A Note on Race, Social Class, and Ethnicity in Addiction/Alcoholism

One of the prevailing myths of alcoholism and addiction in the U.S. is that all races, social classes, and ethnic groups are equally likely to be addicted. This myth feeds into other prevailing myths—primarily that alcoholism/addiction is a medical illness that will be treatable by standard medical techniques. "'Addiction,' declares Brookhaven's [Dr. Nora] Volkow, 'is a disorder of the brain no different from other forms of mental illness'" (Nash, 1997). This bill of goods is now being heavily sold by the National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse. Just as Time has announced that dopamine is at the heart of all addiction, NIMH director Steven E. Hyman (1996) is busily "Shaking Out the [Neurochemical] Cause of Addiction." The data popular and scientific observers point to in support of this proposition is the absence of clear-cut racial and educational differences in exposure to drugs over people's lifetimes (SAMHSA, 1996).

In the case of alcohol, better educated, richer, and white Americans are actually far more likely to drink than less educated, poorer, and African and Hispanic Americans. However, those in the high-consumption categories who do drink are far less likely to become alcoholic than drinkers in the low-consumption groups. Decades of Alcohol Research Group surveys point out that, the higher one's social class, the more likely one is to drink and the less likely one is to drink abusively (Cahalan and Room, 1974; Hilton, 1987). Despite the emergence of this truth in surveys it sponsors, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) released a popular poster, captioned "The Typical Alcoholic American" showing every kind of racial, ethnic, and occupational group—thereby emphasizing the notion of alcoholism as "an equal opportunity destroyer." This, even as social and ethnic variables are regularly found to be the best predictors of alcoholism (Cahalan and Room, 1974). Even psychiatric researchers who strongly endorse the disease model find overwhelming cultural determinism of alcoholism. Vaillant (1983), for example, found Irish Americans were seven times as likely to become alcoholic over their lifetimes as Mediterranean (Italian) Americans living close by in inner-city Boston. Helzer and Canino (1992) found a fiftyfold difference in DSM III alcohol abuse/alcohol dependence lifetime prevalence between Koreans and Mexican Americans, on the one hand, and Chinese, on the other.

Such social differences drown out bloodline differences in alcoholism (e.g., Vaillant, 1983)—indeed, adopted-away studies have built an entire model of genetic etiology by ignoring such differences. If social differences are irrelevant to alcohol/drug abuse, then we can create an "objective" science of addiction and treatment can be provided without considering the social realities and meanings of people's lives. However, medical epidemiologists themselves don't actually believe this claptrap. At meetings of alcohol epidemiologists who claim that alcohol consumption must be curbed because it is inherently dangerous, I notice that they all drink socially. And the claim that all social groups are equally susceptible to drug addiction is belied by the inner-city destruction wrought by drug abuse. Some then claim that middle-class users are able to disguise their addictions because of their greater social resources. But if addiction is defined by lack of control, this is a self-contradicting statement.

Who Is Being Treated?

Those who continue to believe that alcoholics and addicts appear equally among all social, ethnic, and racial groups may be stunned to learn that, if this is true, less well-educated, poorer, and minority American are being overserviced for alcohol and drug problems! (Certainly, this would be a unique case of overservicing of these groups.) The National Admissions to Substance Abuse Treatment Services, Treatment Episode Data Set (TEDS), 1992-1995 (SAMHSA, 1997) compared treatment episodes among different social groups to the prevalence of these groups in the general American population. Whites are 20 percent underrepresented in substance abuse treatment relative to their presence in the population, matched almost exactly by the overrepresentation of African Americans. Full-time workers are even more underrepresented, while those unemployed and not in the labor force are 20 percent overrepresented. Lest this be deduced to be the result of drug/alcohol abuse rather than a precondition, consider that those who have some college education are about 25 percent underrepresented in substance abuse treatment.

But does this greater exposure to treatment produce improved outcomes for these groups? The answer seems to be not. There are several possible explanations for this. One is that middle-class Americans receive better treatment than lower-SES Americans. In fact, the more likely explanation is that treatment is less important than the social resources of the drinker or drug-consumer both in the development of problems and in their remediation. Thus, while those enrolled in private treatment programs, who are almost by definition employed and/or socially stable (see Finney and Moos, 1991; Walsh et al., 1991), show relatively good improvement rates, those enrolled in inner-city treatment programs often fare very poorly indeed. In one remarkable study (which purported to discover that moderate drinking was almost impossible for treated alcoholics), of those treated in an inner-city alcoholism ward, 7 percent survived and were in remission at from 5-8 years following treatment (Helzer et al., 1985).

Although lower-SES Americans are more likely to receive alcoholism treatment, in the overall tidal wave of expanding treatment, many more middle-class Americans are receiving alcohol and substance treatment as well. Betty Ford came to typify such middle-class alcoholism patients who enter private hospitals, like that named for her. But the most common new alcohol treatment enrollee is an adolescent (Bascuas, 1992). Such middle-class patients, in addition to being better-off economically and more likely to be insured than the alcoholics who typified the founders of AA, for example, don't drink as much as earlier clinical alcoholics. Because less drinking is required to qualify for treatment, by the end of 1980s a substantial number of Americans over the age of 18 had been treated for alcoholism. A 1990 general population survey found that 4 percent of U.S. men (1 percent of women) had sought formal help (including AA) for a drinking problem in the past year, and 8 percent (2 percent of women) had done so at some point in their lives (Room and Greenfield, 1993). Unfortunately, Room and Greenfield gave no breakdowns by any social, educational, or economic indicators.