Overcoming Tobacco and Alcohol Abuse
In the 1970s and 1980s I worked at the University of London’ prestigious Institute of Psychiatry’s Addiction Research Unit. I worked on the second floor in a team led by a famous addictionologist, Sir Griffith Edwards. Downstairs, Dr Michael Russell led a team researching nicotine addiction. The work that was done at the ARU at that time helped define the nature of dependence and it informed the scientific criteria that are used to this day.
The scientific description of dependence is really helpful because it clarifies the confusion created by everyday use of the words like ‘alcoholic,’ or ‘addict.’ These scientific distinctions often get lost because addiction treatment is heavily influenced by the lay recovery movement. These distinctions aren’t just academic -- they are important because they help clarify treatment goals and objectives.
Now here is a very important point. Physical dependence exists on a continuum – you can be mildly, moderately or severely dependent on a substance. It is not an all-or-nothing state, as is often implied by the term ‘alcoholic.’ The stereotypic alcoholic is someone who is severely dependent, drinking to avoid withdrawal (‘the hair of the dog’) often early in the day. People’s alcohol use can still be problematic even if they are only mildly physically dependent. Physical dependence is characterized by difficulty stopping drinking once started and having real difficulty going without alcohol for even a day. Alcohol and alcohol seeking become the main priority of the severely dependent person.
When someone is more than modestly physically dependent, total abstinence is the only realistic treatment goal.
Now in addition to physical dependence there is also the concept of psychological dependence. This means that in certain situations, which could be external cues, like at a bar, or internal cues, e.g., when you’re angry – are associated with drug use. So if you use alcohol or nicotine whenever you’re stressed, for example, you are psychologically dependent. Again psychological dependence exists on a continuum and you could be mildly, moderately or severely psychologically dependent. Note that although degrees of physical and psychological dependence are generally well correlated and it’s surely true that if you’re severely physically dependent you are also going to be severely psychologically dependent, it is possible to be severely psychologically dependent but not significantly physically dependent. For example, if you drink whenever you’re depressed, but you don’t get depressed that often, you have a strong psychological dependence but might not be physically dependent at all.
A third diagnostic criterion is abuse. When someone is diagnosed with alcohol or tobacco abuse it implies that they are neither physically nor significantly psychologically dependent. Abuse is officially used for such people who, while they show few signs of dependence, get into trouble when they indulge. For example, some one may drink every other weekend but when they do drink they get into fights, get DUI’s, etc., etc.