November 6, 2002
Disease or Disorder
It’s Friday night at the Rod and Gun club, my dad and brother are drinking with the “boys” and having a grand time. By the time they get ready to leave dad is pretty well snookered so my brother drives home. It’s a snowy night with poor visibility and as he pulls into the driveway he gets a little too close to the hill. He jumps out to help my dad out of the truck, but by the time he gets to the other side the truck door is open and no dad in sight! As he looks around he sees two little feet sticking out of the snow at the bottom of the hill. My dad had opened the door, fallen out, and rolled down the hill headfirst into a snow bank (Charles)! Sounds pretty funny, I know. We have set our expectations of intoxication to conform to a certain level of tolerance. How many comedic routines have been built around the funny drunk? I can even remember certain celebrities that were known for their drunkenness, such as, Dean Martin or Foster Brooks. As the daughter of an alcoholic I can tell you it’s not all that funny. The rest of that story is, that night was the beginning of a weeklong binge that ended with my dad hospitalized for alcohol poisoning. Alcoholism is a progressive disease, one that affects the individual, their family, and society as a whole. Despite evidence to the contrary alcoholism is still being treated as a disorder rather than a disease. The pendulum has swung back and forth on this issue throughout history, but currently there are proponents in both camps. On the side of disorder are the behaviorists and some mental health experts, on the other side are doctors, researchers, organizations, and individuals that believe a definite genetic link exists in families afflicted with this disease. I include myself in the latter category. Witnessing the devastating effects of this disease on my own family I know the importance of recognizing and treating alcoholism medically and not as a behavioral disorder. The former assumes medical intervention the latter assumes the individual has control over their actions if they just modify their behavior. I believe if we, as a society, take the step of recognizing alcoholism as a disease we would be much more proactive in promoting prevention, particularly in families that already have one alcoholic. Since the genetic link has been accepted for breast cancer, the media has done an excellent job of reminding women to have mammograms especially if a close relative has had this disease. Alcohol prevention could be promoted in the same way. If there were public reminders about treating the disease in your family I believe it would have a profound effect on the recovery of alcoholics as well as the rate of alcoholism in this country.
In recent years there has been conclusive evidence of a genetic link showing a difference in the DNA of alcoholics. In 1990 scientists Kenneth Blum and Ernest Noble discovered in the q22-q23 region of chromosome 11 a genetic mutation they would later call A1 allele (Beyond the Influence 42). This was a huge discovery, proving beyond a doubt that alcoholics have a physiologic change when they are exposed to alcohol. Authors Ketcham and Asbury note, “Looking at this one genetic variation in brain tissue, the researcher could predict with 75% accuracy whether the brain belonged to an alcoholic or nonalcoholic”. There is more research to be done of course, but the evidence is irrefutable, “That certain genes or gene combinations determine whether or not a specific individual will be predisposed to the disease of alcoholism” (Beyond the Influence 43).
Unfortunately there are still factions within the scientific community that continue to promote the theory that alcoholism is a behavioral disorder that can be controlled with behavior modification treatment. Professor Henry Fingerette a consultant to the world Health Organization has written a book Heavy Drinking: The Myth of Alcoholism the Disease. According to Prof. Fingerette, “Instead of looking at heavy drinkers as victims of some wayward gene or physical abnormality, we can now see them in a truer light: as a diverse group of people who for diverse reasons are caught up in a particularly destructive way of life”(Heavy Drinking 66). He is joined in this conjecture by behaviorist such as, Alan Marlett of the University of Washington, who refers to alcohol problems as “maladaptive lifestyle habits” (Under the Influence 6). Professor Fingarette will not even use the word alcoholic and refers to them as “heavy drinkers” throughout his book. It is ironic that one of the symptoms of alcoholism is to deny its existence and to avoid at all costs referring to oneself as an alcoholic, although not an alcoholic himself, the professor seems to have a classic case denial! Yet Professor Fingarette and those like him represent qualified professional opinions that prevent the general public recognition of alcoholism as a disease.
The truly sad part of the conflict between those who believe alcoholism is a disease and those that believe it’s a disorder is the recovery treatment of the alcoholics when they finally seek help. When you understand alcoholism is a disease, (whose only cure is abstinence) is inherited in the same way, as a predisposition to some cancers, the concept of its fatality is implicit. On the other hand, if you think that it’s simply a lack of controlling certain behaviors not only is your treatment doomed to be ineffective (complete abstinence is the only cure), but you will prolong the disease and it’s effect on the families involved as well as the society the alcoholic lives among (Beyond the Influence 144).
To examine how we came to this particular point in time let’s look at some recent history of alcoholism. The term alcoholism was not used until 1849 when Dr. Magnus Huss wrote Chronic Alcoholism. During the 1800-1830”s consumption of alcohol increased to the highest in our history (7.10 gal/person/year)(Alcoholism 23). This was met with a backlash temperance movement with such organizations as the Women’s Christian Temperance Union. This culminated in the passing of prohibition in1920, and interestingly enough also ended our country’s acceptance of alcohol as a disease (Alcoholism 24). With the repeal of the 18th amendment (legalizing alcohol) alcoholism was usually treated only in its final stages with most attention focused on controlling one’s behavior. Not until the 1980’s did the term disease and preventative treatments become more widely accepted. However as the managed care concept took hold by the 1990’s expensive inpatient care was replaced by less effective (and less expensive) outpatient care. (Beyond the Influence 8) By the mid 80’s the term alcoholism was being replaced with alcohol abuse, which infers the victim is choosing to “abuse” the product. A subtle difference to be sure, but one that greatly impacts how the public views alcoholics and their treatment.
If you think this issue doesn’t concern you consider these statistics. This is a disease that crosses all gender, age and socio-economic lines. The majority of alcoholics are men; unfortunately women are closing that gap. 22.8% men and 8.9% women consider themselves binge drinkers (Alcoholism Source Book 59) The young (4.4million binge drinkers), the old (15% men 12% women) and all of us in between (32 million binge drinkers) (Alcoholism Source Book 59). One study done in 1996 showed a slightly higher incidence of alcoholism in welfare recipients but only by 1.2% (Alcoholism Source Book 61). However the one place we do see a sharp increase in the occurrence of alcoholism is in families. Depending on the study, sons with alcoholic fathers, are anywhere from 25-50% more likely to become alcoholic than the general population. Even more impressive is the correlation between adoptees with a biological alcoholic parent raised in a nonalcoholic home. Several studies done in the early 1970’s showed these children to be “3-4 times more likely to become alcoholic…”(Beyond the Influence 41). In the presence of such statistics how can the public still perceive alcoholism to be anything other than a disease? The answer lies in education and public awareness.
According to the health reference, Alcoholism Source Book, there are many types of programs designed to educate our children, some more effective than others. The biggest issue we need to overcome is implementation of these programs. Currently we have a hodgepodge of programs: The Saving Lives Program in Massachusetts (a community/education to reduce drunk driving), Life Skills Training (education grades 7-9 to resist peer pressure & boost self esteem), Project Northland (community/education to prevent and reduce alcohol use in teens), D.A.R.E. (law enforcement/grades 5&6alcohol awareness). The first three programs are multifaceted involving the community, parents, and educators. Implemented over a period of three years or more they give a more in depth and extensive experience to the participants. All showed a significant improvement in statistics on drunk driving, & lowered incidence of alcohol use among students involved in the programs. (Alcoholism Source Book 455-456). The last program is short term (a few classes with police officers in grade 5 and/or6) and shown to be ineffective in making any impact on alcohol use (Alcoholism Source Book 457). Looking at the difference and effect program can have on the very lives of our children why are we not insisting on mandatory programs in all of our schools for grades 6-12?
One reason is our tolerance for drunkenness has been raised to such an extreme level that parents will pay for their kids to go on spring break, even though they know there will be massive amounts of drinking going on. This is due in no small part to the concept that anyone can get drunk once in a while and “no harm done”. If the statistics for alcoholism in teens that drink before the age of 21 were as widely published as rate of cancer among smokers perhaps parents wouldn’t take spring break so lightly. According to authors Ketchum and Asbury, “People who start drinking before the age of 15 are four times more likely to develop alcoholism than those who start drinking at age twenty-one” (Beyond the Influence 271). If you question the effect parents can have on their teens just take a look at the success of MADD. Prom night used to be a time of tragedy for many families across the country, but with the consistent efforts of mothers keeping the facts in the public’s eye the stats for deaths resulting from drunk driving are way down. Other community intervention programs have also had success, in the Massachusetts program, Saving Lives, there was a 40% decrease in teen drinking and driving (www. niaaa.nih.gov/). Even those that think alcoholism is a disorder agree on this point, they just don’t understand that when you can admit to the inevitability of a disease that is genetically predisposed you strengthen your case for funding and the importance of your message.
A prime example of how this disease progresses is my Dad’s history with alcohol. Those that understand alcoholism as a disease have discovered three definitive stages, (early, middle and late) (Beyond the Influence 52) As the oldest of four children I remember my dad when he was in early stage, a time of near normalcy punctuated with occasional “parties and nights on the town”. Those nights when my dad would arrive home drunk were fairly infrequent 2 maybe 3 times a month, and not scary just a fun-loving dad that walked kind of funny. By the time I was in my early teens weekend drinking was a routine, still usually social, but sometimes my dad would drink all by himself and always to the point of drunkenness. Still he never drank during the week and always went to work. I left home at the age of 18, got married, and moved away. Unlike my siblings I did not have to watch his decline into middle and late stage alcoholism drink by drink, day by day. His drinking at this time became less and less controlled. He often drank alone and now the drinking would radically change his personality. From a loving husband and father to a mean and surly drunk, unable to control his actions and often putting those he loved most in the world at risk (Charlene). Retirement at an early age was the final factor that dropped him into the abyss, and while he was already late stage and would certainly have reached this point eventually, the lack of any structure in his life turned him into a binge drinker almost overnight. My sister Barbara had an unfortunate perspective on this time. She had recently moved back home with her two small children and recalls the many episodes of binge drinking when she had to remove herself and the kids for their own safety (Barbara).
As you can see the process to reach late stage took over 20 years, had we understood the nature of his disease we certainly would have attempted to intervene while he was in early stage. This is the most critical area where the behaviorists fail, by not recognizing you can no more control this disease by controlling your drinking than a cancer victim can control the growth of cancer cells in their bodies. Early intervention is so key in this disease (as with most diseases) if people and doctors accepted the genetic link and recognized the symptoms of their disease they could seek treatment at this critical time. Note (Beyond the Influence 53, 54,60, 61,72). Unfortunately, we can’t change the course my Fathers life took but I have educated myself and my children on the very real risks associated with drinking because of their heritage.
Armed with the knowledge that is now available to us we have a unique opportunity to educate the public and target potential alcoholics. A public information campaign (similar to those seen for smoking or getting screened for genetically predisposed cancers) would alert parents and hopefully adolescents to the dangers inherent in underage drinking. According to the NIAAA “Adolescent alcohol use is one of the most difficult behaviors to change because alcohol is so ingrained in the U.S. culture”(www.niaaa.nih.gov/). In some cultures consumption of alcohol is prohibited by religion or state laws, but when was the last time you planned a celebration that didn’t include the use of wine, beer or other alcoholic beverage? Where do we draw the line on what is “tipsy”(acceptable behavior) and routinely drunk (unacceptable)? Does inviting Aunt Sally to the next family gathering make you uneasy because her behavior changes when she drinks? Does Granddad always have a drink in his hand no matter what time of day you stop by? These are the kinds of questions we should be asking ourselves and our loved ones, but if we continue to think of alcoholism in terms of “those people” and their “uncontrolled behavior” we’re doomed to an increase in our already horrific alcoholism statistics.
Public education, tougher DWI laws and mandatory classes in all public schools are a start in the campaign for public awareness, but the medical profession is where a real difference for the family can be made. Just as you are routinely asked about family medical history your family alcohol history should be included In this way patterns of drinking could be detected, and follow up for prevention and/or intervention could be established. The cost to society in lost productivity and potential is enormous, through missed time at work (by the alcoholic or their spouse) to potential wasted as the alcoholic degenerates or their families are barely functioning as they try to cope. The greatest cost of all however is the “walking wounded”, the children of alcoholics, who sadly, often go on to be alcoholics themselves. The legacy left by an alcoholic is one of depression and trauma, often surfacing 10, 20 even 30years later.
As the evidence mounts, it is more apparent than ever, that now is the time to take action. Statistics reveal a growing problem of alcoholism in our society. Researches have discovered at least one of the gene combinations that will predispose a person to alcoholism by the way their bodies and minds react to the alcohol. Physicians in mental & physiological fields have recognized the physical characteristics to watch for in a persons’ reaction to alcohol. So what are we to do with all this information? There is any number of things. First and foremost, understand that this is a disease as deadly and progressive as any cancer, and then get the word out through various forms of media about the signs of alcoholism, and the genetic link that puts these families at risk. Secondly but just as important educate our young. Not with a couple of classes in elementary school or a section during a health semester, but with extensive and ongoing programs that involve the parents and community. I would recommend starting the programs in the 5th grade but then continuing them through high school with adjuncts activities that required parental and community support. Last but certainly not least the treatment and care of alcoholics and their families. In most inpatient programs the involvement of the families is always encouraged and sometimes required, but this is far from the case everywhere. The closer we can come to this ideal the more effective and far reaching recovery will be for those involved. For not only will the alcoholic get help, but also their families and especially the children will have their awareness raised and some of the future problems will be averted.
The price we pay every day we delay in implementing these programs and initiatives cost us millions maybe billions of dollars. Hours of productivity lost to alcoholics too hung over to come to work, to spouses abused and home hiding their bruises, to children too upset to concentrate in school. Property damages from cars wrecked to fires started by alcoholics passed out or too drunk to notice their cigarettes or the pot burning on the stove. We pay in lives lost, a car full of teens their lives cut short because the one driving didn’t know his brain reacted differently to alcohol. We pay in tiny infants born with fetal alcohol syndrome; their moms didn’t know that even a few drinks would affect her unborn baby. We pay with the lives and future of our children for every day that another kid goes uneducated about alcoholism we run the risk of creating another alcoholic. We must ask ourselves, when does the price get too high?