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Contents 1 Opening paragraphs 1.1 Common ground 1.2 Manual of style: lead section 1.3 Intro, second half 1.4 Important points to cover 1.5 Comments on Developing a Strategy 1.6 Formatting 1.6.1 Blood tests 1.7 Do we really need to be Citing another encyclopedia? 1.8 Tobacco, not alcohol, is most widely abused substance 1.9 Why we don't use the word "dependency" in our primary definition 2 Terminology Section 2.1 A Psychiatrist's definition of abuse 2.2 Taking a stab at dependence 3 Identification and Diagnosis section 3.1 Diagnosis 3.2 A removal 3.2.1 Diagnosis 4 Treatment Discussions 4.1 Curing by moderation (Reposted comment from archive) 4.2 Regarding Pharmacological Extinction 4.3 Edits on Detox section 5 References Section 5.1 The following removed as no evidence of being cited any more 6 Things which impact the entire article 6.1 APA vs APA 6.2 Systemic geographical bias 6.2.1 Globalising this article 7 Conversation between editors 7.1 Regarding recent edits 7.2 Please be more careful 7.3 Alcoholism Discussed in Popular Media by Alcoholism Experts 7.4 Talk Page Discussion 7.5 Mirror site? 7.6 Our assertion about early onset of drinking 7.7 Holy Snifters, Batman! 7.8 Gabbard 7.9 Terminology in epidemiology section 7.10 Request for clarificiation on recent edits 7.11 Looking for more information on Allele testing 7.12 Rephrasing 7.13 2nd paragraph 7.14 Point that needs work 7.15 Addiction 7.16 images 7.17 sinclair method/Pharmacological extinction 7.18 Blossoming list of detox drugs 7.19 Forms of Alcoholism Debate 7.20 WITCH BURNING

Opening paragraphs

Common ground

For background on this decision, see Archive3

I think we're very close to something useable and it's just a matter of a couple of words. Let's try to find the common ground between these two:

1. Alcoholism is the consumption of alcoholic beverages—which contain the drug ethanol—to the extent that such use causes physical or mental harm, or interferes with the drinker's normal personal, family, social, or work life.¹² Such chronic use causes a diseased condition marked by psychological and physiological disorders.
2. Alcoholism is the urge to consume alcoholic beverages to an extent that results in physical or mental harm, or interferes with the drinker's normal personal, family, social, or work life. The resulting chronic use can result in many psychological and physiological disorders.

What about this:

• 3. Alcoholism is the consumption of, or preoccupation with, alcoholic beverages to an extent that such use causes physical or mental harm, or interferes with the drinker's normal personal, family, social, or work life.³⁴ The resulting chronic use can result in many psychological and physiological disorders.

Opinions? --Doc Tropics ^{Message in a bottle} 20:23, 6 July 2006 (UTC)

Note that "addictive medical condition" is one of two major meanings, the other being "chronic excessive drinking". A person who no longer drinks could be considered an "alcoholic" under the first meaning, while a frequent, heavy, deleterious drinker who does not appear to satisfy the medical diagnosis can still be considered an "alcoholic" under the second meaning.

Clearly, it seems that the medical diagnosis is currently prevalent in the field, but the fact remains that all general sources do include that other meaning and it is not necessarily clearcut to distinguish between the two.

The primacy of the medical diagnosis may also be a recent phenomenon: The OED, 1989, whose definition appears to be primarily based on the 19th-century meaning, has alcoholism: "The action of alcohol upon the human system; diseased condition produced by alcohol." All of the quotations, spanning 1852 to 1882, indicate the "excessive drinking" meaning, not the "addictive medical condition" meaning. If the article is to be specifically about the modern medical definition, then that needs to be explicitly stated, and the other definition still warrants mention as it is the origin of this meaning. —Centrx?talk • 21:53, 6 July 2006 (UTC)

It sounds like we need to add a section for "Historical treatments of Alcoholism", or maybe "Historical views of Alcoholism". It seems reasonable that the main article would deal with contemporary views, but there is a lot of historical info that would be interesting and useful. --Doc Tropics ^{Message in a bottle} 22:18, 6 July 2006 (UTC)

There's no question that alcoholism has been redefined over the years. One of the reasons for the 1992 JAMA article was as an attempt to bring consensus to an area that had previously been fraught with multiple perspectives. If anyone had said that there's poor consensus in defining alcoholism, I'd be the first to agree. Still, I think it is reasonable for us to use more recent definition sources, at least for the first paragraph, then potentially explore earlier ones later in the article. The '92 definition does not talk of excessive use or of craving or of urges. The first paragraph above labelled "1." works. So does the third one, because preoccupation is spoken of in the DSM-IV definition. The second one doesn't quite fit. When you get right down to it, alcoholism is the repeated use of ethanol despite one's best interests. But we can't really say that, can we? Drgitlow 23:38, 6 July 2006 (UTC)

Heh, heh...if we could write the whole article at that level we'd be done in an hour. It seemed that there were hang-ups with both versions 1 and 2 so I tried to distil the commonalities into #3. --Doc Tropics ^{Message in a bottle} 00:40, 7 July 2006 (UTC)

I think you did an excellen job, Doc. Does everyone else find definition #3 to be acceptable?Medical Man 01:15, 7 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

Agreed! Yes. Drgitlow 01:30, 7 July 2006 (UTC)

Agreed! (#3 is excellent and has my full support) Mr Christopher 14:34, 7 July 2006 (UTC)

Agreed. Robert Rapplean 23:35, 7 July 2006 (UTC)

Needless to say, I'm thrilled that we seem to be achieving something like consensus on this. I'm just waiting to hear from R. Rapplean before making any changes to the article itself. I'd also like to hear from Centrx, but he's a busy guy and his contributions may be infrequent. My thanks to all of you for being willing to work together and compromise for the sake of the article. --Doc Tropics ^{Message in a bottle} 15:38, 7 July 2006 (UTC)

In a brief exchange on his Talkpage, Centrx?talk expressed "no serious objections" to the proposed intro and suggested that we might as well proceed. I'm going to make the change in the article now, but if anyone, especially Robert Rapplean (who didn't have a chance to comment yet) does have a serious objection, then we can revisit it. Otherwise, I think we're ready to tackle the next sentence :) --Doc Tropics ^{Message in a bottle} 18:06, 7 July 2006 (UTC)

As mentioned I am in favor of door number three, but based on the history of this article, I'd really like to get Robert's opinion/buy off on this prior to making any changes. Again, based on the history until Robert buys off I do not feel we have consesus and for us to make changes without his opinion, if nothing else, looks bad. Mr Christopher 18:21, 7 July 2006 (UTC)

Sorry for taking so long to get back to this - had a bit of a busy 24 hours. I believe that this is a workable compromise, although I'm not the least bit opposed to "alcoholism is the repeated use of ethanol despite one's best interests". We could fill in the details in later sentences. Robert Rapplean 23:35, 7 July 2006 (UTC)

Thanks Robert. I agree that we can fill in the details later in the article, both on that, and other topics as well. I think this constitutes "full consensus" for our little workgroup (O we band of brothers) so I'll go ahead and make the change. --Doc Tropics ^{Message in a bottle} 23:40, 7 July 2006 (UTC)

"Marked by...disorders" means both that it results in these disorders, but also that it can be caused by these disorders, such as with a depressed person using alcohol to drown his sorrows. That is, the disorders may be found together with alcoholism, not only as a direct result of it. —Centrx?talk • 01:16, 8 July 2006 (UTC)

Manual of style: lead section

Manual of style, a guide not a policy suggests:

In general, specialized terminology should be avoided in an introduction. Where uncommon terms are essential to describing the subject, they should be placed in context, briefly defined, and linked.

Thought this might help. You all are making real progress. Keep up the good work. --FloNight ^talk 15:40, 6 July 2006 (UTC)

Intro, second half

I'll copy in the remainder of the intro below this (I took the liberty of bluelinking "disease"). I wanted to offer an observation about cites: Cites are a good thing in any article and a necessity in a complex article, but the presence of 7 cites at the end of a single sentence suggests that a rewrite might be in order for the sake of clarification. Regarding the actual content of these sentences, I have no problems with what's being expressed there, but this is where your collective expertise is so important: is there a general consensus that this is a good representation of the issue?

• Most medical clinicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors and characterized by compulsive drinking with impaired control, and preoccupation with and use of alcohol despite adverse consequences. However, the disease theory is still controversial and there is disagreement on the issue after 200 years of debate. U.S. Supreme Court decisions, books and scientific journal articles demonstrate this lack of consensus.

Yes, why don't you pare down the references to what you think appropriate. Thanks,Medical Man 18:58, 7 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

I'm going to be in a meeting for the rest of the afternoon, but I'll check in this evening. If no one else has started by then I'll have a go at it. If all 7 cites are necessary (I haven't read through all yet) then I would look at simply re-arranging things so that it's a bit tidier. My initial thought is that having more than 2 cites per statement ends up confusing rather than clarifying the issue. --Doc Tropics ^{Message in a bottle} 19:14, 7 July 2006 (UTC)

Gentlemen, I do not feel we have consensus yet on the first section/sentence yet that sentence has now been changed in the article which puts Robert in an awkward position should he object to it. I can't speak for Robert and I think "preoccupation" is an excellent compromise but he has yet to chime in and has expressed specific concerns regarding the opening sentence/para. Respectfully, can we wait for consensus on the first section before pressing on to the next? Mr Christopher 19:24, 7 July 2006 (UTC)

No problem. And I don't think Robert should feel diffident about voicing any objection(s) he might have.Medical Man 20:09, 7 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

My apologies if I jumped the gun. I reverted myself until we have full consensus. --Doc Tropics ^{Message in a bottle} 20:53, 7 July 2006 (UTC)

Thank you both :-) Mr Christopher 20:55, 7 July 2006 (UTC)

While waiting for RR to get back to us, I followed the link to MOS which Flonight provided for us (above) and based on the guidelines there, I have a sketchy proposal for the second half of the intro (not even the actual words yet; just an idea about what needs to be there):

1. Trim down what we have now to simply mention the epidemiology/controversy exists. Save all the details for the main body of the article.
2. New sentence re: diagnosis and treatment. As above, this should be a brief mention without going into details.
3. New sentence re: societal impact, politics and public health.

This is just my first thought after reading through things again. Any input? --Doc Tropics ^{Message in a bottle} 23:28, 7 July 2006 (UTC)

Let me back up a little and rewrite this (without compromising my thoughts at all) segment. Obviously, there will be disagreement and we'll need to compromise...one problem here is the definition of "medical." Rather than trying to define that, I'd stick with using terms like "physicians." The other problem is this whole "controversial" thing. I know MM has posted extensive references to there being a controversy, but even the Supreme Court isn't a medical resource and the other evidence cited is not from peer-reviewed literature in the medical field. The fact that sociologists have a different perspective is important to underscore. The fact that the legal system has a different perspective is also an important area to cover. But we shouldn't confuse people into thinking that their physicians are uncertain or are still arguing about something that they've long ago agreed upon. That's been my whole gripe from the start. MM has made clear to me how extensive the controversy is, but it still hasn't crossed the line from the lay public into the physician community.

Here's where we're starting:

• Most medical clinicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors and characterized by compulsive drinking with impaired control, and preoccupation with and use of alcohol despite adverse consequences. However, the disease theory is still controversial and there is disagreement on the issue after 200 years of debate. U.S. Supreme Court decisions, books and scientific journal articles demonstrate this lack of consensus.

I'd go here:

• Addiction Medicine specialists consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors (I'd leave out the rest of the sentence because we just gave the definition in the last paragraph). However, the disease theory is still controversial outside the physician community and there is disagreement on the issue after 200 years of debate. U.S. Supreme Court decisions, books and scientific journal articles demonstrate this lack of agreement.

Drgitlow 23:43, 7 July 2006 (UTC)

I actually think that the 3rd sentence is essentially "details" that should appear in the main text rather than intro. I'm also wondering if we can "dumb-down" the first category a bit; I'm not at all sure an average reader will grok Addiction medicine specialists and WP doesn't have a page by that name to explain it. What about this:

• While Addiction Medicine specialists consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors, the disease theory is not universally accepted, and still considered controversial by some practicioners, even after 200 years of research and debate.

I'm not convinced I'm giving enough to each side here, but I've got a pretty thick skin, so go ahead and slap me around :) --Doc Tropics ^{Message in a bottle} 00:07, 8 July 2006 (UTC)

Healthcare professionals, Physicians, Addiction Treatment Professionals, Addiction specialists, Doctors, Clinical specialists in addiction, Clinicians, Addiction Therapists, Addiction Counselors...every one of those is a different group of people, but I provide this list just so we can pick and choose what we want to say. Addiction medicine specialists are board-certified addiction specializing physicians, just as Family Practitioners are physicians who are board-certified in Family Practice. But I think you're right that it's not a known entity like Internist or Surgeon or Psychiatrist. Even within medicine, many doctors think that addiction specialists are psychiatrists...they're not. About 40% of addiction specialists are indeed psychiatrists but the rest aren't. You're just trying to get me to start a new article on Addiction Medicine, aren't you?! :) Drgitlow 00:54, 8 July 2006 (UTC)

(Couldn't resist...started an Addiction Medicine page!) Drgitlow 01:00, 8 July 2006 (UTC)

LOL, it worked didn't it? I've added the shiny new bluelink and changed my contrib to match. --Doc Tropics ^{Message in a bottle}

I do not know if it is accurate, but a previous argument was that physicians agree on 'disease' but that alcoholism counselors were much more divided? —Centrx?talk • 01:22, 8 July 2006 (UTC)

That's roughly the impression I have at this point, but I'm waiting to hear more from the actual experts. --Doc Tropics ^{Message in a bottle} 02:16, 8 July 2006 (UTC)

I'd like to make the following observations:

• It doesn't seem accurate to say that "physicians agree" that alcoholism is a disease given the fact that at least one in five doesn't agree and with some evidence that the proportion of those who disagree may be higher. I think we could honestly say that the majority agrees.

• It would seem to be incorrect to assume that the AMA speaks for American physicians. Its membership has declined over the years and is currently only about 244,000 of the 800,000 active US physicians. At best, it can be said to speak for only about 30.5% of active US physicians.

• If we get too narrow in our reference group and report something like "X% of American psychiatrists whose practice is primarily devoted to treating alcoholics define alcoholism as a disease...," then we've provided an unintentionally misleading definition for readers.

• I think the evidence supports a statement to the effect that smaller proportions of other treatment professionals accept the disease concept. If we try to be too specific about different categories within that rubric (see Drgitlow's list above and his observation about physician confusion about who does what to whom) we'll complicate matters and confuse readers -- and perhaps ourselves!

Here’s a suggested revision based on Drgitlow’s draft: Most physicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors. The disease theory remains controversial, however, especially outside the physician community and there is disagreement on the issue after 200 years of debate. Medical Man 03:40, 8 July 2006 (UTC)

Wow MM, great input and many excellent points! In fact, they tie in neatly with something I wanted to bring up. There is some heated discussion on WP regarding systemic bias and "U.S.-centrism" in our articles. I think that the more we can "globalize" this article the wider its appeal will be. I'm not suggesting something silly like dropping all cites from the AMA...but maybe we could avoiding referencing too many American organizations in the main text, or try to tie-in with some international organizations. This is just a little something to think about, I don't see it having a major impact either way. Your latest revision of the intro looks good to me; the syntax of the second sentence seems a little awkward because it has been revised so many times, so I might suggest a minor tweak there. Otherwise, I'm good with it! And I'm putting it in bold below this so it doesn't get lost. --Doc Tropics ^{Message in a bottle} 04:02, 8 July 2006 (UTC)

Thanks, Doc. I'm surprised that there's controversy about the obvious US-centric focus of most articles. In the controversies section of our article we can mention the fact that the disease theory generally receives less support in many other parts of the world. This pan-world matter is something we may want to keep in mind as we work on the piece.Medical Man 16:27, 8 July 2006 (UTC)

• Most physicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors. The disease theory remains controversial, however, especially outside the physician community and there is disagreement on the issue after 200 years of debate. Medical Man 03:40, 8 July 2006 (UTC) reposted by Doc Tropics ^{Message in a bottle} 04:04, 8 July 2006 (UTC)

Medical Man is absolutely correct to say that while the AMA may be the "voice" of American Medicine, it no longer has adequate membership to put the necessary oomph into its message. That said, the way the AMA develops policy is through a representative system made up of delegates from medical state and specialty societies. THOSE societies have much greater membership, and the specialty societies are probably much closer to 100%. So the AMA policy was established based upon a vote of the delegates from the other societies, not internally by its own members. One of the really strange things about the AMA is that if you're an AMA member but NOT a member of a state or specialty society, you actually have no voice at all within the AMA policy-making body. Another oddity is that the AMA could have no members at all yet would still represent American Medicine due to its house of delegates. That's a big reason why the AMA remains a powerful lobby in Washington (for good or bad) despite their primary membership being what it is.

I disagree with Medical Man's statement about physicians in which he notes that at least one in five doesn't agree. That was the result of a single non-random survey and an unvalidated source. I'm not saying it's not possible that the survey results aren't representative of physicians in general, but I'm saying it's highly unlikely. The type of survey that was conducted is the usual step that might be taken prior to conducting a research-oriented random survey.

But...and here's the best part...I'm pretty comfortable with MM's suggested revision. I'd probably amend the last sentence slightly to read: The disease theory remains controversial primarily outside the physician community, where there is disagreement on the issue after many years of debate. Drgitlow 04:05, 8 July 2006 (UTC)

• Medical Man 03:40, 8 July 2006 (UTC) reposted by Doc Tropics ^{Message in a bottle} 04:04, 8 July 2006 (UTC) and by Drgitlow 04:07, 8 July 2006 (UTC)

I would like to propose a one word edit to Drgitlow's streamlined revision:

Most physicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors. The disease theory remains controversial primarily outside the physician community, and there is disagreement on the issue after many years of debate. Medical Man 16:27, 8 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

By the way, is it at all controversial that alcoholism falls into the addiction category? Don't we want to say that alcoholism is one of the addictions, and that most physicians also consider it a disease? Or is that getting way too picky? Drgitlow 04:10, 8 July 2006 (UTC)

Heh, heh, I would not have said "...way too picky", but now that you mention it... :) Seriously, remember that our Hypothetical Reader has (at best) a high school education. As long as we can communicate the basic ideas in an understandable manner we'll be doing good. I'm quite content to go with either your version, or MM's, unless someone else wants to incorporate more changes into either one. --Doc Tropics ^{Message in a bottle} 04:18, 8 July 2006 (UTC)

Drgitlow, I think your hunch that the point might be a little too involved (I won't say picky) is correct. Perhaps that would be one of the many controversies discussed elsewhere in the article.Medical Man 16:27, 8 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

I am going to make a suggestion in a new section below this one. This will in no way compete or take away from the existins tactical discussion you folks are having here. 06:02, 8 July 2006 (UTC)

Doc, I agree that we try to keep potential readers in mind. As you indicate, their reading level may not be so high as we might assume. We will probably have failed is we don't accurately and effectively communicate with most readers, many of whom will probably be junior and senior high school students.Medical Man 16:27, 8 July 2006 (UTC)

I'm comfortable with MM's edit of the two sentences above. Drgitlow 18:05, 8 July 2006 (UTC)

So what we have so far is:

Alcoholism is the consumption of, or preoccupation with, alcoholic beverages to an extent that such use causes physical or mental harm, or interferes with the drinker's normal personal, family, social, or work life.[3][4] The resulting chronic use can result in many psychological and physiological disorders. Most physicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors. The disease theory remains controversial primarily outside the physician community, and there is disagreement on the issue after many years of debate.

I'm going to recuse myself of this portion of the discussion. I believe I've already more than adequately made my point that the disease discussion is a categorization of the problem, not an actual description or explanation of it, and will not significantly benefit the audience of this article. As such, it should exist as a subsection, or even in a separate article. That said, I believe that the rest of you are well on your way to consensus and I'll leave that decision to you. Robert Rapplean 20:16, 8 July 2006 (UTC)

I am in great disagreement over the change in direction of this definition. We went from describing what alcdoholism is and somehow got side tracked into an article about doctors opinions and non-doctor opinions and we're making some all inclusive claims again. That sort of thing erodes credibility. Again, I think we'd be wise to discuss an objective othwerwise we're going to get side tracked as it appears we are doing now. Just my $02. Mr Christopher 00:38, 9 July 2006 (UTC)

That's OK...let's back up then. I think Chris and Robert have important points here. Why don't the two of you rewrite the first few sentences to satisfy your point about our being sidetracked. If I understand, the first two sentences are OK, and then the next two need to be removed from the intro, with the topic revisited elsewhere in the article. So what should be the next two sentences of the introduction instead?Drgitlow 23:22, 9 July 2006 (UTC)

Important points to cover

Instead of attempting to hack prose, let's have a bit of brainstorming regarding what pieces of information people would want to know regarding alcoholism. I'll start it out. Robert Rapplean 18:27, 10 July 2006 (UTC)

• Is or results in uncontrollable drinking
• is not entirely under the drinker's control
• Has many causes, all of which work towards encouraging a drinker
• Has many treatments, few of which can boast high success rates
• Is very controversial
• Most people have strong opinions which prevent them from considering the whole picture (so get multiple opinions if you want a balanced viewpoint)
• Is not completely understood by anybody

I'd do this a little bit differently, as follows:

1. A functional definition of alcoholism
2. The epidemiology of alcoholism
3. The typical course of a case of alcoholism
4. Available treatment methodologies and their outcomes
5. Brief discussion of related conditions (alcohol-induced mood disorder, etc.)
6. Possible causes (and I'm putting this down lower because it's an area that has no definitive explanation and many potential explanations)
7. Controversies

It is important to recognize that nearly all disease states have extensive controversy - what is the REAL cause of juvenile diabetes, for example. You'll see extensive controversy in the scientific literature regarding the RIGHT way to progress scientific research to determine how to cure diabetes (something we haven't achieved yet because we still don't know the entire mechanism). And yet the entry about diabetes doesn't say "is not completely understood by anybody" or "is very controversial." If we're really putting together a NPOV, then it's important to truly be neutral. The medical field is as comfortable with its position on alcoholism as it is with hypertension or cancer, which is to say there is much uncertainty accompanied by confidence regarding the current approach and treatment methodologies as being the best currently available. This isn't an article about the controversies; rather it is an article about alcoholism. I'd therefore suggest that we keep the controversies but not place them throughout an otherwise well-educated entry. Drgitlow 20:19, 10 July 2006 (UTC)

I agree that we need to keep controversies in perspectives. On the other hand, I think there's good reason why there haven't been great controversies (at least beyond the research community) about juvenile diabetes. JD has no history of being considered the result of moral failure, inadequate willpower, degenerate character, or lack of religious faith. Those who suffer dibetes haven't been accused of wasting their family income, abusing their spouses, neglecting their children, costing the taxayer unnecessary expense for treatment, or engaging in violence and crime because of their disease. Concern over diabetes has never led to a national prohibition against the manufacturing, distribution or sale of sugar. And the list of differences goes on and on.Medical Man 02:55, 11 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

On #2, Could you better define epidemiology for me? Robert Rapplean 22:49, 10 July 2006 (UTC)

Sure. Epidemiology is a branch of public health which covers the study of incidence, distribution, and control. Typical areas of epidemiologic research include the percentage of the population impacted by a given condition, the distribution pattern and possible cultural and geographic implications, the cost of not treating to the public, the cost of treating to the public, and so forth. So a typical entry for epidemiology of a disease might say: "x% of people suffer from abc, with y% of those individuals ultimately dying of their illness. A greater percentage of those in the northeast have abc than those in the southwest. It is unclear as to whether this is the result of environmental conditions or of other factors. Due to extensive complications of abc, the cost of treatment averages $z per patient per year." and so on. Drgitlow 23:13, 10 July 2006 (UTC)

The article should also address the etiology or cause(s) of alcoholism. Epidemiology is typically the first step in trying to understand a disease. However, we have much better confidence in our understanding once we know the actual physiological proceses at work. HIV/AIDS provides a good example. The first step was epidemiological; who was suffering the disease, where did they live, where did the disease spread geographically and demographically, what common characteristics did suffers have, etc. But that was preliminary. Next came research to understand the physiological processes at work. That then permitted good pharmacological research on the disease.Medical Man 02:55, 11 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

Ok, I think we need to take a step even further back and ask who our audience is. I think we can rule out medical professionals -- they have much better references for such a thing. As such, I think that the epidemiology should be deprioritized because that's largely useful to people who have to deal with many cases of it. It shouldn't be entirely removed, though, because it is of interest to our audience from the perspective of "how common is this". We also want to include social impact, obviously, and be able to give an overview to someone who wants to volunteer to facilitate for groups that help alcoholics.

Instead of "The typical course of a case of alcoholism", can we approach that from the perspective of "How to identify alcholism"? I think that the content would be very similar, but that the later would be a question that your typical reader would want answered.

I definitely like the "available treatment methodologies and their outcomes", but as Medicine Man hinted at above, I feel that we need to first describe the many factors involved with a person's decision to drink, and that they all need to be addressed for a treatment to be effective. Can we move "Current theories on the causes" above that? We should definitely mention that the lack of ability to identify a single cause makes treatment of it very difficult and often unsuccessful. Although this information isn't firm, I think it's important to know before people consider available treatments.Robert Rapplean 17:59, 11 July 2006 (UTC)

1. A functional definition of alcoholism
2. How Alcoholism is identified
3. Current theories on the causes
4. Available treatment methodologies and their outcomes
5. Epidemiology (includes societal impact), but we should use a more reader-friendly word
6. Brief discussion of related conditions (alcohol-induced mood disorder, etc.)
7. Controversies
8. History

I don't disagree with your rearrangement, but I'm worried. How alcoholism is identified depends in large part upon how it is defined, which depends upon which model one follows. Under the medical model, alcoholism is diagnosed, fairly simply, with reference to the disease description in any of a number of textbooks (such as the DSM-IV). Those who disagree with that model, however, would have other approaches which, in some cases, don't include diagnosis at all. So we might want to go this route:

1. A functional definition of alcoholism
2. Theory 1

1. Who supports this theory
2. How to identify
3. How to treat
4. Potential complications

1. Theory 2

1. How to identify
2. How to treat

and so on until you get to the controversies section. Drgitlow 19:15, 11 July 2006 (UTC)

I only disagree with this because it suggests a false dilema about which theory is most accurate. Pretty much everyone agrees, for instance, that peer pressure and believe that alcohol consumption provides value to a person's life are definitely components in the addiction. The moral incompetence theory, on the other hand, has wide acceptance and poor scientific support. Pharmacological extinction has the reverse condition. Nonetheless, I happen to know various people who would probably fall into all three categories, and require treatment for each of them. Additionally, treatment methods don't just target a single cause. AA, for instance, goes head to head with the moral issue, and treats the neurochemical addiction by providing its members with "supplementary fortitude". Antibuse treats the neurochemical addiction via counter-stimulation when the drinker drinks. I believe that the Betty Ford clinics treat the physical dependence through detox, and provide life counciling to try to convince the person that they don't want to drink, and then teach the person how to distract themselves from the craving. Pharmacological extinction relieves the person of the craving naturally, and deals with the dependence by allowing the drinker to reduce his intake over time.

All of this means that there's significant overlap between the theories, so we can't seperate them out as cleanly as that. This is why in the original article I separated out the three forms of addiction that alcohol causes, and then was planning on describing how each treatment deals with each form of addiction. Does that make sense?

As far as "how it's defined" is concerned, I think we can stick with "continued drinking after negative consequences become obvious" and describe how to identify it from that perspective. A person who doesn't drink any more but still has the urge probably doesn't need US to tell him how to identify it. Robert Rapplean 21:57, 11 July 2006 (UTC)

And that brings us back to another key question: who are the readers that this is being written for? You're right that some people will come here because they're wondering if they're alcoholic. But others will come because they want to know what the history is of the term (which we haven't really discussed at all); still others will be concerned friends and family members looking to make sure their loved one takes the path most likely to result in improvement. That's why I think we have a responsibility to not only be fair to the Wiki methodology but also to present information in a manner most likely to be useful.

Your original approach is concerning to me only because it suggests that alcohol causes alcoholism. While alcohol is indeed a necessary ingredient without which someone could never become alcoholic in the first place, it doesn't cause the onset of the disease through biochemical or behavioral alteration. If an individual is a social drinker, we can't turn them into an alcoholic through provision of alcohol. On the other hand, if someone has never before had alcohol, we have to assume they have about a 10% chance of being alcoholic (but not knowing it because they've never had alcohol). Does alcohol turn those 10% into alcoholics? Not in a medical sense - they were there to begin with but didn't know it. But in a generic sense, perhaps one could make that argument. ??? Drgitlow 03:48, 12 July 2006 (UTC)

Ok, I've added "history" as a section for this article. I agree with your comments in that paragraph, and feel that the direction we're headed covers them. Let me know if you feel otherwise.

I'm not sure why my direction suggests that. Could you elaborate? I do feel that uncontrolled drinking is the primary indicator of alcoholism. There are others, of course, but they all stem from uncontrolled drinking. I also think that the 10% genetic propensity for alcoholism is one of the things that could truly be referred to as a disease. Call it "Alcoholism Predisposition A", or something similar in medical jargon if you will. It's only a predisposition, though, and doesn't bloom into alcoholism unless the person gets into the habit of drinking. Essentially, drinking and "AP A" must both exist in the same person for the condition to develop. How can we convey that? How medically supported is that? Robert Rapplean 15:38, 12 July 2006 (UTC)

I think the best way for me to answer that is by example. I got called once to a college fraternity identified by the school as being a place where alcohol use was "out of control." In interviewing the students, I found that nearly all of them drank great volumes of alcohol from time to time. Many of them drank with abandon during parties and at other times. Only a few (about 15%) were alcoholic, based upon repeated use of alcohol despite hardship (grades dropping below their acknowledged abilities, losing girlfriends, being put on academic probation, arrests secondary to public intoxication, etc.) and some of these individuals were drinking less in total quantity than some of their friends who had no such problems. If I had tried to diagnose these students because of uncontrolled drinking, I wouldn't have had a clue. There's no question that some of those students who drank a lot but hadn't had problems yet might end up being diagnosable, but at the time they weren't.

In my book, all those who have alcoholism have the genetic propensity (whatever that turns out to be precisely) because I believe this disease to be genetically moderated, but I can't readily prove my contention. All I can do is point to studies (such as the Shedler/Block studies) that indicate significant differences in children between those who eventually end up with substance use disorders and those who don't.

And the condition isn't about a habit. Alcoholics drink differently than others from their very first drink when they recognize what the alcohol does to/for them. Talk to 50 alcoholics...they not only remember their first drink, but recall it with a smile and a sparkle in their eye. Talk to anyone not an alcoholic...their recollection is about the same as if you asked them when the first time was that they had cranberry juice. Who knows? It didn't mean anything to them. And if it didn't mean anything, then it can't cause a problem. Drgitlow 01:28, 13 July 2006 (UTC)

I can barely stand alcohol, and I remember that my first drink was gin out of a glass soda bottle when I was 15. Some friends of mine in highschool went to a park, and one of the girls was dating a 23 year old, who brought the gin. Although I got drunk, I merely remember it as being dizzy and confused. I have an exceptional memory, though, so that doesn't in any way disprove what you said.

The college issue that your describing is an excellent example of what we might call "Alcoholism Predisposition B", which is social circumstances that provide a very high psychological benefit to drinking. Everybody has their personal set of scales in which they value experiences, and people who are fresh out from under their parent's thumb have an unusually high valuation of new social experiences. It isn't unusual, uncommon, or unexpected that some of these teenagers value new social experiences more than they value their educational experiences. Alcohol is a social lubricant in that it makes dealing with unfamiliar people much easier, and as such runs rampant under these conditions.

It's drinking alcohol beyond the point where it is causing obvious, chronic damage to your life. This is still a form of alcoholism, even though its root cause isn't the aforementioned "AP A". It's just that this form of alcoholism requires a completely different form of treatment, and goes away quickly when the person is removed from the encouraging environment. There is significant overlap between sufferers from AP A and AP B because they are mutually supporting. We might even go on to categorize things like "AP C", where the person drinks as a coping mechanism for unpleasant or stressful life circumstances and other psycho/social maladies. Personally I like to lump them in as being a psychological addiction, but then again I'm not trying to treat them.

So, again, we definitely CANNOT call heavy drinking alcoholism unless it's causing obvious, chronic damage to the drinker's life. Once that qualification is met, though, it becomes alcoholism regardless of the cause. Robert Rapplean 16:10, 13 July 2006 (UTC)

You've got an interesting definition going. It's not the standard in the field, but it's pretty reasonable, and your last paragraph is entirely correct. Drgitlow 21:07, 13 July 2006 (UTC)

Well, the entire idea of a genetic propensity for a neurological addiction throws a lot of the "standard in the field" on its ear, I'm afraid, and the evidence I keep digging up seems to support it. I've certainly bent no shortage of my neurons over trying to sort this all out.

So I think we're finally coming to an agreement on how to characterize "active" alcoholism. I'd like to temporarily table the discussion of "passive" alcoholism (where a person needs a support group to help them resist the desire to drink) and "remissive" alcoholism (where a person has reverted their drinking conditioning, but could return to alcoholism if they drink without an opioid antagonist in their system) for a later time in favor of going back to discussion what direction the article should head in after the initial description of alcoholism.

1. A functional definition of alcoholism
2. How Alcoholism is identified
3. Current theories on the causes
4. Available treatment methodologies and their outcomes
5. Epidemiology (includes societal impact), but we should use a more reader-friendly word
6. Brief discussion of related conditions (alcohol-induced mood disorder, etc.)
7. Controversies
8. History

Running with being able to identify alcoholism as "continued consumption of alcohol dispite obvious, chronic damage to the drinker's life.", I think we can start with the various cannonical methods of recognizing it, maybe with a summary that characterizes the obvious symptoms for non-doctors.

OH, my wife also mentioned that kids doing book reports are also among our target audience. I don't think that adds anything to the details, but does effect our language and usage level somewhat. Robert Rapplean 22:46, 13 July 2006 (UTC)

Robert, you speak of active, passive, and remissive alcoholism. These terms are not part of the medical perspective on alcoholism. From a medical perspective, one either has the disease or one does not. As in hypertension, an individual taking antihypertensives may bring his blood pressure back to normal. Thirty years later, that individual may still have normal blood pressure if he's been taking his medications. He still has the disease of hypertension. But it's been properly treated and the individual will not have the morbidity or mortality rates that one would expect from a case of untreated hypertension. Similarly, an alcoholic receiving proper treatment and not drinking will have morbidity/mortality rates that are close to normal. I suppose one might put descriptors upon the different states - a hypertensive taking anti-hypertensives, a diabetic on insulin therapy with normal hemoglobin a1c measures, an alcoholic who isn't drinking - all are in the same place with respect to their illness, but they still have the illness. I understand that you're still approaching this from a non-disease perspective and are therefore taking a different route to get to the descriptions, but it's tough for me to imagine that we're going to get a consensus if we're ultimately at odds about definition, cause, treatment, and beneficial outcomes. I'm not sure what the 'right' thing to do is, however. Drgitlow 02:39, 21 July 2006 (UTC)

The "active, passive, and remissive" conditions are my words for three states that an alcoholic can be in, which really need to be differentiated. An active alcoholic is currently drinking more than is healthy for him. A passive alcoholic is someone who suffers from a strong desire to drink (obsesses about it), but is abstaining for whatever reasons. A remissive alcoholic is someone who has extinguished the desire to drink, but can re-develop it if they drink without an endorphin blocker. Technically they are all alcoholics, but their condition is in a different state and needs to be handled differently from a treatment perspective. What terminology would you like to apply to these? Robert Rapplean 03:29, 21 July 2006 (UTC)

I absolutely understand how you're defining your terms, and it's not a bad categorical approach, but it isn't a standard. In medicine, the terms used are partial remission and full remission, both of which can be either early or sustained. The remission states refer to the presence or absence of disease symptoms, so they don't refer to whether someone has stopped drinking, although you can generalize that an individual in full remission is likely not drinking at all. I actually prefer your terminology, since it is MUCH more clear and would probably be used accurately by clinicians and easily understood by the lay public. But I don't think this article is the place to introduce new terminology not generally used in the field. If, on the other hand, there's a citation you could use to indicate that these terms have been suggested as a new approach, that would work. Drgitlow 04:54, 26 July 2006 (UTC)

On that point, I have to agree with you that my terminology might be considered original research, which is definitely against Wikipedia policy. The idea of a person being completely clear of the desire to overdrink is pretty well new to the field, so I'll ask the doctors in Finland what their preferred terminology is, and if they have a reference for it. Robert Rapplean 16:04, 26 July 2006 (UTC)

Ok, I've checked with the good Doctor and he tells me that the terms he thinks are most commonly used are "active alcoholics", "remissive alcoholics" (but that we should double-check with what the AA calls them and use that instead if it's different), and "post-alcoholics". Apparently the post-alcoholic stage is so new that there's no established term for it. Robert Rapplean 19:22, 28 July 2006 (UTC)

In that case, we should probably follow WP:NEO (no neologisms), and stick to established terms, defining where necessary. Now I'm curious, are you actually in Finland, or do you just have contacts there? --Doc Tropics ^{Message in a bottle} 19:33, 28 July 2006 (UTC)

That works for me. I don't feel that people grasp a concept unless they have a word to tie the ideas to, but that's not really our job, I guess.

I was raised in St. Louis, Mo, and currently reside in Denver, CO. I have contacts in Finland because I spent a bit of time researching Dr.Sinclair for an interview I did with him for Intellectual Icebergs. Sinclair is one of those strange inexplicable creatures that actually acts out of a desire to help his fellow man. Many people claim that they do, but when it comes right down to it they're usually too tied up in their own wealth or ego to let go of ideas that do more harm than good. What I discovered in my research is that Dr. Sinclair's work is very well reasoned and strongly supported, but not very well accepted because it contradicts the work of people who have more influence, and have their egos, career or income tied to a competing philosophy.

Dr. Sinclair was raised and trained in the US, but currently works for the Finnish health department. He has been very helpful in providing me with requested information to help me understand the quagmire that is alcoholism treatment in the US and Europe. I've also made a few calls to his institute an the Contral clinics, although the language barrier is often a problem, and Dr. Sinclair himself has been very responsive to my requests and provides some extremely valuable insight into both the medical and political issues. Robert Rapplean 17:50, 30 July 2006 (UTC)

Comments on Developing a Strategy

I think we'll be more effective in the tactical discussion (what words do we use to explain alcoholism) if we have a clear set of objectives for the remaining definition first. So rather than talk about what to write in this section, let's talk about what our objective is for the remaining definition section. If we first have an objective then I think finding the words will come much more naturally. It would be worth reviewing what we have agreed upon to give us an idea of how to approach finishing the definition. I'll have some thoughts on the subject but I plan on not being here much over the weekend. I'm not saying wait for me, only that I might not be around much. Anyhow, it's something to think about and what we have agreed upon I think is very respectful to the reader and non-confrontational. I think the reader would so far say "Ok, they're not trying to sell me anything and what they're saying makes sense" and want to continue reading. So far the introductory definition seems quite credible to me. 06:14, 8 July 2006 (UTC)

I agree that we've made some real good progress and have a "credible" definition. I'm also open to anything that will help us move forward. Unfortunately, I'm going to be out of town for about a week so I'll have to leave it to the rest of you. And I can just see you all breathing a big sigh of relief at my upcoming vacation: Finally, some peace and quite around here, they say. Seriously, keep up the good work, all of you. :) --Doc Tropics ^{Message in a bottle} 06:52, 8 July 2006 (UTC)

Formatting

I've made several minor edits, mostly for the sake of formatting, and I think I see a need for many, many more. I really don't anticipate these will be "controversial" since the changes are largely cosmetic in order to Wikify the article, but if I accidently turn something into nonsense feel free to revert it and mention it here. --Doc Tropics ^{Message in a bottle} 21:12, 20 July 2006 (UTC)

I just moved or deleted the first 9 cites in order to keep them with (what I think is) the proper text, and to reduce redundancy. I'm hoping someone will review this carefully because it was a bit of a headache and I may have goofed. I did it in 2 rounds of editing, clearly marked, so it should be easy to correct. --Doc Tropics ^{Message in a bottle} 12:20, 21 July 2006 (UTC)

OK, that didn't go well. I totally bolluxed it and had to revert myself. I'll try again when I haven't been awake for 20+ hours. --Doc Tropics ^{Message in a bottle} 12:25, 21 July 2006 (UTC)

Blood tests

Do the superscript numbers in this section mean anything anymore? I assume they were references to footnotes either in the article they came from or an earlier version of this wiki article. Any ideas? Nunquam Dormio 18:48, 26 July 2006 (UTC)

ND, I'm afraid the majority of our cites, links, and refs need a major overhaul. Your work in formatting and streamlining has been excellent, and I was hoping you could help in this area as well. I've tried but I lack any subject-matter expertise, and usually just end up with a headache. I'm beginning to wonder if we need to just "burn" all three sections and start over? That sounds like a potential headache as well, so I'm somewhat at a loss. --Doc Tropics ^{Message in a bottle} 19:07, 26 July 2006 (UTC)

Do we really need to be Citing another encyclopedia?

In reviewing the cites in our first paragraph, both of the remaining cites are to other encyclopedias (Medline Plus Medical and Britanica). I think that it's a very poor showing that, for our first paragraph, we have to point to another encyclopedia and say "See, they think so, too!" After some consideration, I think it would be a better policy to back up our opening section with the rest of the article, and if we need to back up individual statements in the rest of the article, then we should find more authoritative sources than other encyclopedias. Unless someone protests, I'm going to remove those two references. Robert Rapplean 17:15, 23 July 2006 (UTC)

I agree (although I thought Medline was a Journal rather than an Encyclopedia). It really bothers me to see refs to EB anywhere; I'm sure we can do better. Once you've taken care of those two, would you like to sort through 3 - 9? I tried to reduce and reposition those more appropriately; maybe you'll have better luck :) --Doc Tropics ^{Message in a bottle} 17:21, 23 July 2006 (UTC)

I realized that Medline self-identifies as an encyclopedia so I went ahead and removed the first two cites. They're still available in the history of course, so if anyone really wants to replace them it's easy enough. I couldn't find a specific WP:POLICY against citing other encyclopdias, but I strongly agree that our intro should stand on its own and we should think carefully about citing other encyclopedias anywhere, ever. --Doc Tropics ^{Message in a bottle} 01:21, 24 July 2006 (UTC)

I also removed a broken link from the next section. --Doc Tropics ^{Message in a bottle} 01:53, 24 July 2006 (UTC)

Tobacco, not alcohol, is most widely abused substance

46 million US adults are smokers and most are addicted says the CDC. Tobacco smoke contains at least 43 carcinogens. The CDC estimates that male smokers lose an average of 13.2 years of life and females lose an average of 14.5 years of live because of smoking the numerous health problems it causes.

For these reasons, the Alcoholism article is in error, the qualification is not "weasel words" and the reference is not a "nonsense link." Non-smoker 01:24, 24 July 2006 (UTC)— Non-smoker (talk • contribs) has made few or no other edits outside this topic.

The referrence was a nonsense link because it had absolutely no bearing on the article at all; if you want to use a link like that to prove a point it can be done here on the Talkpage, but not in the article. I removed the weasel words because "alcoholism affects over 15 million people" is a verifiable fact, not an estimate. I realize that you are new to WP and I'm sorry if my initial response seemed harsh to you. Since we're in the process of trying to reduce the cites in this article, it was largely a case of bad timing. Please don't get frustrated, this article has been under construction for a while :) --Doc Tropics ^{Message in a bottle} 01:45, 24 July 2006 (UTC)

XXXXXXXX

I'm not trying to prove a point only to correct a verifiable error on the Alcoholism page.

The 15 million alcoholics is only an estimate, not a verifiable fact. (And where is the reference supporting it?) All we have are estimates of the incidence of any diseases or behaviors because no census (to my knowledge) has been taken of these diseases or behaviors. A CDC estimate is an official estimate of the U.S. government. So it appears that to be in every way as strong a statistic as the 15 million estimate. So over 45 million is roughly three (3) times 15 million.

In what way am I wrong?Non-smoker 02:55, 24 July 2006 (UTC)— Non-smoker (talk • contribs) has made few or no other edits outside this topic.

Sorry for the confusion about "prove a point"; I was trying to explain that if you disagree with a point in the article you could post the link that you used on the Talkpage to discuss it, but I'm sure you understand that linking to a website about smoking isn't appropriate in an article about alcoholism. Since I'm really just a humble simple> woefully undereducated editor I'm hoping that one of our resident eggheads subject-matter experts will address the balance of this : ) --Doc Tropics ^{Message in a bottle} 03:40, 24 July 2006 (UTC)

Hi, there. This is one of the resident eggheads. Non-smoker, you are quite correct that tobacco smoking is a bigger problem than alcoholism, but let me disect the terminology here. I'm going to quote a few numbers here to start us off:

Alcoholics: about 15 million (as per the NIAAA)

Tobacco smokers: about 45 million (let's assume you're right)

Alcohol drinkers: about 200 million (as per SAMSA)

For alcohol, there is a clear distinction between alcohol users and alcohol abusers. Most of us just plain don't have a problem with it, and can occasionally drink it safely on a regular basis with no hint of long-term damage. Most of us do not suffer from the addiction that it causes in others.

Tobbacco doesn't have that quality. 100% of all tobbacco smokers will get addicted over time. Nicotine supplements and replaces choline in such a way that our body forgets that it needs to make its own. Also, there is no way to smoke tobacco safely. Even small amounts of it will increase your risk of cancer by small amounts, while large amounts of it will increase your risk of cancer by large amounts. Thus, you could make the argument that all tobacco use is a drug abuse problem.

Where the real problem comes in is that there is no standard definition for the term "abuse" because it's a term that's been used too much by people with political agendas to mean "use of something that I don't approve of". Once you tie a term to morality it takes on a relative quality necessary for a line that people draw immediately beneath themselves to identify who they are superior to. Thus, in our current culture, drinking alcohol and smoking tobacco become "use" while alcoholism becomes "abuse".

I do know that tobacco induced medical costs far exceed alcohol induced medical costs, although it would take some doing to dig up the numbers, and the total cost of alcohol would also need to include property damage, divorce bills, and similar difficult to pin down expenses. Can anyone else give some input on this? Robert Rapplean 17:52, 24 July 2006 (UTC)

Thanks RR, I knew I could count on one of the editors here to reply in more depth and detail than I'd be able to. My strongest objection to Non-smoker's changes was the addition of the cite which linked to a smoking-related website. I may well have been overreacting when I deleted the text that was added; my primary concern was trying to manage the size and scope of this article at a time when we're trying to trim extraneous details. If other editors feel that the text was appropriate, I won't object again. I do think that we need to be concerned about the overall size and readability of this article however, and any further additions should be carefully scrutinized. --Doc Tropics ^{Message in a bottle} 18:08, 24 July 2006 (UTC)

The page says that "alcoholism is the most common substance abuse problem." But that is simply wrong if 15 million are addicted to alcohol and 46 million are addicted to tobacco. Why not say that "alcoholism is one of the most common substance abuse problems"? That would seem to be accurate. Are you going to let an error stand to avoid linking to a page citing the source of a statistic? That seems like a strange priority.Non-smoker 19:03, 24 July 2006 (UTC)— Non-smoker (talk • contribs) has made few or no other edits outside this topic.

In retrospect I have no significant objection to the sentence reading "alcoholism is one of the most common substance abuse problems." That phrase would be acceptable, but the link is not. Citations in an article about alcoholism should link to the topic of alcoholism, not websites about cigarette smoking, heroin addiction, crystal meth, or any other unrelated topic. Please feel free to re-insert your original phrasing, but I hope you won't add the link again without consensus to do so. Thanks for engaging in discussion; even when we don't agree, this is far more productive than edit-warring and reverts :) --Doc Tropics ^{Message in a bottle} 19:20, 24 July 2006 (UTC)

As for the addition of the word "estimated", since we don't actually state a number down to any precision it can safely be assumed that it's an estimation. All numbers of that form are an estimation, simply because you can't exactly take a weekly nation-wide survey and ask everyone if they're an alcoholic. Numbers for tobacco users are a little easier to pin down because health insurance keeps tabs on it, but lying about smoking for health insurance purposes is common, and those who don't have life insurance are more likely to smoke than those who do, so those numbers are similarly suspect. I favor leaving out the "estimated" because it can be presumed, but will look to see if Wikipedia has a policy on that kind of concept.

The cites, on the other hand, are another issue. We're definitely trying to eliminate cites in the opening paragraphs. Also, the page that is referenced doesn't say anything about alcoholism. I'd agree that it doesn't belong in the article, although it can be mentioned on the talk page in order to make a point.

I'd like to be a little more specific than calling it one of the most common. I'd really like to get across that it's many times more prevalant than opiate addictions, for instance. I'm sure that we can come up with some kind of wording that relays that without overlooking the problems that smoking causes. Robert Rapplean 19:43, 24 July 2006 (UTC)

I noticed that Non-smoker decided to update this himself. I like the statement, but think that it may be a sweeping generalization. I'm willing to leave it as it is, though, until we have the time to dig up more specific information on the rates of various substance abuse problems throughout the world. Robert Rapplean 04:24, 25 July 2006 (UTC)

I'd like to make several points regarding this discussion. The first is that there are many people for whom nicotine/tobacco use does not become an addiction. While all tobacco use is "bad" with respect to causing health-related consequences, one can make the same argument for alcohol (although alcohol in small quantities is said to be helpful from a cardiac perspective, it is harmful from multiple other perspectives, including hepatic, neurologic, etc.). There are many who smoke cigarettes "once in a while" when they go to social occasions or when they're with someone else who smokes, yet do not become addicted for whatever reason. This is a subject of ongoing research to determine why some people get addicted to nicotine quickly while others do not. There's no question that alcohol addiction is a MUCH greater problem in terms of cost to society and # of people afflicted than ALL other substance addictions combined - except for nicotine, as pointed out above. Drgitlow 04:47, 26 July 2006 (UTC)

My experience with tobacco smokers is that nicotine addiction takes several months of continuous smoking in order to set in. Unlike alcohol, nobody sucks down their first Camel and says "I gotta get me some more of that!", they think, "That's not so bad, and now I fit in with the cool crowd!". The psychological/social addiction sets in first, giving time for the physical addiction to get its grip. I smoked myself for about three weeks just because I was curious and I didn't get addicted, but the trial period was too short for that to be meaningful. The primary reason that the factors of nicotine addiction are so difficult to pin down is because the signal to noise ratio is so high. The cost/benefit formula for the initial picking up of the habit involves nearly intangible benefit and negligible cost, so it's often swamped by other considerations.

I will admit, though, that my statement of 100% nicotine addiction is based on those who have picked up smoking. It may be that the unaddictable percentage just forget to purchase the next pack at some point, but I've never met anyone who has smoked for a while and then just lost interest. I'll have to start asking that specific question. I don't think that anybody has done a study where they take x non-smokers, ask them to smoke a pack a day for a year, and then find out how many of them can easily quit, so I think that the evidence is out either way.

But back on topic, can we say "Second only to nicotine addiction, alcoholism is one of the world's most costly drug use problems. Alcoholism is more costly to our world's societies than all other drug use problems, excepting nicotine addiction, combined." Robert Rapplean 16:00, 26 July 2006 (UTC)

That works. Drgitlow 17:50, 26 July 2006 (UTC)

I want the article to keep moving forward, and I especially don't want do be responsible for holding things up. Having said that however, I'd really rather avoid extraneous references to other substances unless it's a direct comparison that's important to a particular point. I'd also like to make the following statement:

• While it's important for us to always assume good faith please let me offer my frank opinion. Non-smoker, an apparently new user with absolutely no contrib history outside this article has suddenly appeared and begun inserting references about cigarette smoking into an article about alcoholism. While honest consensus between editors is critical to our project, I am somewhat dubious about the honesty of these contributions. I really don't feel that they are relevant or productive, nor do I feel a need to compromise by inserting irrelevant or inappropriate material for the sake of appeasing an editor with a single purpose account. I certainly won't object to any reasonable suggestion by any established editor, but I think that we should carefully scrutinize the comments of newcomers with no previous edit history.

--Doc Tropics ^{Message in a bottle} 18:14, 26 July 2006 (UTC)

Hi, doc, thanks for voicing your concern. Fortunately, in this case, nicotine addiction is in my field of expertise (social impact of drug use), and I can verify that his claims of social damage and addiction rates are reasonably accurate, at least in the US. I feel that referencing nicotine addiction, but not specifically smoking, gives the reader a feel for where alcoholism falls in the heirarchy of drug-related social problems. If you would like this to be cited then we can tag it as needing citation, but I'm comfortable with the statement. Robert Rapplean 20:06, 26 July 2006 (UTC)

Because I recently had a very negative experience with an SPA elsewhere on this wiki and it's entirely possible that I'm overreacting because of that. I will certainly be pleased to agree with RR and Dr. G on this. --Doc Tropics ^{Message in a bottle} 20:28, 26 July 2006 (UTC)

Doc Tropics, I noticed that you added the word abuse after the word drug in the third sentence of the article. That's a very politically charged word, and I'm not sure we can fairly use it. Most people don't know the difference between immoral, illegal, and harmful, and our population would apply varying amounts of the three to that word depending on their background. Some people, for instance, would insist that you can't abuse something if it isn't illegal - that it would be misuse or overuse. Others would insist that there's no difference between use and abuse. This is especially a problem when attempting to apply those words to legal drugs like alcohol and tobacco. Would you mind if we changed the wording to "drug use", but still linked it to the drug abuse article? Robert Rapplean 02:37, 28 July 2006 (UTC)

Thanks for bringing that up. I mostly changed the wording to provide the link, so I've already made the change you suggested. Good catch! --Doc Tropics ^{Message in a bottle} 03:06, 28 July 2006 (UTC)

PS - Does the rest of it look ok? We're all making lots of changes and it's going well, but it's important to stay in touch this way. --Doc Tropics ^{Message in a bottle} 03:16, 28 July 2006 (UTC)

I'm quite impressed with the progress we've been making. I'm purposely taking it slow to give others an opportunity to catch my slips. I definitely need to thank everyone who has caught my misspellings. I'm making small changes while code is compiling, so I don't always have time to triple-check my spelling. I still want to move the Terminology section up, and replace the statement about addiction with something that describes how addiction applies to alcoholism. Time, time. Robert Rapplean 05:16, 28 July 2006 (UTC)

I just reviewed the Terminology section and I agree that an actual mention of addiction, in addition to the link, would be useful. Moving the section up higher in the article also makes sense. I'd say go ahead; we know that we can always discuss things and make more changes as necessary. --Doc Tropics ^{Message in a bottle} 05:43, 28 July 2006 (UTC)

Why we don't use the word "dependency" in our primary definition

who came up with a stupid definition that omits the word dependency / Palx 14:13, 4 August 2006 (UTC)

Hi, Palx. Opine much? Dependency refers to the body's physical adaption to a persistant high alcohol level. It's a very strong indicator of alcoholism, but is not the ONLY strong indicator of alcoholism, nor is it a required symptom for alcoholism to be diagnosed. There is a misperception that the dependence on alcohol is synonymous with alcoholism, but dependence is an adaption while alcoholism is a misdirected drive. Robert Rapplean 16:20, 4 August 2006 (UTC)

The big reason, Palx, is that dependence itself can mean many things. To some, dependence is synonymous with addiction; to others, dependence refers to a physiologic state. Psychiatrists use the term dependence the way other physicians use the term addiction. Dependence to some is a disease state while to others it represents a natural mammalian response to specific groups of drugs. Because of the many standards (and resulting confusion) around this term, we elected not to incorporate it within the definition of alcoholism itself. That way, we can be clear about what alcoholism means without using other terms which, while clear to some, might not be clear to all readers. Drgitlow 02:12, 5 August 2006 (UTC)

Terminology Section

I took a stab at the definition of Addiction. It's a simplification of what the article has to say, and I think that's what we need here. Please let me know if you find a problem with it.

I'd like to revisit our definitions of 'abuse' and 'dependence'. Right now the page currently reads:

Abuse and Dependence have standard medical diagnosis definitions in the DSM-IV-TR, but this terminology is now under discussion for change as DSM-V is being prepared.

What this translates to is that "abuse and dependence have definitions, but these definitions might change". I think we'd be better off if we actually provided the readers with a definition that's currently accurate. I do have to say, though, that most politicians have never opened a DSM, and they have more influence over the commonly understood definition of abuse than any doctor does. Robert Rapplean 18:19, 30 July 2006 (UTC)

A Psychiatrist's definition of abuse

Hey, Dr. Gitlow. I noticed that you adjusted the aforementioned section to say:

A psychiatrist would probably quote the DSM-IV and state that the presence of abuse is based upon the definition provided there.

I was hoping to give the reader a better perspective on the considerations a medical professional would have for labelling something as abuse. This kind of says that "if you're not smart enough to read the DSM that I'm not going to tell you." Could you elaborate a little for our audience? Robert Rapplean 00:01, 4 August 2006 (UTC)

See what you think of the changes I implemented just now. I'm trying to avoid actually putting the full working definition of 'abuse' and 'dependence' as defined in DSM-IV, but we could present an overview of this in a sidebar. I figured that would be covered in the entries for abuse and dependence, but now that I've just looked those up, there really isn't much there. Think it belongs here? Drgitlow 03:16, 5 August 2006 (UTC)

It's a definite improvement, but I think you misunderstand how most people think of the DSM. To be more specific, most people don't know the DSM from Billy Joe Bob. To illustrate how this effects people's comprehension of what you're writing, I'm going to copy what you wrote here, replacing all references to the DSM with references to Billy Joe Bob:

The term abuse has a variety of possible meanings. Within psychiatry, Billy Joe Bob has a specific definition involving a set of life circumstances which take place as a result of substance use. Within politics, abuse is often used to refer to the illegal use of any substance. Within the broad field of medicine, abuse sometimes refers to use of prescribed medication in excess of the prescribed dosage or to use of a prescription drug without a prescription. The term can therefore cause confusion due to the possibility that an audience doesn't share a single definition.

Dependence also has a variety of definitions. The standard psychiatric diagnosis of dependence is defined by Billy Joe Bob, but here the terminology is being reconsidered by Billy Joe Bob due in part to the many working definitions for dependence.

The first paragraph works because it actually describes abuse, but the second one doesn't actually tell the audience anything. I believe that what we're really looking for here is a summary of the definition, using the DMS as your reference. Does this convey what I'm trying to get at? I'd write it myself but I figured it would be better from someone who knew the DSM better. Robert Rapplean 17:50, 6 August 2006 (UTC)

Got it. In part, I've been avoiding a more detailed approach because the precise definition has a copyright issue. Give me a couple of days to find out the extent to which I can simply summarize and that will get us around the Billy Joe Bob issue. Drgitlow 03:33, 7 August 2006 (UTC)

Taking a stab at dependence

I created a straw model for a definition of dependence in the terminology section. I belive that it's reasonably accurate and more informative than what it replaced, but feel free to pick it apart. Robert Rapplean 16:26, 15 August 2006 (UTC)

Identification and Diagnosis section

I've moved all of the diagnosis information into one place. I'd like to change this heading to something less technical, preferably something like "Identification", specifically to avoid controversy over whether this is a medical, behavioral, or spiritual problem. Also, many of the entries here refer to concepts that aren't discussed in this article, and we need to fix that.

Could we have a bit of brainstorming about the various ways of identifying an alcoholic? I'd like to put each major method under its own subheading. Obviously the DSM and CAGE models belong there.

I'd also like to expand on my first paragraph that describes the difficulties involved in diagnosis. Can we put a section in previous to it that describes the various addiction factors that contribute to alcoholism? I think that would properly belong in the "extended definition" section of the article. Robert Rapplean 22:39, 20 July 2006 (UTC)

I'll leave the technical end of things to our panel of experts, but the changes you've made so far look good to me; it's a better format for the info I think. I also agree that "addiction factors" does belong in the extended definition (unless it gets so long that it deserves its own section). It seems we've re-established enough goodwill that you could go ahead and edit, just be prepared to discuss if anyone objects. Happy editing! --Doc Tropics ^{Message in a bottle} 02:15, 21 July 2006 (UTC)

The CAGE isn't a diagnostic test. It is simply a screening test used to identify those individuals likely to have alcoholism. As an analogy, to diagnose primary hypertension, one might conduct a screening test of measuring blood pressure. A single result of an elevated blood pressure may have many causes, one of which is primary hypertension. The DSM definition of alcohol dependence is a diagnostic definition for the disease of alcohol dependence (DSM's term for alcoholism). The 1992 JAMA article's definition of alcoholism is another diagnostic definition for the disease. From a medical standpoint, a physician will ask a series of questions designed to determine whether an individual's intake of alcohol has led to adverse outcomes in a repetitive manner. If the answer is 'yes,' then the individual is alcoholic. If 'no,' then intake of alcohol may be either nonpathologic or causing something other than alcoholism. For instance, let's say an individual comes in to see me complaining of significant anxiety, but has NO other problems. And let's say that individual honestly reports drinking 2-3 beers each day. That patient possibly has an alcohol-induced anxiety disorder. I then tell the patient that their anxiety, which is causing significant discomfort, may be a result of alcohol intake. I recommend cessation of alcohol use and a re-examination in 1 month. If in one month the patient has not stopped drinking despite the possible adverse reaction, now I must consider alcoholism as one possible diagnosis. Drgitlow 02:30, 21 July 2006 (UTC)

An interesting example Dr. G, and well written. Keeping in mind our Hypothetical Reader (who is still working towards a high school diploma), is it possible to clarify the difference between screening and diagnosis within the article a bit? It seems that the different techniques could probably stay in the same section since, to a layman, the difference appears to be a rather minor one? I think this actually sums up a challenge facing the article overall: We really need to bring the overall level down a bit to make it more accessible to our HR, but without dumbing it down so much it turns into nonsense. --Doc Tropics ^{Message in a bottle} 02:48, 21 July 2006 (UTC)

This is definitely an important distiction, and one of the reasons why I wanted to rename the section "Identification" instead of "diagnosis". Remember that our target audience doesn't contain a lot of medical professionals, so if it gets to the diagnosis stage we probably just need to give a brief overview of "how do them doctor guys know, anyway?" As such, the screening is a good tool that people can use in order to help them decide that maybe they really do need to see a doctor about this, and as such is perfect for our audience. Robert Rapplean 03:29, 21 July 2006 (UTC)

OK, who forgot to log in? :) I went waaay out on a limb and unilaterally changed the section header to "Identification and Diagnosis", although "Screening and Diagnosis" might also be appropriate. --Doc Tropics ^{Message in a bottle} 03:27, 21 July 2006 (UTC)

Doh. That was me. I own that IP address, so I should make it a synonym to my name. Robert Rapplean 03:29, 21 July 2006 (UTC)

Diagnosis

The current diagnosis section opens with a sentence that reads that diagnosis of alcoholism is difficult. I'm not sure what that statement is, whether it's an opinion or a value judgment in and of itself, but it's certainly not true for an addiction medicine specialist. Alcoholism is our bread & butter -- making the diagnosis is about as easy as pulling weeds. Can we reword that? Drgitlow 18:16, 23 July 2006 (UTC)

Rewording might be appropriate, if handled with care. I just read through that section again and it seems to be refering to "borderline" cases, but that isn't clearly stated. If you can clarify that without delving too deep into "specialist stuff" it would be perfect :) --Doc Tropics ^{Message in a bottle} 18:24, 23 July 2006 (UTC)

I believe that this can be fixed by changing the leading word "diagnosis" to "identification". I agree that diagnosis isn't terribly hard. If a person tells you that they have trouble not drinking then that pretty well settles it (oversimplification, I know). The difficult part comes in when other people are trying to decide if their loved ones are alcoholics. This usually involves attempting to apply the observer's priorities on the drinker, which is more often than not a mis-match. This is where the difficulty comes in. Again, trying to keep the non-medical-professional audience in mind. Does that make sense? Robert Rapplean 04:40, 25 July 2006 (UTC)

It makes sense to me, and I'm probably the lowest-common-denominator around here :) I also tweaked a couple of words in the opening sentence of this section. --Doc Tropics ^{Message in a bottle} 04:51, 25 July 2006 (UTC)

RR, your latest change to "Identification and Diagnosis" does an excellent job of clarifying! It's a good use of NPOV languange that should be understandable to everyone, and hopefully agreeable to all the editors as well. This is exactly the kind of cleanup that the article needs. --Doc Tropics ^{Message in a bottle} 15:55, 25 July 2006 (UTC)

I've heard that there is now a test they can do that sees if you have one of the more common genes in people with addictive personalities. Does anyone else know anything about this?--Twintone 19:06, 14 September 2006 (UTC)

A removal

I have removed the following chunk from the page because it was in the identification and diagnosis section. It doesn't really seem to fit, but I've archived it here in case we want to use it later for something. Regardless, it's a rather large quote that should probably be broken up and explained, or paraphrased. Robert Rapplean 18:17, 16 August 2006 (UTC)

Diagnosis

In 1992, a joint committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine was formed to establish a definition of alcoholism that could be used in a clinical setting. That committee defined the condition as a "primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal...characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic."

Treatment Discussions

Curing by moderation (Reposted comment from archive)

There is reason that healthcare professionals have a tough time accepting any treatment that involves continued drinking. The Pendery article in Science in 1982 (Science. 1982 Jul 9;217(4555):169-75.) essentially blew the moderation movement out of the water by demonstrating that over the long-term, patients who truly had alcoholism and who tried to drink in moderation either a) died of alcohol-related disease, b) ended up with significant morbidity due to alcohol-related disease, or c) had successfully entered abstinence. One method of diagnosing the disease is to simply see whether a patient tries to control their alcohol intake; if they do, they probably have alcoholism (noone tries to control their orange juice intake -- if they did, one would think there's something wrong). Drgitlow 16:53, 3 July 2006 (UTC)

You're mistaking pharmacological extinction with moderation. Moderation is an attempt to use personal habits and willpower to attempt to decrease one's drinking habits to a more healthy level. Pharmacological extinction is an attempt to reverse conditioning placed upon a person's neurochemistry by providing stimulus, but by blocking the reward mechanism. I agree and accept that moderation doesn't work, but there is a great deal of evidence indicating that PE does. Robert Rapplean 21:45, 3 July 2006 (UTC)

Regarding Pharmacological Extinction

I think that the countersite on pharmacological extinction needs to be more closely examined. PA isn't an attempt at moderation, and the cited study is dated 1982, before PA was developed, which was around 1992. PA is based on observations that overdrinking prone rats have overactive endorphin systems. Endorphin is our body's chemical mechanism for making us want to perform behaviors like sex, exercise, and fighting, which aren't terribly productive or efficient in their own right but which provide notable benefits in the long run. It has been demonstrated that the consumption of alcohol releases endorphins in our system, so the theory is that alcoholism is caused by the inappropriate rewarding of our neurological system when we drink.

Pavlov demonstrated that providing a stimulus coupled by a reward causes conditioning, but he also proved that providing the stimulus without the reward causes the extinction of that conditioning. Bell without food results in cessation of salivation over time. For alcoholism the bell is all of the sensations involved with drinking alcohol, and the reward is an endorphin reward to our neurons. Naltrexone is an opioid antagonist. In short, it blocks our bodies from being rewarded when we drink. Thus, if we drink alcohol while on naltrexone, our neurons unlearn their drinking impulses.

So, again, it has nothing to do with attempting to moderate drinking, it has to do with providing stimulus without reward so that the urge to drink is extinguished. Thus, any study which involves moderation without naltrexone use has nothing to do with this. Similarly, any study which involves naltrexone (or nalphamene, or noloxone) coupled with abstinence or abstinence encouraging therapies (like AA) similarly demonstrates nothing about PE. If you would like a complete list of the studies which have been performed involving opioid antagonists, let me know. I have a list that was updated around Nov 2004. Robert Rapplean 02:13, 5 July 2006 (UTC)

Robert, the PE approach is a behavioral modification approach combined with neurochemical findings. And I see your point about it leading to abstinence through a process which involves some continued use of alcohol for the behavioral modification to occur. It's a fascinating idea. My understanding of it is that it works theoretically as follows:

Alcohol causes the production of endorphins. In some individuals, alcohol causes endorphins to a greater extent than usual. This causes those individuals to have a reduced ability to refuse alcohol (because, simply put, the alcohol is too enjoyable for them to refuse even if it causes them hardship). Naltrexone, among other drugs, stops the endorphins from getting their message through by antagonizing the neurotransmitter system involved. Therefore, if you give the naltrexone and these individuals drink, they will no longer feel the enjoyment they once did. Behavioral modification will result due to the lack of positive feedback and the drinker will ultimately be able to stop drinking on his or her own.

While liver toxicity is an issue with naltrexone, the doses necessary here would be low enough as to present a low risk of hepatic damage (in general), even when combined with alcohol. I reviewed the Sinclair paper from Alcohol & Alcoholism 36(1)2-10. 2001 that discusses this in greater detail. What Sinclair reports is something that hasn't been replicated well in US trials since the US trials haven't followed his instruction that naltrexone be given simultaneously with alcohol. This provides a potential explanation as to why the US trials for naltrexone have been less than successful. All very interesting and deserving of additional study. Drgitlow 02:43, 5 July 2006 (UTC)

This is almost correct. Right idea, but the theory states that it's a neurochemical effect, not a behavioral one. In order to clarify, I want to Quote Dr. Sinclair directly:

"On the other question, you are correct that mixing naltrexone and disulfiram together will not work. Many people would expect it to, but this expectation is based on the incorrect common sense understanding of behavior (CUB). CUB says that a person sits and contemplates what behaviors will bring pleasure and what will bring pain, and then choose to make the behavior expected to produce the most net pleasure. Inherent in this view is the idea that pleasure and pain add together algebraically. Like pleasure has positive numbers and pain has negative. So if you have behavior that produces something good (+2) but then you shock the person for doing it (-3), the end result is the algebraic sum -1, so the person will avoid doing that. If you only give a little shock (-1), the sum is +1 and the person will continue doing it. If you really wollop them (-5), then the sum is -3 and the person will avoid the behavior completely. This seems so logical. It is the basis for our legal system, the basis for economic, the basis for how most people raise their kid, and the basis for how most people treat others. It is, however, defini