ALCOHOLISM

This section contains articles on some aspects of chronic drinking: Abstinence versus Controlled Drinking and Origin of the Term. For further information on this subject, see Disease Concept of Alcoholism and Drug Abuse and the sections on Complications, on Treatment and on Withdrawal.

Abstinence versus Controlled Drinking

The position of Alcoholics Anonymous (AA) and the dominant view among therapists who treat alcoholism in the United States is that the goal of treatment for those who have been dependent on alcohol is total, complete, and permanent abstinence from alcohol.

Abstinence was at the base of Prohibition (legalized in 1919 with the Eighteenth Amendment) and is closely related to prohibitionism—the legal proscription of substances and their use.

Although temperance originally meant moderation, the nineteenth-century Temperance Movement 's emphasis on complete abstinence from alcohol and the mid-twentieth century's experience of the Alcoholics Anonymous movement have strongly influenced alcohol- and drug-abuse treatment goals in the United States. Moral and clinical issues, however, have been irrevocably mixed.

The disease model of alcoholism and drug addiction, which insists on abstinence, has incorporated new areas of compulsive behavior—such as overeating and sexual involvements. In these cases, redefinition of abstinence from total avoidance to "the avoidance of excess" (what we would otherwise term moderation) is required.

Abstinence can also be used as a treatment-outcome measure, as an indicator of its effectiveness. In this case, abstinence is defined as the number of drug-free days or weeks during the treatment regimen—and measures of drug in urine are often used as objective indicators.

CONTROLLED DRINKING

By extension, for all those treated for alcohol abuse, including those with no dependence symptoms, moderation of drinking (termed controlled drinking, or CD) as a goal of treatment is rejected (Peele, 1992). Instead, providers claim, holding out such a goal to an alcoholic is detrimental, fostering a continuation of denial and delaying the alcoholic's need to accept the reality that he or she can never drink in moderation. One painful example of this is the case of Audrey Kishline, author of Moderate Drinking: The New Option for Problem Drinkers, and founder of the group Moderation Management. In the summer of 2000, Kishline pleaded guilty to a vehicular homicide incident in which she killed a father and his twelve-year-old daughter when she drove the wrong way on a Washington State highway. Her blood alcohol level at the time of the accident was 0.26—three times the legal limit.

In Britain and other European and Common-wealth countries, controlled-drinking therapy is widely available (Rosenberg et al., 1992). The following six questions explore the value, prevalence, and clinical impact of controlled drinking versus abstinence outcomes in alcoholism treatment; they are intended to argue the case for controlled drinking as a reasonable and realistic goal.

1. What proportion of treated alcoholics abstain completely following treatment?

At one extreme, Vaillant (1983) found a 95 percent relapse rate among a group of alcoholics followed for eight years after treatment at a public hospital; and over a four-year follow-up period, the Rand Corporation found that only 7 percent of a treated alcoholic population abstained completely (Polich, Armor, & Braiker, 1981). At the other extreme, Wallace et al. (1988) reported a 57 percent continuous abstinence rate for private clinic patients who were stably married and had successfully completed detoxification and treatment—but results in this study covered only a six-month period.

In other studies of private treatment, Walsh et al. (1991) found that only 23 percent of alcohol-abusing workers reported abstaining throughout a two-year follow-up, although the figure was 37 percent for those assigned to a hospital program. According to Finney and Moos (1991), 37 percent of patients reported they were abstinent at all follow-up years 4 through 10 after treatment. Clearly, most research agrees that most alcoholism patients drink at some point following treatment.

2. What proportion of alcoholics eventually achieve abstinence following alcoholism treatment?

Many patients ultimately achieve abstinence only over time. Finney and Moos (1991) found that 49 percent of patients reported they were abstinent at four years and 54 percent at ten years after treatment. Vaillant (1983) found that 39 percent of his surviving patients were abstaining at eight years. In the Rand study, 28 percent of assessed patients were abstaining after four years. Helzer et al. (1985), however, reported that only 15 percent of all surviving alcoholics seen in hospitals were abstinent at 5 to 7 years. (Only a portion of these patients were specifically treated in an alcoholism unit. Abstinence rates were not reported separately for this group, but only 7 percent survived and were in remission at follow-up.)

3. What is the relationship of abstinence to controlled-drinking outcomes over time?

Edwards et al. (1983) reported that controlled drinking is more unstable than abstinence for alcoholics over time, but recent studies have found that controlled drinking increases over longer follow-up periods. Finney and Moos (1991) reported a 17 percent "social or moderate drinking" rate at six years and a 24 percent rate at ten years. In studies by McCabe (1986) and Nordström and Berglund (1987), CD outcomes exceeded abstinence during follow-up of patients fifteen and more years after treatment (see Table 1). Hyman (1976) earlier found a similar emergence of controlled drinking over fifteen years.

4. What are legitimate nonabstinent outcomes for alcoholism?

The range of nonabstinence outcomes between unabated alcoholism and total abstinence includes (1) "improved drinking" despite continuing alcohol abuse, (2) "largely controlled drinking" with occasional relapses, and (3) "completely controlled drinking." Yet some studies count both groups (1) and (2) as continuing alcoholics and those in group (3) who engage in only occasional drinking as abstinent. Vaillant (1983) labeled abstinence as drinking less than once a month and including a binge lasting less than a week each year.

The importance of definitional criteria is evident in a highly publicized study (Helzer el al., 1985) that identified only 1.6 percent of treated alcoholism patients as "moderate drinkers." Not included in this category were an additional 4.6 percent of patients who drank without problems but who drank in fewer than thirty of the previous thirty-six months. In addition, Helzer et al. identified a sizable group (12%) of former alcoholics who drank a threshold of seven drinks four times in a single month over the previous three years but who reported no adverse consequences or symptoms of alcohol dependence and for whom no such problems were uncovered from collateral records. Nonetheless, Helzer et al. rejected the value of CD outcomes in alcoholism treatment.

While the Helzer et al. study was welcomed by the American treatment industry, the Rand results (Polich, Armor, & Braiker, 1981) were publicly denounced by alcoholism treatment advocates. Yet the studies differed primarily in that Rand reported a higher abstinence rate, using a six-month window at assessment (compared with three years for Helzer et al.). The studies found remarkably similar nonabstinence outcomes, but Polich, Armor, and Braiker (1981) classified both occasional and continuous moderate drinkers (8%) and sometimes heavy drinkers (10%) who had no negative drinking consequences or dependence symptoms in a nonabstinent remission category. (Rand subjects had been highly alcoholic and at intake were consuming a median of seventeen drinks daily.)

The harm-reduction approach seeks to minimize the damage from continued drinking and recognizes a wide range of improved categories (Heather, 1992). Minimizing nonabstinent remission or improvement categories by labeling reduced but occasionally excessive drinking as "alcoholism" fails to address the morbidity associated with continued untrammeled drinking.

5. How do untreated and treated alcoholics compare in their controlled-drinking and abstinent-remission ratios?

Alcoholic remission many years after treatment may depend less on treatment than on post-treatment experiences, and in some long-term studies, CD outcomes become more prominent the longer subjects are out of the treatment milieu, because patients unlearn the abstinence prescription that prevails there (Peele, 1987). By the same token, controlled drinking may be the more common outcome for untreated remission, since many alcohol abusers may reject treatment because they are unwilling to abstain.

Goodwin, Crane, & Guze (1971) found that controlled-drinking remission was four times as frequent as abstinence after eight years for untreated alcoholic felons who had" unequivocal histories of alcoholism" (see Table 1). Results from the 1989 Canadian National Alcohol and Drug Survey confirmed that those who resolve a drinking problem without treatment are more likely to become controlled drinkers. Only 18 percent of five hundred recovered alcohol abusers in the survey achieved remission through treatment. About half (49 percent) of those in remission still drank. Of those in remission through treatment, 92 percent were abstinent. But 61 percent of those who achieved remission without treatment continued drinking (see Table 2).

6. For which alcohol abusers is controlled-drinking therapy or abstinence therapy superior?

Severity of alcoholism is the most generally accepted clinical indicator of the appropriateness of CD therapy (Rosenberg, 1993). Untreated alcohol abusers probably have less severe drinking problems than clinical populations of alcoholics, which may explain their higher levels of controlled drinking. But the less severe problem drinkers uncovered in nonclinical studies are more typical, outnumbering those who "show major symptoms of alcohol dependence" by about four to one (Skinner, 1990).

Despite the reported relationship between severity and CD outcomes, many diagnosed alcoholics do control their drinking, as Table 1 reveals. The Rand study quantified the relationship between severity of alcohol dependence and controlled-drinking outcomes, although, overall, the Rand population was a severely alcoholic one in which "virtually all subjects reported symptoms of alcohol dependence" (Polich, Armor, and Braiker, 1981).

Polich, Armor, and Braiker found that the most severely dependent alcoholics (eleven or more dependence symptoms on admission) were the least likely to achieve nonproblem drinking at four years. However, a quarter of this group who achieved remission did so through nonproblem drinking. Furthermore, younger (under 40), single alcoholics were far more likely to relapse if they were abstinent at eighteen months than if they were drinking without problems, even if they were highly alcohol-dependent (Table 3). Thus the Rand study found a strong link between severity and outcome, but a far from ironclad one.

Some studies have failed to confirm the link between controlled-drinking versus abstinence outcomes and alcoholic severity. In a clinical trial that included CD and abstinence training for a highly dependent alcoholic population, Rychtarik et al. (1987) reported 18 percent controlled drinkers and 20 percent abstinent (from fifty-nine initial patients) at 5 to 6 year follow-up. Outcome type was not related to severity of dependence. Nor was it for Nordström and Berglund (1987), perhaps because they excluded "subjects who were never alcohol dependent."

Nordström and Berglund, like Wallace et al. (1988), selected high-prognosis patients who were socially stable. The Wallace et al. patients had a high level of abstinence; patients in Nordström and Berglund had a high level of controlled drinking. Social stability at intake was negatively related in Rychtarik et al. to consumption as a result either of abstinence or of limited intake. Apparently, social stability predicts that alcoholics will succeed better whether they choose abstinence or reduced drinking. But other research indicates that the pool of those who achieve remission can be expanded by having broader treatment goals.

Rychtarik et al. found that treatment aimed at abstinence or controlled drinking was not related to patients' ultimate remission type. Booth, Dale, and Ansari (1984), on the other hand, found that patients did achieve their selected goal of abstinence or controlled drinking more often. Three British groups (Elal-Lawrence, Slade, & Dewey, 1986; Heather, Rollnick, & Winton, 1983; Orford & Keddie, 1986) have found that treated alcoholics' beliefs about whether they could control their drinking and their commitment to a CD or an abstinence-treatment goal were more important in determining CD versus abstinence outcomes than were subjects' levels of alcohol dependence. Miller et al. (in press) found that more dependent drinkers were less likely to achieve CD outcomes but that desired treatment goal and whether one labeled oneself an alcoholic or not independently predicted outcome type.

SUMMARY

As of 2000, there is no conclusive evidence to show that one single method of treatment is consistently more successful than another (Project MATCH). One of the largest (U.S.) clinical experiments—sponsored by the National Institute on Alcohol Abuse and Alcoholism—shows that of the three major treatments studied (cognitive-behavioral therapy [CBT], twelve-step facilitation [TSF], and motivational enhancement therapy [MET]), none emerged the clear "winner."

A group of 952 outpatients (some still drinking) and 774 patients (previously receiving residential/day hospital treatment) participated in the study, that spanned over twelve weeks. The two groups were each divided into three separate groups, each group receiving one of the three treatments.

Particpants were polled immediately after treatment and again every three months for a year in an effort to document their subsequent progress. Patients of all three treatments exemplified good and sustained results. In all, only 10 percent of the participants dropped out of the study itself; two-thirds finished the treatment(s). The percentage of days abstinent (PDA) rose in all three groups by 60 percent (from 20 to 80 percent), and suffered only minimal decline in the next year.

Controlled drinking (CD) is one of a number of approaches with an important role to play in alcoholism treatment. CD, as well as abstinence, is an appropriate goal for the majority of problem drinkers who are not alcohol-dependent (though there is no proven scientific method to determine who can and who cannot stop drinking after one or two drinks). In addition, while controlled drinking becomes less likely the more severe the degree of alcoholism, other factors—such as age, values, and beliefs about oneself, one's drinking, and the possibility of controlled drinking—also play a role, sometimes the dominant role, in determining successful outcome type. Finally, reduced drinking is often the focus of a harm-reduction approach, where the likely alternative is not abstinence but continued alcoholism.

(See also: Alcohol ; Disease Concept of Alcoholism and Drug Abuse ; Relapse Prevention ; Treatment )

BIBLIOGRAPHY

Booth, P. G., Dale, B., & Ansari, J. (1984). Problem drinkers' goal choice and treatment outcomes: A preliminary study. Addictive Behaviors, 9, 357-364.

Edwards, G., et al. (1983). What happens to alcoholics? Lancet, 2, 269-271.

Elal-Lawrence, G., Slade, P.D., & Dewey, M.E. (1986). Predictors of outcome type in treated problem drinkers. Journal of Studies on Alcohol, 47, 41-47.

Finney, J. W., & Moos, R. H. (1991). The long-term course of treated alcoholism: 1. Mortality, relapse and remission rates and comparisons with community controls. Journal of Studies on Alcohol, 52, 44-54.

Goodwin, D. W., Crane, J. B., & Guze, S. B. (1971). Felons who drink: An 8-year follow-up. Quarterly Journal of Studies on Alcohol, 32, 136-147.

Heath, D. B. (1992). Prohibition or liberalization of alcohol and drugs? In M. Galanter (Ed.), Recent developments in alcoholism: Alcohol and cocaine. New York: Plenum.

Heather, N. (1992). The application of harm-reduction principles to the treatment of alcohol problems. Paper presented at the Third International Conference on the Reduction of Drug-Related Harm, Melbourne, Australia, March.

Heather, N., Rollnick, S., & Winton, M. (1983). A comparison of objective and subjective measures of alcohol dependence as predictors of relapse following treatment. Journal of Clinical Psychology, 22, 11-17.

Helzer, J.E. et al. (1985). The extent of long-term moderate drinking among alcoholics discharged from medical and psychiatric treatment facilities. New England Journal of Medicine, 312, 1678-1682.

Hyman, H. H. (1976). Alcoholics 15 years later. Annals of the New York Academy of Science, 273, 613-622.

Lender, M. E., & Martin, J. K. (1982). Drinking in America. New York: Free Press.

License to Drink: Can boozers learn moderation ? Atragedy rekindles debate about a controversial Program. (2000) Time, 156, 47.

Mc Cabe, R. J. R. (1986). Alcohol-dependent individuals 16 years on. Alcohol & Alcoholism, 21, 85-91.

Miller, W.R. et al. (1992). Long-term follow-up of behavioral self-control training. Journal of Studies on Alcohol, 53, 249-261.

NordstrÖm, G., & Berglund, M. (1987). A prospective study of successful long-term adjustment in alcohol dependence. Journal of Studies on Alcohol, 48, 95-103.

Orford, J., & Keddie, A. (1986). Abstinence or controlled drinking: A test of the dependence and persuasion hypotheses. British Journal of Addiction, 81, 495-504.

Peele, S. (1992). Alcoholism, politics, and bureaucracy: The consensus against controlled-drinking therapy in America. Addictive Behaviors, 17, 49-61.

Peele, S. (1987). Why do controlled-drinking outcomes vary by country, era, and investigator?: Cultural conceptions of relapse and remission in alcoholism. Drug and Alcohol Dependence, 20, 173-201.

Peele, S., Brodsky, A., & Arnold, M. (1991). The truth about addiction and recovery. New York: Simon & Schuster.

Polich, J. M., Armor, D. J., & Braiker, H. B. (1981). The course of alcoholism: Four years after treatment. New York: Wiley.

Project MATCH Research Group (1997). Matching alcoholism treatments to client heterogeneity: Project AUTCH post-treatment drinking outcomes. Journal of Studies on Alcohol, 58, 7-29.

Provet, Ph. D., P. (2000). Why addiction cannot be moderate. Alcoholism & Drug Abuse Weekly, 12, no. 30: 5.

Rosenberg, H. (1993). Prediction of controlled drinking by alcoholics and problem drinkers. Psychological Bulletin, 113, 129-139.

Rosenberg, H., Melville, J., Levell, D., & Hodge, J. E. (1992). A ten-year follow-up survey of acceptability of controlled drinking in Britain. Journal of Studies on Alcohol, 53, 441-446.

Rychtarik, R. G., et al. (1987). Five-six-year follow-up of broad spectrum behavioral treatment for alcoholism: Effects of training controlled drinking skills. Journal of Consulting and Clinical Psychology, 55, 106-108.

Skinner, H. A. (1990). Spectrum of drinkers and intervention opportunities. Journal of the Canadian Medical Association, 143, 1054-1059.

Subak-Sharpe, G. J. (1995). The Columbia University College of Physicians and Surgeons Complete Home Medical Guide. New York: Crown Publishers, Inc.

Treatment of Alcoholism-Part II. (2000) Harvard Mental Health Letter 16

Vaillant, G. E. (1983). The natural history of alcoholism. Cambridge: Harvard University Press.

Wallace, J., et al. (1988). 1. Six-month treatment outcomes in socially stable alcoholics: Abstinence rates. Journal of Substance Abuse Treatment, 5, 247-252.

Walsh, D. C., et al. (1991). A randomized trial of treatment options for alcohol-abusing workers. New En-land Journal of Medicine, 325, 775-782.

Stanton Peele

Revised by Kimberly A. McGrath

Origin of the Term

The term alcoholism is of relatively recent date; knowledge of the adverse effects of heavy alcohol (ethanol) consumption is not. A proverb describes alcohol as "both mankind's oldest friend and oldest enemy." Alcohol occurs in nature, and humans have long known how to ferment plants to create it; both its moderate and excessive use have therefore occurred since prehistory. The Bible cautions: "Do not look at wine when it is red, when it sparkles in the cup and goes down smoothly. At the end it bites like a serpent and stings like an adder" (Proverbs 23:31-32). A drunken Noah (Genesis 9:20-28) is one of a long line of such literary descriptions. In the classical era of the Greeks and the Romans we have drunks in the Character Sketches of Theophrastus, in the Satyricon of Petronius Arbiter, and in the Epistles of Seneca. In the 1600s, we have Shakespeare's porter in Macbeth (Act II, Scene 3) and others.

Viewing the long-term adverse effects of alcohol as a disease is a concept that also predates the term alcoholism. Benjamin Rush (1745-1813) and Thomas Trotter (1760-1832), both physicians, wrote extensively in this vein, using words such as drunkenness ; their elder contemporary Benjamin Franklin (1706-1790) produced a glossary of 228 synonyms in use in 1737 for "being under the influence of alcohol." It was not until 1849 that the Swedish physician and temperance advocate Magnus Huss (1807-1890) first used the word alcoholism in his book Alcoholismus Chronicus (The Chronic Alcohol-disease). Huss's term, used originally in a descriptive sense to denote the consequences of the prolonged consumption of large quantities of alcohol, has come to connote a disease, believed by some to result in such consumption.

Huss meant by the term chronic alcoholism "those pathologic symptoms which develop in such persons who over a long period of time continually use wine or other alcoholic beverages in large quantities" and stated that it "corresponds with chronic poisoning." His book is filled with detailed case histories illustrating the various symptoms that might occur. Sweden was at that time highest in the list of countries that consumed liquors, and Huss, as attending physician to the Serafim Clinic In Stockholm, had ample opportunity to observe cases. The London Daily News of December 8, 1869, carried a story on "the deaths of two persons from alcoholism," which according to the Oxford English Dictionary was the first popular use of the word in English. From that time on, its use in both the professional and the popular literature greatly expanded. This is partly because of the natural process that popularizes usage of certain words and partly because of deliberate activities on behalf of the term alcoholism.

The period of national prohibition in the United States (1919-1933) was accompanied by a lack of attention to the consequences of alcohol consumption, for understandable reasons. Such consumption was illegal—permanently, it was assumed—and as a result, it was thought that there would be little in the way of consequences. Indeed, such consequences as cirrhosis of the liver did decline abruptly during this period. But as enthusiasm for prohibition waned, and especially after it was repealed, a need to promote treatment became increasingly evident. One group involved in this promotion used alcoholism as the key word in their efforts, and accordingly were called the alcoholism movement by sociologists who subsequently studied their work. In an early statement of this movement, Anderson (1942) predicted that "When the dissemination of these ideas is begun through the existing media of public information, press, radio, and platform, which will consider them as news, a new public attitude can be shaped." It was also felt that the term, together with the disease connotations attached to it, would encourage the involvement of physicians in its study and treatment. The medical profession was viewed as critical to the success of the effort to increase the nation's concern about the consequences of alcohol consumption. The formation of the National Council on Alcoholism, the largest public interest group in this area, was a project of the same movement. Their successful efforts may be the reason that the term alcoholism developed and sustained a popularity in the United States beyond anything it achieved in Europe and even in Scandinavia, where it was first used.

MEANING BROADENS

As the term alcoholism became widely used, its meaning broadened. In a 1941 review of treatment, ten definitions of chronic alcoholism and sixteen definitions of alcohol addiction were collected from the international literature. Originally used by Huss to refer to a disease that consisted of the consequences of alcohol consumption, alcoholism came in time to represent a disease that caused high levels of alcohol consumption (Jellinek, 1960). A variant theory attempts to preserve the original meaning: High levels of alcohol consumption resulted in consequences of various kinds, particularly in terms of damage to the central nervous system, which damage in turn caused the high levels of consumption to continue (Vaillant, 1983). That is, the term alcoholism evolved overtime from a primarily descriptive term to a largely explanatory concept. An example of a definition of alcoholism with clear explanatory intent is one that R. C. Rinaldi and colleagues produced in 1988 through an elaborate consensus exercise (a Delphi process) among eighty American experts, who defined the term as "a chronic, progressive, and potentially fatal biogenetic and psychosocial disease characterized by tolerance and physical dependence manifested by a loss of control, as well as diverse personality changes and social consequences." As a counterpoint to this line of development, a growing and increasingly influential literature holds that problems developing in the context of alcohol consumption do not constitute a disease at all (Fingarette, 1988).

The greater interest taken in alcohol consumption and its consequences as a result of the popularization of the term alcoholism has been gratifying as well as useful. But the broadening of meaning of the term, with much attendant controversy among the advocates of various definitions, has become problematic. For example, in a review of alternative definitions, Babor & Kadden (1985) concluded: "Clearly, the past and present lack of consensus concerning the definition of alcoholism and the criteria for its diagnosis does not provide a solid conceptual basis to design screening procedures for early detection or casefinding." Because of its imprecise meaning, the term alcoholism has for some time now been dropped from the two major official systems of diagnosis of diseases, the International Classification of Diseases of the World Health Organization and the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. A recent comprehensive study of treatment deliberately avoided the use of the word alcoholism as too narrow in its focus, while suggesting that the word was not incompatible with the phrase that it chose to use—alcohol problems —to refer to any problem occurring in the context of alcohol consumption (Institute of Medicine, 1990, pp. 30-31).

COMPLEX PROBLEMS

These recent attempts to be precise in the use of words represent a return to the more straightforward, descriptive use of alcoholism by its originator, Huss. Two major realities contributing to this change of direction have been widely recognized since Huss first used the term in the 1840s. One is that the problems people experience are complex, including those that may arise in the context of alcohol use. Although alcohol may be a factor in some such problems—even an important factor—it is not often the full explanation for them. Multiple factors, including heredity, early environment, cultural factors, personality factors, situational factors, and others, contribute to the development of human problems and must be considered in their resolution. This formulation should not be taken to minimize the important role of alcohol in such problems or to say that the reduction or elimination of alcohol consumption may not be a critical factor in the resolution of problems in particular individuals. The other reality has to do with the extremely broad spectrum of problems that arise in the context of alcohol consumption. Although a substantial proportion of these problems arise from those who drink too much over a long period of time and who usually have multiple problems (those to whom the term alcoholism is usually applied), an even greater burden of problems arises from those who drink too much over short periods of time, and who have only a few problems. The simple reason is that there are more of the latter than of the former (Institute of Medicine, 1990, chapter 9). To reduce the burden upon society effectively, both kinds of populations must be dealt with. An exclusive concentration on alcoholism may cause this reality to be overlooked.

Costly Consequences.

The term alcoholism retains, and probably will always retain, its place in general, nontechnical speech as an indicator of serious problems that are the consequences of prolonged heavy alcohol consumption. Its continued popularity has some advantages, for the public-health consequences of such alcohol consumption are horrendous. The presence of a convenient shorthand term for this fact in the public consciousness—alcoholism —serves as a continuing reminder of this major unfinished item on the public-health agenda. Certainly, there is a legitimate place in Western society for the use of alcohol. But with equal certainty, too many individuals fail to use alcohol wisely or well.

The ravages that prolonged exposure to alcohol produces in the human body are manifold, as Huss well understood; they include neurological problems (damage to the central and peripheral nervous systems), cirrhosis (fibrosis and shrinking) of the liver, hypertension (high blood pressure), and many forms of cancer, particularly of the digestive tract, to name but a few. If to these are added the consequences of short-term but intense exposure to alcohol and the intoxication it produces, one can include a high proportion of all accidents, burns, all types of violence including suicide, and especially automobile crashes, as well as the common behavioral effects of intoxication with which we are all too familiar. Small wonder that almost 30 percent of all admissions to hospitals in the United States are of persons with severe alcohol problems; yet most of these problems go unrecognized, and the individuals go untreated. About 50 percent of American women have or have had a parent, blood relative, or spouse to whom they would apply the term alcoholism ; the figure is closer to 40 percent for men. The difficulties that this creates are legion—and its remediation would be a remarkable step forward.

(See also: Addiction: Concepts and Definitions ; Disease Concept of Alcoholism ; Treatment, History of )

BIBLIOGRAPHY

Anderson, D. (1942). Alcohol and public opinion. (1942). Quarterly Journal of Studies on Alcohol, 3, 376. An early manifesto of the alcoholism movement.

Babor, T. F., & Kadden, R. (1985). Screening for alcohol problems: Conceptual issues and practical consideratiions. In N. C. Chong & H. M. Cho (Eds.), Early identification of alcohol abuse. Washington, DC: U.S. Government Printing Office.

Bynum, W. F. (1968). Chronic alcoholism in the first half of the 19th century. Bulletin of the History of Medicine, 42, 160-185. An excellent review of medical thought about alcohol problems at the time of Magnus Huss.

Fingarette, H. (1988). Heavy drinking: The myth of alcoholism as a disease. Berkeley: University of California Press. A comprehensive summary of the evidence against the disease concept of alcoholism.

Huss, M. (1852). Chronische Alkoholskrankheit oder Alcoholismus Chronicus (Alcoholismus chronicus or the chronic alcohol disease). Translated by G. van dem Busch into German from the Swedish, with revisions by the author. Stockholm and Leipzig: C. E. Fritze. Original published 1849.

Institute of Medicine. (1990). Broadening the base of treatment for alcohol problems. Washington, DC: National Academy Press. A detailed contemporary review of all aspects of treatment.

Institute of Medicine. (1987) Causes and consequences of alcohol problem: An agenda for research. Washington, DC: National Academy Press. A comprehensive look at some basic issues in the field that includes extensive chapters on the medical, social, and psychological consequences of alcohol consumption.

Jellinek, E. M. (1960). The disease concept of alcoholism. Highland Park, NJ: Hillhouse Press. The classic book on the disease concept. If read carefully, it is more skeptical than credulous.

Rinaldi, R. C., Steindler, E. M., Wilford, B. B., & Goodwin, D. (1988). Clarification and standardization of substance abuse terminology. Journal of the American Medical Association, 259, 555-557.

Turner, T. B., Borkenstein, R. F., Jones, R. K., & Santora, P.B. (Eds.) (1985). Alcohol and highway safety. Supplement no. 10 to the Journal of Studies on Alcohol. New Brunswick, NJ: Rutgers University Center of Alcohol Studies. Covers multiple aspects of this complex and highly important area.

Vaillant, G. E. (1983). The natural history of alcoholism: Causes, patterns, and paths to recovery. Cambridge: Harvard University Press. An ingenious attempt to discover what happens to people with severe alcohol problems by tracing their histories over long periods of time.

Frederick B. Glaser