spite of such consequences may be.
Socially, alcoholism's effects far exceed those of all other drugs combined, especially inasmuch as it is considered among the leading causes of death. ('Nicotine', as opposed to smoking, is not in the same order of magnitude--how the claims of its 'greater cost' is allowed to stand uncited is another mystery.)
As for the range of its effects, the 19th century suggestion that you could study all medicine, simply by studying the one disease of syphillis, is more than matched currently by substituting the study of alcoholism. It has an unparallelled range of effects, physical and mental, and that holds as well in its effects throughout the population. Estimates of susceptibility to the disease itself range as high as 10% of the population (potential alcoholics); and the effects extend to all those in contact with the active alcoholic, an enormous part of the population, compared with that affected by any other disease.
Given this, how one can choose to seriously discuss alcoholism, the disease, while moving the 'disease theory' elsewhere, escapes me. Who on earth authorized any such travesty? To discuss 'two (professionally undifferentiated) forms' of alcoholism, as is done in this discussion, is nonsense ... to anyone who does know the disease. The former version mentioned here is not considered alcoholism at all, 'professionally'. It may be a problem, true, and one that can use some treatment or prevention (as is an issue, for instance, on many college campuses), but this is not alcoholism in itself. The very way of phrasing much of this, referring to "professional disagreement", leads to the question, as to whence the greater expertise of the current authors arises.
As one among many non-professional indicators, I'd point out that 'endorphins' (which are not morphine-related) have virtually nothing to do with alcohol or alcoholism, popular though the notion may be. Alcohol has its own neurochemical effects, in the first place. The process of alcohol addiction has to do with conversion of alcohol metabolites in the alcoholic to THIQs (tetrahydroisoquinolines), quite similar in fact to the structure of morphine. The addiction itself becomes self-propelling, and requires no positive motivator the further it progresses ... other than the negative one of staving off withdrawal.
Likewise, the notion that the turning point in the disease is when "others help them realize" the negative road they are on, is spectacularly untrue to life. One of the most glaring features of alcoholism, is its long-term imperviousness both to consequences and to the input of others. The single most effective agent in recovering from alcoholism, Alcoholics Anonymous, is in no way based on helping alcoholics realize the negatives involved, which they are all too often aware of (though they may be unaware that alcohol is the cause of the trouble, rather than a failing solution.) It is based on showing that there is a real, positive alternative, such as their own alcoholic thinking suggests is impossible.
As with most diseases, the primary question for most people is, what can be done about it. Here the article is woefully poor. The authors list 5 'mutual help' organizations, for instance, as though they were of equivalent value, although only one has any substantial rate of success in dealing with the disease. Likewise, suggesting 'group therapy or psychotherapy' for "underlying psychological issues" both implies that the alcoholism may be a secondary rather than primary disease, contrary to current thinking, and overlooks the history of failure in that area--aside from such specialized treatment as is aimed entirely at abstention, and generally recommends participation in A. A.
The notion that "the American Psychiatric Association considers remission to be a condition where the physical and mental symptoms of alcoholism are no longer evident, regardless of whether or not the person is still drinking" (emphasis mine) is uncited, unlikely, and contrary to virtually every current thought on the subject. Agreement is effectively universal that an alcoholic cannot drink safely at all, ever again, that the first remedy is complete abstinence--except for the opinion of the authors here. In fact, they uncritically list Moderation Management as a 'resource', along with Alcoholics Anonymous, MM taking the position that alcoholics can learn to drink safely--without noting that MM's founder is herself in prison due to subsequent vehicular double manslaughter, while having a blood alcohol level 3 times the legal limit.
In fact, the entire discussion which is entertained on that question, under the heading of 'Rationing and Moderation', runs counter to any professional notion of alcoholism. There may indeed be "harm reduction" in other areas of drug abuse and addiction--much of the harm of heroin addiction, for instance, is not directly caused by the chemical, as by all that goes with it. In the case of alcohol and the alcoholic, it is the alcohol 100%, and there is no such thing as 'harm reduction' by any form of controlled drinking.
It is a truism that non-alcoholics never even think about "controlling their drinking" ... and that alcoholics, as the disease progresses, do think about it, and can't. At this point, for the authors to even be discussing the issue for more than one sentence, indicates that it is not alcoholism they are speaking of. They should not be writing about alcoholism, at all. FutharkRed 04:04, 3 February 2007 (UTC)
- You know, I don't even know where to start on this. You are so thorougly woefully uninformed about alcoholism that you could only be a medical professional or an AA councilor. Possibly a psychiatrist, as they are the ones who usually insist that the DSM knows all. Pretty much everything in this entire article has been backed up one side and down the other by papers, books, and studies. At one point we had to start clearing off the references because some sentances had more reference marks than they did words. It's not like all of this information was made up by somebody. Please take a look in the archives, and present your own evidence that conflicts with what you see here. We all had to.
- For starters, cigarette smoking kills an estimated 440,000 americans each year, whereas alcohol only kills 80,000 by the same (NIDA) accounting. No, I'm not going to start tallying up wife beatings and drunken bar fights. Endorphin release is a well known effect of alcohol consumption, although most people attribute its addictive effects to the dopamine that the endorphins trigger the release of. By anyone who's actually looked at the statistics, AA is less effective than no treatment whatsoever. Even playing patty-cake has higher success rates than AA meetings. - Robert Rapplean 07:59, 3 February 2007 (UTC) Most people that are in jail are in there for dealing with drugs. 5 February 2007
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- Robert, your comment, "You are so thorougly woefully uninformed about alcoholism that you could only be a medical professional or an AA councilor," is hostile and uncalled for. You're better than that! Drgitlow 19:00, 11 February 2007 (UTC)
- *sigh* Ok, I'll agree that it was hostile and unproductive. Having put untold hours into reconciling the highly varied ideas of what alcoholism is, and having someone spout This may be the poorest article in Wikipedia at us kind of puts me on edge. Nonetheless, I do owe FurtharkRed an apology, that was very unprofessional of me.Robert Rapplean 19:33, 14 February 2007 (UTC)
FutharkRed, I agree with 96% of what you wrote, and indeed the version of this article that I wrote many months ago reflected the standard understanding of the scientific and medical communities that you accurately represent. I was broadly attacked by others here and after several months we compromised on the entire article, which as it stands is tolerable by many but I don't think any of us would say it is accurate from any single perspective. Part of the compromise, which I still strongly disagree with (but I was firmly outvoted), involved the removal of the entire medical understanding of alcoholism as a disease. Ridiculous, I know, but that's the way Wikipedia works.
By the way, the area where we disagree, and I'll be as clear as I can be here: As defined by DSM-IV, there are a variety of symptoms that constitute the disease of alcohol dependence. Note that quantity and frequency of use are not included within these symptoms. That is critically important, as it reflects the fact that alcohol dependence is not defined by amount of use or frequency of use. Now look at how DSM-IV defines remission on p. 196 of the TR edition. Remission refers to the criteria for dependence or abuse, not to amount of use. As a result, one can continue to have substance use but also have remission. That is the way the definition is generally understood by addiction medicine specialists. That said, I of course agree with you that abstinence is required for recovery. The psychiatric definition of disease remission is not equivalent to the medical definition of recovery. In fact, many of us in the medical addiction field don't use the psychiatric definition but rather use the medical one (JAMA 1992 article referred to elsewhere here). So I suspect that you and I completely agree on what's necessary to treat patients, but we appear to disagree on the meaning and intent of the DSM definition, and that's simply an academic question, no? Drgitlow 18:56, 11 February 2007 (UTC)
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- Dr. G., thank you very much. Not just for your kind remarks, and your thoughts on the subject in question ... but for restoring mine to the discussion page in the first place! They were originally appended to the discussion of the lead paragraph, and almost immediately removed by the author of that paragraph, as being beyond discussion!
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Actually, I moved it to the bottom of the discussion page, where it now resides. As mentioned in the comment in history, it opens numerous new discussions based on one that was archived quite a long time ago, and as such deserved its own heading.Robert Rapplean 19:33, 14 February 2007 (UTC)
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- That removal, with the remover's comments, would have had me avoiding work on the article for a long while. I don't refer to the personal slant, but to the absolute lack of objectivity, from what would appear to be the article's lead author! To cite "a medical professional or an AA councilor. Possibly a psychiatrist" as certain sources of ignorance on the subject; to claim that "AA is less effective than no treatment whatsoever"; to remove the disease concept, AMA or APA or otherwise, from the article--all of these indicate an extraordinarily prejucidial approach. And removing criticism in such a manner indicated little chance for a direct approach to the article.
As evidensible here, this is a collection of things that need to be argued individually.
To cite "a medical professional or an AA councilor. Possibly a psychiatrist" as certain sources of ignorance on the subject
We get a very broad selection of people here who insist that their perspective on alcholism is the only possible one. These range from a variety of medical professionals (mental and physical health) to alcoholism councilors, religious fanatics, and outright bigots. There is a lot of vertical information passed within these groups, but not a whole lot of horizontal information passed between them. Those with the largest and most professional groups are the ones who most strongly insist that their view of alcoholism is the one and only true view of alcoholism, and they generally take the greatest amount of evidence to convince them that it isn't as black and white as all that. They take their professional perspective and years of experience as a bedrock to insist that no other group could possibly have a clue about the topic. The resulting arguments can be very frustrating and time consuming.
to claim that "AA is less effective than no treatment whatsoever"
You should have a look at the Orange Papers, specifically their page on effectiveness. I'm not going to say that this is the only perspective that's valid - we try to recognize all perspectives, including this one. Among the many peer reviewed studies that he sites, there's one where they had the patients gather in an AA-like meeting and play Patty Cake. This "treatment program" had statistically identical results to the AA meetings. So I was exagerating when I said "less effective", my apologies, please replace that with "no more effective".
A fair accounting of AA indicates a dropout rate of about 95%. AA doesn't consider these dropouts to be part of their failure rate, but they are nonetheless people for whom the AA program was a failure. This 5% success rate is roughly equivalent to the rates for spontaneous remission, which suggests that AA has no meaningful effect at all. There is an immense body of evidence that supports this idea, and as such we aren't really swayed by arguments that AA is the only effective treatment option. Robert Rapplean 19:33, 14 February 2007 (UTC)
- Just a few notes about this depiction of A. A., and the methods of the article and the discussion.
- It appears that declarations by the American Medical Association and the American Psychiatric Association, with only slight differences in terms and detail, to the effect that alcoholism is a primary disease, are considered of dubious value "for definitive or treatment purposes". On the other hand, something like the anonymous "Orange Papers" web site qualifies for authoritative citation.
Do we have to go through this every four months? FYI, the definition of "Alcoholism is a primary, chronic disease..." was one originally proposed for the opening definition in this article. It was altered severely to what it currently is because anybody who understood the terms primary and chronic probably wouldn't be going to Wikipedia for their information. Unsuitability for the audience had more to do with it than medical, clinical accuracy. As you seemed to have completely missed (and I'm REALLY not enjoying repeating myself today), I didn't say that this is the only perspective that's valid - we try to recognize all perspectives, including that of the AMA and APA. Put another way, we cannot dismiss any of these perspectives if they are supported by multiple clinical studies.
- How does Wikipedia go about weighing sources? Surely there should be something a little better, for such strong declarations? Perhaps the original "peer-reviewed" research papers, if really meaningful and verifiable?
The Orange Papers are really nothing more than a convenient way of referencing a large number of these kinds of papers. I'll make it easy on you and copy the citations that answer the many accusations that you make, making it obvious that you really have no intention of actually considering anyone else's perspective.
- Bearing in mind of course that some of the most famous such 'research' of the past, especially that devoted to proving that alcoholics could learn to drink safely, turned out to be fraudulent.
Logic foul: Hasty Generalization
- But can the "Orange Papers" be considered objective by any standards? ýAgent Orangeý, indeed.
Logic foul: Ad Hominem attack
- Regarding our standards for objectivity, and the citing of sources when a matter might be questioned, how does the expression "a fair accounting" serve for a question such as the effectiveness of A. A? Who is doing the accounting, of what, and how & and, perhaps, why? More bluntly, A. A. being what it is, how could any such "accounting" be done at all? The only records A.A. keeps are of groups that have registered, and a rough survey every few years, to estimate the global numbers and composition of those attending meetings at the time, at the request of social scientists for their own research. The surveys appear to show a fairly steady 2 million people world-wide at an A. A. meeting on a given day, 1.25 million living in the U. S. and Canada. No records of individual attendance or membership are kept at all.
- That is, at no level does A. A. keep the kind of records, or set criteria for 'membership' (which a person might then be said to "drop out" of), or track people that do or don't go to meetings, or set standards of success and failure, that would make any such "accounting" possible, "fair" or otherwise. So on what could such a statement possibly be based? And why is it put in these terms, of ýdropping outý and ýfailureý?
I do wish you would actually read the Orange Papers before maligning them so thoroughly. I quote:
For many years in the 1970s and 1980s, the AA GSO (Alcoholics Anonymous General Service Organization) conducted triennial surveys where they counted their members and asked questions like how long members had been sober. Around 1990, they published a commentary on the surveys: Comments on A.A.'s Triennial Surveys [no author listed, published by Alcoholics Anonymous World Services, Inc., New York, no date (probably 1990)]. The document has an A.A. identification number of "5M/12-90/TC". Averaging the results from the five surveys from 1977 to 1989 yielded these numbers:
* 81% are gone (19% remain) after 1 month;
* 90% are gone (10% remain) after 3 months,
* 93% are gone (7% remain) after 6 months,
* and 95% are gone (5% remain) at the end of one year.
- Along the same lines, how on earth do we know how many people have gone into "spontaneous remission" with "no treatment at all", as specified here? Who are they going to tell, and why? And do they even know it themselves, or consider anything of the sort to have happened? (If it were actually "spontaneous", how would anybody know? And how does one "spontaneously" remit from this sort of condition? It isn't malaria.) There is no science in this at all, no real foundation, just made-up numbers and polemics attacking A. A., which should have no part in framing such an article.
Spontaneous remission is measured by a person not drinking based on their own decision to not drink. Not as scientific as a thermometer, but it's a pretty clear indicator that a person has gotten their cravings under control.
- One of the sad facts is that there is little hard information on treatment "results", period. A. A.ýs survey (which doesnýt measure total membership, just meeting makers that day), is still one of the few such measures around. A study has been underway at Staten Island University Hospital in New York for the past 5 years, but no results are available as yet ý and such a study is a novelty in the field. Very few treatment facilities do any serious follow-up, and such responses as they may get are hardly definitive, even in the short run, let alone life-long. And that is in cases where hard records are kept, where tracking and follow-up would seem natural ... as opposed to the autonomous, amorphous 80,000+ A. A. groups, which keep no such records at all. Yet all of this is being expressed as though there were real research involved.
- Aside from exaggeration in the early days as to its effectiveness ý including plain exaggeration of its members ('100' sounded better than 78 or so, and "rarely ... fail" was meant to be encouraging to the newcomer) ý A. A. claims no "success rate". How can they, when success is measured "one day at a time", and when the active alcoholic population remains so huge? Above all, A. A. most certainly does not claim to be "the only effective treatment option." Where did that come from? And how does it enter this discussion?
Your original statement was "The single most effective agent in recovering from alcoholism, Alcoholics Anonymous...". Others have suggested that it's the only effective treatment option. Neither of these is even close to true. For starters, the doctors in the Contral clinic in Finland are seeing 25% of their patients in complete abstinence and 87% of their patients reduce use below cellular damage levels after a three month treatment, with a 99+% retention rate, and a 50% maintenance rate in five-year follow up studies. AA doesn't even retain 25% much less have them all be abstinant at three months.
- This is the whole problem with all of these criticisms. You cite a single clinic in Finland and unsubstantiated percentage rates, and hocus pocus like "below cellular damage levels". I am sure the founder of MM had usage "below cellular damage levels" for a while, but she ended up back in prison. AA, on the other hand, has 73 years of proven recovery by its programs adherents. Many who stay sober for a lifetime. No other program can say the same. To equate short-lived and minor recovery programs with a phenomenon like AA, which has spawned literally hundreds of groups patterned after it, is patently ridiculous.
- AA doesn't lend itself to scientific study, because unlike other programs it 1) doesn't take attendance, 2) relies on self-diagnosis, 3) takes all comers, and 4) doesn't follow up or measure anything. This makes it easy to shoot at for pompous academics. And boy do they shoot. That is OK, because AA doesn't care. But it makes Wikipedia look stupid to have an article equate a worldwide organization with millions of members with splintered personality cults having a few thousand.
- But most professionals in the field do seem to find A. A. the best available choice for their clientele.
Logic foul: argument Ad Populum (appeal to popularity)
- People who don't go to meetings are not considered "failures" by A. A. ý why should they be? And how do our "fair accountants" know whether they (A. A. or individual) have "failed" in any given cases? Who is keeping count, and what are the standards? If they had gone to meetings, but stopped going and stayed sober, they are successes. If they didn't stay sober (after going to A. A., and then "dropping out"), perhaps they should have stayed!
Actually, that's one of the funniest things about AA effectiveness, is that the various studies indicate that staying in AA has absolutely no effect on a person's likeliness to fall off the wagon, and those who stay in AA are more likely to engage in binge drinking.
"A Controlled Experiment on the Use of Court Probation for Drunk Arrests", Keith S. Ditman, M.D., George G. Crawford, LL.B., Edward W. Forgy, Ph.D., Herbert Moskowitz, Ph.D., and Craig MacAndrew, Ph.D., American Journal of Psychiatry, 124:2, August 1967, Page 163
"A RANDOMIZED TRIAL OF TREATMENT OPTIONS FOR ALCOHOL-ABUSING WORKERS", The New England Journal of Medicine, Volume 325, pages 775-782, September 12, 1991
Jim Orford and Griffith Edwards, 1977, Alcoholism : a comparison of treatment and advice, with a study of the influence of marriage, Oxford [England] and New York : Oxford University Press, ISBN: 0-19-712148-9
The Natural History of Alcoholism: Causes, Patterns, and Paths to Recovery, George E. Vaillant, Harvard University Press, Cambridge, MA, 1983, pages 283-286.
- It would make more sense, come to think of it, to cite as A. A. "failures" those who did not "drop out", but still drank with disastrous consequences!
Odd that you should mention that...
Outpatient Treatment of Alcoholism, by Jeffrey Brandsma, Maxie Maultsby, and Richard J. Welsh. University Park Press, Baltimore, MD., page 105
- In fact, A. A. is generally not considered "treatment" at all, but mutual help, a very different thing. (Which has been known to upset some treatment professionals over the years.) Given that the only membership requirement is that a person want to stop drinking, and that the central method (according to the A. A. Preamble) is that they do it together ... the real test with the "Patti-cake" group would not have been, how they "succeeded" as compared to A. A., but as opposed to trying to stay sober alone, presuming they really wanted to do so. With something as blatantly insulting as this 'experiment', though, I can't even imagine the patients' state of mind. And to cite this nonsense as meaningful here, with "statistically identical results" ... for how long did they continue to play Patti-cake? for how long did they not drink? And again, statistics "identical" to what ý since we've already seen that the A. A. statistics were themselves made up out of thin air?
- Evaluating the "success" of A. A. is difficult as can be, but evaluating its "failure" is absurd, and useless. A few fairly objective statements can be made, I believe, on the positive side.
- In the first place, a great many people obviously have gotten sober in some part through A. A., in addition to whatever "spontaneous remissions" there may have been in the past 71 years, compared to the dismal prospects for recovery before that time. Whatever addition A. A. made to that recovery rate, certainly merits some serious investigation. There has been nothing else comparable.
Yet another quote from the Orange Papers:
The first mistake was in assuming that because some people recover in A.A. rooms, that they recover because of Alcoholics Anonymous. That is assuming a cause-and-effect relationship where none may exist. We can, with equal validity, say, "I know that people recover in hospital rooms that are painted green -- I've seen it with my own eyes. So the healing effects of green rooms are an established fact."
- Second, A. A.'s notion that some sort of disease was involved in the alcoholic condition, and their success in using that concept to maintain sobriety, has led not only to basic research confirming the idea, but above all to treatment of many sorts, such as was not the case before. [As a corollary consideration, just as the tobacco companies hired scientists to prove that smoking was a "life style choice", rather than a profound nicotine addiction over which they had no real control, there is a great deal of insurance money at stake, in denying that alcoholism is "really" a disease.]
"AA said alcohol is a disease first, therefore AA is an effective organization"? Are we still talking about their effectiveness in curing alcoholism, or just listing their glories?
- Third, well before the advent of group therapy, A. A. showed the great usefulness of such "mutual help", in dealing with what had been considered a hopeless condition, and which since has proved applicable to almost anything.
- Fourth, A. A. inspired, informed and helped populate the treatment field, with its contributions to successfully treating alcoholism and other addictive diseases.
- Fifth, the members of A. A. are simply a tremendous resource, for dealing with this disease. Given the profound despair that alcoholism instills in those who suffer from it, the members of A. A. give living proof that living sober is attainable for anyone that wants it. That is, seeing is believing, and especially in the numbers and variety that A. A. affords. And since the members' understanding of the key to staying sober is to help others do so as well ý the famous 12th Step ý this fits together quite well. FutharkRed 11:15, 15 February 2007 (UTC)
Logic foul: Begging the Question. The last three statements suggests that AA is a great organization because its model of treatment is so effective. The effectiveness of the treatment is the primary issue that we are arguing.
[Here continueth the entry by Futharkred of 2/12/07:]
- On the other hand, once calmed down and objective again myself, and willing to put the necessary work into the subject, I would have approached Wikipedia's overseers directly, to remedy the situation. The subject is too important to leave it in such a condition; and that very importance could also reflect on Wikipedia's own reputation as a source of objective knowledge.
Quite aside from the usual measures of the importance of alcoholism--morbidity, mortality, economic impact, social consequences, and so forth--I recently came across a novel indicator, which really puts it in perspective. That is, the author of a book on using English around the world offhandedly presents the statement: "the word drunk holds the record for having the greatest number of synonyms--2,231." Dickson's Word Treasury (Paul Dickson, Wiley, 1992), as cited in Do's and Taboos of Using English Around the World, p. 20 (Roger Axtell, Wiley, 1995)] World-wide, it appears, this has been the human condition most on people's minds, for a long time.
As for our 4% 'disagreement', there really should have been none. I apologize for not having re-checked the DSM before adding that statement; it's been several years since I looked at it. I agree with your view, that there does seem to be a peculiarity in perspective and terminology on the part of the APA, with its phantom "remission", which does reduce its usefulness in treating the disease. Perhaps they also suffer constraints, though, in being used for insurance purposes ... such as a qualified version of "remisson" would not have served? And on the matter of frequency and quantity of drinking, as diagnostic requirements, I likewise agree completely, they are not of the essence, just potential clues.
You seem to have an excellent approach to this subject, and I'd be glad to work with you on improving the article. Previously, there seemed no useful point in even reading it in detail, let alone thinking of how to re-work it. Who else is currently engaged in this? You speak of a 'majority' decision to exclude the disease concept, even as a working definition of what "alcoholism" is. In rejecting the majority views in the treating fields of medicine, psychiatry, counseling, and A. A., on what higher authority does this majority base its claims?
The key ingredient, I do believe, would be restoring the primacy of the disease concept, both for definitive and organizational purposes. Without that disease concEpt, aside from lack of scientific objectivity and practical usefulness, you wind up with an incoherent mess, encyclopedically! FutharkRed 23:01, 12 February 2007 (UTC)
- The argument of whether or not to classify alcoholism as a disease has absolutely no impact on identification or treatment. Which label we happen to stick on it is tangetial to the understanding of the problem. It's actually a mostly political issue, argued in congress to determine if they're going to provide funding for treatment. Personally, I believe that it's a disease. Regardless, the argument about it was completely consuming the alcoholism article, distracting from the things that would actually be useful to people suffering from the problem. It deserved it's own article, and you can argue the point till your blue in that location. If you can come to a solid conclusion there, then you have my word that this article will reflect the results of that argument. Robert Rapplean 19:33, 14 February 2007 (UTC)
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- I agree that classification has political ramifications, but there are health and societal ramifications as well. For example, if alcoholism is a disease, then it should be treated by physicians and other healthcare professionals just as any other disease is. If alcoholism is a disease, then an individual would not be blamed by society for having that disease. Of course, personal responsibility is important for this as for other chronic disease states (e.g. someone with juvenile diabetes needs to monitor their blood sugar, eat properly, take insulin as necessary, etc.). If alcoholism is NOT a disease, then there's little reason for these individuals to be medically monitored and treated, and society can attach responsibility fully to the individuals so afflicted. We wouldn't be having this discussion for any other disease; that alone indicates that alcoholism still carries a great deal of misplaced stigma. Drgitlow 20:48, 14 February 2007 (UTC)
Ok, I've done some thinking, and here's the problem. We have to produce a peice of text that faces up to the dual nature of the word alcoholism. From my perspective, the success of pharmacological extinction in Finland pretty effectively demonstrates that for your archetypical alcoholic, the problem is very much a physiological condition that can be treated medically. Thus, it is a disease. And yet there are also numerous people out there who have sensibly done the cost/benefit analysis, and are continuing to drink irresponsibly large amounts because they don't want to admit that the problems it's causing have increased beyond a managable level. For these people, it's not a medical problem - it's a behavioral maladjustment. Not all people have the strong endorphin response that results in the first type of alcholism, but some of those who don't will still wind up drinking beyond the reasonable level. How do we reflect this? Robert Rapplean 15:48, 15 February 2007 (UTC)
- I completely agree. I think the first step is to compile a list of distinct usages of alcoholism that are common enough to mention. Perhaps a new section would be best for this? --Elplatt 22:18, 15 February 2007 (UTC)
I'd love to, Elplatt, but anybody of any professional standing who has anything to say about alcohol pretty well insists that it must be one or the other. More to the point, they state that their thoughts on the matter are the only ones that make any sense. This makes the idea "original research", which is verboden on Wikipedia. Even if we could find someone who professed this philosophy, it would still be a drop in the ocean of disagreement. I'm open to ideas for remedying this. Robert Rapplean 03:57, 16 February 2007 (UTC)
Let's have some optimism. We don't need to resolve the disagreement, just represent it. I've come across plenty of published discussions of the conflicting views on alcoholism. If different authorities make different claims about alcoholism, presenting them separately shouldn't count as original research. In any case, creating a list of the different views can't hurt. I'll begin a new section on the discussion page for it, but I'm open to further suggestions about if and how they should be incorporated into the article. --Elplatt 04:55, 16 February 2007 (UTC)
Suggested Terminology Changes
As most contributors to this article know, terminology is a serious obstacle in writing intelligibly about alcoholism. The general public, the scientific community, and different portions of the medical community all have their own definitions of alcoholism, which are largely incompatible with each other.
The approach taken by the authors of this article so far has been to present "a meticulously gathered consensus based on evidence presented from many perspectives" according to Robert Rapplean. Such an approach is at best misleading.
A consensus on the definition of "alcoholism" does not exist. Any reference material used to support the statements in this article was written with a particular definition of alcoholism in mind, and the statements they make may or may not be true for the definition used in this article. The fact is, any statement about alcoholism can only be understood in the context of the author's definition of alcoholism.
For instance, a 1989 study by the Canadian government found that 77% of alcoholics recovered without treatment. However, when one reads the study it becomes clear that their definition of alcoholic was a problem drinker, or someone meeting the DSM IV criteria for alcohol abuse (rather than alcohol dependence). This information is vital to interpreting the results of the study.
There is an easy way to please everyone and present accurate information. The article should accurately reflect the common usage of the term, and plainly acknowledge that there are many common usages, not construct an artificial and misleading consensus definition.
Furthermore, although definitions of alcoholism vary, the definitions are based on factors with much more well accepted definitions. These factors are the ones described in the Terminology section of the article. In the past I've suggested that the current authors stick to these well defined terms and avoid making statements about "alcoholics" or "alcoholism," and have been met with some opposition. However, if you can't understand why I would recommend against saying "alcoholics are..." please first ask yourself why the Nigger article doesn't contain the phrase "niggers are..." (I don't intend this statement to be derogatory towards anyone, but rather to point out that some terms can't be used to make factual claims). --Elplatt 21:49, 6 February 2007 (UTC)
- You make some very valid ponts, Elplatt, but I'd disagree that there is no consensus on the definition of alcoholism. In fact, there is broad consensus within the medical community (the 1992 JAMA article referred to in the text is one of the better examples of this, as is DSM-IV itself) as to what alcoholism is. What you are, I believe, referring to, is the lack of understanding of that consensus outside the professionals and organizations that came together to settle upon this definition. And as you point out, even in the scientific community there are many who lack understanding. This isn't totally unusual, and other well-defined diseases like diabetes and hypertension have both broad consensus and many who disagree with or who lack understanding of that consensus. Indeed, even in the alcoholism treatment community, we often gather to discuss our differing perspectives and views regarding definition, treatment, prognosis, and so forth. That is routine for any science where understanding is gradually improving as technology and research advance. Indeed, though, we can make broad statements based upon available research that indicates typical disease course for those with alcoholism; the statements won't apply to all, but will apply to a majority. It's like saying that the blue spruce grows to 50-100'. Not all of them will, but that's a typical final height for the tree. Drgitlow 18:45, 11 February 2007 (UTC)
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- Regarding the terminology, and whether to change it, Dr. Jellinek apparently proposed at one time to introduce the term "Jellinek Syndrome" as a clinical-sounding replacement for "alcoholism", precisely to avoid the negative connotations of that name. This was a good many years ago, when "alcoholic" was still mainly pejorative rather than diagnostic, but even then the notion was politely put aside ... by the sober alcoholics. Being sober, they felt no such opprobrium in the name, and in fact felt it helped to hit the issue directly, rather than try a euphemistic finesse.
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- This sense seems to have been correct. These days, objection to the term is more commonly confined to those who object: "But that would mean I couldn't drink any more!" For those who want to stop, it is more often accepted with a sense of relief. [A sense of delight in the case of one young fellow, whose first experience with it was hearing an attractive nurse refer to him as "acute alcoholic". He opted to stay for treatment, and then to stay sober, even after getting the terms straightened out.]
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- On a lighter note, in the 1940s there apparently was some strain between A.A.'s New York office and some West Coast members, the latter feeling they weren't getting the proper sort of support ... at which point some of the latter threatened to set up on their own, under the name of "Dipsomaniacs Anonymous". "Alcoholic" looks better all the time! FutharkRed 11:53, 15 February 2007 (UTC)
Forms of Alcoholism Revisited
Different authorities in the field of alcoholism use the term "alcoholism" to mean different things. This discussion topic has been created to compile a list of the many definitions of alcoholism. This section is not for proposing new terms or debating which definition is best, or "correct," which would be original research. So please feel free to add or correct definitions to best match what you have come across in the published literature.
In my reading, I've come across the following different uses of the term alcoholism:
A - Any drinking in spite of negative consequences, including by choice, referred to as "problem drinking" in some medical literature.
B - Drinking despite negative consequences because of a compulsion / loss-of-control. This is more or less equivalent to DSM-IV "alcohol abuse."
C - Drinking progressively more despite negative consequences to relieve withdrawal symptoms. This is more or less equivalent to DSM-IV "alcohol dependence."
In my reading, every description of alcoholism has fallen pretty close to one of these three categories. Please suggest any changes or additions that might be necessary. --Elplatt 05:40, 16 February 2007 (UTC)
- Thanks for getting this started. I would be elated if this could be incorporated in the article. For easier reference, I have labeled each of the three conditions A, B and C.
- What you've laid out in A, B, and C correspond to psychological, neurochemical, and physical addiction to alcohol. Each of these is a real and demonstrated phenomena, and needs to be dealt with individually when treating a patient. It can be very confusing because the three are mutually self supporting. Neurochemical addiction, for instance, will artificially enhance a drinker's perceptions of the positive aspects of drinking resulting in a strengthening of the psychological addiction. Physical addiction will prevent a drinker from digging in their heels and halting the addiction process through a cold turkey technique. Psychological addiction will convince the drinker that drinking is beneficial, allowing the other two to get their foothold.
- I agree with A and B, but most of the doctors I've talked to insist that C just doesn't happen unless A and/or B exist first. Essentially, C becomes a secondary reinforcer for A and/or B. Also, I don't think that anyone considers an alcoholic to be cured of alcoholism once they've gone through detox, which does effectively cure C. I believe that the DSM refers to both A and B as dependence, whereas physical medicine refers to C as dependence. Dr. Gitlow, can you weigh in here? Robert Rapplean 17:17, 16 February 2007 (UTC)
It's quite possible that there is some overlap between these different definitions, I didn't mean to give the impression that there wouldn't be. I'm more concerned with identifying different meanings of "alcoholism" and there may not be a one-to-one correspondence between a meaning and a particular physical/psychological condition.
Type A was meant to include all kinds of problematic alcohol use. It certainly includes what you call "psychological addiction" but it also includes people who aren't addicted at all, and simply drink in spite of negative consequences by choice. For instance, plenty of people willingly drink to get drunk throughout college (often with negative consequences), and "settle down" after graduating.
I think type B would include both the psychological and neurochemical addiction you referred to. My main point with B was that the drinker's body responds normally to the alcohol, but for some reason they still have extreme difficulty controlling their drinking. When psychologists write papers comparing "internet addiction" to alcoholism, this is what they're talking about. This also seems to be Dr. Gitlow's definition. Are there groups that refer to psychological addiction but not neurochemical addiction as alcoholism (or vice versa)?
Which brings me to C. I meant C to specify that the drinker's body responds differently to alcohol. Some references refer to alcoholics as having an marked higher tolerance to alcohol right off the bat. You're right that this should include recovering alcoholics. So perhaps it's not the state of dependence, but the inability to drink without becoming physically dependent.
Thoughts? --Elplatt 18:21, 21 February 2007 (UTC)
- A few thoughts. (A) seems to me to be a parent category of (B) and (C). I wouldn't say that (B) necessarily involves a difficulty in controlling drinking, as it's often the result of a lack of recognition that drinking is a problem for them. It's more of a grand state of denial. (C) is also known for denial, but mostly because it is usually found with (B) in its earlier stages and provides (B) with chemical reinforcement. Robert Rapplean 02:49, 26 February 2007 (UTC)
I agree with the comments on denial. I'm beginning to think that both B and C fall into the AMA definition of alcoholism, while A is the common usage. Perhaps the big distinction in the article should be between common alcholism and AMA alcoholism. Further info about different views and subclasses of AMA alcoholism could go in an AMA alcoholism section. I also think that facts about studies and reasearch should be classified under AMA alcoholism, while most history should be under common alcoholism. Does that sound reasonable? --Elplatt 19:36, 26 February 2007 (UTC)
Revised list, 02/26/07, per RR:
A - Any drinking in spite of negative consequences, including by choice, referred to as "problem drinking" in some medical literature. This includes both addicted and non-addicted states.
B - Drinking despite negative consequences. A normal physical response to alcohol, but denial of negative consequences.
C - Drinking despite negative consequences. Extreme difficulty controlling drinking augmented by a tendency to become physically dependent.
- There are still a few holes in the plan. I don't think that B falls into the AMA alcoholism category. For medical practitioners, there is a very strong delineation between B and C. Those that fall into B generally don't require much treatment because consuming neuroinhibitors is a self correcting behavior. Because of differences in body chemistry it's a self reinforcing behavior for those in category C. You can see the biggest difference in non-social drinking habits. Those in category B will readily overdrink around others, but generally don't drink much when alone unless there's something like depression triggering it. For those in category C, drinking is valuable as a solitary activity with no need for other contributing factors. Drinking results in an e