The disease of addiction

In 1939, Alcoholics Anonymous World Services, Inc. published Alcoholics Anonymous. Commonly referred to as the Big Book, this volume served to spread a new message of recovery across the nation and throughout the world. In addition to outlining a program of recovery, the book contained a "To Whom It May Concern" letter dated July 27, 1938, from a doctor specializing in the treatment of alcoholism and other drug addictions.

The physician, Dr. William D. Silkworth, was Medical Director at Charles B. Towns Hospital in New York City. Of particular interest was the doctor's depiction of alcoholism/addiction as an "allergy," Also, in the chapter "More About Alcoholism," the condition was termed an "illness."

This may sound like old news today, but in 1939, portraying addiction as a physical illness was new and innovative. Silkworth indicated that the basis of this portrayal was the "phenomenon of craving." Rather than invoking psychological or environmental origins, he instead regarded the root causes to be within the physiology of the person -- the body itself. Although primarily anecdotal, Silkworth's observations and the insights of recovering AA members would eventually be verified by more scientific researchers. James Milam, Kathleen Fitzgerald, R.S. Caldoret, Marc Schuckit, and many others would demonstrate the biogenic nature of alcoholism and drug addiction.

The disease model of addiction presumes that different people have different reactions to the presence of mood-altering chemicals within their body-systems. In fact, recent research clearly indicates that people have varying experiences with any introduced substance -- whether it is alcohol, nicotine, antibiotics, milk, or a Poptart -- and that these experiences are not based upon one's personality, psychological make-up, or environment. Of course, not everyone experiences the phenomenon of craving for another drink or another drug or another doughnut. The problem has been that those who do experience this craving have been deemed weak-willed, flawed in personality, or mentally ill.

The chief indicators of the disease of addiction do not appear in the DSM (Diagnostic Service Manual) IV. The DSM IV only denotes symptoms that occur in the later progressive phases, or symptoms that represent consequences of the disease, such as withdrawal, efforts to stop or control use, or drinking despite a serious health problem. The disease model of addiction, however, recognizes that the condition existed long before these more advanced symptoms appeared.

The primary signs of the presence of the disease include:

1. Abnormal metabolism of mood-altering chemicals. This abnormality is most easily recognized with alcohol, or ethanol, which is technically a sedative drug and toxic to the body. Before the sedative effects of alcohol are experienced, the drug is first enjoyed as a stimulant by most everyone. For the individual with normal metabolism, the stimulant effect is short-lived and, following additional consumption, is replaced by the sedative effect. This explains why the normal drinker has little problem saying "no" to another drink. When the stimulant effect has subsided and the sedative/toxic effects are being experienced, it takes no great amount of will-power, character, common sense or mental health to say "no more." However, alcoholics metabolize alcohol in another way, causing them to experience a prolonged stimulant effect and thereby postponing the sedative effect. The ability to consume larger amounts of alcohol then sets the stage for the next significant factor in the disease.

2. Variance of effect. A person who consumes large amounts of alcohol necessarily produces, in the liver, increased amounts of acetaldehyde, the primary chemical by-product. In people with an abnormal metabolism -- those with the disease -- two things occur. First, because of the ability to consume larger amounts of alcohol, acetaldehyde is created in larger amounts. And second, because the breakdown of acetaldehyde to acetate is less efficient in the alcoholic, a further build-up of acetaldehyde occurs. This large amount of acetaldehyde then invades the brain and is treated as a toxic substance. The brain, in turn, creates a new, opiate-like substance -- tetrahydraisoquinolone, or TIQ -- when it metabolizes the excess acetaldehyde. Thus the alcoholic gets "high" from the combined actions of the stimulant effect of ethanol and the narcotic effect of TIQ. The physical experience of alcohol consumption is therefore quite different for the person with this special metabolism.

3. Tolerance Increase: Once again related to the difference in alcohol metabolism, the alcoholic will experience an increased ability to sustain the stimulant effect and corresponding avoidance of the sedative/toxic effect. Since the disease dynamic requires more and more alcohol to attain the ethanol/opiate "high" as described earlier, larger amounts are consumed with greater frequency, and cellular adaptation -- addiction -- is greatly promoted and hastened.

4. Relationship Development: It is a human characteristic to try to form a relationship with anything that makes us feel good -- be it material possessions, sex, food or sports. Because of the physiological make-up of the alcoholic, the association with alcohol begins with a courtship that does not initially appear dangerous or threatening. As the amount and frequency of use increase, so does the denial process that protects alcohol from blame for consequences that are being experienced.

An important psychological dynamic of this relationship is the diminished significance and enjoyment once derived from activities that brought fulfillment, such as school, job, family, hobbies, and self-development. The attractiveness and intensity of the "high" make these pursuits both boring and difficult and are now viewed by the alcoholic as drudgery.

As the disease progresses, the alcoholic struggles more and more with these psychological issues. Some alcoholics apply great amounts of willpower to control their drinking in order to fulfill their obligations to school, job, and family, while others disconnect from most of their responsibilities to be free to pursue their relationship with alcohol. Still others may have so little control over the addictive process or their behavior while drinking that they are forced into the criminal justice system.

So this is the "disease" of alcoholism. While the process is very similar to that found in other drugs, many substances are more addictive than alcohol and may not require the same degree of physiological predetermination.

It is important to understand that different people experience the effects of drugs differently and that this difference is primarily physiological -- not psychological or environmental, nor an issue of character, willpower, or mental health.