The Meaning of Addiction - 3. Theories of Addiction - Alcohol-Dependence Syndrome

Written by Stanton Peele

The alcohol-dependence syndrome suffers from the tension of acknowledging the complexity of alcoholic behavior. As its supporters note, "the control of drinking, like any other behavior, is a function of cues and consequences, of set and setting, of psychological and social variables; in short, control, or loss of it, is a function of the way in which the alcoholic construes his situation" (Hodgson et al. 1979: 380). Within this framework, Hodgson et al. regard withdrawal symptoms to be a strong cue for alcoholics to return to heavy drinking. However, the appearance of withdrawal in alcoholism is itself variable and subject to drinkers' subjective constructions. Moreover, such symptoms are regularly overcome by alcoholics in their drinking careers and in any case are limited in duration. Avoidance of withdrawal simply cannot account for continued drinking (see Mello and Mendelson 1977). There is a more basic objection yet to the alcohol dependence concept. In his critique of "the concept of drug dependence as a state of chronic exposure to a drug," Kalant (1982) remonstrated that dependence concepts have "ignored the most fundamental question—why a person having experienced the effect of a drug would want to go back again and again to reproduce that chronic state" (p.12).

Whereas speculation about human drug dependence has been influenced greatly by generalizations from animal research (generalizations that are largely incorrect, see chapter 4), the alcohol-dependence syndrome has had to fly in the face of animal research. It is difficult to get rats to drink alcohol in the laboratory. In his seminal research, Falk (1981) was able to induce such drinking through the imposition of intermittent feeding schedules that the animals find highly uncomfortable. In this condition, the rats drink heavily but also indulge in excessive and self-destructive behavior of many kinds. All such behavior—including drinking—depends strictly on the continuation of this feeding schedule and disappears as soon as normal feeding opportunities are restored. Thus, for rats that had been alcohol-dependent, Tang et al. (1982) reported "a history of ethanol overindulgence was not a sufficient condition for the maintenance of overdrinking" (p.155).

On the basis of animal research, at least, alcohol dependence seems to be strongly state-dependent rather than a persistent characteristic of the organism. Rather than being contradicted by human behavior, this phenomenon may be even more pronounced for humans. The supposed biological basis of drinking behavior in the alcohol dependence model is thus unable to deal with major aspects of alcoholism. As one of the authors (Gross 1977: 121) of the alcohol-dependence syndrome observed:

The foundation is set for the progression of the alcohol dependence syndrome by virtue of its biologically intensifying itself. One would think that, once caught up in the process, the individual could not be extricated. However, and for reasons poorly understood, the reality is otherwise. Many, perhaps most, do free themselves.

Control of Alcohol Supply

Sociological theory and research has been the main counterpoint to disease theories of alcoholism (Room 1983) and has made decisive contributions in depicting alcoholism as a social construction, in discrediting the idea that drinking problems can be organized into medical entities, and in disproving empirical claims regarding such bedrock disease notions as inevitable loss of control and reliable stages in the progress of alcoholism (see chapter 2). Yet some sociologists have also been uncomfortable with the idea that social beliefs and cultural customs affect levels of drinking problems (Room 1976). In place of such sociocultural interpretations of alcoholism, sociology as a field has now largely adopted a supply-of-alcohol perspective based on findings that alcohol consumption in a society is distributed in a unimodal, lognormal curve (Room 1984).

Since a large proportion of the alcohol available is drunk by those at the extreme end of this skewed curve, increases or decreases in alcohol availability are believed to push many drinkers above or below what might be considered a heavy and dangerous drinking level. Alcohol supply policy recommendations thus include raising taxes on liquor to lower overall consumption. The alcohol supply model is most certainly not a biological theory and does not itself lead to theoretical derivations about alcohol metabolism. Yet as Room (1984: 304) has pointed out, it can be rationalized with the disease-theory view that those at the extreme of the curve have lost control of their drinking. In fact, the model fits best with the alcohol-dependence syndrome, where alcoholic behavior is conceived principally to be the result of excessive consumption.

At the same time, the alcohol-supply view violates a number of sociologically based findings. Beauchamp (1980), for example, propounded the alcohol-supply argument while reporting that Americans consumed from two to three or more times as much alcohol per capita in the late eighteenth century as they do today and yet had fewer alcohol problems in the colonial period. Nor does the supply model make good sense of discontinuities in consumption within a given region. Alcohol problems in France are centered in the nonwinegrowing regions that must import more expensive alcoholic beverages (Prial 1984). In the United States, fundamentalist Protestant sects consume less alcohol per capita because many of these groups abstain. However, these groups—and the relatively dry regions of the South and Midwest—also have higher alcoholism rates and incidences of binge drinking (Armor et al. 1978; Cahalan and Room 1974). How also do the Jews, located principally in the highest consumption areas in the country (urban and Eastern), maintain an alcoholism rate one-tenth or less than the nationwide rate (Glassner and Berg 1980)? On the policy side, Room (1984) noted that efforts to curtail supplies have often backfired and led to greater binges in consumption.

At a psychological level, the idea that people incur the costs of alcoholism simply because they have more alcohol available to them makes little sense. For example, what exactly is the impact on the alcoholic of making supplies harder to obtain? The result of limiting the ready medical supply of narcotics was to turn many men into alcoholics (O'Donnell 1969). Vaillant (1983) found that abstaining alcoholics were highly prone to abuse other substances or to form alternate compulsive involvements. Here the sociological level of analysis, like the metabolic, suffers from a lack of a grasp of the individual's overall addictive ecology. The popularity of alcohol-supply ideas within a community noted for its opposition to disease ideas may make one pessimistic about whether there still can remain any intellectual resistance to metabolic theories of alcoholism and addiction.