Alcoholism: Is nature or nurture to blame?
The conundrum of alcoholism; Is nature or nurture to blame?
There is a wrenching scene in the classic movie It's a Wonderful Life where George Bailey and his guardian angel are sitting in a small tavern, observing how different Bedford Falls would have been had George not been born.
In staggers old Mr. Gower, an unshaven pathetic rubby who is the object of the merrymakers' scorn and ridicule. Seltzer is sprayed in his face. He's unceremoniously tossed out on his ear.
You see, George Bailey wasn't there as a young boy to catch Mr. Gower's absent-minded mixup of pills that took someone's life.
The movie's implication is clear. That one cruel twist of fate charted a grim, inescapable path for Mr. Gower that led straight to the haven of the bottle.
Such is the paradox of alcoholism, or perhaps more accurately, our thinking about alcoholism.
Is alcoholism a disease or a character flaw? Are alcoholics born or are they made?
The answer is both. Or neither, if you prefer, depending on whether you view the shot glass as half empty or half full.
Most researchers now agree that there is a genetic predisposition towards alcoholism in some people. That's some people, not all. For example, the risk of alcoholism for sons of alcoholic fathers is 25 per cent.
But genetics alone doesn't tell the whole story.
Studies of identical twins who have been adopted and raised by different families have shown that one twin doesn't always follow in the alcoholic footsteps of the other sibling.
Since they both have the same genetic makeup, there must be other factors at work: cultural differences, socioeconomic pressures, family and friends, even personal factors.
History hasn't always been as charitable, however, to the problem drinker. In the past, alcoholics have been viewed as weak-willed individuals without the moral fortitude to overcome their character failing.
The fact that some alcoholics can, indeed, resist the temptation only reinforced the notion among non-alcoholics that the battle with the bottle has less to do with biology than it does with psychology.
By 1956, the pendulum had swung enough that the American Medical Association officially recognized alcoholism as a disease.
Current research into alcoholism is now aimed at finding a genetic basis, which could then lead to more effective drug treatments.
"It seems to be that you can convert just about anybody to an alcoholic by exposing them to drink for long enough at high enough quantities," said Dr. Anthony Carr, a psychiatrist at the Hamilton Psychiatric Hospital and medical director of the Alcohol and Drug Relapse Prevention Program at Hamilton General Hospital.
"But people's resistance and susceptibility varies.
"Some people's brains are set up so that it's very hard for them to become an alcoholic," Carr noted. "It would take a long time at high exposure to make them an alcoholic. Some people's brains are set up so that it's very easy for them to become an alcoholic.
"But neither of them are alcoholics to start with."
There are a number of factors in favour of considering alcoholism as a disease:
* The illness can be described.
* The course of the disease is predictable and progressive.
* The disease is primary, meaning that it's not just a symptom of another disease.
* It is permanent.
* It is terminal. If left untreated, alcoholism inevitably results in premature death.
But there is also one major shortcoming to the alcoholism-as- disease model.
"The disease concept is unhelpful when it comes to the actual treatment," Carr said. "If you have a disease, you go to the doctor and say 'fix it.' You don't expect to have to work at it yourself.
"If you come to my alcohol clinic and you want to get better, you are going to have to do the work," Carr added. "I can advise you and point you in the right direction, but I can't treat your alcoholism."
That's what has made treating alcoholism so difficult. It's perhaps the only disease where the affected person also holds the key to the cure.
The first hurdle is the most formidable one: the alcoholic must recognize there's a problem that needs fixing.
Until that happens, any other type of intervention or treatment will fail.
The second problem is a subtle variation of the first.
The alcoholic must recognize that someone else's help is necessary. Very few true alcoholics can beat the bottle without the emotional, psychological and even medical support of others.
The third problem is even more subtle.
Alcoholics often face a number of other problems because of their drinking -- perhaps a spouse has left, or the children no longer wish to be contacted, or they've lost their job.
Alcohol is often used to help relieve pain -- pain that the alcoholic must now face sober, under the harsh glare of reality.
The good news, from a statistical standpoint, is that for alcoholics who can maintain sobriety for two years, the chance of relapse is quite small.
Of course, there have been drugs developed to treat alcoholism but they all have one principal drawback -- they are reactive rather than proactive.
"The big problem is that it only works when you drink," Carr said. "But you're not supposed to be having a drink in the first place.
"It doesn't affect the main problem, which is the desire for a beer."
The most commonly used drug is disulfiram, better known as Antabuse.
When alcohol is broken down, the first byproduct in the chain reaction is acetaldehyde, a rather poisonous substance that's actually used as a pickling agent.
Antabuse blocks the enzyme that breaks down acetaldehyde, and as this byproduct builds up, it provokes a violent reaction.
"You suddenly get very sick and redfaced and the second beer going down meets the first beer coming up," Carr said.
"Therefore you're not able to poison yourself any more.
"You spend a very uncomfortable two or three hours being sick and eventually your body metabolizes the acetaldehyde and you're back to normal."
One of the newer drugs approved for treating alcoholism is called naltrexone. It marks a new approach by attempting to block the pleasurable effects of alcohol in the brain.
Naltrexone occupies the same nerve receptors that are acted upon by alcohol. The idea is that the alcoholic won't receive the same pleasure from drinking and will eventually reduce consumption.
But there are two problems: it only works if you continue to take the medication regularly, and naltrexone doesn't prevent the physical side effects of alcohol, such as loss of co-ordination, slurred speech and poor judgment.
One of the more controversial debates is whether alcoholics can be returned to the level of social drinkers.
Some researchers have put forward examples which suggest that possibility, but Carr noted that almost every longer-term study shows that alcoholics who try to redevelop social drinking habits eventually gravitate back to alcoholism.
Groups such as Alcoholics Anonymous, which promote total abstinence as the only foolproof cure, are naturally worried about reports that suggest alcoholics can be reprogrammed to drink socially.
Here's a rough guide to tracking the progression of an alcoholic. The chronology is from Dr. Anthony Carr, a psychiatrist at the Hamilton Psychiatric Hospital and medical director of the Alcohol and Drug Relapse Prevention Program at Hamilton General Hospital.
* "The 25-year-old alcoholics are in the orthopedic ward, after having fallen off their motorbikes or getting smashed up in their cars.
* "The 35-year-old alcoholics tend to be in the emergency room being treated for an overdose or cut wrists. Thirty-five is old enough that he's now already got some problems at work or with his wife or girlfriend.
* "The 45-year-old alcoholics are in the psychiatry ward. It's now got to the point where they are actually getting depressed and unable to cope. His wife has left him, she's got an injunction not allowing him near the kids, the family won't help, no one will lend him money.
* "The 55-year-old alcoholics tend to be in the neurology ward -- with their neuropathy and their Korsakoff syndrome (confusion and severe memory impairment) and their liver problems and holes in their stomach.
"By now they're crumbling away physically. Fifty-five is quite old for an alcoholic."
* And what about the 65-year-old alcoholic?
"There's not very many alcoholics at 65," Carr said. "Some of them have recovered, some of them have died and some of them are in prison.
"When you talk about actually abusing alcohol, you're not going to last longer than about 20 years. You're either going to stop or die."