Dependence and Society

The connections between sociocultural factors and alcohol dependence may be approached in several ways. Sociocultural factors can be treated as predictors and correlates extrinsic to dependence, viewed as a disease entity. The concept of dependence can be reexamined in terms of its presumed ‘seating’- in the individual's psyche or body - and expanded to include the possibility of seating at supraindividual sociocultural levels. And the idea of dependence can be reinterpreted as ‘culture-bound’, that is, as depending for its existence and meaningfulness on sociocultural characteristics specific to particular times and places. The paper focuses on the latter two approaches, with particular attention to the development of sociological ‘constructionist’ thinking that views the concept and experiential reality of addiction or dependence as a product of particular cultural conditions rather than as a transcultural universal.     

The measurement of alcohol dependence and impaired control in community samples

The concept of the Alcohol Dependence Syndrome has been influential in the field of alcohol studies in the 1980s. The Severity of Alcohol Dependence Questionnaire (SADQ) is one of a generation of alcohol problem scales developed to measure degree of dependence rather than presence or absence of‘alcoholism’. This paper describes the development of a form of the SADQ for community samples of drinkers (SADQ-C) and its relationship to a brief scale designed to measure impaired control over drinking. In a sample of 52 problem drinkers, SADQ and SADQ-C correlated almost perfectly (r = 0.98). In a larger sample of 197 attenders at a controlled drinking clinic, Principal Components Analysis revealed one major factor accounting for 71.7% of the total variance. High internal reliability was indicated with a Cronbach's Alpha of 0.98. Application of this instrument in a random survey of Western Australian households is then described. It was necessary to remove items relating to‘reinstatement of dependence’for this sample. A single major factor was identified by principal components analysis, accounting for 69.1% of the total variance. In both the clinic and the community samples SADQ-C scores correlated highly with Impairment of Control scores. The findings are interpreted as supporting the view that there is a single dimension of alcohol dependence upon which all persons who drink alcohol with any regularity may be located.     

What if alcoholism had not been invented? The dynamics of American alcohol mythology

This essay speculates on what might have been had alcoholism not been invented. The invention is viewed as a product of the ongoing myth-making process whereby society continuously defines and redefines alcohol, seeking to integrate it into the culture in ways that allow enjoyment of its pleasures with minimum pain. Had alcoholism not been invented, (a) the myth-making process might have yielded another simplistic explanation of drunkenness, but more likely alcohol would have remained the supposed cause; (b) the per capita alcohol consumption uptrend of some 50 years standing might not have reversed as it did in 1982; (c) chronic drunkards might still be denied life-saving hospitalization which gains them more time for the natural reform process to work for them; and (d) local communities nationwide might have taken common-sense actions to facilitate the natural rehabilitation process and provided more benefit to more alcoholics for less cost than treating alcoholism. It is expected that Americans will continue to drink and will continue to seek a more harmonious relationship with alcohol. The informal social controls will continue to largely constrain individual appetites for alcohol's pleasures, and most alcoholics will continue to gain control of their excessive drinking in the natural course of events with or without exposure to alcoholism treatment.     

The Measurement of Opiate Dependence

The application of a dimensional concept of dependence which has received much attention over recent years in relation to alcohol, is explored here in relation to opiate dependence. A Severity of Opiate Dependence Questionnaire (SODQ) was completed by 98 subjects attending a New York drug treatment clinic. The factor structure of this questionnaire was explored and a strong first factor (39% of variance) identified which loaded on items conceptually related to a dimensional opiate dependence syndrome. Some preliminary investigation was made of issues relating to validity: SODQ correlated significantly with ‘number affixes a day’ and with a subjective measure of dependence (OSDQ), but not with quantity of heroin used or milestones in drug career. Research leads are discussed.     

The Severity of Alcohol Dependence Questionnaire (SADQ) in a Sample of Irish Problem Drinkers

Validation of the Severity of Alcohol Dependence Questionnaire (SADQ) was attempted in a sample of 102 Irish problem drinkers. Analysis of questionnaire responses showed reasonable accord with the findings of the designers of the SADQ, suggesting that the questionnaire is a useful and valid instrument for the investigation of alcoholics. The findings gave qualified support for the concept of the alcohol dependence syndrome. Maximum agreement with a findings gave qualified support for the concept of the alcohol dependence syndrome. Maximum agreement with a clinician's rating of moderate and severe dependence was achieved at a cut-off score of 30 on the SADQ. Results also suggested it might be possible to use the SADQ to distinguish between minimal and mild to moderate dependence.     

The Alcohol Problem in America: From Temperance to Alcoholism

This paper traces the ideology and politics of the ‘liquor problem’ in America from its invention or discovery at the end of the 18th century up to the present. In the 17th and 18th centuries alcohol was highly regarded, universally consumed, and even Puritans called it‘the Good Creature of God'. In the early 19th century, physicians and laymen developed and promulgated a new scientific and popular view of alcohol as an addicting, toxic, and dangerously unpredictable stimulant - and they organized a mass movement to spread their ideas and to get people to give up drinking. Throughout the 19th century, temperance supporters regularly referred to alcohol addiction as a disease beyond the control of the will and engaged in reform and treatment efforts for habitual drunkards. They campaigned against alcohol because they believed it to be the cause of most of the major social problems in America. In short, they made alcohol a scape-goat. The paper then discusses the passage and repeal of national Constitutional prohibition. They should be understood in the context of the new economic and political conditions of 20th century America - especially the new power of the corporation, the decline of the old middle class, and the rapid growth of the industrial working class. The middle class supported prohibition as a panacea for many social problems, but the 18th Amendment's passage was achieved partly through the help of the corporate sector. Similarly, the repeal effort was led by the key elements of the corporate rich. Repeal was passed, and alcohol regulatory systems were designed and put into place, in the midst of the Great Depression - in large part as a response to the political forces the Depression unleashed. Since the 1930s, concerns and policies about alcohol have focused on helping to aid the treatment and recovery of‘alcoholics'. The paper traces the development of Alcoholics Anonymous and the spread of its ideas about alcoholism and its organizational forms; it also briefly looks at new public health and social scientific ideas about ‘alcohol problems’ or ‘alcohol abuse'. The paper suggests that both alcoholism and public health conceptions have much more in common with 19th century temperance ideas than is usually thought. Indeed, nearly all present day ideas - like addiction - are derived from temperance ideas. Further, both 19th and 20th century forumulations have a tendency to blame drinking and individual behaviour for many problems which have much broader political and economic causes.     

Measuring Onset of 'Caseness' in Studies of Stressful Life Events and Alcohol Abuse

The selection of criteria to operationalize concepts in empirical research is not an arbitrary process. Rather, it must be guided by the nature of the hypotheses being tested. Failure to do this will render the hypotheses themselves absurd. These points are discussed in relation to the particular demands of testing hypotheses concerning the relationship between life events and ‘onset’ of alcohol abuse. It is argued that the alcohol dependence syndrome provides the most valid set of criteria for operationalizing the latter concept.     

Deliberate induction of alcohol tolerance: empirical introduction to a novel health risk

Aims Alcohol tolerance is a hallmark indicator of alcohol dependence. Even so, the allure of peers' admiration for having the ability to drink heavily may lead some adolescents and young adults to practice, or ‘train’, to increase their tolerance (particularly at US colleges, where heavy drinking is highly prevalent and central to the social culture). This is a potential health hazard that has not been documented empirically. Thus, we initiated a study of tolerance ‘training’ and its association to risky and heavy drinking. Design, setting and participants A cross‐sectional online survey of 990 college student life‐time drinkers at a large Midwestern US university. Findings Of the sample, 9.9% (n = 97) reported deliberately ‘training’ to increase tolerance. On average, they reported increasing from approximately seven to 10 US standard drinks in a night prior to ‘training’ to 12–15 drinks at the end of ‘training,’ over approximately 2–3 weeks' duration. Although the proportion of frequent binge drinking among ‘non‐trainers’ (34.4%) was similar to national rates, ‘trainers’ were much more likely to be frequent bingers (76.3%; OR = 6.15). Conclusions A number of students report deliberately inducing alcohol tolerance, probably directly increasing the risk for alcohol poisoning and other acute harms and/or dependence. This phenomenon might additionally be applicable to other populations, and deserves further study and attention as a potential personal and public health risk. Prevention efforts might aim to reduce the perceived importance of heavy‐drinking abilities.     

The Alcohol Problem in America: From Temperance to Alcoholism

This paper traces the ideology and politics of the ‘liquor problem’ in America from its invention or discovery at the end of the 18th century up to the present. In the 17th and 18th centuries alcohol was highly regarded, universally consumed, and even Puritans called it ‘the Good Creature of God’. In the early 19th century, physicians and laymen developed and promulgated a new scientific and popular view of alcohol as an addicting, toxic, and dangerously unpredictable stimulant - and they organized a mass movement to spread their ideas and to get people to give up drinking. Throughout the 19th century, temperance supporters regularly referred to alcohol addiction as a disease beyond the control of the will and engaged in reform and treatment efforts for habitual drunkards. They campaigned against alcohol because they believed it to be the cause of most of the major social problems in America. In short, they made alcohol a scape-goat. The paper then discusses the passage and repeal of national Constitutional prohibition. They should be understood in the context of the new economic and political conditions of 20th century America - especially the new power of the corporation, the decline of the old middle class, and the rapid growth of the industrial working class. The middle class supported prohibition as a panacea for many social problems, but the 18th Amendment's passage was achieved partly through the help of the corporate sector. Similarly, the repeal effort was led by the key elements of the corporate rich. Repeal was passed, and alcohol regulatory systems were designed and put into place, in the midst of the Great Depression - in large part as a response to the political forces the Depression unleashed. Since the 1930s, concerns and policies about alcohol have focused on helping to aid the treatment and recovery of ‘alcoholics ‘. The paper traces the development of Alcoholics Anonymous and the spread of its ideas about alcoholism and its organizational forms; it also briefly looks at new public health and social scientific ideas about ‘alcohol problems’ or ‘alcohol abuse’. The paper suggests that both alcoholism and public health conceptions have much more in common with 19th century temperance ideas than is usually thought. Indeed, nearly all present day ideas – like addiction – are derived from temperance ideas. Further, both 19th and 20th century forumulations have a tendency to blame drinking and individual behaviour for many problems which have much broader political and economic causes.     

Underdiagnosis of Alcohol Dependence in Psychiatric Inpatients

Abstract

Alcoholism is prevalent among psychiatric inpatients, and accurately diagnosing alcohol prob lems is a critical step in treatment planning. The authors diagnosed alcohol dependence in 35 psychiatric inpatients by blind review of interview protocols and hospital records. They then examined the frequency with which admitting and attending clinicians diagnosed alcohol abuse and dependence in these patients. Alcoholism was underdiagnosed; 24% of the clinicians' diagnoses included no alcoholism diagnosis, 39% were alcohol abuse, and only 37% were alcohol dependence. Underdiagnosis was strongly associated with the presence of a comorbid psychosis, as well as with patients' denial of alcoholism and with less severe alcoholism. The authors discuss the patient and clinician variables which may contribute to underdiagnosing alcoholism and recommend educational and administrative measures to improve clinicians' diagnostic sensitivity.     

Progress in the development of topiramate for treating alcohol dependence: from a hypothesis to a proof-of-concept study

Advances in neuroscientific knowledge have evoked interest in developing effective medications for the treatment of alcohol dependence. Pharmacological approaches that involve the use of relatively specific medications at a particular neuronal target to modulate corticomesolimbic dopamine neuronal activity, the critical pathway for expression of the reinforcing effects of abused drugs, have yielded modest efficacy in the treatment of alcohol dependence. A new approach is needed. Because corticomesolimbic dopamine neurons interact with a variety of neurotransmitters that modulate its effects in the nucleus accumbens, it might be possible to more reliably control these dopaminergic effects with a medication that acted contemporaneously on more than one neuromodulator of dopamine function. Additionally, because alcohol use results in neuronal adaptations due to sensitization, the chances of effective therapy might be bolstered by administering a medication that also has utility with mitigating its chronic effects. My proposed conceptual framework suggests that a medication that facilitates inhibitory gamma-aminobutyric acid-A input and antagonizes excitatory glutaminergic afferents to the nucleus accumbens would have pharmacotherapeutic potential in treating the alcohol dependence syndrome because these effects would act contemporaneously to suppress corticomesolimbic dopamine release. Through similar effects, topiramate might also aid chronic drinkers to wean themselves off alcohol and might ameliorate the symptoms of alcohol withdrawal. This commentary highlights the scientific concepts and clinical evidence for the development of topiramate in the treatment of alcohol dependence.     

A case-control study of risk factors of alcohol misuse in Czech women: are there four types of female alcoholism?

Three samples of Prague women aged 20-49 were interviewed with regard to hypothetical risk factors of alcoholism: 139 inpatients diagnosed as alcohol dependent, 39 inebriated females admitted for 1-day detoxification, and 718 randomly selected women (the controls). Irrespective of case definition, father's alcoholism, incomplete family of origin, conduct disorders in childhood and adolescence, and social surroundings marked by heavy drinking were supported as risk factors of alcoholism. A factor analysis of alcohol-related problems led to two dimensions (dependence, disruptiveness) and consequently to four types of female alcoholism with different patterns of risk factors.     

Efficacy of nicotine patch in smokers with a history of alcoholism

BACKGROUND: Smokers with a history of alcohol dependence may have more difficulty quitting, might relapse to alcohol use, and might especially benefit from nicotine replacement therapy for smoking cessation. METHODS: One hundred fifteen smokers with a history of alcohol dependence (median of 5 years previously) were randomly assigned to either a 21-mg nicotine patch or placebo in a trial designed to be as similar as possible to a prior study that examined smokers with no history of alcoholism. Both studies were of heavy smokers with similar levels of nicotine dependence; thus, any differences in trials would be due to a history of alcohol problems per se. RESULTS: In the current trial, adjusted prolonged smoking abstinence in those with a history of alcohol dependence was higher in the active than the placebo group at end-of-treatment (28% vs. 11%; odds ratio, 3.2; p = 0.04) and at 6-month follow-up (24% vs. 6%; odds ratio, 4.9; p = 0.02). Among subjects not lost to follow-up, none reported drinking problems or increases in craving for alcohol. Smoking abstinence was not lower and the odds ratio for nicotine patch therapy was not greater in smokers with a history of alcohol dependence than in smokers with no such history. CONCLUSIONS: Heavy smokers with a history of alcoholism benefit from nicotine patch treatment. A history of alcohol problems after a period of stable sobriety does not appear to influence smoking outcomes or response to nicotine replacement. Although no smokers relapsed to alcohol use, a trial that follows up all subjects is needed to verify this.     

The effect of naltrexone on alcohol's stimulant properties and self-administration behavior in social drinkers: influence of gender and genotype

Background: Few pharmacological treatments for alcohol dependence are available. Moreover, the best supported treatment, naltrexone hydrochloride, appears to work for only some. Methods: To investigate potential predictors of these differential responses, 40 social drinkers (20 women) were administered 6 days of treatment with naltrexone vs. placebo in a double‐blind, counterbalanced, crossover design. At the end of each treatment period, participants received a single dose of their preferred alcoholic beverage followed by the opportunity to work for additional alcohol units using a progressive ratio (PR) breakpoint paradigm. All subjects but one were genotyped for the A118G polymorphism of the mu opioid receptor gene (OPRM1). Results: Naltrexone decreased the ethanol‐induced ‘euphoria’ to a priming dose of alcohol in two subgroups: (i) in women, and (ii) in subjects with the A118G polymorphism of the mu opioid receptor gene (OPRM1). Naltrexone did not decrease motivation to work for additional alcoholic beverages on the PR task regardless of gender or genotype. Conclusions: The results add to the evidence that naltrexone decreases positive subjective effects of alcohol, with preferential effects in distinct subgroups. Similar effects in heavier drinkers might decrease alcohol use.     

Negative alcohol expectancy predicts post-treatment abstinence survivorship: the whether, when and why of relapse to a first drink

Using survival analysis, the association was explored between positive and negative alcohol expectancies measured on admission to a non-residential alcohol dependence treatment unit and post-treatment relapse to a first drink (first slip). A reliable association between negative alcohol expectancy (but not positive) and relapse was found. The active negative alcohol expectancies were distal rather than proximal: proximal expectancies surround consumption (‘same day’ expectancies) and distal expectancies relate to the ‘next-day’ following consumption or those longer term expectancies coming from ‘continued drinking’. Only the ‘next day’ component of distal expectancies formed a reliable association with relapse. The use to which negative alcohol expectancy as measured by the Negative Alcohol Expectancy Questionnaire might be put is discussed in terms of (i) a bottom-up representation of motivation for recovery to help treatment match and (ii) a provisor of detailed, client-specific information for structuring motivational interventions.     

Pharmacogenetic Treatments for Drug Addiction: Alcohol and Opiates

Aims: Psychiatric pharmacogenetics involves the use of genetic tests that can predict the effectiveness of treatments for individual patients with mental illness such as drug dependence. This review aims to cover these developments in the pharmacotherapy of alcohol and opiates, two addictive drugs for which we have the majority of our FDA approved pharmacotherapies. Methods: We conducted a literature review using Medline searching terms related to these two drugs and their pharmacotherapies crossed with related genetic studies. Results: Alcohol's physiological and subjective effects are associated with enhanced β-endorphin release. Naltrexone increases baseline β-endorphin release blocking further release by alcohol. Naltrexone's action as an alcohol pharmacotherapy is facilitated by a putative functional single nucleotide polymorphism (SNP) in the opioid mu receptor gene (Al18G) which alters receptor function. Patients with this SNP have significantly lower relapse rates to alcoholism when treated with naltrexone. Caucasians with various forms of the CYP2D6 enzyme results in a ‘poor metabolizer’ phenotype and appear to be protected from developing opioid dependence. Others with a “ultra-rapid metabolizer” phenotype do poorly on methadone maintenance and have frequent withdrawal symptoms. These patients can do well using buprenorphine because it is not significantly metabolized by CYP2D6. Conclusions: Pharmacogenetics has great potential for improving treatment outcome as we identify gene variants that affect pharmacodynamic and pharmacokinetic factors. These mutations guide pharmacotherapeutic agent choice for optimum treatment of alcohol and opiate abuse and subsequent relapse.     

Nomenclature and Classification of Drug- and Alcohol-related Problems: A Shortened Version of a WHO Memorandum*

Earlier work in this field is reviewed and present concepts and terminologies are examined in detail. A revised way of dealing with ideas implicit in the terms ‘drug abuse’ or ‘drug misuse’ is proposed; the term ‘neuroadaptive state’ is suggested as an alternative to ‘physical dependence; a profile is given of the elements that constitute a drug dependence syndrome’; and the need to differentiate conceptually between ‘dependence’ and ‘drug related disability’ is stressed. A model of dependence is outlined in which dependence is considered as a psycho-physiological-social syndrome determined and kept going by a complex system of reinforcements. The bearing of the foregoing considerations on work towards the revision of relevant classification systems is considered, and, in the final section, several recommendations on nomenclature are brought together and suggestions are made for research that might lead to refinement of classification and diagnostic systems.     

Sweet liking, novelty seeking, and gender predict alcoholic status

BACKGROUND: The relationship between a hedonic response to sweet taste and a propensity to excessive alcohol drinking is supported by both animal and human studies. There is evidence indicating that the tendency to rate more concentrated sweet solutions as the most pleasurable (i.e., sweet liking) is associated with the genetic vulnerability to alcoholism. However, sweet liking by itself is insufficient to predict the alcoholic status of the individual. Our previous study indicated that alcoholic status can be predicted by a combination of hedonic response to sweet taste and personality profile as measured by the Tridimensional Personality Questionnaire (TPQ). This study was designed to further test this hypothesis. METHODS: Participants were 165 patients admitted to a residential treatment program for the treatment of alcoholism, drug dependence and/or interpersonal problems secondary to substance-abusing family members. In addition to a routine medical examination, on the 24th day after admission, patients completed the TPQ, the standard sweet taste test was conducted, and paternal family history of alcoholism was evaluated. RESULTS: Sweet liking was strongly associated with a paternal history of alcoholism. The odds of receiving an alcohol dependence diagnosis were shown to increase, on the average, by 11% for every one-point increase in the TPQ novelty-seeking score in sweet-liking but not in sweet-disliking subjects. Gender contributed independently to the probability of alcohol dependence, with males exhibiting higher rates of alcoholism than females. CONCLUSIONS: These findings support the hypothesis that a hedonic response to sweet taste is associated with a genetic risk for alcoholism. Alcoholic status may be predicted by a combination of sweet liking, the TPQ novelty-seeking score, and gender in a mixed group of alcoholic, polysubstance-dependent, and psychiatric patients.