Since 1956, alcoholism has been considered a primary disease by the American Medical Association. It has only been recently, however, that research has discovered the etiology of the disease of alcoholism and other drug addiction. Through animal studies as well as imaging studies of humans, scientists have concluded that addiction is a disease of the brain. The part of the brain that malfunctions is the mesolimbic dopamine system, the seat of reward system that reacts to pain and pleasure. More specifically the neurotransmission system is hijacked permanently by alcohol and psychoactive drugs. At some point in the addict’s drinking/using life a metaphorical switch is thrown that causes the flooding or depletion of neurochemicals, foremost of which is dopamine. At this point the addict has lost all voluntary control of alcohol/drug consumption and drinks/uses drugs simply to feel “normal”. The biological need for drugs leads, inevitably, to damage the rest of the addict’s life.
Dr. James Milam, in his landmark book, Under the Influence, describes the predictable path of the disease of alcoholism. The same path is travelled in drug addiction. Following are excerpts from his work:
The Early, Adaptive Stage of Alcoholism
One of the first symptoms of alcoholism is, ironically and tragically, an ability to increase alcohol intake and still function “normally.” It is ironic because most diseases incur immediate and obvious penalties, not benefits, and result in reduced functioning rather than improvement in functioning. But in the early stages of alcoholism, the alcoholic is not sick, in pain, or visibly abnormal. In fact, the early, adaptive stage of alcoholism appears to be marked by the opposite of disease, for the alcoholic is “blessed” with a supernormal ability to tolerate alcohol and enjoy its euphoric and stimulating effects. This improvement in functioning is tragic because the alcoholic has little or no warning of the deterioration inevitably to follow.
In the early stage, the disease is subtle and difficult to recognize. It is characterized by adaptations in the liver and central nervous system, increased tolerance to alcohol, and improved performance when drinking.
The early stage of alcoholism is characterized by Adaptation, Tolerance, and Improved Performance:
Adaptation: A general biological rule holds that when any bodily system is under stress it either adapts of suffers damage. Adaptation is actually a tool of survival, helping the body endure stressful changes in internal or external environments. Adaptational responses occur rapidly, spontaneously, and in most cases, without the person’s conscious knowledge.
The adaptations which occur in the early stage of alcoholism are of two kinds: those affecting the metabolism of alcohol, and those taking place in the central nervous system and contributing to addiction. Both types of adaptation have direct effects on the alcoholic’s ability to drink large amounts of alcohol without becoming intoxicated (tolerance) and actually to function better when he is drinking than when he is not drinking (improved performance).
Tolerance: Every drinker has a specific tolerance to alcohol. Below his tolerance level, the drinker can function more or less normally; at levels above his tolerance threshold, he will act intoxicated. Tolerance is therefore a condition that can only be measured accurately in a laboratory where the drinker’s blood level and behavior can be carefully monitored.
Alcoholics typically experience a dramatic climb in tolerance in the first stage of alcoholism and can often drink huge amounts of alcohol without showing obvious impairment of their ability to walk, talk, think, and react. Anyone who observes the early- and middle-stage alcoholic’s drinking behavior is familiar with the fact that the typical alcoholic can drink as much as a liter of wine, a dozen beers, or even a bottle of whisky without acting drunk.
Improved Performance: In this early, hidden stage of alcoholism, the only visible difference between the alcoholic and the non-alcoholic is improved performance in the alcoholic when he drinks and a deterioration in performance when he stops drinking.
Alcoholics in the early, adaptive stage of their disease also show improvement of functioning as the blood alcohol level begins to rise. But unlike the non-alcoholic, this improvement continues with additional drinking. Even when blood alcohol remains at fairly high levels—levels which would overwhelm the non-alcoholic, causing him to stumble, stutter, and sway—the early alcoholic is often able to talk coherently, walk a straight line, or skillfully maneuver a car. Only when the alcoholic stops drinking and his blood alcohol level (BAL) descends, does his performance deteriorate—and it does so very rapidly.
Tragically, the alcoholic can only temporarily control his drinking behavior. Over a period of years, the cells’ dependence on alcohol becomes more firmly entrenched until, at some point, the alcoholic no longer has a choice. He needs alcohol to function, and he suffers terribly when he stops drinking. The benefits of adaptation are gradually overshadowed by the penalties of deterioration.
The Middle Stage of Alcoholism
The middle stage of alcoholism is characterized by Physical Dependence, Craving, and Loss of Control:
As physiological changes gradually occur, the penalties of drinking begin to outweigh the benefits. Pleasurable drinking for a “high,” a lift in feeling and performance from a relatively normal base, gives way to a more urgent “drinking for medicine” to “cure” the pain and misery caused by previous drinking. The basic cause of the increase in penalties is deterioration. Organs and systems that once welcomed the large doses of alcohol and tolerated its toxic aftereffects are being damaged. Now when the alcoholic stops drinking, his suffering is more severe and prolonged.
Physical Dependence: As [the alcoholic] drinks more, and more often, to get the desired effect, the cells of his body are soaked in alcohol for long periods of time. The cell membranes become increasingly resistant to alcohol’s effects, and the mitochondria within the cells increase in size and shift functions in order to accommodate the alcohol. With these changes, the adapted cells are able to live and thrive in an environment where alcohol is continually present in large amounts.
If the alcoholic over-drinks his tolerance, the cells will be overwhelmed, and he will get drunk. If he stops drinking, the addicted cells will suddenly be thrown into a state of acute distress. They have become unable to function normally without alcohol. The cells’ distress when alcohol is no longer present in the body, or when the BAL is falling, is evident in various symptoms known as “the withdrawal syndrome.” Withdrawal symptoms demonstrate that physical dependence exists; they are the visible signs of addiction.
Craving: Craving is the overwhelming need for a drink. Like everything else in alcoholism, craving is progressive. In the middle stages of the disease, craving becomes a need—the alcoholic needs to drink because his cells are physically dependent on alcohol. As tolerance increases and physical dependence sets in, the alcoholic gradually loses psychological control over his physiological need for alcohol. Finally, will power, self-restraint, and the ability to say “no” have no power over alcoholic craving. The physical need for alcohol overshadows everything else in the alcoholic’s life.
Loss of Control: As the alcoholic progressively loses control over his drinking, he is no longer able to restrict it to socially and culturally accepted times and places. He often drinks more than he intended, and the drinking continues despite extremely punishing consequences. He may drink in the morning, at lunch, in the middle of the night; he may drink in the car, the bathroom, the garage, or the closet as well as the tavern. His drinking behavior can no longer be disguised as normal or even heavy drinking. His inability to stop drinking—despite his firm resolution that he will stop after one or two—is striking confirmation that he is physically addicted to alcohol.
The alcoholic loses control over his drinking because his tolerance decreases and the withdrawal symptoms increase. The alcoholic’s tolerance, which was so high in the early stages of the disease, begins to decrease because his cells have been damaged and can no longer tolerate large amounts of alcohol. While tolerance in lessening, the withdrawal symptoms are increasing in severity. The alcoholic is now in the dangerous position of needing to drink because he suffers terribly when he stops drinking but being unable to handle the high levels of alcohol needed to relieve the symptoms. He has also lost the ability to judge accurately how much alcohol his body can handle. As a result, he often over-medicates himself with alcohol, drinking to the point where he either loses consciousness or becomes so violently ill that he is forced to stop drinking.
The Late, Deteriorative Stage of Alcoholism
The late, deteriorative stage of alcoholism is characterized by Malnutrition, Secondary Disease, and Death:
The late-stage alcoholic spends most of his time drinking, since otherwise his agony is excruciating. During the late stages of alcoholism, the alcoholic’s mental and physical health are seriously deteriorated. Damage to vital organs saps the alcoholic’s physical strength; resistance to disease and infection is lowered; mental stability is shaken and precarious. The late-stage alcoholic is so ravaged by his disease that he cannot even understand that alcohol is destroying him. He is only aware that alcohol offers quick and miraculous relief from the constant agony, mental confusion, and emotional turmoil. Alcohol, his deadly poison, is also his necessary medicine.
Malnutrition: All alcoholics suffer from malnutrition to some degree. A number of factors work together to make this condition almost synonymous with alcoholism. Large amounts of alcohol interfere with digestion and passage of nutrients from the intestines into the bloodstream. The alcoholic’s liver has a decreased ability to convert and release nutrients and make them available throughout the body. Without adequate nutrients, the cells, already weakened by long exposure to alcohol’s toxic effects, are not able to create bone, tissue, blood, or energy. The sick and injured cells thus do not have the resources to repair themselves, and damage continues unchecked.
Even the alcoholic’s earliest psychological and social problems stem from or are aggravated by nutritional deficiencies. For example, a thiamine deficiency (extremely common in alcoholics) can cause loss of mental alertness, easy fatigue, loss of appetite, irritability, and emotional instability. If the deficiency is allowed to continue, more severe mental confusion and loss of memory may develop.
In the later stages of alcoholism, the alcoholic is often so sick that he cannot eat, thus aggravating the already serious nutritional deficiencies. Massive vitamin or mineral deficiencies caused by long and heavy drinking may result in several unusual diseases of the central nervous system, including polyneuropathy (tingling sensations), Wernicke’s encephalopathy (headaches, tingling, double vision), Korsakoff’s psychosis (hallucinations), and amblyopia (blurred vision).
Secondary Diseases have been scientifically linked with late-stage alcoholism.
Heart: Heart Failure is characterized by symptoms of cardiomyopathy (disease of the heart muscle), cardiac arrhythmia (abnormal variations of heart beat), and hypertension (high blood pressure).
Liver: Fatty Liver is characterized by enlarged, inflamed fatty deposits. Symptoms include nausea, jaundice, and loss of appetite.
Hepatitis, or alcoholic hepatitis, is characterized by a liver which becomes inflamed, swollen, and extremely tender.
Cirrhosis is characterized by a liver which is virtually plugged with scar tissue, and which can no longer remove poisons and toxins from the body’s blood supply.
Gastrointestinal Disorders: Gastritis is an inflammation of the stomach lining severe enough to cause bleeding, bloating, indigestion, nausea, and headache.
Ulcers form in response to increased secretions of hydrochloric acid in late-stage alcoholics.
Respiratory Tract Diseases: In general, alcoholism causes damage to the lungs by interfering with the body’s normal defense mechanisms and thereby making the alcoholic susceptible to respiratory infection and injury. This interference with normal functioning can lead to:
- Chronic Bronchitis
- Lung Abscess
In addition, alcoholics appear to have an increased risk of head and neck, esophageal, lung, and liver cancers. In each of these cancers, alcohol probably acts in a different way, sometimes directly affecting the cells, other times indirectly increasing the cells’ susceptibility to cancer. Late-stage alcoholics also exhibit a higher risk for pancreatitis, an inflamed gland condition characterized by severe pain in the upper abdomen, nausea, vomiting, and constipation.
If the alcoholic continues to drink, alcohol will kill him one way or another. Estimates vary, but according to one source, one-third of alcoholic deaths are from suicides or accidents such as drownings, fires from passing out with a lighted cigarette, head injuries from falling, accidental poisoning, or car crashes. Those who survive these hazards are destroyed by direct and massive damage to body organs and systems.
Causes of Death in a Group of Alcoholics include: cardiovascular disease (30%), cirrhosis (24%), upper gastrointestinal & lung cancer (15%), alcoholism (14%), pneumonia (7%), and other causes (14%).—from W. Schmidt and R.E. Popham, unpublished data, “Deaths in 1823 Male Alcoholics, Corrected for the Expected Mortality in Each Subgroup” (1978).
Stages of Recovery
Recovery can take up to two years to become firmly established. Early recovery spans the first six months for most patients, and is the time when the risk of relapse is the highest. This is the time the patient is struggling with the major adjustments he must make. He begins to deal with the environmental and social cues to drink or use again, he develops new ways of dealing with stress at work and in personal relationships, he learns to deal with the mood swings and depression common in early recovery, he must begin the process of building a sober support system through attendance in AA or other support groups, and he starts developing sober social circles and activities.
Middle Stage Recovery
This occurs during the second six months of sobriety. During this time the patient must learn to deal with the physical, social, and psychological adjustments of sobriety. New relationships must be forged with loved ones because the behaviors of the past have changed so in recovery. The patient commonly goes through a grieving process, both over losses that occurred during drug use, and also over the loss of their “old life” and old friends. Reestablishing the ability to experience emotion is important, because addiction causes abnormal responses to loss. Part of recovery is learning to deal with past unresolved loss.
Late Stage Recovery
The third stage of recovery begins after one year. By this time the patient has gone through the adjustment process of early- and middle-stage recovery. He has gained confidence that the support systems and tools learned in treatment and recovery work. This is a time of stability and of becoming comfortable with recovery. However, abstinence alone does not necessarily mean a successful recovery is under way. There is a difference between being “Dry” (abstinent) and “Sober” (in successful recovery).
The “Dry” patient is not presently using alcohol or drugs, however he has not changed his past using lifestyle, nor come to comfortable terms with the need for permanent sobriety. He is ambivalent about life, where the “Sober” person looks forward to his new life of sobriety. The “Dry” patient feels abstinence as a constant sacrifice, and frequently thinks about using. The “Sober” patient sees abstinence as a gift to himself. The “Dry” patient continues the self-centered ways of his past, maintaining the old behaviors, friends, and activities. He doesn’t take care of himself physically or psychologically, and continues to suffer from guilt and shame because he has not come to terms with his past or present life. Patients who are merely “Dry” have a much higher risk of relapse than those “Sober” patients who have made major life changes necessary for successful long-term recovery.