We talked last time about semantics, discussing the topic of whether the treatment we provide to patients with addictive disease is “medical”, independent of our training and approach. If we drill down even further, we soon come back to the entire issue of whether we’re discussing a disease. This is something we’ve dealt with before, but the rather well-done site by Stanton Peele brought the issue back to the front of the line for me (http://www.peele.net/index.html). For those not familiar with Dr. Peele, the site provides his background at length, focusing on his harm reduction approach to addiction. He describes his approach as being “nonmedical” but also states that “addiction is a pattern of behavior and experience which is best understood by examining an individual’s relationship with his/her world.”

Addiction and behavior
Is that definition, in fact, not medical? Many diseases include specific patterns of behavior — sometimes, they are grieving processes; sometimes, they focus on interpersonal relationships; and sometimes, they are introspective decision processes. Aren’t the behavior patterns simply a subset of the entire disease picture and, therefore, medical? Peele states on his website that “… the conventional notion of addiction as an uncontrollable ‘disease’ is baseless.” Therein lies the problem. If, indeed, that is what the conventional notion is, then the conventional notion is indeed baseless. Addiction itself — the development of tolerance/withdrawal in the presence of ongoing use of a substance — is not the disease of which we all regularly talk. Unfortunately, incorporating the word addiction, addictive disease does not even require that addiction be present. We could also look at Peele’s use of “uncontrollable,” which also would lead to the conventional notion being baseless if that notion truly assumes the disease to be such.

If we take a person known to have alcoholism and place him on an island with no available alcohol, is he still alcoholic? If we take a person who we know (we have a time machine and are, therefore, certain) will one day have alcoholism, but they haven’t had any alcohol yet — are they alcoholic now? The disease is not about the alcohol but, rather, about the genes and environment that have led up to an individual’s use of alcohol in a dysfunctional manner. While, as Peele points out, this dysfunctional activity is best understood by examining an individual’s relationship with others; that is, in part, only because we haven’t even begun to elucidate the scientific underpinnings of this disease.

As we look at alcoholism versus alcohol use versus alcohol promotion on websites, it is clear there is much confusion regarding what constitutes disease and what constitutes behavior. People drinking at a social gathering is a behavior, even if the people involved are teenagers. It may be an illegal behavior, or an unhealthful behavior, but it isn’t a disease state. It may be something that we are asked to treat and, indeed, our intervention in the behavior can be quite useful, but a successful intervention doesn’t define something as a disease. An alcoholic who is, despite his liver failure, drinking heavily, even after being informed of the medical importance of his stopping alcohol intake, is exhibiting behavior. In this case, the behavior is a sign of disease, just as a diabetic’s thirst and subsequent water intake when glucose levels are high is a behavior signified by disease.

Another site with clearly defined opinions about alcohol is http://www2.
potsdam.edu/hansondj, which is hosted by David Hanson, a sociologist at SUNY Potsdam. The About Your Host portion of the site states, “As one who does not require outside research funding, Dr. Hanson is free to draw whatever conclusions logic dictates without regard to whomever might be pleased or offended.” And, here I’ve been moving forward with the misguided belief that scientists are supposed to be free to draw exactly such conclusions, whether funded, seeking funding, or performing research with their own available assets. Much of the information at this site is not only helpful but difficult to locate otherwise. For instance, Hanson has a section describing how long it takes for a given amount of alcohol to be metabolized. He also follows the alcohol-related headlines in the news; as a result he presents fairly extensive evidence of alcohol intake in moderation as a source of better health and longer life.

Take a look at http://www2.potsdam.edu/hansondj/AlcoholAbuse.html. There you will find discussion of alcohol abuse that ignores the medical definition of the disease. If a college student drinks heavily and vomits thereafter, he does not have the disease of alcohol abuse (p. 199, DSM-IV-TR). Clearly, we can argue that the student is abusing alcohol, but that isn’t alcohol abuse — the disease defined in the medical literature. This, again, is a semantic issue, and it may well be that Hanson’s description here isn’t meant to describe the disease state defined in DSM-IV but, rather, the lay definition of alcohol abuse. Throughout the site are presentations of useful information and links, such as one link to the legal codes of each state. While it is clear from Hanson’s commentary that he has specific perspectives on various regulatory issues with respect to alcohol that are in disagreement with the medical community, his site is well organized and thought provoking.

Peele and Hanson have both invested extensive time commitments to their pursuit of alcohol-related information. They’ve both made a business for themselves in which they present opinion and perspective often uncommon within the treatment community but backed by scholarly exploration of available facts. And, since the end of this particular story hasn’t been written, perhaps, they will ultimately be proven correct. The difficulty, however, is that sites of equal quality in terms of layout, update frequency, depth and breadth of content are not easily found when we’re looking for the contemporary scientific or medical perspective. These two sites, and others like them, therefore serve to inform the public without an appropriate counterbalance.

Dr. Gitlow is on the Board of the American Society of Addiction Medicine and serves as Chair of the American Medical Association’s Task Force on Alcohol. His views here are his individually held opinion and do not necessarily reflect the views of the AMA or of ASAM.

This article is published in Counselor,The Magazine for Addiction Professionals, February 2006, v.7, n.1, pp.68-69.

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