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Alcoholism
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Alcoholism is a term with multiple and sometimes conflicting definitions to describe the detrimental effects of alcohol intake.
In common and historic usage, alcoholism refers to any condition that results in the continued consumption of alcoholic beverages despite health problems and negative social consequences. Modern medical definitions describe alcoholism as a disease and addiction which results in a persistent use of alcohol despite negative consequences.
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Alcoholism is a term with multiple and sometimes conflicting definitions to describe the detrimental effects of alcohol intake.
In common and historic usage, alcoholism refers to any condition that results in the continued consumption of alcoholic beverages despite health problems and negative social consequences. Modern medical definitions describe alcoholism as a disease and addiction which results in a persistent use of alcohol despite negative consequences. In the 19th and early 20th centuries, alcoholism, also referred to as dipsomania described a preoccupation with, or compulsion toward the consumption of, alcohol and/or an impaired ability to recognize the negative effects of excessive alcohol consumption.
Although not all of these definitions specify current and on-going use of alcohol as a qualifier for alcoholism, some do, as well as remarking on the long-term effects of consistent, heavy alcohol use, including dependence and symptoms of withdrawal.
While the ingestion of alcohol is, by definition, necessary to develop alcoholism, the use of alcohol does not predict the development of alcoholism. It is estimated that 9% of the general population is pre disposed to alcoholism based on genetic factors. The quantity, frequency and regularity of alcohol consumption required to develop alcoholism varies greatly from person to person. In addition, although the biological mechanisms underpinning alcoholism are uncertain, some risk factors, including social environment, stress, emotional health and genetic predisposition, have been identified.
Definitions and terminology
The definitions of alcoholism and related terminology vary significantly between the medical community, treatment programs, and the general public.
Medical definitions
The Journal of the American Medical Association defines alcoholism as "a primary, chronic disease characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking."
The DSM-IV (the standard for diagnosis in psychiatry and psychology) defines alcohol abuse as repeated use despite recurrent adverse consequences. It further defines alcohol dependence as alcohol abuse combined with tolerance, withdrawal, and an uncontrollable drive to drink. (See DSM diagnosis below.)
According to the APA Dictionary of Psychology, alcoholism is the popular term for alcohol dependence. Note that there is debate whether dependence in this use is physical (characterised by withdrawal), psychological (based on reinforcement), or both.
Terminology
Many terms are applied to a drinker's relationship with alcohol. Use, misuse, heavy use, abuse, addiction, and dependence are all common labels used to describe drinking habits, but the actual meaning of these words can vary greatly depending upon the context in which they are used. Even within the medical field, the definition can vary between areas of specialization. The introduction of politics and religion further muddles the issue.
Use refers to simple use of a substance. An individual who drinks any alcoholic beverage is using alcohol. Misuse, problem use, abuse, and heavy use do not have standard definitions, but suggest consumption of alcohol to the point where it causes physical, social, or moral harm to the drinker. The definitions of social and moral harm are highly subjective and therefore differ from individual to individual.
Within politics, abuse is often used to refer to the illegal use of any substance. Within the broad field of medicine, abuse sometimes refers to use of prescription medications in excess of the prescribed dosage, sometimes refers to use of a prescription drug without a prescription, and sometimes refers to use that results in long-term health problems. Within religion, abuse can refer to any use of a poorly regarded substance. The term is often avoided because it can cause confusion with audiences that do not necessarily share a single definition.
Remission is often used to refer to a state where an alcoholic is no longer showing symptoms of alcoholism. The American Psychiatric Association considers remission to be a condition where the physical and mental symptoms of alcoholism are no longer evident, regardless of whether or not the person is still drinking. They further subdivide those in remission into early or sustained, and partial or full. The fellowship known as Alcoholics Anonymous does not use the term "remission" because AA's basic text, which was first published in 1939, uses the terms "recover" and "recovered" to describe those who have stopped consuming alcohol by addressing their underlying problem. On page 64, the AA text says "Our liquor was but a symptom. So we had to get down to causes and conditions."
Etymology
The term "alcoholism" was first used in 1849 by the physician Magnus Huss to describe the systematic adverse effects of alcohol.
In the United States, use of the word "alcoholism" was largely popularized by the founding and growth of Alcoholics Anonymous in 1935. AA's basic text, known as the "Big Book," describes alcoholism as an illness that involves a physical allergy and a mental obsession. Note that the definition of "allergy" used in this context is not the same as used in modern medicine.
A 1960 study by E. Morton Jellinek is considered the foundation of the modern disease theory of alcoholism. Jellinek's definition restricted the use of the word "alcoholism" to those showing a particular natural history. The modern medical definition of alcoholism has been revised numerous times since then. The American Medical Association currently uses the word alcoholism to refer to a particular chronic primary disease.
A minority opinion within the field, notably advocated by Herbert Fingarette and Stanton Peele, argue against the existence of alcoholism as a disease. Critics of the disease model tend to use the term "heavy drinking" when discussing the negative effects of alcohol consumption.
Epidemiology
(15+), in litres of pure alcohol]]
Substance use disorders are a major public health problem facing many countries. "The most common substance of abuse/dependence in patients presenting for treatment is alcohol." In the United Kingdom, the number of 'dependent drinkers' was calculated as over 2.8 million in 2001. The World Health Organization estimates that about 140 million people throughout the world suffer from alcohol dependence.
Within the medical and scientific communities, there is broad consensus regarding alcoholism as a disease state. For example, the American Medical Association considers alcohol a drug and states that "drug addiction is a chronic, relapsing brain disease characterized by compulsive drug seeking and use despite often devastating consequences. It results from a complex interplay of biological vulnerability, environmental exposure, and developmental factors (e.g., stage of brain maturity)."
Current evidence indicates that in both men and women, alcoholism is 50-60% genetically determined, leaving 40-50% for environmental influences.
A 2002 study by the National Institute on Alcohol Abuse and Alcoholism surveyed a group of 4,422 adult alcoholics and found that after one year some were no longer alcoholics, even though only 25.5% of the group received any treatment, with the breakdown as follows:
- 25% still dependent
- 27.3% in partial remission (some symptoms persist)
- 11.8% asymptomatic drinkers (consumption increases chances of relapse)
- 35.9% fully recovered — made up of 17.7% low-risk drinkers plus 18.2% abstainers.
In contrast, however, the results of a long term (60 year) follow-up of two groups of alcoholic men by George Vaillant at Harvard Medical School indicated that "return to controlled drinking rarely persisted for much more than a decade without relapse or evolution into abstinence." Vaillant also noted that "return-to-controlled drinking, as reported in short-term studies, is often a mirage."
Identification and diagnosis
Multiple tools are available to those wishing to conduct screening for alcoholism. Identification of alcoholism may be difficult because there is no detectable physiologic difference between a person who drinks frequently and a person with the condition. Identification involves an objective assessment regarding the damage that imbibing alcohol does to the drinker's life compared with the subjective benefits the drinker perceives from consuming alcohol. While there are many cases where an alcoholic's life has been significantly and obviously damaged, there are always borderline cases that can be difficult to classify. Unless they have M.C. type symptoms, and in these cases are probably alcoholics, no diagnosis needed.
Addiction Medicine specialists have extensive training with respect to diagnosing and treating patients with alcoholism.
Screening
Several tools may be used to detect a loss of control of alcohol use. These tools are mostly self reports in questionnaire form. Another common theme is a score or tally that sums up the general severity of alcohol use.
- The CAGE questionnaire, named for its four questions, is one such example that may be used to screen patients quickly in a doctor's office.
- The CAGE questionnaire, among others, has been extensively validated for use in identifying alcoholism. It is not valid for diagnosis of other substance use disorders, although somewhat modified versions of the CAGE are frequently implemented for such a purpose.
- The Alcohol Dependence Data Questionnaire is a more sensitive diagnostic test than the CAGE test. It helps distinguish a diagnosis of alcohol dependence from one of heavy alcohol use.
- The Michigan Alcohol Screening Test (MAST) is a screening tool for alcoholism widely used by courts to determine the appropriate sentencing for people convicted of alcohol-related offenses, driving under the influence being the most common.
- The Alcohol Use Disorders Identification Test (AUDIT) is a screening questionnaire developed by the World Health Organization. This test is unique in that it has been validated in six countries and is used internationally. Like the CAGE questionnaire, it uses a simple set of questions - a high score earning a deeper investigation.
- The Paddington Alcohol Test (PAT) was designed to screen for alcohol related problems amongst those attending Accident and Emergency departments. It concords well with the AUDIT questionnaire but is administered in a fifth of the time.
Genetic predisposition testing
Psychiatric geneticists John I. Nurnberger, Jr., and Laura Jean Bierut suggest that alcoholism does not have a single cause—including genetic—but that genes do play an important role "by affecting processes in the body and brain that interact with one another and with an individual's life experiences to produce protection or susceptibility." They also report that fewer than a dozen alcoholism-related genes have been identified, but that more likely await discovery.
At least one genetic test exists for an allele that is correlated to alcoholism and opiate addiction. Human dopamine receptor genes have a detectable variation referred to as the DRD2 TaqI polymorphism. Those who possess the A1 allele (variation) of this polymorphism have a small but significant tendency towards addiction to opiates and endorphin releasing drugs like alcohol. Although this allele is slightly more common in alcoholics and opiate addicts, it is not by itself an adequate predictor of alcoholism, and some researchers argue that evidence for DRD2 is contradictory.
DSM diagnosis
The DSM-IV diagnosis of alcohol dependence represents one approach to the definition of alcoholism. In part this is to assist in the development of research protocols in which findings can be compared with one another. According to the DSM-IV, an alcohol dependence diagnosis is:
Urine and blood tests
There are reliable tests for the actual use of alcohol, one common test being that of blood alcohol content (BAC). These tests do not differentiate alcoholics from non-alcoholics; however, long-term heavy drinking does have a few recognizable effects on the body, including:
However, none of these blood tests for biological markers are as sensitive as screening questionaires.
Effects of long term alcohol misuse
The primary effect of alcoholism is to encourage the sufferer to drink at times and in amounts that are damaging to physical health. The secondary damage caused by an inability to control one's drinking manifests in many ways. Alcoholism also has significant social costs to both the alcoholic and their family and friends. Alcoholics have a very high suicide rate and studies show between 8% and 21% of alcoholics commit suicide. Alcoholism also has a significant adverse impact on mental health. The risk of suicide among alcoholics has been determined to be 5,080 times that of the general public.
Physical health effects
It is common for a person suffering from alcoholism to drink well after physical health effects start to manifest. The physical health effects associated with alcohol consumption may include cirrhosis of the liver, pancreatitis, epilepsy, polyneuropathy, alcoholic dementia, heart disease, increased chance of cancer, nutritional deficiencies, sexual dysfunction, and death from many sources. Severe cognitive problems are not uncommon in alcoholics. Approximately 10% of all dementia cases are alcohol related making alcohol the 2nd leading cause of dementia.
Mental health effects
Long term misuse of alcohol can cause a wide range of mental health effects. Alcohol misuse is not only toxic to the body but also to brain function and thus psychological well being can be adversely affected by the long-term effects of alcohol misuse.
Psychiatric disorders are common in alcoholics, especially anxiety and depression disorders, with as many as 25% of alcoholics presenting with severe psychiatric disturbances. Typically these psychiatric symptoms caused by alcohol misuse initially worsen during alcohol withdrawal but with abstinence these psychiatric symptoms typically gradually improve or disappear altogether. Panic disorder can develop as a direct result of long term alcohol misuse. Panic disorder can also worsen or occur as part of the alcohol withdrawal syndrome. Chronic alcohol misuse can cause panic disorder to develop or worsen an underlying panic disorder via distortion of the neurochemical system in the brain.
Social effects
The social problems arising from alcoholism can be massive and are caused in part due to the serious pathological changes induced in the brain from prolonged alcohol misuse and partly because of the the intoxicating effects of alcohol. Being drunk or hung over during work hours can result in loss of employment, which can lead to financial problems including the loss of living quarters. Drinking at inappropriate times, and behavior caused by reduced judgment, can lead to legal consequences, such as criminal charges for drunk driving or public disorder, or civil penalties for tortious behavior. An alcoholic's behavior and mental impairment while drunk can profoundly impact surrounding family and friends, possibly leading to marital conflict and divorce, or contributing to domestic violence. This can contribute to lasting damage to the emotional development of the alcoholic's children, even after they reach adulthood. The alcoholic could suffer from loss of respect from others who may see the problem as self-inflicted and easily avoided.
Alcohol withdrawal
Alcohol withdrawal differs significantly from most other drugs in that it can be directly fatal. Drugs which have a similar mechanism of action to alcohol also have a similar risk of causing death during withdrawal, including barbiturate and benzodiazepine withdrawal. For example it is extremely rare for heroin withdrawal to be fatal. When people die from heroin or cocaine withdrawal they typically have serious underlying health problems which are made worse by the strain of acute withdrawal. An alcoholic however, who has no serious health issues has a significant risk of dying from the direct effects of withdrawal if it is not properly managed.
Alcohol's primary effect is the increase in stimulation of the GABAA receptor, promoting central nervous system depression. With repeated heavy consumption of alcohol, these receptors are desensitized and reduced in number, resulting in tolerance and physical dependence. Thus when alcohol is stopped, especially abruptly, the person's nervous system suffers from uncontrolled synapse firing. This can result in symptoms that include anxiety, life threatening seizures, delirium tremens and hallucinations, shakes and possible heart failure.
Acute withdrawal symptoms tend to subside after 1 - 3 weeks. Less severe symptoms (e.g. insomnia and anxiety) may continue as part of a post withdrawal syndrome gradually improving with abstinence for a year or more. Withdrawal symptoms begin to subside as the body and central nervous system makes adaptations to reverse tolerance and restore GABA function towards normal. Other neurotransmitter systems are involved, especially glutamate and NMDA.
Treatments
Treatments for alcoholism are quite varied because there are multiple perspectives for the condition itself. Those who approach alcoholism as a medical condition or disease recommend differing treatments than, for instance, those who approach the condition as one of social choice.
Most treatments focus on helping people discontinue their alcohol intake, followed up with life training and/or social support in order to help them resist a return to alcohol use. Since alcoholism involves multiple factors which encourage a person to continue drinking, they must all be addressed in order to successfully prevent a relapse. An example of this kind of treatment is detoxification followed by a combination of supportive therapy, attendance at self-help groups, and ongoing development of coping mechanisms. The treatment community for alcoholism typically supports an abstinence-based zero tolerance approach; however, there are some who promote a harm-reduction approach as well.
Texas Tech University in Lubbock, Texas, has developed a model to support college students who are in recovery from addictive disorders such as alcoholism. .
Effectiveness
When considering the effectiveness of treatment options, one must consider the success rate based on those who enter a program, not just those who complete it. Since completion of a program is the qualification for success, success among those who complete a program is generally near 100%. It is also important to consider not just the rate of those reaching treatment goals but the rate of those relapsing. Results should also be compared to the roughly 5% rate at which people will quit on their own. A year after completing a rehab program, about a third of alcoholics are sober, an additional 40 percent are substantially improved but still drink heavily on occasion, and a quarter have completely relapsed.
Detoxification
Alcohol detoxification or 'detox' for alcoholics is an abrupt stop of alcohol drinking coupled with the substitution of drugs that have similar effects to prevent alcohol withdrawal.
Detoxification treats the physical effects of prolonged use of alcohol, but does not actually treat alcoholism. After detox is complete, relapse is likely without further treatment. These rehabilitations (or 'rehabs') may take place in an inpatient or outpatient setting.
Group therapy and psychotherapy
After detoxification, various forms of group therapy or psychotherapy can be used to deal with underlying psychological issues that are related to alcohol addiction, as well as provide relapse prevention skills.
The mutual-help group-counseling approach is one of the most common ways of helping alcoholics maintain sobriety. Many organizations have been formed to provide this service. Alcoholics Anonymous was the first group, and has more members than all other programs combined. Some of the others include LifeRing Secular Recovery, Rational Recovery, SMART Recovery, and Women For Sobriety.
Rationing and moderation
Rationing and moderation programs such as Moderation Management and DrinkWise do not mandate complete abstinence. While most alcoholics are unable to limit their drinking in this way, some return to moderate drinking. A 2002 U.S. study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) showed that 17.7% of individuals diagnosed as alcohol dependent more than one year prior returned to low-risk drinking. However, this group showed fewer initial symptoms of dependency. A follow-up study, using the same NESARC subjects that were judged to be in remission in 2001-2002, examined the rates of return to problem drinking in 2004-2005. The major conclusion made by the authors of this NIAAA study was "Abstinence represents the most stable form of remission for most recovering alcoholics".
Medications
A variety of medications may be prescribed as part of treatment for alcoholism.
- Antabuse (disulfiram) prevents the elimination of acetaldehyde, a chemical the body produces when breaking down ethanol. Acetaldehyde itself is the cause of many hangover symptoms from alcohol use. The overall effect is severe discomfort when alcohol is ingested: an extremely fast-acting and long-lasting uncomfortable hangover. This discourages an alcoholic from drinking in significant amounts while they take the medicine. A recent 9-year study found that incorporation of supervised disulfiram and a related compound carbamide into a comprehensive treatment program resulted in an abstinence rate of over 50%.
- Naltrexone is a competitive antagonist for opioid receptors, effectively blocking our ability to use endorphins and opiates. Naltrexone is used in two very different forms of treatment. The first treatment uses naltrexone to decrease cravings for alcohol and encourage abstinence. The other treatment, called pharmacological extinction, combines naltrexone with normal drinking habits in order to reverse the endorphin conditioning that causes alcohol addiction.
Naltrexone comes in two forms. Oral naltrexone, originally but no longer available as the brand ReVia, is a pill form and must be taken daily to be effective. Vivitrol is a time-release formulation that is injected in the buttocks once a month.
- Acamprosate (also known as Campral) is thought to stabilize the chemical balance of the brain that would otherwise be disrupted by alcoholism. The Food and Drug Administration (FDA) approved this drug in 2004, saying "While its mechanism of action is not fully understood, Campral is thought to act on the brain pathways related to alcohol abuse... Campral proved superior to placebo in maintaining abstinence for a short period of time..." The COMBINE study was unable to demonstrate efficacy for Acamprosate.
- Topiramate (brand name Topamax), a derivative of the naturally occurring sugar monosaccharide D-fructose, has been found effective in helping alcoholics quit or cut back on the amount they drink. In one study heavy drinkers were six times more likely to remain abstinent for a month if they took the medication, even in small doses. In another study, those who received topiramate had fewer heavy drinking days, fewer drinks per day and more days of continuous abstinence than those who received the placebo. Topiramate works by reducing dopamine so that drinkers no longer get any pleasure from consuming alcohol and is the only medication shown to be effective for persons who are still drinking.
Dual addictions
Alcoholics may also require treatment for other psychotropic drug addictions. The most common dual addiction in alcoholics is a benzodiazepine dependence with studies showing 10 - 20% of alcoholics having problems of dependence and/or misuse problems of benzodiazepines. Dependence on other sedative hypnotics such as zolpidem and zopiclone as well as opiates also occurs as well as illegal drugs. Benzodiazepine withdrawal can like alcohol be medically severe and include the risk of psychosis and seizures if not managed properly. Benzodiazepine dependency requires careful reduction in dosage to avoid a serious benzodiazepine withdrawal syndrome and health consequences. Benzodiazepines have the problem of increasing cravings for alcohol in problem alcohol consumers. Benzodiazepines also increase the volume of alcohol consumed by problem drinkers.
Women and alcoholism
Alcoholism has a higher prevalence among men, though in recent decades, the number of female alcoholics has increased. It is important to articulate the different biological and social ways alcoholism manifests in women in order to understand barriers to treatment and effective recovery strategies.
Biological differences and physiological effects
Biologically, women have symptom profiles from their alcohol use that differ in important ways from men. They experience a telescoping of physiological effects from alcohol use. Equal dosages of alcohol consumed by men and women generally result in women having higher blood alcohol concentrations (BACs). This can be attributed to many reasons, the main being that women have less body water than men. A given amount of alcohol, therefore becomes more highly concentrated in a woman's body. Besides this fact, women also become more intoxicated, which is due to different hormone release.
Women develop long-term complications of alcohol dependence more rapidly than do alcoholic men. Additionally, women have a higher mortality rate from alcoholism than men. Examples of long term complications include brain, heart, and liver damage and an increased risk for breast cancer. Additionally, heavy drinking over time has been found to have a negative effect on reproductive functioning in women. This results in reproductive dysfunction such as anovulation, decreased ovarian mass, irregular menses, amenorrhea, luteal phase dysfunction, and early menopause.
Psychological and emotional effects
Psychiatric disorders are generally more prevalent among those with alcohol disorders. This is true for both men and women, however the disorders differ depending on gender. Women who have alcohol-use disorders have co-occurring psychiatric diagnosis such as major depression, anxiety, panic disorder, bulimia, post-traumatic stress disorder (PTSD), or borderline personality disorder. Men with alcohol-use disorders more often have co-occurring diagnosis of narcissistic and antisocial personality disorders, bipolar disorder, schizophrenia, impulse disorders and attention deficit/ hyperactivity disorder.
Women with alcoholism are also more likely to have a history of physical or sexual assault, abuse and domestic violence than those in the general population. This trauma can lead to higher instances of PTSD, depression, anxiety, and a greater dependence on alcohol.
Societal barriers to treatment
Attitudes and social stereotypes about women and alcohol can create barriers to the detection and treatment of female alcohol abusers. Such beliefs stigmatize women who drink by characterizing them as "both generally and sexually immoral" or the "fallen women." Fear of stigmatization may lead women to deny that they are suffering from a medical condition, to hide their drinking, and to drink alone. This pattern, in turn, leads family, physicians, and others to be less likely to suspect that a woman they know is an alcoholic.
Women also tend to have a greater fear that the negative implications from the stigma will reflect poorly on their families. This may also keep them from seeking help.
Implications for treatment
Research has indicated a lack of adequate training for practitioners both in problematic alcohol use in general, and in relation to women's issues. The complexity of alcohol use disorders, particularly with gender-related issues, indicates that the need for practitioners' knowledge, insight and compassion is enormous. Better education and awareness surrounding the gender implications of alcoholism will help care providers to adequately treat women who suffer from alcoholism. Early intervention will also increase the probability of recovery.
Societal impact
The various health problems associated with long-term alcohol consumption are generally perceived as detrimental to society, for example, money due to lost labor-hours, medical costs, and secondary treatment costs. Alcohol use is a major contributing factor for head injuries, motor vehicle accidents, violence, and assaults. Beyond money, there is also the pain and suffering of the individuals besides the alcoholic affected. For instance, alcohol consumption by a pregnant woman can lead to Fetal alcohol syndrome, an incurable and damaging condition.
Estimates of the economic costs of alcohol abuse, collected by the World Health Organization, vary from one to six per cent of a country's GDP. One Australian estimate pegged alcohol's social costs at 24 per cent of all drug abuse costs; a similar Canadian study concluded alcohol's share was 41 per cent.
A study quantified the cost to the UK of all forms of alcohol misuse as £18.5–20 billion annually (2001 figures).
Stereotypes
Stereotypes of alcoholics are often found in fiction and popular culture. The 'town drunk' is a stock character in Western popular culture.
Stereotypes of drunkenness may be based on racism or xenophobia, as in the depiction of the Irish as heavy drinkers. In Australia, Canada, and the United States, Aboriginal people have similarly been stereotyped as alcoholics.
On the other hand, studies by social psychologists Stivers and Greeley attempt to document the perceived prevalence of high alcohol consumption amongst the Irish in America.
In film and literature
In modern times, the recovery movement has led to more realistic depictions of problems that stem from heavy alcohol use. Authors such as Charles R. Jackson and Charles Bukowski describe their own alcohol addiction in their writings. The disjoined narrative of Patrick Hamilton's Hangover Square reflects the alcoholism of its central character. A famous depiction of alcoholism, and the psychology of an alcoholic, is in Malcolm Lowry's widely acclaimed novel Under the Volcano, which details the final day of the British consul Geoffrey Firmin on the Day of the Dead in 1939 Mexico and his choice to continue his extreme alcohol consumption instead of returning to the wife he loves.
Films like Bad Santa, Days of Wine and Roses, My Name is Bill W., Withnail and I, Arthur, Leaving Las Vegas, Shattered Spirits and The Lost Weekend, chronicle similar stories of alcoholism.
Politics and public health
Because alcohol use disorders are perceived as impacting society as a whole, governments and parliaments have formed alcohol policies in order to reduce the harm of alcoholism. The World Health Organization, the European Union and other regional bodies are working on alcohol action plans and programs.
See also
Further reading
- Berry, Ralph E.; Boland James P. The Economic Cost of Alcohol Abuse The Free Press, New York, 1977 ISBN 0-02-903080-3
- Milam, Dr. James R. and Ketcham, Katherine Under The Influence: A Guide to the Myths and Realities of Alcoholism. Bantam, 1983, ISBN 0-553-27487-2
- National Institute on Alcohol Abuse and Alcoholism. .
- Pence, Gregory, "Kant on Whether Alcoholism is a Disease," Ch. 2, The Elements of Bioethics, McGraw-Hill Books, 2007 ISBN 0-073-13277-2.
- Royce, James E. and Scratchley, David Alcoholism and Other Drug Problems Free Press, March 1996 ISBN 0-684-82314-4 ISBN 978-0-684-82314-0
- Valliant, George E., The Natural History of Alcoholism Revisited, Harvard University Press, May 1995 ISBN 0-674-60378-8 ISBN 978-0-674-60378-3
- Warren Thompson, MD, FACP. "." Emedicine.com, June 6, 2007. Retrieved 2007-09-02.
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