The medicalization of alcohol problems

Between about 1850 and the late 1950s alcoholism came to be considered a disease caused by some biological reaction to alcohol. This reaction was supposed to be permanent, so the only palliative treatment for alcoholism was permanent abstinence. Still widely believed, this idea is faulty:

Many problem drinkers come to harm from drinking but are not alcoholics. The most notorious contemporary example is the rise in binge drinking, mirrored in the UK by a rapid rise in liver cirrhosis (Leon & McCambridge, 2006). Average personal intake in Europe, excluding abstainers, is in excess of recommended safe limits (Anderson & Baumberg, 2006); we all drink unhealthily and it is counterfactual to stigmatize alcoholics.

Even dependent drinkers have some control over their drinking and some people with severe alcohol problems can moderate their drinking to problem-free levels, often without help (Heather & Robinson, 1983).

Some very heavy drinkers survive unchanged for 30 years or more (Valliant, 2003).

Alcoholics Anonymous (AA) emphasizes abstinence, as do some professional treatments. Other treatments include monitored detoxification for severely dependent drinkers, counselling (see pp. 132–135) to enable the patient find methods of coping other than drinking, or therapeutic communities where patients stay off alcohol and undertake group therapy. Given a choice, some patients opt for abstinence and some for moderating their drinking. Occasional relapses to heavy drinking are common, even amongst those trying to abstain, and patients are taught to expect and cope with this. Controlled follow-up studies suggest that approximately 80% of people treated for alcohol dependence by any method have relapsed within 2 years. Alleged better rates tend to be due to bias (for example, treatment programmes that only admit people who have virtually stopped drinking already) or poorly controlled research (Miller & Sanchez-Craig, 1996).

The 12-steps approach

AA (http://www.alcoholics-anonymous.org) consists of groups of recovering alcoholics who provide one another with mutual support to achieve complete abstinence. Their philosophy is the famous 12-steps approach, which requires that alcoholics surrender to a higher power (or God), admit their wrongs and try to rectify them (see pp. 142–143). People who were heavily dependent, have religious or spiritual feelings and accept abstinence as a goal are likely to benefit most from this approach. AA has less to offer people who are not dependent. Doctors often suggest AA as a supplement to treatment.

Drinking problems and government advice

Even quite moderate drinking increases morbidity (Table 1) and mortality. Consequently, the UK government advises that women should not regularly drink more than 2–3 units of alcohol a day, men should not regularly drink more than 3–4 units of alcohol a day and pregnant women or women trying to conceive should avoid drinking alcohol (National Alcohol Strategy, 2007). A unit or standard drink is usually defined as a half-pint of beer, a small glass of wine or a standard measure of spirits. However, many people, especially young men, drink above these limits (Fig. 1), often due to going out a few nights each week (Hammersley and Dittan 2005).

Table 1 Alcohol, disease and possible benefits

Disease	Beneficial effects
Liver disease – fatty degeneration, fibrosis, acute alcoholic inflammation, cirrhosis	1–2 units per day may reduce the risks of coronary heart disease
Cardiovascular disease – hypertension. Heavy drinking increases stroke risk and coronary heart disease	Red wine lowers cholesterol levels
Cancer – oesophageal cancer, possibly stomach cancer	Small occasional dose of alcohol may serve as a sedative or tranquillizer
Neurological disease – Korsakoff’s syndrome, alcoholism