Alcohol: When Does This Substance Use Become Disordered?

This clinically oriented discussion reviews the ABCs of substance use disorders, putting them in a framework that clarifies their harsh impact, supporting harm reduction and thoughtful prevention.

Source: original oil on canvas; Frank John Ninivaggi MD, 2000

Substance Misuse: Disease, Disorder, or Simply an Overuse Problem?

Whether readily available or manufactured, overusing materials found in nature, a.k.a. drugs that substantially impair biomental status, is problematic. Terms describing this impairing overuse include compulsions, abuse, misuse, dependence, and addictions. Each word has connotations, some helpful, others moralistic and pejorative. The terms “disease,” “disorder,” and “syndrome,” may be used loosely but have medically specific definitions.

Syndrome refers to a grouping of symptomatic problems; disorder means an ordinarily well-functioning system becoming disorganized and impaired; and disease refers to a biological system that had been operating healthily but is becoming impaired, symptomatic, and can be given a diagnosis relating to the cause or causes having specific, measurable pathophysiology.

Most diagnostic systems such as the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the International Classification of Disease (ICD-10), the American Medical Association, Alcoholics Anonymous/Twelve Steps Program, and the Minnesota Model System hold an explanatory disease framework. These systems describe the biopsychosocial circumstances preceding and accompanying impairing drug use. Most, however, do not specify discrete causation. DSM-5 and ICD-10 are descriptive and avoid attributing explanatory causation or clear-cut etiologies. Therefore, they use terms such as “disorder” and “dependence syndromes,” respectively. Dependence is the hallmark of all disordered drug-induced impairments in contemporary medicine.

Most models advocate comprehensive psychosocial treatments and medications when indicated. Seeing drug dependence as a holistic human disorder rather than a harsh demon helps sufferers and treaters engage in recovery as a lifestyle improvement over time.

The American Society of Addiction Medicine (ASAM) outlines the “disease” concept, uses the term “addiction,” and attributes involuntary drug-induced disease states to such causation.

"Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences... Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases."

This disease model proposes substance use as a brain disease with biological factors influenced by motivational, psychodynamic, psychological, social, and cultural factors coalescing to produce the neurobiology of “addiction.” The amount of drug exposure early and habitually is a reinforcing factor to drug-taking becoming addictive. This disease concept of SUD holds that addiction is a primary disorder, not a reaction to other medical or emotional problems such as anxiety or mood. Also, the disease is posited to be progressive and chronic, perpetuated by distortions such as denial, impaired behavioral control, and unmanageable compulsive use. Genetic, psychosocial, and environmental factors contribute heavily to the development and manifestations of this neurobiological disease.

Substance Dependence

Dependence is an inability to control one’s compulsive drug-seeking. DSM-5 diagnoses about ten classes of substances in four groupings:

• impaired control
• social impairment
• risky use
• pharmacological attributes

The central theme is compulsive drug-seeking behavior and continued use despite significant substance-related problems. Continued use correlates with excess beyond reasonable control. In earlier diagnostic systems, physiological dependence as an indicator of the brain’s adaptation to the drug’s effect was critical in identifying dependence, a.k.a. addiction. In the current DSM-5, tolerance and withdrawal satisfy two use disorder criteria out of the eleven for the most common drug disorder, alcohol abuse. Motivation and behavior have replaced these overtly physiological indicators, which now are neither necessary nor sufficient for the diagnosis. Drug dependence has replaced addiction because the word “addiction” has an uncertain definition and a negative connotation.

Substance Use Disorders (SUD) describe a cluster of cognitive, emotional, behavioral, and physiological symptoms showing the individual to continue using the substance despite significant substance-related problems. This psychiatric definition is a medical perspective considering biological, psychological, and social factors, all contributory with harmful consequences.

Drug or substance dependence has three hallmark features:

1. Behavioral dependence is inordinate drug-seeking and pathological use.
2. Psychological dependence stems from the chronic, recurring, or intermittent craving and the desire to take the drug that has become preferred to avoid a dysphoric state.
3. Physiological dependence is less clear-cut but has been characterized by features of drug tolerance (i.e., needing increasing doses to achieve the desired effect) and a withdrawal syndrome (i.e., physiological and psychological distress in the absence of taking the drug). Dependence and withdrawal are no longer used as necessary DSM criteria.

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The DSM classifies three diagnostic levels of substance dependence: mild, moderate, and severe. Only severe SUD is correlated with the common term “addiction,” connoting compulsive use, impaired control, and harmful consequences.

In the drug rehabilitation field, SUD is often associated with the classic “three Cs:

1. Consequences of drug use despite harmful results
2. Compulsion and impaired impulse control over repeatedly taking the drug
3. Inability to control or limit drug use behavior

Alcohol Use Disorder (AUD)

DSM-5 lists eleven criteria for this disorder. Clinically, they involve the daily use of large amounts of alcohol, a regular pattern of heavy drinking lasting weeks or months, periods of sobriety interspersed with binges of heavy drinking, the inability to cut down or stop, repeated efforts to control or reduce drinking, craving, binge drinking, occasional consumption of large amounts of alcohol in one sitting, drinking despite a severe physical disorder or risk of harm, impaired social, interpersonal, or occupational difficulties, tolerance, withdrawal, and legal problems.

There are two main assessments used to determine alcohol use dependence. The RAPS 4 Test (i.e., Rapid Alcohol Problem Screen) uses simple questioning areas to explore alcohol use.

1. Remorse
2. Amnesia/blackout: episodic memory loss
3. Impaired performance
4. Need for a morning eye-opener (“hair of the dog effect”)

The item "remorse" after drinking identifies 83 percent of those with alcohol dependence and 44 percent of those meeting the criteria for harmful drinking. A positive response to any one of the four items gives a sensitivity of 93 percent and a specificity of 87 percent for alcohol dependence. Sensitivity (true positive cases) and specificity (true negative cases) are consistently high across gender and ethnic subgroups.

Alcohol Misuse? The Answer Depends on the Level of the Question Asked

The DSM-5 states that alcohol use is a common disorder, hovering around 10 percent of the population. Some authorities say that the difference in current versus lifetime dependence, like in other epidemiological studies and long-term clinical investigations, shows the erratic course of alcohol dependence when measured over the years.

For example, nonpathological alcohol use is described in the following way: “While most drinkers sometimes consume enough alcohol to feel intoxicated, only a minority (less than 20 percent) ever develop alcohol use disorder. Therefore, drinking, even daily, in low doses and occasional intoxication do not by themselves make this diagnosis.” (DSM-5 p.496)

Therefore, the diagnosis relies on the way the phenomenon is measured. The DSM-5 approach provides a dimensional view that biopsychosocial markers can supplement. Behavior and performance can be self-identified and measured by others as functional or impaired. Laboratory investigations can assess an individual’s medical status. Putting all the above together integrates them into a picture suggesting health and relative wellness or impairment. The growing prevalence of treatment centers, the opioid crisis, and the current rash of depressions and suicides related to drug use are telling.

Drug dependence is treatable. Gaining a locus of control includes motivation, optimism, a belief in change, and openness to the help and support available on many need levels.