DISEASE CONCEPT OF ALCOHOLISM AND DRUG ABUSE

Throughout most of recorded history, excessive use of Alcohol was viewed as a willful act leading to intoxication and other sinful behaviors. The Bible warns against drunkenness; Islam bans alcohol use entirely. Since the early nineteenth century, the moral perspective has competed with a conceptualization of excessive use of alcohol as a disease or disorder, not necessarily a moral failing. The disease (or disorder) concept has, in turn, been evolving with considerable controversy since then, and has itself been challenged by other conceptual models. Because this article is concerned primarily with the disease concept, the other models will be mentioned only briefly.

Among the first to propose that excessive alcohol use might be a disorder, rather than willful or sinful behavior, were the physicians Benjamin Rush, in the United States, and Thomas Trotter, in Great Britain. Both Rush and Trotter believed that some individuals developed a pernicious "habit" of drinking and that it was necessary to undo the habit to restore those individuals to health. Words such as habit and disease were used to convey interwoven notions. Trotter saw "the habit of drunkenness" as "a disease of the will," while Rush saw drunkenness as a disease in which alcohol was the causal agent, loss of control over drinking behavior the characteristic symptom, and total abstinence the only effective cure. In 1849, a Swedish physician, Magnus Huss, introduced the term alcoholism ["alcoholismus"] to designate not only the disorder of excessive use but an entire syndrome, including the multiple somatic consequences of excessive use.

Late-nineteenth-century physicians, although not the first to see habitual use of other drugs (such as Opiates, Tobacco, Coffee) as disorders, are credited with stressing the idea that each was but a subtype of a more generic disorder of inebriety. However, they also minimized Trotter's and Rush's notions of learned behavior as a central feature of a generic disorder of inebriety and emphasized instead the idea of a disorder rooted in acquired or inherited biological malfunction or Vulnerabil-Ity. This more biologically based view of inebriety was used in Britain and the United States by advocates of publicly funded treatment facilities—inebriate asylums. Many temperance leaders also supported the establishment of treatment facilities. However, while physicians advocated treatment, temperance leaders, still convinced that alcohol itself was the root of the problem, pushed for its control and, eventually, for its prohibition.

In the United States, the ratification in 1920 of the Eighteenth Amendment, which prohibited the production, sale, and distribution of alcohol, temporarily dampened scientific inquiry into the nature of alcoholism. But concern about the problematic and excessive use of other drugs, such as Opioids, Cocaine, and Barbiturates, continued to stimulate writings both in the United States and abroad. Was excessive drug use a disease, a moral failure, or something else—perhaps something in between?

By the mid-twentieth century, the rise of Alcoholics Anonymous (AA), the publications of E. M. Jellinek, and the establishment of the Yale Center for Alcohol Studies revived interest in exploring the nature of Alcoholism. In the early 1960s, the idea reemerged that, for certain "vulnerable" people, alcohol use leads to physical addiction—a true disease.

EARLY MODELS OF THE DISEASE CONCEPT

Central to the disease concept of alcoholism put forward by Jellinek were the roles of Tolerance and Physical Dependence, usually considered hallmarks of Addiction. Tolerance indicates that increased doses of a drug are required to produce effects previously attained at lower doses. Physical dependence refers to the occurrence of With-Drawal symptoms following cessation of alcohol or other drug use. Although Jellinek recognized that alcohol problems could occur without alcohol addiction, addiction to alcohol moved to the center of scientific focus.

Despite being couched in the language of science, the reemergence of the disease concept of alcoholism was not a result of new scientific findings. Jellinek believed it was necessary to see alcoholism as a disease in order to increase the availability of services for alcoholics within established medical facilities. He also recognized that efforts to prevent alcoholism would still have to address the complex cultural, demographic, political and economic issues contributing to the problem. Although he sometimes appeared to take a broad view of the disease concept of alcoholism, he reserved the disease category for those individuals manifesting tolerance, withdrawal symptoms, and either "loss of control" or "inability to abstain" from alcohol. These individuals could not drink in moderation; with continued drinking, their disease was progressive. Others who drank merely in response to psychological stress ("alpha alcoholism") and those who sustained toxic consequences from alcohol but were not physically dependent ("beta alcoholism") did not qualify for his more explicit and restrictive definition of disease. Jellinek's view of alcoholism as a progressive disease is sometimes referred to as the "classic" disease model to distinguish it from later perspectives of a disorder or syndrome more powerfully influenced by learning and social factors.

Alcohol researcher and theorist Thomas Babor has pointed out that when definitions specify alcohol addiction or dependence as a disease entity, it can be argued more convincingly that "dependence is an organically based entity which produces a characteristic set of signs and symptoms… and increases the probability of repetitive drinking behavior."

The American Psychiatric Association included alcoholism in the first edition (1952) of the Diagnostic and Statistical Manual of Mental Disorders. In the second edition (DSM-II ), published in 1968, the group followed a precedent set by the World Health Organization's International Classificationof Diseases (ICD-8 ) and included three subcategories of alcohol-related disorders: alcohol addiction, episodic excessive drinking, and habitual excessive drinking. Both of these publications included alcoholism among the personality disorders and certain other nonpsychotic disorders, implying that the alcohol use was either secondary to an underlying personality problem or a response to extreme internal distress. This view of excessive drug use as a symptom of some other psychiatric disorder is sometimes referred to as the symptomatic model. According to this concept, drug or alcohol dependence is not really a disorder in and of itself.

Meanwhile, from the late 1950s and throughout the 1960s, the Expert Committee on Addiction-Producing Drugs of the World Health Organiza-Tion (WHO) continued to formulate and refine definitions of addiction and Habituation that could facilitate WHO's responsibility (required by international treaties) for control of Narcotics, cocaine, and Cannabis. In the 1950s, the presence of physical dependence was emphasized in the definition of drug dependence, and the WHO Expert Committee was still concerned with differentiating between psychic dependence and physical dependence. At one level, the concept of psychic dependence was compatible with the psychodynamic view that these disorders were a response to psychic distress (such as negative mood states). According to the psychodynamic model, excessive alcohol or drug consumption was merely a response to underlying psychopathology. This model was also consistent with Jellinek's view of one of the "species" of alcoholism, in which individuals drink to relieve emotional pain (alpha alcoholism). In 1969, the committee abandoned the effort to differentiate habits from addictions and adopted terminology first proposed by Nathan Eddy and colleagues in 1965, in which the term drug dependence designates "those syndromes in which drugs come to control behavior." The committee recognized that dependencies on different classes of drugs (such as alcohol, opiates, cocaine) can differ significantly and that withdrawal symptoms are not always present or necessary aspects of dependence (see Table 1).

In 1972, alcoholism was included in a listing of diagnostic criteria for use in psychiatric research published by Feighner and coworkers. The defining criteria for alcoholism included withdrawal symptoms, loss of control, severe medical consequences, and social problems. In the same year the Na-Tional Council on Alcoholism also outlined criteria for diagnosing alcoholism, which emphasized tolerance and physical dependence and incorporated certain concepts developed by Alcoholics Anonymous. This definition, and one issued jointly with the American Medical Society on Alcoholism in 1976 (see Table 1), represented an attempt to emphasize the seriousness of the disorder, the experience of clinicians and of recovering alcoholics, and the view that alcoholism is a primary or independent disorder, not merely a manifestation of an underlying personality problem. These statements come close to being current definitions of the classic disease model.

PROBLEM DRINKING AS A DISTINCT DIMENSION

The importance of what can now be called the classic "disease model" of alcoholism as a primary focus for health programs was challenged in 1977 by a report of a WHO Expert Committee on alcohol-related disabilities. This report stressed that not everyone who develops a disability related to alcohol use exhibits alcohol dependence or addiction, nor would such an individual necessarily develop a dependence in the future. The report asserted that some alcohol-related disabilities represent a dimension of problem drinking distinct from the disease of alcoholism or alcohol dependence syndrome. This perspective provided support for policies aimed at reducing overall alcohol consumption, not just at promoting abstinence among vulnerable individuals. The report described the alcohol dependence syndrome itself as a learned phenomenon, not a disease state, which is either present or absent, but "a condition which exists in degrees of severity." It is important to recognize that this syndrome perspective does not take a position on whether alcoholism should be considered a disease.

The concept of dependence as a syndrome is quite similar to that put forward in 1965 by drug-abuse researcher Jerome Jaffe, who viewed addiction as standing at one end of a continuum of involvement in drug use: "In most instances it will not be possible to state with precision at what point [along the continuum] compulsive use should be considered addiction," Jaffe observed. He emphasized that "the term addiction cannot be used interchangeably with physical dependence. It is possible to be physically dependent on drugs without being addicted and… to be addicted without being physically dependent." In this view, the behavioral disorder, not physical dependence, is the syndrome. Jaffe defined addiction as "a behavioral pattern of drug use, characterized by overwhelming involvement with the use of a drug (compulsive use), the securing of its supply, and a high tendency to relapse after withdrawal." This proposed generic notion of dependence is applicable to Stimulants and Hallucinogens (for which physical dependence is not a significant factor), as well as to alcohol, opiates, and Sedative-Hypnotic drugs (for which physical dependence is a factor). The Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised (DSM-III-R), published by the American Psychiatric Association more than twenty years later, in 1987, also used such a generic definition.

FROM PSYCHIC AND PHYSICAL DEPENDENCE TO DEPENDENCE SYNDROME

The changing perspectives on the general concept of drug dependence, given momentum by the 1977 WHO report on alcohol and by other research, were ultimately reflected in changes in the definitions and other positions of the World Health Organization and in its 1980 International Classification of Diseases, 9th edition (ICD-9). With its publication, the concept of an alcohol dependence syndrome formally emerged at an international level. The ICD-9 concept of dependence was based on a 1976 proposal by researchers Griffith Edwards and Milton Gross, who defined seven characteristics of the alcohol dependence syndrome and proposed that there are certain implicit assumptions to the syndrome: First, it is a symptom complex involving both biological processes and learning. Second, it should be defined along a continuum of severity, rather than as a discrete category. Third, dependence should be differentiated from alcohol-related disabilities. Both dependence and disabilities exist in degrees, rather than on an allor-none basis. There is some evidence that people with more severe degrees of alcohol dependence who seek treatment have a different clinical course from those with less severe dependence.

By the late 1970s, the American Psychiatric Association's Diagnostic and Statistical Manual, 3rd edition (DSM-III), moved away from more descriptive and psychodynamic orientation toward a nomenclature in which specific diagnostic criteria were laid out for specific syndromes. In the case of alcohol and drug dependence, the original drafts of DSM-III considered inclusion of a dependence syndrome that varied in degree of severity and in which tolerance and physical dependence were important, but not essential, criteria for diagnosis. At the last moment, however, it was decided that tolerance and physical dependence were both necessary and sufficient for a diagnosis of drug dependence; the presence of other criteria listed were by themselves insufficient without tolerance and physical dependence. Nevertheless, by distinguishing drug (or alcohol) dependence from drug (or alcohol) abuse, DSM-III recognized the two-dimensional conceptualization previously put forth in the WHO report of 1977 and in ICD-9.

In 1980, during the short interval between the publication of DSM-III and the beginning of work on DSM-III-R, a WHO working group met to further refine terminology. One result of the meeting was the publication of a WHO memorandum on nomenclature and classification of drug- and alcohol-related problems that endorsed the concept that drug dependence is a syndrome that exists in degrees and that can be inferred from the way in which drug use takes priority over a drug user's once-held Values. The criteria for making this inference included many of those mentioned by Edwards and Gross in their 1976 paper and some that had been developed for DSM-III. The WHO memorandum, while recognizing the importance of tolerance and physical dependence, did not view these phenomena as always essential and required. It endorsed again the two-dimensional perspective—not all drug or alcohol problems are manifestations of dependence; and harmful or hazardous use can occur independently of the decreased flexibility and constricted choice that are the hallmarks of the dependence syndrome. This perspective was underscored by pointing out that the presence of physical dependence per se (as in the case of patients taking drugs for pain) was not in itself sufficient for the diagnosis of dependence. The memorandum also presented a model of dependence emphasizing that the dependence phenomenon is not a property of the individual but resides in the relationships among the elements in the model—social, psychological, and biological. This view has been called the biopsychosocial model.

CRITERIA FOR DIAGNOSIS OF A GENERIC DEPENDENCE DISORDER

The American Psychiatric Association's DSM-III-R, published in 1987, built on both DSM-III and the WHO memorandum. It presented nine criteria for diagnosing a generic dependence syndrome, applied to a wide variety of drugs. The user must have experienced at least three criteria in order for the practitioner to consider any degree of dependence to be present. Neither tolerance nor physical dependence was a required criterion. The presence of more than three criteria would indicate a more severe degree of dependence. Drug abuse was a residual category used for designating drug-related problems when dependence was not present.

The DSM-III-R conceptualization of dependence was controversial. Because for many years physical dependence and tolerance had been considered evidence of "true disease," many clinicians believed that changing these criteria from the necessary and required status they had had in DSM-III was a mistake that erroneously broadened the category of drug dependence. Much of the focus in the development of DSM-IV, published in 1994, was on how to restore the primacy of these phenomena in the diagnosis of drug and alcohol dependence. DSM-IV defines seven generic criteria for alcohol and other drug dependence. Three are required for a diagnosis of alcohol or other drug dependence. Although tolerance and withdrawal are listed first, they are not required—but the clinician must specify whether either is present.

Despite these concerns, there was little argument about the importance of psychological and sociological factors in the development and perpetuation of the syndrome—that is, there was still consensus about the biopsychosocial model.

At the same time, at the international level, the framers of ICD-10 continued the evolution begun in ICD-9 and adhered closely to the concepts of dependence outlined in the 1977 WHO report and 1981 WHO memorandum. Published in 1992, ICD-10 includes a generic model of drug dependence with similar criteria for alcohol, tobacco, opioids, and other drugs that affect the brain. Like DSM-IV, ICD-10 presents a number of criteria (six) for determining the presence of the alcohol (or drug) dependence syndrome; at least three of these must be present for the clinician to judge that the syndrome exists to some degree.

ICD-10 does not include a diagnostic category of alcohol or drug abuse but instead includes a category of harmful use —a pattern of use that is causing damage to mental or physical health. Unlike DSM-IV, which defines drug or alcohol (substance) abuse as "a maladaptive pattern of use" causing significant impairment or distress and interpersonal, family, and legal problems (e.g., arrests), ICD-10 does not consider such patterns of use and consequences necessarily to be evidence of harmful use.

ICD-10 and DSM-IV share important characteristics that represent a further evolution in understanding drug and alcohol dependence syndromes. In contrast to some disease-oriented defintions that see alcoholism as uniformly progressive, in ICD-10 and DSM-IV the course of the disorder is not one of uniform progression or predictable cure, but there are a variety of significant states of remission. For example, DSM-IV distinguishes early remission (within the first 12 months) from sustained remission (at least 12 months); within each of these it differentiates full remission from partial remission (i.e., all criteria for dependence have not been met, although at least one has been met intermittently or continuously). DSM-IV also recognizes the circumstances supporting remission and allows for distinctions such as remission while the user is in a controlled environment (where substances are highly restricted) or remission from drug of dependence when the user is maintained on a similar agonist. The categorization of states of remission (abstinence) in ICD-10 is somewhat similar, although the distinction between early and sustained remission is not made.

CHALLENGES TO THE DISEASE CONCEPT

The classic disease model of alcoholism and drug dependence has served as a challenge to some behavioral researchers and social scientists; they have raised a number of questions about biologically based theories of such behaviors. Critics of the disease concept point to studies showing that some former alcoholics could apparently return to normal drinking. Such findings challenged the concept of alcoholism as a progressive disease. The concept of inevitable "loss of control" over drinking was also challenged by Merry's study (1966) in which alcoholics were given drinks containing either vodka or a placebo (no alcohol) on alternate days and reported having no more desire to drink after consuming the vodka than after the placebo. The results suggested that if "loss of control" did occur in alcoholics, it was not triggered as a biological response to alcohol but rather as a learned response with associated Expectancies concerning drinking behavior. Researchers Nancy Mello and Jack Mendelson also reported, in 1971, that alcoholics did not manifest "loss of control" in their drinking behavior and did not drink to avoid withdrawal symptoms. The work of Mello and Mendelson and of other researchers led to the conclusion that drinking behavior could be shaped like any other operant in a behavioral paradigm. Other researchers challenged the notion of alcoholism as a distinct entity (with clear differentiations between alcoholics and nonalcoholics), as well as the concepts of inevitable progression to loss of control and of alcoholism as a permanent and irreversible condition precluding the possibility of moderate drinking. (For these and other references, see Meyer, 1992.)

These findings by behavioral researchers in the laboratory had counterparts in large surveys of drinking practices conducted by the RAND Corporation. Evidence in the general population indicated that some alcoholics might be able to drink moderately without relapsing to excessive drinking.

These and other such challenges to the disease concept of alcoholism sharpened the debate and clarified the construct. Efforts to replicate some of these earlier studies sometimes led to conflicting results, calling into question the conclusions they had drawn or leading to refinements. RAND Corporation found at later follow-up that severely dependent alcoholics had to remain abstinent in order to maintain improvement. Several studies appeared to confirm that severely dependent alcoholics might be different from those who were less dependent. Some researchers, such as Hodgson, reported that small doses of alcohol had a "priming" effect (i.e., stimulated a strong urge to drink more), the magnitude of which correlated with the severity of alcohol dependence. Other researchers criticized the methodology used in previous studies. (For references, see Meyer, 1992.)

These findings help to explain why, beginning in the late 1970s, the classic disease concept was being reexamined and redefined as a symptom complex called "dependence" or "dependence syndrome." However, this shift has not satisfied some critics who object to any conceptualization that comes close to viewing compulsive alcohol or other drug use as a disease or disorder. The debate over the disease concept continues to be more heated in the alcohol field than in other areas of addictive disorders, such as compulsive use of opioids. In the early 1990s, however, an analogous and equally heated debate has developed about the conceptualization of tobacco smoking.

While health professionals throughout the world now generally agree that some forms of drug and alcohol use should be seen as disorders (at least for record-keeping and some public policy purposes), dissent from this view persists. The most compelling arguments against the disease concept have come from social and behavioral scientists. This may be partly because behavioral clinicians tend to work with less seriously impaired individuals, while physicians usually deal with people whose dependence has become more severe; and also because the physician's primary-care office may be where early identification of substance-abuse problems and effective behavioral interventions is most likely to take place.

ALTERNATIVE MODELS

Swedish researcher Lars Lindström's summary of current perspectives on the nature of alcoholism is equally applicable to the divergent views about other forms of excessive and/or compulsive drug use. Each of these models attempts to explain why people use alcohol or drugs, why use escalates to excessive and/or harmful levels, why some people continue drug use despite the harmful consequences, how and why they stop using drugs, and why they relapse after a period of abstinence. The perspectives include the moral model, which holds that individuals have choice and are accountable for their behavior; the disease model (both the classic and its variants); the symptomatic model, which views excessive drug or alcohol use as a symptom of underlying psychiatric disorder; the learning model (drug addiction and alcoholism are learned behaviors); the social model, which emphasizes the primacy of environmental factors, such as availability, social controls, interpersonal relationships; and the biopsychosocial model, which attempts (in several variants) to synthesize elements of other models, taking into account biology, vulnerability, psychopathology, and cultural, social, economic, and pharmacological factors. The dependence syndrome model is probably best viewed as a variant of the biopsychosocial model.

Lindström points out that these models are now rarely encountered in pure form: each commonly incorporates elements from other perspectives. Furthermore, proponents of a particular model may, in practice, give greater emphasis to the central features of another. For example, Alcoholics Anonymous (AA) generally espouses the disease model. Yet because AA holds people accountable for the consequences of their drug use and emphasizes the central role of spiritual alienation in the perpetuation of alcoholism, AA's approach may also be seen as a variant of the moral model.

Although the term disease concept is often used synonymously with biological or medical model, these terms do not always convey the same ideas, especially with respect to implications for treatment. For example, the medical model of treatment is frequently contrasted with the social or social recovery model, now widely used and advocated in California. Medical-model programs are generally characterized not only by a philosophy about the problem but also by hospital-based detoxification, often pharmacologically assisted, and outpatient components in which there are formal treatment plans. Attention is paid to careful record keeping and professional credentials of the treatment staff. Physicians retain medical and legal responsibility for the overall program. In contrast, social-model recovery programs reject the involvement of professional staff and many of the activities of the medical model, such as the data gathering, licensing, and record keeping that link funding to units of service for specific patients. Instead, these programs emphasize the experience and knowledge that staff derive from the recovery process built on Twelve-Step mutual-help principles. There are no patients—only participants—and the role of staff is to manage the environment. Yet social models, in emphasizing the critical role that people "in recovery" play in the helping process, are employing a term—recovery —that is itself derived from the classic disease concept, which views alcoholism as a permanent disease state for which the only cure is total abstinence and the twelve-step AA program as the best route to such abstinence.

PERSISTENCE OF THE MORAL PERSPECTIVE

Despite the preponderance of medical opinion that some drug and alcohol users have a disorder—a diminished capacity to choose freely whether or not to use a particular substance—the moral models retain some vitality. In 1882, when the disease concept was first gaining momentum, the Reverend J. E. Todd wrote an essay entitled "Drunkenness a Vice, Not a Disease." In the late 1980s, the disease concept critics Fingarette and Peele put forth almost precisely the same thesis. Peele has argued that the disease concept exculpates the individual from responsibility, runs counter to scientific facts, and is perpetuated for the benefit of the treatment industry. However, his thesis has been criticized for using the classic disease model as a "straw man" because it does not take into account the more recent adoption of the bio-psychosocial model.

Some sociologists in the United States have noted that the term alcoholic is still commonly used as a synonym for drunkard rather than as a designation for someone with an illness or disorder. The word addict is similarly used in a pejorative way, even when it is used more loosely to refer to a wide range of relatively benign behaviors, such as running or watching television. In the minds of most people, the concept of alcoholism or drug addiction as a disorder or disease can coexist quite comfortably with the concept of drunkenness or drug use as a vice. Since the nature of drug dependence is so closely linked to questions about the nature of free will and human volition—issues that have fascinated philosophers and scientists through the ages—it is likely that the disease concept of addiction will continue to be debated for a long time to come.

(See also: Addiction: Concepts and Definitions ; Alcoholism ; Causes of Substance Abuse ; Tolerance and Physical Dependence ; Treatment, History of, in the United States )

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Jerome H. Jaffe

Roger E. Meyer