Is Alcoholism a Disease or a Choice?

man pouring beer from a tap

Humanity’s relationship with alcohol is almost as old as civilization itself. Almost as soon as people discovered fermentation, it became apparent that some people could become dependent on alcohol. In 1784, physician and father of the American temperance movement, Benjamin Rush, identified an “uncontrollable and irresistible desire to consume alcohol” among certain people.(1) For most of human history, however, alcoholism was seen as a moral shortcoming or a lack of discipline. People suffering from alcoholism were said to be “unable to hold their liquor”. This misconception has stubbornly persisted into the present day, unfortunately. Why laypeople might view alcoholism this way is somewhat understandable. Most of us are still conditioned to think of disease only as an acquired infection like influenza or an illness like cancer. Others see the disease model as a “cop-out” or an attempt by the addict or alcoholic to shirk responsibility. Mental illness in general, is still widely misunderstood and unfortunately can carry a certain stigma.

Alcoholism is Classified as a Disease

Some may be surprised to know that the debate over whether to categorize alcoholism and addiction as a disease was largely settled in the medical and scientific community more than 60 years ago. In fact, the American Medical Association formally recognized alcoholism and addiction as a disease as early as 1956. (2) The AMA’s position was even cited in the U.S. Supreme Court case (Budd v. California, 385 U.S. 909 (1966) (3). Dr. William Silkworth of New York City’s Towns Hospital is widely recognized as the first clinician to study and endorse the disease model of alcoholism. His pioneering work in treating alcoholics and advising the founders of Alcoholic Anonymous was directly responsible for transforming the way the medical community viewed alcoholism.

As Alcoholics Anonymous grew as a new resource for people struggling with alcohol, clinicians and scientists began to study the phenomenon of alcoholism and addiction from a different point of view. In the past, most chronic relapse patients were seen as “lost causes”, destined to be institutionalized for what was left of their lives. Following the work of Dr. Silkworth and others, they recognized that medical treatment combined with social intervention and therapy was yielding more promising results than anyone had seen with traditional methods alone. Today alcohol dependence is understood as a disease and listed as such in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association (APA).

Treatment for Alcoholism is Still Evolving

Thanks to the revolution in gene research, we are beginning to unravel the genetic component which makes some people so much more susceptible to chronic alcohol abuse. Two genes related to alcohol metabolism, ADH1B and ALDH2 have shown the strongest correlation with the risk of alcoholism. (4) The greater scientific understanding of the roots of alcoholism paired with a more data-driven approach to treatment has brought a new era in addiction treatment to fruition. Perhaps more than ever, the medical and recovery communities are working as partners and the long-term efficacy of treatment for alcoholism is the focus. It’s widely accepted that recognizing alcoholism as a disease was the essential sea change that needed to occur for more effective treatment to begin to be developed.

(1) https://academic.oup.com/alcalc/article/35/1/10/142396
(2) https://jamanetwork.com/journals/jama/article-abstract/318639
(3) https://www.ama-assn.org/delivering-care/public-health/court-listened-ama-defining-alcoholism-disease-not-crime
(4) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056340/

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