WHAT IS AN ALCOHOLIC?

Three factors conspire to make alcoholism a difficult subject to grasp and to study. Because many of the antics of the inebriated are good for a laugh people often joke about alcoholics. What is, in fact, a considerable medical and social problem is thus eased out of serious consideration with a smile. Secondly, moral overtones colour our opinions, making it hard to amass information and arrive at proper judgements. Consequently an objective assessment of the alcoholic is difficult. A girl who gets drunk at a party, a man who drives a car when intoxicated, someone who spends so much on drink that his family’s well-being is affected – with what words do we appraise them ? Censure, blame, condemnation, disgust ? Or do we despise, ostracize, punish? Almost certainly we do not sympathize, feel responsible or try to understand. However, to study the problem of alcoholism scientifically it is necessary to be free of condemnatory attitudes. Moreover, such an approach is essential if anyone, doctor or friend, is to be accepted by an alcoholic as competent to understand and help him.

Lastly, the problem of alcoholism is made more difficult by lack of technical terms which are generally understood. What is an alcoholic? Without being adequately defined the term is too readily applied to embrace everybody who drinks abnormally. Not all these are alcoholics. Furthermore, there are many different types of alcoholics and many varied patterns of alcoholism. Some define the alcoholic from the vantage point of the sufferer; they name as an alcoholic the person who recognizes that he has to stop drinking but cannot do so. Others have focused on the observable consequences of uncontrolled drinking; they define an alcoholic as a person whose drinking has

caused increasing problems in his health, his domestic or social life or with his work. Others emphasize the quantity of alcohol consumed and the pattern of the drinking habits; only the man who regularly drinks till he is helpless is an alcoholic from their point of view.

A frame of reference is necessary if the subject is not to remain nebulous. While the social aspects of alcoholism are very important we prefer to think of alcoholism as a medical condition and shall use the following terminology.

Some people are teetotallers.

Most people drink moderately. They may from time to time get drunk. These are social drinkers.

Some people drink excessively, though not necessarily in their own eyes; their excess may show either by the frequency with which they become intoxicated or by the social, economic, or medical consequences of their continued intake of alcohol. These are excessive drinkers. Those excessive drinkers whose drinking gives rise to personal and social difficulties would do well not to equivocate but to recognize that alcohol lies at the root of their problem. Many excessive drinkers who have growing difficulties arising from their use of alcohol may be in serious need of medical care and can respond to appropriate treatment. However, it is important to grasp that not all excessive drinkers are alcoholics, though probably the great majority of them proceed to this next stage.

Alcoholics are people with a disease that can be defined in medical terms and requires a proper regime of treatment. Alcoholics are addicted to alcohol. Alcohol addicts are unable spontaneously to give up drinking. Though they may go without a drink for a few days, or sometimes for even longer periods inevitably they revert. The greater the need to stop drinking the more difficult do they find it to do so. Besides this characteristic of the alcohol addict,1 that he cannot go for long without alcohol, he generally suffers from withdrawal symptoms -short-lived (though often serious) physical or mental ill-effects which supervene when drinking is temporarily halted for a few days or even hours.

Most alcoholics proceed to a stage where their brains or their bodies have been so harmed by alcohol that the effects persist even when they are not drinking. This stage may be reached by some excessive drinkers who had not manifested addiction. It is called chronic alcoholism. The term should only be applied when the body has been physically damaged by alcohol.

To classify a particular drinker may not be easy, yet it is essential if he is to be helped. We cannot properly proceed until we know whether he is a social drinker, an excessive drinker, an excessive drinker with problems, an alcoholic (i.e. an alcohol addict), or has reached the further stage of chronic alcoholism.

Addiction to alcohol is different from addiction to most dangerous drugs, such as opium, heroin, and cocaine. In the first place, addiction to alcohol is far more accepted by society because drinking is to a large extent socially condoned. Secondly, drug addicts may work up to a dose far exceeding what would be fatal to an ordinary person; alcohol addicts on the other hand do not require to go on increasing their intake in the same way. Although the habituated alcoholic is not as affected by alcohol as the novice drinker, nevertheless he does not need to drink greatly increased quantities to continue to get the desired effect. When the drug addict stops he experiences a craving; physiological changes set up a subjective need for more of the drug. He also develops withdrawal symptoms which are promptly alleviated by another single dose. The alcoholic may be able to abstain for quite long periods without craving, particularly if he is in a hospital or other institution.

If he does experience withdrawal effects they are generally not abolished by a single further drink. The term addict, however, is appropriate to alcoholics in one very important sense. All addicts are dependent upon the substances they take. They may not, in the case of alcohol, require it constantly, nor does the need necessarily betoken physical dependence. It may be a psychological dependence, so that the alcoholic may rely on alcohol, either continuously or from time to time, to free him from unbearable tensions. With its aid he can face his problems, his family and himself. He is dependent upon alcohol to function efficiently as a social being. It is the irony of this which makes alcoholism into a problem, for the very stuff on which he relies in order to function has the inexorable physiological effect of impairing function.

To resolve this situation, to help the alcoholic to be able to conduct his life without alcohol, is called ‹“treatment’. So we can now understand the whole of the World Health Organization definition1 of the alcoholic:

Alcoholics are those excessive drinkers whose dependence on alcohol has attained such a degree that they show a noticeable mental disturbance or an interference with their mental and bodily health, their interpersonal relations and their smooth social and economic functioning; or who show the prodromal signs of such developments.

They therefore require treatment.

‹“Treatment’ suggests something which only doctors can give. But the help which alcoholics require has to be given by those associated with them, family, friends and employers as well as social agencies and physicians. Directly or indirectly alcoholism is everyone’s concern.

It is a growing problem. The World Health Organization2 has

1. World Health Organization. Expert Committee on Mental Health (1952). Alcohol Subcommittee Second Report. W.H.O. Technical Report Series, No. 48.

2. Expert Committee on Mental’Health (1951). Report on the First Session of the Alcoholism Subcommittee. W.H.O. Technical Report No. 42, Annex 2.

estimated that there are 3 50,000 alcoholics in Britain, a quarter of whom show physical and mental deterioration. The size of this figure clearly argues the magnitude of the problem, though in our opinion estimates like this are not reliable. It is difficult to see how an accurate count can be obtained. Alcoholism is not a notifiable disease nor is it definable in unambiguous, operational terms so that everyone can readily agree whether or not someone is an alcoholic. Moreover, many alcoholics do not come to any agency interested in counting them. General practitioners, for instance, know of only about a ninth of the alcoholics among their registered patients.1 In general hospitals, many alcoholics are treated for physical illnesses without their alcoholism being diagnosed or recorded. Data are, however, available about admissions to psychiatric hospitals. In England and Wales in 1959, 26 men and 6 women per million of the population, respectively, were admitted for the first time with a diagnosis of alcoholism or alcoholic psychoses.2 The corresponding rates for Scotland (1961) were 175 men and 30 women.3 (Alcoholism here refers to Code 322 of the International Statistical Classification of Diseases and Causes of Death.) These Scottish rates are seven times as high for men, five times for women.

Of course, only a small proportion of alcoholics are ever admitted to a psychiatric hospital. Most never get there. Some die without ever receiving psychiatric treatment. Alcoholism is a killing disease: cirrhosis of the liver, malnutrition, road accidents and suicide all take a heavy toll. Although there are no reliable figures for deaths in which excessive drinking plays a part, physicians who see a lot of the problem know that the

1. Parr, D. (1957). ‹“Alcoholism in general practice’. British Journal of Addiction, J4, 25.

2. Registrar General (1962). Statistical Review of England and Walesfor the year iff?. Supplement on Mental Health. London: H.M.S.O.

3. General Board of Control for Scotland (1957-62). Annual Reports for the years 19 j6 to 1961. Edinburgh: H.M.S.O. established alcoholic who is not successfully treated has a greatly reduced expectation of life. This is reflected in the official statistics of the Registrar General showing the grossly increased mortality of people in high risk occupations. Publicans, for instance, have a death rate from cirrhosis of the liver nine times as high as for all men of comparable age.1

None of these sources satisfactorily answer the question of how many alcoholics there are ? The World Health Organization statistics are based on a formula which uses the figures for deaths registered as due to cirrhosis of the liver. This implies that one can know both the percentage of such deaths that are due to alcohol and the percentage of alcoholics who develop this liver disease. But we do not. The only way in which we could really find out the size of the alcoholic population would be by going into the community and counting them. Such a survey would present considerable difficulties and has never been done in Britain. A recent household study2 in a mixed racial residential area of New York City (Washington Heights) revealed three men and one woman per 100 population aged 20 or over who had drinking problems. Most of these disclosed the fact themselves to the interviewers. An approach to a solution would be to ask key people in the community such as general practitioners, clergymen and police to list the alcoholics they know. But the more ‹“key people’ you ask the more alcoholics you will find. The eventual estimate arrived at will reflect the extent of the search and must always be an approximation. Such an approach was used in Cambridgeshire,3 and showed that 6-2 of every thousand adult men (women, 1-4) were alcoholic.

1. Registrar General (1957). Decennial Supplement, England and Wales, if //. Occupational Mortality, Par/ 2, Vol. 2. London: H.M.S.O.

2. Bailey, M. B., Haberman, P. W. and Alksne, H. (1965). ‹“The Epidemiology of Alcoholism in an Urban Residential Area Quarterly Journal of Studies on Alcohol, 26, 19.

3. Moss, M.C. and Beresford Davies, E. (1968).‹“A Survey of Alcoholism in an English County’. Privately printed, Geigy (U.K.) Ltd.

Do we need to know the exact prevalence? The only practical reason for wanting it is to determine the need for services and we are already sure that whether there are 500,000 or 50,000 alcoholics in Britain, present services, both social and medical, fall far short of requirements.

So far we have looked at the size of the problem primarily from a medical standpoint. The fact that alcoholism is a disease should be more generally appreciated in Britain both by the public and by doctors. In 193 5 the American Medical Association passed a resolution that: ‹“Alcoholics are valid patients.’ This is the counterpart of W.H.O.’s: ‹“They therefore deserve treatment.’ In Britain many doctors and others responsible for organizing medical services are loath to accept this.

Alcoholism also poses social problems both for the community and for the individual alcoholic and his family. In most cities there are to be found depressed areas where alcoholics congregate, limbos where they eke out poverty-stricken, degenerate, sometimes psychotic existences. Alcoholism leads to absenteeism and unemployment, debt, crime, social decline and sometimes child neglect. The average family in Britain spends 13 s. 6d. a week on drink, about four per cent of its weekly expenditure, but in an alcoholic’s household the proportion can easily become ten times as much.

There are other social ills which, if they cannot directly be laid at the door of alcoholism, are certainly related to it. There is highly suggestive evidence that alcoholics swell the numbers of arrests for drunkenness and are responsible for many road accidents due to drinking. We discuss this in Chapter 13.

Recently there has been a steep rise in convictions for the offence of drunkenness and it is especially worrying that this increase has been noteworthy even for people under the age of 21. In the Metropolitan Police District of London alone, in 1963 there were 35,485 convictions for drunkenness and 1,587 of these were of youths under 21. Those concerned to sell drink have long been aiming to attract women into the pub, thus securing the custom of their male friends. More recently they have been beaming their advertisements particularly at teenagers.1 The increase in drinking by youngsters is now being reflected clinically by an increase in the number of established alcoholics still in their twenties. Many of these will die in their thirties.

Whether an alcoholic is viewed as a medical or as a social problem will profoundly affect the future course of his disorder. Where the alcoholic is dealt with by the courts he is likely to spend time in jail in an atmosphere that is both custodial and punitive, not directed at his rehabilitation. Where medical treatment is available and doctors are prepared to accept responsibility for the management of his condition, the institution to which the alcoholic is admitted is more likely to be a hospital. The measures adopted then will be therapeutic, designed to foster his self-respect and sustain his resolve to overcome his disability. Today in Britain each method is applied and the disposal generally depends not upon the individual’s needs but on the relatively trivial circumstance that brings him to the notice of one or other service. Anyone responsible for dealing with an alcoholic ought to obtain all the information he can, medical and social, and reflect seriously in every case whether the allocation decided upon fits the individual requirements.

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