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Murky Definitions Cloud Moderate-Drinking Debate

by Carlton K. Erickson

The recovering community largely has been responsible for defining the term “alcoholic.” To members of Alcoholics Anonymous (AA), anyone who believes him/herself to be powerless over alcohol is an “alcoholic.” And any member who remains abstinent, faithfully attends meetings, and works the 12 Steps is thought of as a “recovering alcoholic."

Yet attending AA meetings does not involve diagnostic criteria, since the only requirement for membership is a desire to stop drinking. In other words, AA is a program of self-diagnosis. (“Hi, I'm John, and I'm an alcoholic.”)

I am placing “alcoholic” in quotation marks because the word means different things to different people. AA is clear about its view of alcoholism: It is when a person cannot consistently control alcohol use, to the point that it is damaging his/her life. On the other hand, if one looks at the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) Web site (www.niaaa.nih.gov) under “Frequently Asked Questions (FAQs) for the General Public,” the definition of “alcoholism” states, “also known as alcohol dependence,” with these symptoms:

• Craving—a strong need, or urge, to drink

• Loss of control—not being able to stop once drinking has begun

• Physical dependence—withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety after stopping drinking

• Tolerance—the need to drink greater amounts of alcohol to get “high”1

The following description is provided:

For clinical and research purposes, formal diagnostic criteria for alcoholism also have been developed. Such criteria are included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, published by the American Psychiatric Association, as well as in the International Classification [of] Diseases, published by the World Health Organization (See also “Publications,” Alcohol Alert No. 30: Diagnostic Criteria for Alcohol Abuse and Dependence.).

The preceding description on NIAAA's Web site is self-contradictory since, unlike the NIAAA definition, the DSM does not define alcohol dependence as including craving or as always including physical dependence and tolerance. Adding to the confusion is the observable fact that many “alcoholics” experience frequent episodes of craving and impaired control, accompanied by associated life problems, long before they develop the later-stage symptoms of physical dependence and tolerance. Are those people who do not satisfy enough DSM criteria mislabeling themselves when they attend AA meetings?

It is almost as if our field has multiple personalities. Personality one, AA, believes that anyone who realizes that alcohol has negatively affected his/her life, can't seem to quit on his/her own, and wants to get help is an “alcoholic.” Personality two, NIAAA, reflecting the bulk of the latest alcohol research, believes that an “alcoholic” should have the four symptoms that are supported by science. Yet many “recovering alcoholics” would dispute this, since their lives were wrecked by alcohol long before they experienced any serious withdrawal symptoms beyond a memorable hangover.

Personality three, the psychiatric community, believes “alcoholism” isn't a scientific term and that a diagnostic discernment must be made between volitional alcohol abuse and pathological alcohol dependence (using the diagnostic criteria spelled out in the DSM-IV). In fact, scientists involved in NIAAA-funded research have published numerous articles on the differentiation and epidemiology of alcohol abuse versus alcohol dependence (see, for example, Hasin et al2 and Koob et al3).

It is not surprising, then, that some scientists advocate that some “alcoholics” can return to “moderate drinking” or “social drinking,” depending on whose definition of “alcoholism” they are using. AA members would argue that an “alcoholic” is by definition someone who can't use alcohol without losing control. So what these scientists fail to realize is that “alcoholics” (as defined by AA and most neuroscientists) should not try to drink “socially,” since to do so might lead to a downward spiral of addiction.3

As a caring human and a scientist, I wonder why anyone would advocate that people who have major problems with alcohol should ever try to drink “responsibly.” It is fine for social drinkers to drink responsibly, but if someone is “alcohol-dependent” (as defined by NIAAA and the DSM) or an “alcoholic” (as defined by AA folklore), why is it important even to suggest that drinking alcohol might be beneficial?

Please, let us develop a unifying message: Some people can learn to drink responsibly (depending on the level of problems resulting from use) by means of better information, positive peer pressure, maturation, or sometimes coercion, fear, or even punishment But the truly alcoholic/addicted/dependent—take your choice until the definitions are clearer—usually need professional and medical help (proven interactional and behavioral therapy, formal “treatment,” and new abstinence-enhancing medications) followed by supportive follow-up programs such as AA.

Certainly unscientific labels and folk terminology confuse the alcohol-overdrinking problem, but any responsible person (especially someone who depends upon evidence) can see that some people can control their drinking (abusers) and some people can't (alcohol-dependent). Anyone who argues against this is either not in touch with the mainstream, respected alcohol-research literature or has a personal agenda that might benefit from further examination.

PhD, is Director of the Addiction Science Research and Education Center at the University of Texas at Austin's College of Pharmacy.