Pat Dollard

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The LA Times:

Seventy years ago, Bill Wilson — the co-founder of Alcoholics Anonymous — declared his powerlessness over alcohol in a book by the same name. The failed businessman contended that, as an alcoholic, he had to “hit bottom” before changing his life and that sobriety could only be achieved through complete abstention.

For generations, Americans took these tenets to be true for everyone. Top addiction experts are no longer sure.

They now say that many drinkers can evaluate their habits and — using new knowledge about genetic and behavioral risks of addiction — change those habits if necessary. Even some people who have what are now termed alcohol-use disorders, they add, can cut back on consumption before it disrupts education, ruins careers and damages health.

In short, say some of the nation’s leading scientists studying substance abuse, humans travel a long road before they become powerless over alcohol — and most never reach that point.

“We’re on the cusp of some major advances in how we conceptualize alcoholism,” says Dr. Mark Willenbring, director of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism. The institute is the nation’s leading authority on alcoholism and the major provider of funds for alcohol research. “The focus now is on the large group of people who are not yet dependent. But they are at risk for developing dependence.”

Many of these people need not give up alcohol altogether. The concept of so-called controlled drinking — that people with alcohol-use disorders could simply curb, or control, their drinking — has existed for many years. Evidence now exists that such an approach is possible for some people, although abstinence is still considered necessary for those with the most severe disease.

The overall reassessment has been fueled by the groundbreaking National Epidemiologic Survey on Alcohol and Related Conditions, the largest and most comprehensive look at alcohol use in America. The project surveyed 43,000 people 18 and older in 2001 and 2002, and again in 2004 and 2005, with the results released in increments beginning in 2006.

This survey alone has been enough to convince even national addiction experts that they’ve been too narrow in their approach to alcohol disorders. But the findings are being further bolstered by research in genetics and psychology.

Perhaps the most remarkable finding of the epidemiologic study was how many Americans experienced an alcohol-use disorder (either abuse or the more severe dependence) at some point — and how many recovered on their own. About 30% of Americans had experienced a disorder, the research showed, but about 70% of those quit drinking or cut back to safe consumption patterns without treatment after four years or less.

Only 1% of those surveyed fit the stereotypical image of someone with severe, recurring alcohol addiction who has hit the skids.

The data suggest that there are two forms of alcohol disorders: one that fits the traditional view of alcoholism, in which the need for a drink takes over a person’s life, and a time-limited form in which people drink heavily for a period but then cut down and recover.

“It can be a chronic, relapsing disease. But it isn’t usually that,” Willenbring says.

Differentiating

Alcohol abuse is defined as use that repeatedly contributes, within a 12-month period, to the risk of bodily harm, relationship troubles, problems in meeting obligations and run-ins with the law. Alcohol dependence includes the same symptoms, plus the inability to limit or stop drinking; the need for more alcohol to get the same effect; the presence of withdrawal symptoms; and a consumption level that takes increasing amounts of time.

“For a long time there was an emphasis on alcoholism as if it were one thing,” says Carol Prescott, a psychology professor at USC who has studied alcohol-use disorders. “I think that has been abandoned. People with alcohol-related problems don’t all look the same at all. Some people only have problems for a short time. Others develop disorders that are ultimately fatal to them.”

The other key finding from the survey is that, at least once in the previous year, 28% of adults had exceeded the daily or weekly limits at which drinking is considered low-risk.

For men, low-risk drinking is defined as no more than four drinks on any given day or no more than 14 drinks per week. For women, the limit is three drinks per day or seven drinks per week. (A standard drink is 12 ounces of beer, eight to nine ounces of malt liquor, five ounces of wine or 1.5 ounces of 80-proof spirits.) The majority of Americans who drink beyond these limits have mild to moderate disorders, meaning they occasionally have trouble controlling their intake, Willenbring says.

That’s where the overall risk assessment comes in. Willenbring compares it to treating high blood pressure or cholesterol before the condition develops into heart disease.

“People with mild to moderate alcohol disorders can be treated with medications or behavioral therapy with a primary care doctor,” he says. “But many people can do this on their own without having a professional. The idea is teaching people how to reevaluate their drinking.”

In the national survey, about half of the people who’d had an alcohol-use disorder recovered, enabling them to drink at low-risk levels without symptoms of dependence. “Some people are uncomfortable with that,” Prescott says. “It’s a safer prescription to tell someone to quit. But the studies suggest that a large proportion of people are able to cut down and aren’t out-of-control.”

Risk predictors

Other clues can also presage alcohol problems — and should be taken into account when people assess their alcohol consumption:

* Young age at first drink. Perhaps because of changes in the still-developing brain and because they associate with peers who are also heavy drinkers, people who drink at age 15 or younger are at particularly high risk of developing an alcohol problem. The national survey found that nearly half of people who become alcohol-dependent do so by age 21 and 75% by age 25.

* Flushing reaction to alcohol. Some people carry a gene mutation — ALDH2 — that affects alcohol metabolism and causes them to turn red when they drink. Seen mostly in people of Asian descent, the gene is linked to a higher risk of alcohol-use disorders but, conversely, the uncomfortable flushing effect often dissuades these people from drinking.

* Low sensitivity to alcohol. Some people need to drink more to feel an effect compared with the typical person — often referred to as the ability to “drink everyone else under the table.” At least five genes are thought to be linked to this proclivity. An estimated 40% of children of alcoholics carry this trait.

* Specific gene mutations. They include a mutation of the 5HTT gene, which is linked to low serotonin levels in the brain and is found in 60% of people who were alcoholics at age 40, and a mutation of the GABA (A) gene that is linked to a low sensitivity to alcohol.

* The presence of behavioral, emotional or psychiatric disorders — or smoking dependence.

Any of these factors, when combined with a pattern of exceeding drinking limits, should help people gauge their personal risk, experts say.

Dr. Marc Schuckit is director of the Alcohol and Drug Treatment Program at the Veterans Affairs San Diego Healthcare System, which has revolutionized what is known about genetic influences of alcohol, particularly the concept of low sensitivity. He says genes are responsible for about 60% of the risk of alcohol-use disorders and environmental factors account for the other 40% — and the two factors conspire to create alcohol-use disorders.

“It’s theoretically possible to take kids before they first drink, find out whether they have any gene variations, and say to them, ‘If you choose to be a drinker, then be careful because it’s very likely that you’ll need to drink more to have the same effect,” he says.

Based on the growing knowledge of risk factors, experts at the National Institute on Alcoholism and Alcohol Abuse and other policy-setting health organizations say Americans’ drinking habits should be screened during visits with their primary-care doctor or during emergency room visits.

“From what we know from scientific studies, there are some very clear things that can be done,” Willenbring says. “But people don’t ordinarily think of looking to science for how to improve drinking problems.”