Talk:Disease theory of alcoholism

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[edit] "The Disease model of addiction is probably the most controversial and debated topic in the entire field of substance abuse/addiction"

“The Disease model of addiction is probably the most controversial and debated topic in the entire field of substance abuse/addiction. One would have to be well informed on the subject to even attempt to understand the controversy intelligently. This site will not claim to know for sure one way or the other (disease/not disease) but will present a little of both sides of the on going debate with in the professional circles. First, we must accurately define Disease, since when the word disease is mentioned most think of something like cancer, aids, heart, etc., something which can be isolated in part and extracted from the body and visibly viewed and observed by the eye under a microscope or other apparatus. This is not the case with the "disease of alcoholism/addiction" or at least not at this time. According to Webster's Dictionary disease is defined as follows: "Disease: Any departure from health presenting marked symptoms; malady; illness; disorder." Then we must go on to define concept as well, which according to Webster's is: "Concept: A notion, thought, or idea." This popular model of addiction is credited to E.M. Jellinek who presented a comprehensive disease model of alcoholism in 1960(13). The World Health Organization acknowledged alcoholism as a serious medical problem in 1951, and the American Medical Association declared alcoholism as a treatable illness in 1956. Following Jellinek's work, the American Psychiatric Association began to use the term disease to describe alcoholism in 1965, and the American Medical Association followed in 1966 (14). As with many concepts and theoretical models in the addiction field, the disease concept was originally applied to alcoholism and has been generalized to addiction to other drugs as well. The "disease of addiction" is viewed as a primary disease. That is, it exists in and of itself and is not secondary to some other condition. This is in contrast to the psychological model of Dual Diagnosis (discussed in the next section), which addictive behavior is seen as secondary to some psychological condition.

Arguments Against the Validity of the Disease Concept

As earlier stated, the disease concept is controversial and not without critics. Two well-known critics are Stanton Peele (16) and Herbert Fingarette (15), both of whom have written books, as well as articles disputing the disease concept of addiction. Since the disease concept is attributed to Jellinek, a lot of criticism has been directed at his research, which was the basis for his conclusions about the disease concept. Jellinek's data were gathered from questionnaires that were distributed to AA members through its newsletter, "The Grapevine". Of 158 questionnaires returned, 60 were discarded because members had pooled and averaged their responses, and no questionnaires from women were used. Jellinek himself acknowledged that his data was limited. Therefore, one might wonder why Jellinek's concept of the disease of alcoholism received such widespread acceptance. One reason is that the disease concept is consistent with the philosophy of AA, which is by far the largest organized group dedicated to help for alcoholics. Secondly, as Peele noted: "The disease model has been so profitable and politically successful that it has spread to include problems of eating, child abuse, gambling, shopping, premenstrual tension, compulsive love affairs, and almost every other form of self-destructive behavior... From this perspective, nearly every American can be said to have a disease of addiction." (16) Herbert Fingarette goes on to state that the alcohol industry itself contributes to forming a public perception of alcoholism as a disease, as a marketing ploy: "By acknowledging that a small minority of the drinking population is susceptible to the disease of alcoholism, the industry can implicitly assure consumers that the vast majority of people who drink are not at risk. This compromise is far preferable to both the old temperance commitment to prohibition, which criminalized the entire liquor industry, and to newer approaches that look beyond the small group diagnosable as alcoholics to focus on the much larger group of heavy drinkers who develop serious physical, emotional, and social problems." (15) There are many other criticisms of the disease concept, however we will not go in to them at this time. Instead we will review some of the evidence to support the disease concept.

Arguments Endorsing the Disease Concept

Since the introduction of the disease concept research studies have examined a possible genetic link in alcoholism/addiction. One such study demonstrates that the offspring of alcoholics are approximately three to five times more likely to develop alcoholism than offspring of non-alcoholics (18). However, the genetic influence on other drug addiction has received less research attention. Also, in 1983, there was a popular theory of alcohol addiction expressed by D.L. Ohlms in his book "The Disease Concept of Alcoholism"(17) that proposed that alcoholics produced a highly addictive substance called THIQ during the metabolism of alcohol. THIQ is normally produced when the body metabolizes heroin and is supposedly not metabolized by non-alcoholics when they drink. According to Ohlms, animal studies have shown that a small amount of THIQ injected into the brains of rats will produce alcoholic rats and that THIQ remains in the brain long after an animal has been injected. Therefore, the theory is that alcoholics are genetically predisposed to produce THIQ in response to alcohol, that the THIQ creates a craving for alcohol, and that the THIQ remains in the brain of the alcoholic long after the use of alcohol is discontinued. This would provide a physiological explanation for the fact that recovering alcoholics who relapse quickly return to their previous use patterns. More recent research on genetic causes of alcoholism has focused on some abnormality in a dopamine receptor gene and deficiencies in the neurotransmitter serotonin or in serotonin receptors (19).

As you can see from the above information there is still room for debate and I assure you that the controversy continues.” [1] Medical Man 03:37, 1 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

You've put your finger on the problem. On the one hand, the source that you've cited here recognizes that several groups support the disease concept of alcoholism, groups such as the World Health Organization, the American Medical Association, and the American Psychiatric Association. And then the source cites two individuals, both of whom are well-known in the field for their controversial perspective that is in disagreement with the community standard. Two individuals, however, do not make for a debate and controversy. They are simply standing up to speak out against the status quo. That action is commendable. Without people like them, the world wouldn't change. But the broad scientific, medical, and research communities are not in agreement with these two individuals. Their perspective should be noted, but their perspective does not mean that the entire scientific basis of a disease state should be tossed out by Wikipedia any more than by the academic community. You might assure me that the controversy continues because you wish it would, but in my day-to-day work in this field, with ongoing contact with academic, research, and the scientific communities, I have seen no evidence of any such controversy. There are indeed many controversies in the field...do medications work to treat alcoholics...what genes lead to a predisposition to alcoholism...what percent of patients can be reliably treated with self-help groups; but the broad definition of alcoholism and epidemiology of its incidence and prevalence are all well-known and well-accepted. Drgitlow 04:11, 1 July 2006 (UTC)
Please don't read so selectively. The Research Society on Alcoholism and the American Psychological Association are not "two individuals. They can't be trivialized and ignored. It's obvious to anyone open to reality that "The Disease model of addiction is probably the most controversial and debated topic in the entire field of substance abuse/addiction". There is no consensus and you can't wish it into being.Medical Man 15:23, 1 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.
The Research Society on Alcoholism and the American Psychological Association are not the two individuals I spoke of. Nor are those organizations opposed to the disease model of alcoholism. The two individuals are the ones cited just above, Fingarette and Peele. What is apparently obvious to you isn't to the majority of the scientific and medical communities. It may be that you are much brighter than they are, and that they have some catching up to do, or it may be that you aren't up to date on the topic. Either is a rational explanation. If you really think the RSA and A. Psychological A. are opposed to the disease model of alcoholism, why don't you just ask both organizations to write you a note saying as much. The RSA is founded on the principle that alcoholism is a disease; it's the whole point of the RSA's being in existence. And the A. Psychological Association also appears to have policy on alcoholism and addiction as disease states; I refer you to their website for further information. So you've unfortunately been misled. Why don't you make a phone call and get a letter from either group's board saying that they don't believe in the addiction=disease concept? I suspect you'd get nowhere very quickly. Drgitlow 16:01, 1 July 2006 (UTC)

[edit] “The debate on whether alcoholism is a disease or a personal conduct problem has continued for over 200 years.”

Thomas R. Hobbs, Ph.D, M.D. writes [2] that “The debate on whether alcoholism is a disease or a personal conduct problem has continued for over 200 years.”

He reports that

“Dr. Peele’s view that alcoholism is a personal conduct problem, rather than a disease, seems to be more prevalent among medical practitioners than among the public. A recent Gallop poll found that almost 90 percent of Americans believe that alcoholism is a disease. In contrast, physicians’ views of alcoholism were reviewed at an August 1997 conference held by the International Doctors of Alcoholics Anonymous (IDAA). A survey of physicians reported at that conference found that 80 percent of responding doctors perceived alcoholism as simply bad behavior.”

Dr. Hobbs indicates that

“Based on my experiences working in the addiction field for the past 10 years, I believe many, if not most, health professionals still view alcohol addiction as a willpower or conduct problem and are resistant to look at it as a disease. Part of the problem is that medical schools provide little time to study alcoholism or addiction and post-graduate training usually deals only with the end result of addiction or alcohol/drug-related diseases. Several studies conducted in the late 1980s give evidence that medical students and practitioners have inadequate knowledge about alcohol and alcohol problems. Also, recent studies published in the Journal of Studies on Alcoholism indicate that physicians perform poorly in the detection, prevention and treatment of alcohol abuse.”

I look forward with interest to see what technique(s) you use in an effort to try to debunk this additional evidence regarding the fact that there there is no consensus about the disease hypothesis of alcoholism.Medical Man 16:24, 1 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

No debunking. Dr. Hobbs' statement in the paragraph immediately above is most insightful. It represents why tens of millions of dollars of public and private funds have been spent in the last year to fix the educational problems that Dr. Hobbs points out. Luckily, starting in the next year, hundreds of medical students each year will be trained in the disease model and abstinence-based treatment methodologies. By the end of the decade, all medical students will receive such training. That should solve the survey that was reported at the IDAA meeting and the problems identified by Dr. Hobbs. I wasn't able to find the reference of the 1997 survey in a Medline search, however, so I'm not certain as to the accuracy of the result that Dr. Hobbs reports. Again luckily, more recent attitudinal surveys indicate that physicians have come a long way in terms of recognizing that alcoholism is not a personal choice. You keep trying to say that it's a fact that there is no consensus about alcoholism being a disease, yet there is extensive policy and research in the scientific literature proving otherwise. So you can say it, but it doesn't make it so. Drgitlow 18:10, 1 July 2006 (UTC)
Nice effort, but a completely failed one. We're talking about whether or not a consensus exists now, not in the future.
The 80% of physicians who don't think alcoholism is a disease may be wrong -- but that's completely irrelevant. The essential fact is that there is no consensus among procticing physicians that alcoholism is a disease. And that fact must be adequately reflected in any legitimate encyclopedia article.
There may be a consensus in the future, especially if medical students are "trained" to believe the ideology. That sounds frightenly like Lysenko's "science" under the ruthless dictator Joseph Stalin. I would hope they would instead be educated as professionals to evaluate the conflicting evidence and judge for themselves.Medical Man 18:47, 1 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.
(Mr Christopher, please pardon me for inserting my comments here but I wanted them to follow immediately Gitlow's feeble effort.)
The so called consensus on the disease theory is found primarily amongst medical trade organizations, especially those who financially profit from the existance of such this unproven disease. The fact remains there is no biological test one can take to see if they have "alcoholism" and there is not one gene that anyone has proven causes or indicates problematic drinking.
All the "alcoholism" or alcohol dependency or alcohol abuse type diognostic tests are speculative, subjective and mostly unscientific. The CAGE exam is a laff riot, substitue masturbation or toenail clipping for drinking in the CAGE exam and you'll sooon see ho wstupid it is.
You have an obvious financial stake in this matter, that's why you keep trying to silence any opposition to the unproven assertions made by the various medical trade organizations you belong to. In short, you're an AA counselor with a lot of degrees and you have a vested interest in misleading people into having a blind faith in this unproven disease. Mr Christopher 18:20, 1 July 2006 (UTC)
And I suppose you'd argue that physicians have a vested interest in people remaining ill. If they all get better, the poor doctors wouldn't earn an income. Your repeated efforts to figure out what I do for a living aren't getting you very far, though. I have neither a financial stake in this matter nor am I an AA counselor. I eagerly await your sharing with us your basis for your position on this matter. Drgitlow 19:54, 1 July 2006 (UTC)
drgitlow, please respond. As I indicate above, your reaction to the fact that 80% of physicians reject the disease theory is completely irelevant; you ignore the present and jump to the future. Thus, my evidence stands and demonstrates clearly that there is currently no consensus regarding the disease model. Thus, the case is over.Medical Man 03:31, 3 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

Nice try, Medical Man. You have the results of a single survey (which, by the way, you haven't provided a citation for...the citation has to be of the ORIGINAL survey report, not of someone inventing it out of thin air). A single survey doesn't mean that you have evidence, and it certainly doesn't demonstrate anything clearly. As I said, over 1000 physicians came together in the House of Delegates, representing American physicians in state and specialty societies, and voted that alcoholism is a disease. The World Health Organization considers alcoholism a disease. Of course there's consensus. Your "evidence" that one "survey" indicated otherwise doesn't change the facts. But if you can find the original citation, please share it so that we can figure it all out. Drgitlow 04:02, 3 July 2006 (UTC)

I have provided you the reference from a reputable published source, which doesn't have to be the survey itself.
You've invented out of thin air your belief that "Of course there's consensus." I've repeatedly shown you evidence to the contrary. You then either ignore it or try to explain it away like a child who desperately wants to continue believing that Santa exists. Santa doesn't exist and neither does a consensus.Medical Man 16:33, 3 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

[edit] "The disease concept remains controversial”

Roger E. Meyers, M.D., writing in The Lancet, reports that “The disease concept remains controversial.” [3]Medical Man 19:04, 1 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

The article you cite is actually by Roger E. Meyer (Lancet 1996;347:162-166). And let's be honest about what he writes:

The most robust evidence of persistent deficits in homoeostasis comes from clinical studies in alcoholics and heroin addicts. We need to identify persistent residual abnormalities in receptor function and gene expression that might be linked to clinical observations and the development of new pharmacotherapies. But there is a real excitement about the possibilities offered by molecular neurobiology to increase understanding of the pathophysiology of addiction. Molecular biologists studying rat strains that differ in drug or alcohol preference (or differential drug reinforcement) might also be able to account for (a) the differential initial reinforcing properties of drugs/alcohol, (b) the differential vulnerability to conditioning of the reinforcing stimulus properties of drugs/alcohol and sensitisation, and (c) the differential changes in gene expression of neurons in the mesolimbic dopamine system that might explain mechanisms of addiction and relapse. These animal models offer promise in understanding the molecular basis of "risk", and of characterising the pathophysiology of addictive disease(s) that have intrigued physicians for 200 years.

That's his conclusion. Look closely at his last sentence wherein he refers to the entire field as that of "addictive disease."

His statement that the disease concept remains controversial refers to an article in the British Medical Journal in 1976, when indeed the disease concept was still controversial. Thirty years have passed, the controversy is over, consensus statements have been issued by respected medical organizations, and your effort to indicate that the controversy is still going on refers only to splinter groups that are not generally recognized in the scientific and academic communities. I don't mean to undermine the importance of such varied beliefs, but rather am simply noting the fact that alcoholism and other substance use disorders are accepted within the compendium of disease as treated by physicians around the world. You may, of course, accept this or not based upon your own personal belief system. Drgitlow 20:03, 1 July 2006 (UTC)

We're making progress. You now acknowledge that the author was correct in his assertion (in 1976) that "The disease concept remains controversial." So this means that you agree that the disease idea was controversial in 1976.
Apparently your tactic is to argue that, for whatever reason, there is consensus now. To make this argument you are forced to make the ludicrous assertion that the Research Society on alcoholism and the American Psychological Association are "splinter groups that are not generally recognized in the scientific and academic communities."
I really don't think things can get more bizzare than this, but time will tell.Medical Man 21:45, 1 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

I've always acknowledged that there was indeed a controversy regarding alcoholism and disease in the past. And yes, 1976 was at the tail end of that long-standing issue - it was still a controversy then. I'm NOT calling the RSA and the American Psychological Association splinter groups; they are very much recognized in the scientific and academic community. What I'm saying is that you've placed words in the mouths of those organizations in which you have them saying that alcoholism isn't a disease. I'm sure a quick letter to the Executive Director of both organizations would help you recognize that your thoughts are not reflected by theirs.Drgitlow 22:41, 1 July 2006 (UTC)

[edit] The Myth of Alcoholism as a Disease

Dr. Herbert Fingarette of the University of California, Santa Barbara, author of Heavy Drinking: The Myth of Alcoholism as a Disease says "the disease label is 'a vague slogan with no particular medical meaning.' Fingarette explains that " just about every major belief associated with the idea of alcoholism as a disease has been shown to be wrong. There is no one pattern of drinking that characterizes alcoholics. There is no unique cause of alcoholism. It is not true that an alcoholic who drinks any alcohol automatically loses control. And there is no medical treatment that has been shown to be effective.'"

"Fingarette, who studied a mass of published studies of treatment results, says that no one has ever been able to demonstrate that any treatment has a better success rate than simply letting alcoholics stop on their own. The most that can be said is that the treatment programs did not make matters worse, according to Fingarette." [4].

I again look forward to seeing what technique(s) will be used in an effort to try to debunk the importance of Dr. Meyers' and Dr. Finagrette's observations.Medical Man 19:04, 1 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

Do you have the original source for Dr. Fingarette? The citation above leads to a Psychology Today article. I'd like to read his original work (not his book but his published research). Do you know where to find it? Drgitlow 19:50, 1 July 2006 (UTC)
This is the original source.Medical Man— Medical Man (talk • contribs) has made few or no other edits outside this topic.
Drgitlow, you might find this online article written by Fingarette of interest. Why We Should Reject The Disease Concept of Alcoholism, Herbert Fingarette, Ph. D. Mr Christopher 16:59, 2 July 2006 (UTC)
Thanks, Chris. Indeed, Dr. Fingarette makes an excellent argument. His argument is based in large part on the confusion which is omnipresent in the field in general: many people incorrectly assume that heavy drinkers are alcoholics. There are MANY heavy drinkers who are not alcoholic, who can stop drinking, reduce their drinking, stop and start again without any significant difficulties, and so forth. These individuals, as Dr. Fingarette points out, don't have any genetic predisposition and don't have a disease. Dr. Fingarette also indicates that many who diagnose alcoholism incorrectly believe or feel that alcoholics are not responsible for their drinking. That's less of a medical issue and more of a social policy issue but it might interest you to know that generally speaking addiction medicine specialists feel that alcoholics ARE responsible for their drinking. In my work as a forensic expert, I've testified on many occasions that alcoholics are criminally responsible for their conduct while drinking (there are several conditions that must be met for this to be true, but for the most part if an alcoholic does something while under the influence, they are responsible for their acts).

So in Dr. Fingarette's introduction, the addiction medicine community doesn't agree with his proposition #1 or #4. There is also disagreement with #3...by no means are medical specialists necessary for the treatment and relief of the symptoms. I've seen people who are alcoholic go directly to AA, never go near a physician or therapist office, and do quite well. The World Health Organization and others also disagree with his proposition #2 because it is generally recognized that there is no craving with alcoholism (unlike opioid dependence). So ultimately Dr. Fingarette is quite accurate in noting that the four propositions he notes are inaccurate. But those four propositions aren't why alcoholism is called a disease.

Dr. Fingarette goes on to write extensively in these chapters about heavy drinking. I believe he understands the following to be true: 1) Heavy drinking is not alcoholism. 2) Clinicians often confuse heavy drinking with alcoholism. 3) Clinicians have attempted to call alcoholism a disease, yet confuse the issue by actually referring to heavy drinkers as having the disease. Fingarette also points out some difficulties with many "treatment" programs: "On the contrary, both independent and government research shows expensive disease-oriented treatment programs to be largely a waste of money and human resources (Fingarette, 1989)." I agree entirely with him on that count. The disease is actually treated quite successfully in 1:1 sessions with an outpatient clinician combined with self-help groups. There have been multiple studies demonstrating just that, with 80%+ long term abstinence and successful re-entry into the workforce, in EAP's and among airline pilots (among others).

While the medical community disagrees with Dr. Fingarette regarding his conclusion (alcoholism is not a disease), Dr. Fingarette's important take-home messages are: 1) Don't confuse heavy drinking for alcoholism, and 2) Alcoholics should be responsible for their actions while drinking. I think you'd be hard pressed to find an addiction specialist who disagrees with either point. Drgitlow 18:22, 2 July 2006 (UTC)

And here is Stanton Peele on Fingarette Drgitlow, have you had a chance to read Heavy Drinking: The Myth of Alcoholicm as a Disease? With your back ground and insight I think you would find it a worthy read. Mr Christopher 17:25, 3 July 2006 (UTC)
Now you're starting to come over to an area that I think is very controversial - the area regarding treatment of alcoholism. There are several schools of thought. Much of the research identifies "standard" treatment - bachelors and masters level counselors providing some type of therapy to the patient who simultaneously attends some form of self-help group. This type of treatment shows highly variable efficacy, probably based in large part upon the skill level of the counselor. This type of treatment is standard in community mental health centers and governmentally funded facilities. There's another type of treatment: private care by a medical specialist, also combined typically with 12-step programs or similar. The two approaches have never been compared for efficacy but the outcome studies that used medical specialists have had very good results. Of interest, in other fields, the outcomes have been compared -- that is, if you take a diabetic and have him treated by an endocrinologist, their long term outcome is superior to the outcome if they were treated by a generalist. You may come to find that you and I don't differ very much on our feelings regarding how well (or how poorly) certain treatment approaches work.
There is reason, however, why you keep turning to Peele to support your contentions. He refers to himself on his website as the AntiChrist of the Recovery movement. There's noone out there quite like him. He is skilled with the language, resourceful, and capable of holding his ground during a debate. If indeed there were an extensive literature from other scientists demonstrating agreement with his positions, he would have to be taken more seriously. As it is, though, his view is primarily his view, one which does not reflect the perspective of the overall scientific community. As I've said before, such men are important - one person taking on the status quo leads to evolution and change. Sometimes, though, it's simply one person taking on the status quo. Peele has done this for decades - no change has occurred in response. He and I have had email discussions and have been quite cordial with one another; I even had him as a guest back when I ran the Alcohol and Recovery Forum on AOL. I'm always open to listening to all sides. My listening, however, doesn't change the scientific community's overall perspective on the matter. Drgitlow 18:05, 3 July 2006 (UTC)

[edit] Disease model not popular in countries where it's not profitable

As explained in "The disease model of alcoholism: a Khunian paradigm" [5], "The disease model of alcoholism has a history dating back more than two hundred years, and is considered by many to be the dominant paradigm guiding scientific inquiry and treatment approaches for much of the 20th century. However, as early as the 1960s, the disease model came under attack due to the emergence of anomalous scientific and clinical findings. Outside of the United States, the disease model is considered by many to have been discredited, and has long been abandoned in favor of alternative models, such as social-learning theory (Heather & Robertson, 1997). Yet, in the United States, the disease model and its primary treatment goal of abstinence continue to over-whelmingly dominate the treatment of alcoholism (Rosenberg & Davis, 1994; Rosenberg, Devine, & Rothrock, 1995; Weisner, 1996). Among other explanations, the financial and political motives of the U.S. alcoholism treatment community have been offered to explain why the U.S. continues to lag behind other countries in moving beyond the disease model (Fingarette, 1988; Peele, 1989; Sobell & Sobell, 1995). However, an alternative reason for the reluctance of the alcoholism treatment community to relinquish the disease model is revealed by utilizing Kuhn's (1996) model of scientific progress in an historical analysis of the disease model."

Drgitlow, this seems inconsistent with your argument that 1976 was the tail end of the long disease controversy. What's your explanation?Medical Man 04:16, 2 July 2006 (UTC) — Medical Man (talk • contribs) has made few or no other edits outside this topic.

Paging drgitlow.... What's your explanation???Medical Man 01:31, 3 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.
The author of the linked article is not a medical doctor or neuroscientist. The debate about the disease theory should be based on the evidence presented by experts on disease. (Note: I changed the broken link to the one listed on the wiki page). elplatt 20:55, 20 January 2007 (UTC)
The disease theory is not strictly profitable in the US. Consider TRAYNOR v. TURNAGE, 485 U.S. 535 (1988), in which a decision against the disease theory freed the government from financial responsibility to alcoholic veterans seeking education. The disease theory poses significant financial loss to the government and medical insurance companies, who would be obligated to pay for treatment. elplatt 20:56, 20 January 2007 (UTC)
In recent decades, the US has led the world in neuroscience research. Technologies such as fMRI, PET, etc. are not as available elsewhere. There is no reason to believe that the US is "lagging behind" in the debate, and more reason to believe that the US is forging ahead. elplatt 21:04, 20 January 2007 (UTC)
"as early as the 1960s, the disease model came under attack due to the emergence of anomalous scientific and clinical findings." I have seen no such findings from scientific sources. Please provide references. elplatt 21:06, 20 January 2007 (UTC)

[edit] There is currently no consensus about the disease theory

There is currently no consensus in support of the disease theory, nor has there been one recently as the following documents demonstrate:

  • Korhonen, M. Alcohol Problems and Approaches: Theories, Evidence and Northern Practice. Ottawa: National Aboriginal Health Organizations, 2004 [6]
  • Nackerud, L. The disease model of alcoholism: a Khunian paradigm. Journal of Sociology and Social Welfare, 2002 [7](Presented above but awaiting response from dritlow)
  • Kelly, D. Understanding the Nature of Alcoholism (2001). Discusses the disease controversy. [8]
  • Schaler, J. A. Thinking about drinking: the power of self-fulfilling prophecies. The International Journal of Drug Policy, 1996, 7(3), 187-191 [9]
  • Doweiko, H. E. Concepts of Chemical dependency. NY: Brooks-Cole, 1996.
  • Levy, M.S. The disease controversy and psychotherapy with alcoholics. Journal of Psychoactive Drugs, 1992, 24(3), 251-256. [10]
  • Maltzman, I. Is alcoholism a disease? A critical review of a controversy. Integrative Physiological and Behavioral Science: The Official Journal of the Pavlovian Society, 1991, 26(3), 200-210 {

[11].


[edit] Evidence that there is no consensus that alcoholism is a disease

I have presented, among others,

  • Evidence that the disease theory is not popular in countries in which it is not profitable;
  • Evidence from scholarly publications that consensus doesn't exist; and
  • Evidence from a respected professional publication that 80% of physicians reject the disease theory.

What evidence will it take to convince a true believer ideologue that consensus doesn't exist??Medical Man 20:22, 3 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

Medical Man, let's go through what constitutes "evidence." There are several potential sources of information in the scientific community.

Current medical peer-reviewed literature
Scientific studies
Expert consensus
Professional experience
Personal opinion

When a study is quoted, you need to cite the original literature, not a website that states something without an accurate reference. There is no evidence of any respected professional publication indicating that 80% of physicians reject the disease theory. I don't know where you got that from, but a medline search reveals no such finding. There is no evidence from peer-reviewed literature indicating that consensus doesn't exist. Indeed, as you've pointed out, there are at the least a very vocal minority who disagree with the consensus, but the consensus is present nevertheless -- voted on years ago by International and National organizations. Your evidence that the disease theory is not popular in countries in which it is not profitable isn't evidence - it's a correlation that requires investigation and explanation; no causality is implied. Drgitlow 20:34, 3 July 2006 (UTC)

The fact that the disease theory isn't popular in countries where the doctrine isn't popular demonstrates that there is no world consensus. The question of causality is totally and completely irrelevant.
Disregard the possible causal relationship. The fact remains that in many countries the ideology is not widely held among professionals. That proves there is no consensus. The fact is clear. You are completely wrong, period.
BTW, I've published much more than you have on the subject of alcohol and don't need your condescending lecture. Your list of evidence is incomplete.Medical Man 00:56, 4 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.
Please, then, share with us your list of publications on the subject of alcohol. I'd be very interested in reading your articles and textbook chapters. I'm sure I have much to learn from them. Drgitlow 01:06, 4 July 2006 (UTC)
You would clearly profit from doing more reading. Because you're only an assistant professor, I feel compelled to suggest that you direct your efforts to publishing scholarly books rather than either textbooks or handbooks (which, as you admit, your "textbook" really is). A textbook is usually equated with an article in a refereed journal for purposes of salary increases, promotion, etc. A handbook would probably equate to ½ of an article in a refereed journal.
Very important is advancing knowledge. Defending dogma counts for nothing in academia. Therefore, you might empirically test some of the implications of the disease theory. That might prove useful. Or alternatively, you might test the efficacy of different treatment modalities under different conditions.
You'll find it both personally and professionally rewarding to make original contributions to a field of knowledge.Medical Man 03:46, 4 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

[edit] More evidence: No consensus in alcohol treatment field

A recent study of physicians and non-physician alcoholism treatment practioners in Canada reported that 82% of nonspychiatriatrist and 84% of psychiatrist physicians believe that alcoholism is a "mental disorder," that physicians "largely espouse a disease notion of alcoholism," and that "Physicians are more likely to endorse a disease concept of alcoholism than are nonphysician practioners." Social workers tended to be neutral and counselors tended to accept it on average very mildly. There’s clearly no consensus in the alcoholism treatment field.

Meza, E. et al. Alcoholism: beliefs and attitudes among Canadian alcoholism treatment practioners. Canadian Journal of Psychiatry, 2001, 46, 167-172. [12]Medical Man 21:19, 4 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

Please do not clutter the introduction with 18 external links. A short sentence describing why it is thought that the "disease theory" may be wrong is what is appropriate, and the rest should be put in its own section. Something like, "However, others consider heavy alcohol use to be a wilful decision that is not caused by biological influences outside of the drinker's control." or "However, there is little confirmed evidence that heavy alcohol use is caused by forces outside of a person's control." —Centrx?talk • 21:45, 4 July 2006 (UTC)

Before you cite an article that allegedly supports your contentions, I suggest you read the article. This study, now over five years old, found that 82% of nonpsychiatric physicians and 84% of psychiatrists felt that alcoholism is a disease. The authors' conclusion from the last paragraph of the article: "...physicians favour the disease view of alcoholism and its classification as a psychiatric disorder." Thanks for that new bit of evidence demonstrating what I've said all along - there is a clear consensus in the medical community about alcoholism being a disease. Drgitlow 21:48, 4 July 2006 (UTC)

By the way, "espouse" means adopt or support. Physicians espousing the disease concept means they agree with it. And yes, physicians probably would endorse a disease concept of any disease moreso than would non-medical clinicians. The medical ethic incorporates a disease-oriented approach. The results here could probably be duplicated with any disease. Social workers and counselors are less concerned with disease and more concerned with functional and psychological issues. One is not better than the other -- they are simply different approaches to deal with different things. When I'm treating an alcoholic, I often ask that they see a social worker simultaneously - the social worker and I use different approaches, and the patient takes the approach that works for them (differing depending on the individual patient). Drgitlow 22:10, 4 July 2006 (UTC)

Reality check: If only 82% of nonpsychiatrist physicians endorse the disease concept, that's not conseensus. A substantial proportion of physicians, and an even larger of other treatment professionals, reject the hypothesis.Medical Man 00:05, 5 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

[edit] There is currently no consensus about the disease theory

There is currently no consensus in support of the disease theory, nor has there been one recently as the following documents, among others, demonstrate:

  • Korhonen, M. Alcohol Problems and Approaches: Theories, Evidence and Northern Practice. Ottawa: National Aboriginal Health Organizations, 2004 [13]
  • Nackerud, L. The disease model of alcoholism: a Khunian paradigm. Journal of Sociology and Social Welfare, 2002 [14](Presented above but awaiting response from dritlow)
  • Kelly, D. Understanding the Nature of Alcoholism (2001). Discusses the disease controversy. [15]
  • Is Alcoholism a Disease? In: Tarr, J. D. (ed.) Current Contro0versies: Alcoholism. San Diego: Greenhaven, 1999.
  • Schaler, J. A. Thinking about drinking: the power of self-fulfilling prophecies. The International Journal of Drug Policy, 1996, 7(3), 187-191 [16]
  • Doweiko, H. E. Concepts of Chemical dependency. NY: Brooks-Cole, 1996.
  • Erickson, C. K. Invited review: A pharmacologist’s opinion -- alcoholism: the disease debate needs to end. Alcohol and Alcoholism, 1992, ‘’27(4), 325-328. [17]
  • Levy, M.S. The disease controversy and psychotherapy with alcoholics. Journal of Psychoactive Drugs, 1992, 24(3), 251-256. [18]
  • Maltzman, I. Is alcoholism a disease? A critical review of a controversy. Integrative Physiological and Behavioral Science: The Official Journal of the Pavlovian Society, 1991, 26(3), 200-210 {

[19].

  • Meza, E. et al. Alcoholism: beliefs and attitudes among Canadian alcoholism treatment practioners. Canadian Journal of Psychiatry, 2001, 46, 167-172. [20]
  • Fingarette, H. Heavy Drinking: the Myth of Alcoholism as a Disease. Los Angeles: UCLA Press, 1988.


The lack of consensus has also been demonstrated in other ways:

  • United States Supreme Court decisions
  • The fact that the disease hypothesis is not popular in many countries around the world (Therefore, there is no consensus)
  • Evidence from a respected professional publication that 80% of physicians reject the disease theory. (Secondary sources are completely acceptable. Gitlow probably used them in this handbook).
  • Alcoholics Anonymous acknowledgement that the disease debate is an active one (Alcoholics anonymous. “Is Alcoholism a Disease?” [21]Medical Man 02:07, 5 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.
Yes, we know how you feel. This is the sixth time in just a few days that you've posted an identical topic here. You can simply continue your discussion in the original thread without adding another heading every time you want to tell us again that there's no consensus. Rain, by the way, falls up from the ground and blows around in the wind. We only think it falls from the sky. Drgitlow 02:51, 5 July 2006 (UTC)
Actually, feelings have nothing to do with the subject. What you know or should know is that I have presented strong evidence that there is no consensus about the disease hypothesis.
For example, (a) the United States Supreme Court (“the law of the land“) has rendered its decision, (2) AA reports that the disease debate is an active one, (c ), conservatively, about one physician in five and almost half of counselors fail to accept the theory, and (d) the concept is not widely accepted an many countries around the world.
There is no consensus and you haven’t been able to prove there is one. Sounds like you’re the one who keeps insisting, in spite of evidence to the contrary, that Santa Claus exists. Like it or not, there is no consensus and there is no Santa.
Those who cling to the AA ideology often do so with a religious-like fervor that defies reality. That’s not surprising because the ideology is based on blind acceptance and religion. As the group tells those who dare question the doctrine, "Take the cotton out of your ears and stuff it into your mouth."Medical Man 17:25, 5 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

[edit] a little more on disease

I've said earlier that the AMA has policy stating that alcoholism is a disease. I've done a little more homework and discovered that the following organizations also agree:

  • American Public Health Association
  • American Hospital Association
  • American Psychological Association (contrary to our past discussion, they have actual policy on this)
  • National Association of Social Workers
  • World Health Organization
  • American College of Physicians

As MM has pointed out, there are many individuals (e.g. Fingarette, Peele, etc.) that have questioned this concept. Even MS Levy (a PhD, not an MD), in his article discussing the disease concept controversy (Substance Abuse Treatment, Vol 7, pp245-54. 1990), states, "...the disease concept of alcoholism dominates thinking in this field, and total abstinence from alcohol remains the only goal for alcoholics coming for treatment." He goes on to say, "Many clinicians...act as if it is scientific fact that alcoholism is a disease, refusing to consider other paradigms."

I suspect as I read the article that Dr. Levy is confusing the medical model with something else, but I can't quite figure out what that is. He notes that the disease theory competes with self-medication, sociologic, motivational, and biopsychosocial theories of addiction. But it doesn't. The disease theory takes us back to the definition of disease (there's a Wiki entry on it)...the definition is simply an abnormal condition of body or mind that causes discomfort, dysfunction, or distress. A broken bone is a disease, for example, as can be a depressive or anxiety disorder; and the disease theory is not at all competitive with the possibility that alcoholism could be secondary to something that is ultimately found to be sociologic, biopsychosocial, or motivational.

When physicians say that alcoholism is a disease, all we're saying is that the individual so afflicted is in distress or is uncomfortable as a result of an abnormal condition. I suspect Dr. Levy and others are reading much more into the "disease" concept than is meant. I also suspect that a great deal of this is because the folks who are fighting the disease concept aren't physicians and therefore define the term quite differently from the medical community. What I haven't quite figured out is exactly what they're interpreting the term as meaning.

As I've been looking over the references provided by MM, I've been quite touched by the fact that the writers he has cited are not generally MD's. I've been accused, probably justifiably, as annoyingly suggesting that a scientific article should be left to those who specialize in the science, that if we were writing an article about a plant, we'd want some botanists to be responsible for the meat of the text, and perhaps some poets to describe the plant's beauty. In this case, we're talking about a medical condition and I've suggested that we want many physicians who specialize in its treatment. PhD's, MSW's, and others will provide alternative perspectives based upon their training. I don't think those perspectives are any less important, but I would suggest that they take different aspects of the condition into consideration prior to developing their perspectives. There are fundamental differences between physicians and psychologists, as there are between clinicians and researchers...different people with differing areas of expertise. So in the end I don't want to hear a supreme court justice's feeling about whether alcoholism is a disease any more than he or she would want my feeling as to some subtlety of the law. The fact that there is such law is indeed important - it underscores the continuing stigma against addicts and supports an argument that addicts aren't treated with parity to those with other conditions - but it doesn't suggest that the medical community has failed to have consensus (it does suggest, however, that the medical community has done a lousy job communicating its position). What I want to hear when I read about an illness is what the experts who treat the illness think, based upon their interpretation of the peer-reviewed literature, upon their anecdotal experience providing treatment, and upon their years of experience and training.

Is it important that there is a controversy about whether alcoholism is a disease outside the medical community? I don't think it's important, but I obviously have a bias. Part of that bias is that if those who were against the idea understood what physicians mean by "disease," they wouldn't be as opposed as they are now. And that, in somewhat more than a nutshell, is why I've been approaching this entire topic as I have. I agree with all of you that a neutral perspective is critically important, and I feel we've all come a long way, that our work together has been making great strides, and I don't want to betray the understanding we've all developed. I did feel, however, that I needed to express some of these feelings so that you'd all understand where I'm coming from with this. Drgitlow 20:49, 8 July 2006 (UTC)

I think Drgitlow has identified the problem and, implicitly, the solution. He says that disease is "an abnormal condition of body or mind that causes discomfort, dysfunction, or distress."
He also explains that "When physicians say that alcoholism is a disease, all we're saying is that the individual so afflicted is in distress or is uncomfortable as a result of an abnormal condition. I suspect Dr. Levy and others are reading much more into the "disease" concept than is meant. I also suspect that a great deal of this is because the folks who are fighting the disease concept aren't physicians and therefore define the term quite differently from the medical community."
If we eliminate the confusion, we eliminate the problem. Therefore, I suggest the following:
Alcoholism is the consumption of, or preoccupation with, alcoholic beverages to an extent that such use causes physical or mental harm, or interferes with the drinker's normal personal, family, social, or work life.[3][4] The resulting chronic use can result in many psychological and physiological disorders. Alcoholism can be considered a disease in that it is an abnormal condition of the body or mind that causes discomfort, dysfunction, or distress. Most physicians consider alcoholism an addiction influenced by genetic, psychological, and social factors.Medical Man 01:20, 9 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.


Stuart, thanks for expressing where you are coming from. On the subject of the article and various viewpoints and MDs and such, I am most comfortable with the guidance FloNight talk specifically gave to us in the Encouragement section she created above. She wrote,

"The article needs to reflect as completely as possible all aspects of alcoholism. This means that each verifiable aspect of alcoholism should be written about in a neutral point of view using reliable sources. Every major and significant minor theory should be included."

I am committed to following the Wiki policy and standards she reminded us of so I do not favor the MDs (or addictionologists, etc) opinions being superior, or the only (or mostly) relevant , or being elevated in the article. Alcoholism (and the disease theory) touches many disciplines and professions and medicine (specifically MDs) is only one of them. That's my take on it. Mr Christopher 02:13, 9 July 2006 (UTC)

That is, "minor" within the medical community. —Centrx?talk • 02:47, 9 July 2006 (UTC)


I really like the paragraph that MM has come up with above. It's a very smart way to defuse the issue from all sides. And I agree very much with FloNight's statement that every major and significant minor theories should be included. Dr. Levy did a nice job in his article indicating the various theories, and we might do well as we move forward to have different sections...
  • The Disease Model
  • The Sociology Model
  • The BioPsychoSocial Model
  • etc.

Perhaps coming after the epidemiology section.

Which theories do those of you who don't agree with the disease model support? Drgitlow 02:56, 9 July 2006 (UTC)
I think it important that we identify and describe the various theories whether or not we agree with them. If we disagree with a theory, it's incumbent on us to do our very best to present it as well as if we did support it.Medical Man 21:44, 9 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.
Because different people may have different conceptions of it, perhaps it would be helpful to address what we mean by a model. I use the term to refer to a system of (or for) understanding the etiology and operation of some phenomenon. In the case of alcoholism, any given model has implications for prevention, treatment, expected outcomes, and a number of other matters.Medical Man 16:32, 9 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.
Not only that, but a model could potentially alter the epidemiology of the entire condition. For example, if alcoholism isn't a disease but rather is a social situation akin to simply drinking too much, one might define the condition quite differently, resulting in a very different incidence and prevalence of the condition itself. Drgitlow 23:19, 9 July 2006 (UTC)

[edit] Alcoholism is generally seen as a "different" kind of disease

There seem to be a number of reasons why alcoholism is perceived differently from juvenile diabetes and other diseases. I’d like to extend what I earlier wrote, i.e.: "JD has no history of being considered the result of moral failure, inadequate willpower, degenerate character, or lack of religious faith. Those who suffer diabetes haven't been accused of wasting their family income, abusing their spouses, neglecting their children, costing the taxpayer unnecessary expense for treatment, or engaging in violence and crime because of their disease. Concern over diabetes has never led to a national prohibition against the manufacturing, distribution or sale of sugar."

There are other important differences. If a counselor treats someone with JD, he will be arrested for practicing medicine without a license. If he treats someone for alcoholism, he can do so with no problem. Neither the AMA nor anyone else will object to his treating it nor will they accuse him of practicing medicine without a license.

If people ask their friends for advice about dealing with their alcoholism, they will more likely be urged to attend AA meetings than to consult with a physician.

Primary care physicians themselves tend to avoid dealing with alcoholism and appear to refer patients presenting with it to other alcoholism treatment professionals or to AA.

It seems safe to say that physicians probably conduct a minority of all research on the nature, causes, and treatment of alcoholism although the field might advance more quickly if this were not the case.Medical Man 01:44, 13 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.

I have to agree strongly with MM here. The world still hasn't completely gotten over the idea that alcoholism is caused by weakness of willpower. This has a lot to do with the AP A and AP B that I've been talking about above. Someone who has been through AP B, and then (for instance) graduated college thinks that they know what someone suffering from AP A is going through, and attribute the difference to their own superior willpower. Superiority is a very attractive idea, making this a persuasive argument to a lot of people. Addictions to other drugs are also treated as moral lapses, which is why our country favors incarceration over treatment.
This problem is exacerbated by our inability to point to causation. With diabetes, we can point to the pancreas failing. With seizures (once considered demonic posession) we can point to a shortage of neuroinhibiting chemicals. We may not know why the pancreas is failing or why the person doesn't create enough chemicals, but the sugar-eating or convulsing behavior is explained via a physical mechanism. Until we can explain the alcohol drinking behavior via a physical mechanism many people will continue to tell themselves that they are just morally superior. Robert Rapplean 18:07, 13 July 2006 (UTC)

I was very interested in MM's second pargraph. Counselors treat patients with JD all the time. Joslin in Boston has numerous group therapy sessions, social workers, and therapists for the ongoing care of diabetics. Indeed, it's come to the point in some urban locations where all the docs do is manage the insulin and all the rest is handled by non-MDs. Is that good? It depends. At least one study has shown that outcomes are not as good when specialist MDs aren't handling the care. Similarly, counselors treat patients with alcoholism all the time. The only thing they can't do, as when they treat diabetics, is prescribe medication or carry out an invasive procedure. You've hit the nail on the head with what is becoming a major political controversy. The practice of medicine is much more than conducting surgery or prescribing meds, and yet we've moved to a system in which all the rest of medical practice is practiced by anybody with a piece of paper on the wall. If a bachelors level counselor is treating an alcoholic, is the care being given as good as it is when a specialist MD is treating an alcoholic. I'd suspect not, and the successful outcome rates being demonstrated with such care in the latest research (less than 50% success) are far less than the 75-90% seen in past research with MD's.

The best research typically is conducted by researchers working closely with expert clinicians. The clinicians are physicians, typically, who have a firm understanding of the disease being studied and who are most aware of the desirability of certain outcomes and the difficulties obtaining those outcomes. They work closely with the researchers to design a study that will best reveal methods of obtaining the desired outcomes and of overcoming difficulties. The fact that this is rarely done anymore is a result of a variety of factors (at least some of which have led JAMA to yet again this week change its disclosure requirements). What I look for as a clinician with respect to advising patients is this type of research. Anything less is something where I'd rather see it carried out in practice before I'd treat anyone with it.

I'm no expert in juvenile diabetes, but I'll bet historically it was considered a behavioral issue. I'll do some research to see what I come up with. Drgitlow 21:18, 13 July 2006 (UTC)

[edit] Justice White Quotation

When quoting legal cases, the full case must be reviewed to determine the origin of material. Here is the section of interest from Traynor v Turnage with respect to the quotation recently edited:

Petitioners, however, perceive an inconsistency between 504 and the conclusive presumption that alcoholism not motivated by mental illness is necessarily "willful." They contend that 504 mandates an individualized determination of "willfulness" with respect to each veteran who claims to have been disabled by alcoholism. It would arguably be inconsistent with 504 for Congress to distinguish between categories of disabled veterans according to generalized determinations that lack any substantial basis. If primary alcoholism is not always "willful," as that term has been defined by Congress and the Veterans' Administration, some veterans denied benefits may well be excluded solely on the basis of their disability. We are unable to conclude that Congress failed to act in accordance with 504 in this instance, however, given what the District of Columbia Circuit accurately characterized as "a substantial body of medical literature that even contests the proposition that alcoholism is a disease, much less that it is a disease for which the victim bears no responsibility." 253 U.S. App. D.C., at 132-133, 792 F.2d, at 200-201. Indeed, even among many who consider alcoholism a "disease" to which its victims are genetically predisposed, the consumption of alcohol is not regarded as wholly involuntary.

The quotation, "a substantial body of medical literature...bears no responsibility," is not something Justice White said but rather is something that the District of Columbia Circuit Court stated in their decision. Justice White agreed with their decision. Note that the Supreme Court is not made up of scientists but of lawyers with political and fiduciary issues looming quite large in their minds. The basis of this case was in large part their knowledge that if indeed substance use disorders were to be considered on par with other diseases, the payment system in place would have been bankrupted. That is why so many mental health disorders are considered separately from other medical disorders by third party payors, Courts, and so forth. These decisions are unrelated to whether they are diseases or the degree to which they cause functional difficulty for the afflicted individual.

I have corrected the entry to accurately state what Justice White said in his decision. An alternative approach could include using the original quotation that appeared, but referencing the DC Circuit instead of the Supreme Court. Drgitlow 13:53, 1 July 2006 (UTC)

I think it's fixed now Mr Christopher 22:11, 1 July 2006 (UTC)
Yup. Looks great. Thanks. Drgitlow 22:43, 1 July 2006 (UTC)

[edit] Work on new wording for "a few non-medical alcoholism pundits"

Make suggestions for new wording that meets WP:NPOV, WP:V, and NOR. Comment if you agree or make other suggestions FloNight talk 03:46, 2 July 2006 (UTC)

  1. [22] Gitlow refers to two nationally recognized authors in the field of alcoholism who are critical of the disease theory "a few non-medical alcoholism pundits"

Pundits are well-recognized individuals in a field that actively speak to the public at large or to members of the press on a regular basis. In this case, the individuals to whom I referred are non-medical (e.g. they are not MD's or DO's) and speak actively regarding alcoholism to the press and the public through books, lectures, and talk shows. That makes them pundits. There is no pejorative connotation, but Chris made it clear that he didn't like the term and removed it. I've not added it back. To be fair to the audience, however, it is important that these individuals (Peele et al) be identified properly. They are not physicians nor do they treat individuals with alcoholism. They certainly have a right to an opinion but for us to portray their words as if they have as much importance or applicability to the field as scientists, researchers, and clinicians in the field means that our entry will have little practical value. Drgitlow 04:32, 2 July 2006 (UTC)

Peele is a Phd. Psychologist (A Doctor, but not an MD or DO), as well as an attorney, and has treated people who were dignosed with the debated dignosis [23]. We could also add DeLuca [24] to the list of those with qualms about the disease model, and he's actually an M.D./FASAM, and maybe also add in with Kern, Rotgers, Heit, Geller, Salsitz ... perhaps we could simply specify the credentials as we go, without trying to bias the reader? There's certainly no shortage of examples. Ronabop 06:58, 2 July 2006 (UTC)
Ronabop very good idea. The question "who are these people who question the AMA?" is one that should be answered in the article. I'll wait for others to add their ideas and see what sort of consensus we have prior to making any changes. Mr Christopher 13:42, 2 July 2006 (UTC)
And I forgot, I vote no to calling anyone in this article a "pundit" or use terms like "non-md" as both terms in the context of this article would appear POV if not down right hostile Do others have an opinion one way or another? Mr Christopher 13:46, 2 July 2006 (UTC)
I'm fine with that. I didn't mean pundit to sound pejorative so I'm fine with our not using it. And I never said Peele wasn't a doctor. I said he wasn't medical, which is true. DeLuca would probably be a better choice, Ronabop. Thanks. There isn't any issue of questioning the AMA. The AMA simply forms policy based on input from other organizations.Drgitlow 15:22, 2 July 2006 (UTC)
Actually, I'm puzzled now. I just reviewed Dr. DeLuca's position on his website; I don't see where he is supportive of your position (alcoholism is not a disease). He has had difficulties in the past based upon his confusion of the harm reduction model for treatment of opioid dependence and the abstinence-based treatment model for the treatment of sedative/alcohol dependence. This in part led to his leaving Smithers, if I recall the events there properly. But I don't think he's ever said that sedative dependence isn't a disease. He certainly has extensive background in the field, both in providing treatment and in training; if he is on the non-disease side, he would be a great reference to use here. Drgitlow 15:32, 2 July 2006 (UTC)
Well, it's not just my position, but I think it might better to summarize his (DeLuca's) position as a) excessive drinking may be a problem, and b) other medical conditions can lead to excessive drinking. Thus, drinking to extremes may be a dis-ease in its own right, or it may merely be a *symptom* of greater dis-ease. Victims of "consumption" who drank would not be cured by avoidance of drink, they would simply be hurt more.Ronabop 10:11, 10 July 2006 (UTC)

[edit] Miscellaneous Trivia

Miscellaneous trivia regarding Dr. Benjamin Rush can be placed at Benjamin Rush and doesn't belong in this entry since this isn't an entry about Dr. Rush.

The controversy regarding EM Jellinek's degree can be found at E. Morton Jellinek and also doesn't belong in this entry since this isn't an entry about Jellinek. Drgitlow 16:24, 3 July 2006 (UTC)

I can understand why you want to censor this information about two of the major developers of the disease theory of alcoholism. However, it is essential information to help readers assess their credibility. By vandalizing it, you show a lack of good faith.Medical Man 18:33, 3 July 2006 (UTC)— Medical Man (talk • contribs) has made few or no other edits outside this topic.
No, I show a willingness to discuss it here before something controversial gets put into the article. If you want to help readers assess the credibility of Jellinek and Rush, you'd have to do one of the following: a) refer readers to the full reference of Jellinek and Rush, or b) put extensive information into this article demonstrating the full range of Rush's and Jellinek's biographies. You can't simply say that you're going to put inflammatory statements about them here into this entry and that it's essential information for readers. That's not the way this works. Drgitlow 18:38, 3 July 2006 (UTC)
Medical man, you have now added inflammatory material to the article on three successive occasions. Rather than simply revert the article yet again in response to your action, I think I'll just wait for the mediation to take place on this topic. Drgitlow 19:32, 3 July 2006 (UTC)

[edit] From "Starting our work"

Let me cite a real life example. There's evidence that alcoholism is caused by an excessive production of endorphins when a person drinks. If a person never drinks, then the excessive level of endorphins never results in alcoholism. The excessive production of endorphins is actually a natural variation in human genetics. It allows the people to become more quickly aclimated towards exercise and risky behaviors like hunting and sporting competition. It just happens that the group of people with that particular adaptive trait are also succeptable to becoming addicted to alcohol.
Genetic variation is not a disease. It isn't a mutation, it's a naturally occuring variation that's fairly common in the gene pool. It even provides beneficial effects for many of its recipients.
Do we call addiction a disease? Since endorphin is a naturally produced chemical that acts like morphine (it's name is derived from "endogenous morphine") what we're dealing with, then, is identical to morphine addiction, except that the triggering mechanism is the consumption of alcohol. If not, then we have a real life example where alcholism might not be categorizable as a disease.
Again I have to reiterate that until we know what the cause is, we cannot state authoritatively one way or the other.Robert Rapplean 01:08, 4 July 2006 (UTC)
Let me take issue with a few of the things you've said:
1) Genetic variation indeed is not a disease UNLESS it causes disease. Sickle-cell anemia is a disease, is it not? And it is simply caused by a single gene variation. If a person is heterozygous for that variation, they do not have disease but they have a lower likelihood of getting malaria. We can see why the gene developed, but if you're homozygous, you end up with disease instead of the benefit. Huntington's is also a disease and also genetically based. So I wouldn't say that genetic variation can't cause disease.
2) If a genetic variation causes a different response to alcohol than would otherwise be present, that in and of itself does not mean that a disease is present. For instance, you could have the gene but never drink alcohol. No disease. Or you could have the gene but the different response is in no way dangerous or harmful. No disease. But if you have the gene, and you have alcohol, AND the different response is dangerous or harmful, then you have a disease. Again, though, it depends on how you define disease. What about those folks who are terribly allergic to peanuts: do they have a disease? If they live somewhere where there are no peanuts, they don't. What if they live in the US somewhere and are always being exposed to peanuts, peanut oil, or products that at one time or another came into contact with a peanut?
3) The endorphin issue ... let's say that's true ... that alcoholics are people who have such a response to alcohol due to genetic variation that no one with that response would have the will power to put the alcohol down no matter how bad things got in the rest of their lives. If that were true, wouldn't you say they have a disease if they lived in a community that had lots of alcohol around almost all the time?
4) We don't know what the cause is of migraine headaches. We don't know what causes cancer. We don't know why, of two identical twins, one gets juvenile diabetes and the other doesn't. Lacking the knowledge of a definitive cause, we still call each of those conditions "diseases," don't we? Drgitlow 01:18, 4 July 2006 (UTC)
Point (2), dunno, are allergic reactions considered a disease? It's essentially an autoimmune malfunction, and other autoimmune malfunctions like diabetes and arthritis are considered diseases. Whether we apply the word or not really doesn't help a person who dies from eating peanunts so I'd just take the AMA's word on it.
Point (3),in order to answer that, I need a clear answer to my question: is heroin or morphine addiction a disease?
Point (4) Migraine headaches are caused by fluctuation of blood flow in the brain. This has been demonstrated via MRI's. We don't really know WHY it fluctuates, agreed, but we can at least put our finger on a cause of the migrane. Cancer is caused by errors in cell division. The real question isn't why it happens, but why the normal responses don't clean it up like it does with other cell division errors. Daibetes is caused by a person's autoimmune system attacking the pancreas. You're right that we don't know what triggers it, but the mechanism is pretty well understood. We have no solid explanation for a desire to consume a neurotransmission inhibitor well beyond the point where you can no longer function.

So you feel that a mechanism must be identified and demonstrated as the basis of a disease before the symptoms and signs of the condition can be identified as a disease? You don't mind if the basis of the mechanism is unknown, so for instance in Alzheimer's, you're comfortable calling it a disease based on the histological changes in the brain even though we don't know the reasons as to why some people get the changes and some don't. Am I understanding your position correctly?

Those who agree that alcoholism is a disease generally also feel that opioid addiction is a disease. A different disease to be sure, but a disease.

If you're looking for mechanisms, then it may be some time before any of the psychiatric illnesses (some people include addictive disease in that category, some don't) meet your definition. These diseases are, for the most part, identified and diagnosed in a syndromic manner by identifying symptom clusters. But I'm going to guess that you don't think major depression, panic disorder, or schizophrenia are diseases either based upon your definition above. Am I right? There is a good deal of scientific research demonstrating a variety of environmental and neurotransmitter-based origins of these illnesses, but you want something definitive like the pancreas being attacked or cells running amok. The brain isn't that obvious (and when it is, it usually falls into the neurology category instead of the psychiatry category...but that's another discussion).

I'm just puzzled as to why you'd draw the line at identifying disease only once you know the mechanism. Would you have said the same thing in 1800, when we didn't know squat about any of these things? Drgitlow 01:51, 4 July 2006 (UTC)

The difference between alcoholism and things like cancer is that a person is, certainly, not causing a tumor. If indeed there is a biological reason why an alcoholic responds to liquor differently than other persons, it is similar to an allergy. The allergy itself, the susceptibility, is not a disease. Exposure to the stimulus, yes, produces a diseased condition but, like alcohol, if the allergic one does not eat peanuts there is no disease. If he wilfully and knowingly eats peanuts, he may be foolish or he may do as a result of dementia, and he will get sick, but the peanut-eating itself is not the disease. —Centrx?talk • 03:52, 4 July 2006 (UTC)

[edit] References

We have 17 references in the first section. I've turned some from empty numbered links to fuller references but 17 really is over the top. Could somebody group them in some coherent way e.g. A, B and C argue X while D, E, and F argue Y? Nunquam Dormio 20:21, 26 July 2006 (UTC)


[edit] Categories

I recently added 2 cats to this article, "Alcohol abuse" and "Medical terms". If anyone can think of other cats that would be appropriate it would help increase the article's exposure. BTW - I've been away a while and this article has come a long way. Good work :) --Doc Tropics Message in a bottle 22:58, 27 October 2006 (UTC)

Following suggestions from a more experienced editor, I also changed the first sentence to include a "bolded title". I tried to do it without changing much else, especially the intended meaning. The bolded title is considered a standard stylistic element (hence, needs to be there), but if anyone can write the opening more clearly, feel free. --Doc Tropics Message in a bottle 16:50, 28 October 2006 (UTC)


[edit] Cited papers

It has been suggested (by Elonka) that the "Cited papers" section should be moved into "References" either directly or through in-line cites. Unfortunately, even after reading WP:CITE I'm afraid that if I try to do it myself I'll just make a mess of things. If someone else can tackle this, it's the last thing that needs to be done before removing the "wikify" tag. --Doc Tropics Message in a bottle 17:37, 28 October 2006 (UTC)

Job done Nunquam Dormio 18:29, 28 October 2006 (UTC)
Wow, good job! Thanks ND. I've removed the "wikify" tag. --Doc Tropics Message in a bottle 18:32, 28 October 2006 (UTC)

[edit] Jellinek

I know that EMJ is extremely controversial and the subject of some heated debates. After reading the cite I made a couple of changes which seem to be more accurate and less POV. Specifically, the cite did not state that EMJ has "been called a liar and a fraud". Also, there doesn't seem to any controversy about his Masters degree, only his Doctorate. --Doc Tropics Message in a bottle 17:44, 28 October 2006 (UTC)

[edit] Avoiding circular logic

There are a wide range of opinions on the disease thoery, and they can't all be right. Furthermore, the affect of addictive substances on the brain and body is far from completely understood, even by experts. Given that some of the existing opinions must be at least somewhat misconstrued, and that all are based on partial information, we should avoid using the number of people who take a given opinion as justification for it. Instead, we should focus on reputable scientific results in presenting the argument. Of course we should present information on how widely the disease theory is accepted for completeness, we just shouldn't use it as justification. Elplatt 21:23, 20 January 2007 (UTC)

[edit] THIQ

I found this new NPOV edit and am not comfortable lack of references. I am undoing the edit. It stated:

"During the past decade, a key physiological difference between alcoholics and non-alcoholics was discovered. A medical scientist named Virginia Davis studied the surgically dissected brains of recently deceased winos. She discovered Tetrahydrolsoquinoline – (hereinafter THIQ), in the brains of dissected alcoholics. In metabolizing alcohol, drinker’s bodies first convert alcohol into acetaldehyde. Acetaldehyde is metabolized into acetic acid (vinegar) and then into carbon dioxide and water towards elimination. During the process of metabolizing acetaldehyde, alcoholics derive THIQ, which is stored in their brain. THIQ appears to be manufactured in the brain, and is not produced in the brain of an ordinary drinker of alcohol. Heroin addicts also produce and store THIQ in their brains. THIQ is a potent painkiller, and is far more addicting than morphine. Injecting THIQ into test animals has artificially created alcoholism in laboratory animals. Clear and convincing empirical evidence substantiating the disease concept of alcoholism exists."

--DisneyFreak96 23:13, 20 January 2007 (UTC)

Agreed. The lack of references is concerning. I checked it out and found multiple references to the research, but no information on the research itself. All references I found cited can be traced back to The disease concept of alcoholism by David L. Ohlms. His credentials and the original research should be looked into further. Elplatt 23:46, 20 January 2007 (UTC)

[edit] Article structure

I've significantly restructured the article. However, I've made no significant changes to the content of the article. The new structure distinguishes the theory, history, and controversy from each other, resulting in a clearer and more precise article. Please discuss any further changes to the structure here before making them. --Elplatt 00:36, 24 January 2007 (UTC)

Nice work. Mr Christopher 02:03, 24 January 2007 (UTC)
I agree. It is much clearer than last time I visited. --DisneyFreak96 07:32, 4 February 2007 (UTC)

[edit] Acceptance

The phrase

The disease theory is generally accepted by the medical community

was removed from the intro for being "POV and unsubstantiated." This is not POV, this is fact. Furthermore, this is substatiated in the disease theory of alcoholism#Current acceptance section. Please read the whole article before messing with it. --Elplatt 07:32, 5 February 2007 (UTC)


[edit] Corrected first sentence

I modified the first sentence. Alcoholism is not the same as "problem drinking." Problem drinking is a social construct, not a medical illness, and is based upon cultural issues, not symptoms and signs. Also, the disease concept does not say that alcoholism is the result of a disease, but that it IS a disease. Drgitlow 19:08, 11 February 2007 (UTC)

The first sentence is still not quite right. There's a conflict in the terminology used in this page and in the alcoholism article, which defines as alcoholism as "the consumption of or preoccupation with alcoholic beverages to the extent that this behavior interferes with the alcoholic's normal personal, family, social, or work life." That sounds like the definition of problem drinking to me. (Whether or not I think that is a good definition of alcoholism is beside the point).
The problem is that different reputable sources use the term "alcoholism" to mean different things. In fact, there is no illness called alcoholism by the medical community, only alcohol abuse and alcohol dependence.
Because "alcoholism" is such a confusing and multi-defined term, I think it would be better to define the disease theory in terms of something more concrete, such as alcohol dependence or problem drinking. Thoughts? --Elplatt 19:39, 11 February 2007 (UTC)
I've changed "alcoholism" in the intro to "alcohol dependence" which the NIAA considers equivalent. --Elplatt 04:45, 12 February 2007 (UTC)
Actually, the medical community is pretty settled on alcoholism as the term, with one major exception - the psychiatric field has an equivalent term "alcohol dependence" also in wide use. The definition article published in JAMA was in fact titled, "The Definition of Alcoholism." Your point about problem drinking is well taken, and I suppose it would be easy to say that most people with problem drinking are alcoholic and therefore would fall into whatever definition we use for that illness. It's just that there is no medical disease called "problem drinking," and the term itself seems to indicate problems with alcohol. Alcoholism, the disease, has a great deal to do with things other than alcohol. Use of alcohol among alcoholics is a marker for the presence of a disease which is still there even in alcohol's absence. Drgitlow 19:16, 13 February 2007 (UTC)

Hmmm...still not happy with the lead sentence:

The Disease theory of alcoholism states that some forms of alcoholism, such as alcohol dependence, are disease processes.

The disease theory states that alcoholism is a disease. In the opening line, as it stands, it sounds like some forms of alcoholism are NOT disease processes. There is only one alcoholism; like any disease, it can be mild or severe with a wide range of comorbidities. Can you provide a citation to back the statement that the disease theory speaks only about certain forms of the illness? Drgitlow 19:24, 13 February 2007 (UTC)

The disease theory certainly doesn't refer to what Stanton Peele and other opponents of the theory define as "alcoholism." Many dictionary definitions of alcoholism (reflecting lay usage) aren't compatible with the type of alcoholism described in the disease theory. I'll get specific citations if you'd like, but I doubt this is news to anyone.
By the way, I completley agree with your point about alcohol use being a marker for the presence of a disease, and I think drawing a line between the non-medical behavior of problem drinking and the disease state of alcoholism (alcohol dependence?) is a win for clarity and accuracy. --Elplatt 00:48, 14 February 2007 (UTC)

I think we're getting a little circular in our discussion. Stanton doesn't believe in the disease theory of alcoholism, so his definition of alcoholism will be very different. That's OK. He's allowed his definition. But the disease theory itself is that alcoholism is a disease. What you're saying is that there are other theories out there, and that's perfectly OK but shouldn't interfere with our presenting the single-sided perspective of one approach. Isn't that the point of this specific article? (The alcoholism article itself would be where each theory is introduced, no?) Drgitlow 20:53, 14 February 2007 (UTC)

My point is not that there are different theories of alcoholism, but that there are different definitions of alcoholism. The disease theory states that "alcoholism is a disease," but that means different things to different people. To present the disease theory appropriately, it is necessary to be clear about which definitions of alcoholism it refers to.

Many people consider the word "alcoholism" to refer to any problematic drinking behavior, but the medical definition refers to a more specific state, with particular symptoms and an identifiable progression. The distinction must be made clear, or else the average reader will completely misinterpret this article. (I agree, this should be dealt with in alcoholism as well, and recent discussion is suggesting it will be). --Elplatt 20:05, 15 February 2007 (UTC)

Is it safe to say that most people will find their way to this article after first reading the alcoholism article? Or doesn't that matter? Drgitlow 19:33, 18 February 2007 (UTC)
We still need to find a comfortable first sentence, but I switched it back to something that made sense. The entire disease concept rests on there being a single entity, called alcoholism or alcohol dependence, which is a disease state. Since this article is about the disease concept and not about alcoholism itself, we have to be straightforward about how the disease concept is defined. Drgitlow 01:11, 8 March 2007 (UTC)

[edit] Confusing

Most medical clinicians consider alcoholism a disease influenced by genetic, psychological, and social factors and characterized by compulsive drinking with impaired control and preoccupation with and use of alcohol despite adverse consequences. However, the disease theory is still controversial among the public at large. US Supreme Court decisions, books, and scientific journal articles demonstrate this lack of consensus.

This section is a bit confusing and needs to be clarified. Is the 'scientific journal' part referring to studies relating to the acceptance of alcholism as a disease by the public or is it referring to studies about whether alcholism is a disease. If it's the later, then who are the scientists who still doubt alcoholism is a disease? Since the first sentence and the rest of the article suggest it's not those involve in medical research anyway... (N.B. the fact that there are some studies suggesting alcoholism is not a disease does not indicate a lack of consensus. This would require a resonable large number of studies and/or a resonable number of scientist doubting the theory. The fact that a scientist publishes or is involved in which which may suggest alcoholism is not a disease also should not be taken in itself as evidence the scientist does not accept the theory that alcoholism is a disease.) Nil Einne 15:13, 21 March 2007 (UTC)

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