Many Problem Drinkers are not Alcoholic

Ian Urbina of NY Times kicked off a big debate about addiction with his piece on how changes in the Diagnostic and Statistical Manual of Mental Disorders will affect diagnostic prevalence rates. The new diagnostic criteria aren’t yet finished, and I am not privy to the committee’s discussions. I can however correct one prevalent misunderstanding about how diagnostic criteria are used in the alcohol field.

A number of media stories have claimed that if diagnostic criteria are widened, everyone who drinks in an unhealthy fashion will be labelled an alcoholic. This is no more true that saying that if oncologists start diagnosing polyps then everyone who has one will be diagnosed with Stage IV cancer.

Many people who drink in an unhealthy fashion are not and will never be alcoholics. Recognizing this reality has no effect on the number of people who are diagnosed with alcoholism. In medicine, the typical term uses to describe unhealthy alcohol use isn’t alcoholism but — wait for it — unhealthy alcohol use.

All “unhealthy” means in this case is that there is a significant statistical relationship between the amount and/or frequency of the person’s drinking and some bad outcome, e.g., automobile accidents. Most people who drink in an unhealthy fashion aren’t aware that they are incurring some risk. The main intervention for unhealthy users is simple information and advice e.g., “You may not be aware that you drink more than 80% of the population and as a result have a higher risk of injuries, problems at work, and family problems than you would if you drank less. You might therefore want to consider drinking less”.

My colleague John Cunningham has shown that such information and advice processes can be done on-line by problem drinkers in the privacy of their homes. Given solid information, quite a few cut back to a healthier level of drinking. It’s just not that simple with alcoholics, who typically need more involved intervention in order to change.

I don’t know what term the diagnostic criteria committee will ultimately use for the non-alcoholic segment of the problem drinking population. They might call them problem drinkers, unhealthy alcohol users, people with mild alcohol use disorders or the like. But the new diagnostic system will not call them alcoholics; the people who are writing the criteria are too knowledgeable to confuse two such different populations.

Author: Keith Humphreys

Keith Humphreys is the Esther Ting Memorial Professor of Psychiatry at Stanford University and an Honorary Professor of Psychiatry at Kings College Lonon. His research, teaching and writing have focused on addictive disorders, self-help organizations (e.g., breast cancer support groups, Alcoholics Anonymous), evaluation research methods, and public policy related to health care, mental illness, veterans, drugs, crime and correctional systems. Professor Humphreys' over 300 scholarly articles, monographs and books have been cited over ten thousand times by scientific colleagues. He is a regular contributor to Washington Post and has also written for the New York Times, Wall Street Journal, Washington Monthly, San Francisco Chronicle, The Guardian (UK), The Telegraph (UK), Times Higher Education (UK), Crossbow (UK) and other media outlets.

8 thoughts on “Many Problem Drinkers are not Alcoholic”

  1. Keith, I’m sure you are right that the new diagnostic system (DSM-V) will not label all problem drinkers as alcoholics.

    However, the current system (DSM-IV) doesn’t label ANYBODY as an alcoholic. It doesn’t use the noun “alcoholic” or the term “alcoholism” at all. A caregiver who diagnoses a patient as an “alcoholic” is not following DSM-IV.

    DSM-IV identifies various categories of substance use disorders, the most important of which are “abuse” and “dependence.” Alcoholism is sometimes equated with what DSM-IV calls alcohol dependence, but not always. Alcoholism is a vague, informal, colloquial, and poorly defined term and is used by all kinds of people to mean all kinds of things.

    DSM-IV uses a common terminology across all drugs of abuse. Instead of “alcoholism” and “heroin addiction,” it has “alcohol dependence” and “heroin dependence,” and applies the same principles to both drugs.

    1. @rachelrachel: I believe DSM-V will get rid of abuse and dependence as terms and concepts, because the NESARC showed that the concept that abuse is a less severe form of disorder turned out to be wrong (as it happens, most people develop dependence on alcohol first, then the social consequences later).

      You are almost certainly correct that DSM-V will not use the word alcoholic. When I am using the term here I am doing so for popular communication, the likely term in DSM-V will instead be “alcohol addiction”.

      1. But what will the term in common use be? That’s pretty much what counts? If “unhealthy alcohol user” gets shortened to “alchoholic” we’ll be right in the same place.

        1. Counts to whom? In what context? The DSM aims to provide a consistent taxonomy of psychological disorders so that practitioners (and insurance companies) can speak a common language meaningfully. It doesn’t aim to set colloquial norms. So yes, post-DSM-V, bad journalists will continue to write misinformed pieces.

      2. I like the idea of not using the term “alcoholic”. I’ve known several people you might classify as “problem drinkers” in some way but who definitely not alcoholics in the traditional sense of the term, and one of their classic and consistent defense mechanisms when their drinking was pointed out was to say “I’m not an alcoholic”, as if that term exhausts all the ways in which drinking could be problematic.

        So getting rid of that term could be very helpful.

      3. I wasn’t finding fault; I just thought a clarification was in order.

        Thanks for your tip on the NESARC; I will look that up.

        In popular communication, the word “alcoholic,” which started out as a medical term, has become a synonym for the older word “drunkard.” If somebody tells me that so-and-so is an alcoholic, most often they are not performing a clinical diagnosis.

  2. Well, someone has to be in the 80%; even if everyone reduced their drinking by 75%, you’d still have someone in that upper 80% echelon. Especially if you have 20% or so of the population that doesn’t drink at all.
    Or course, at some point the like cohort will start to be rather disturbing… I’d imagine the 75% or 80% cohort has a rather different look than the upper 90s…at that point the simple statement of “these are your peers” is likely enough to spark a change in the non-dependent / abusive ‘unhealthy’ drinker.

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