Talk:Alcoholism

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Cleanup attempt: Hello, there, and welcome to the discussion regarding the Alcoholism article. I am currently attempting to rearrange this page so that it has sections which mirror the sections on the parent article. I'm also going to move various resolved issues to the archive. Robert Rapplean 16:03, 22 July 2006 (UTC)

This article is about Alcoholism. Discussions regarding the Disease Theory of Alcoholism have been moved to their own page, so please discuss that topic on that page, and we will summarize the results in this article.

Opening discussion

Starting our work

The article starts with:

Alcoholism is a condition within the Substance Use Disorders category that describes a multifactorial condition widely believed to be based upon both genetic (Lowinson JH, Ruiz P, Millman RB, Langrod JG. Substance Abuse, A Comprehensive Textbook, 4th Ed. 2005) and environmental factors.

This sentence has been edited so much as to no longer make grammatical sense. From a medical perspective, alcoholism is but one of the substance use disorders. While it is only one, it is also the most prevalent and most costly to our society when compared with the others. Alcoholism is 20x or so more prevalent than opioid addiction, for example. Perhaps that information should be in the leading paragraph? The citation here is one of the two major textbooks in the field of addictive disease and the content of this sentence is more or less the first line of nearly all the major texts in the area. But interestingly, we haven't said what the condition is, and that could be a much better introduction.

It's easier to say what alcoholism is NOT. It's not heavy drinking. It's not illegal use of alcohol (e.g. a 15 year old drinking). What I'd like to do is start off this way, and I've tried to temper wording in a manner I hope will be acceptable to all:

Alcoholism is a primary and progressive condition in which alcohol is used in an ongoing or intermittent manner despite one's best interest as measured via psychosocial function. In a 1992 JAMA article, the Joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine published this definition for alcoholism: "Alcoholism is a primary chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, mostly denial. Each of these symptoms may be continuous or periodic."

I assume that some of you have another definition of alcoholism that you'd like to see in the lead-off paragraph, so perhaps the lead-off should also have an alternative definition for readers to consider? Drgitlow 20:42, 3 July 2006 (UTC)

I don't know if alcoholism is officially classified as a disease under medical definitions, but the current introduction is horrible, in defining it specifically in terms of a medical condition under categories and then filling up with a bunch of references from medical societies. This is a general-purpose encyclopedia, not the DSM. Even a medical encyclopedia would never start off an entry this way. For comparison, here is the first paragraph of the Britannica introduction, s.v. "Alcoholism":

excessive and repetitive drinking of alcoholic beverages to the extent that the drinker repeatedly is harmed or harms others. The harm may be physical or mental; it may also be social, legal, or economic. Because such use is usually considered to be compulsive and under markedly diminished voluntary control, alcoholism is considered by a majority of, but not all, clinicians as an addiction and a disease.

Here is the first sentence of the article at Medline Plus[1]:

Alcoholism is an illness marked by drinking alcoholic beverages at a level that interferes with physical health, mental health, and social, family, or occupational responsibilities.

—Centrx?talk • 20:55, 3 July 2006 (UTC)

Drgitlow, I agree the intro needs some work and is fuzzy at best. Due to the lack of editorial consensus and the current demonstrated mistrust amongst most of us alcoholism editors here, I would suggest we put this one on one ice for the time being and instead let's get our feet wet on something slightly less caustic before we tackle the definition of alcoholism. I think we need some baby steps so to speak.

I am currently writing something to add to the Pro/Con section that I think will give us a good opportunity to learn how to establish editorial consensus and it's on a topic that is slightly less volatile. Realistically I think we are weeks (or longer) away from having an article that everyone feels does a good job of articulating the subject of alcoholism, so I think we can address some of the more explosive subjects best if we wait until we've got a little editorial consensus under our belts. That's my take on it. If you agree then by all means go ahead and write what you think would be appropriate but I would suggest you not present for comments on the talk page until we ("we" meaning all the editors who are either active or wish to be active when things cool down) have established an ability to work constructively together. Mr Christopher 21:03, 3 July 2006 (UTC)

Centrx, you make excellent points. You didn't suggest alternative wording, but taking your thoughts into account, perhaps an approach like this would be better:

Alcoholism is an illness in which individuals intermittently or continuously use alcohol despite such use causing them objectively determinable harm in areas of personal, social, educational, and occupational function or in terms of increasing medical complications. Alcoholism is diagnosed not by the quantity or frequency of alcohol used but rather by the degree to which alcohol's use has caused harm to the individual.

The textbook definition of alcoholism (the JAMA reference) can be incorporated into some of the following text. Since we have had ongoing discussion regarding different opinions on the subject, it might be useful to have sidebars of boxed text to the entry that include the DSM-IV definition, the JAMA article definition, as well as any other pertinent definitions.

All that being said, I agree with Chris's point above as well and don't mind just coming back to this once we're done working elsewhere in the article. I don't even know if Chris and others feel the same way about the word "illness" as they do about "disease." The two words have different meanings to me: a broken bone is a disease, but not an illness; but I don't know if there's a standard there or not. Drgitlow 21:12, 3 July 2006 (UTC)

I think you both make very good points, I simply think this specific subject is ripe for a nuclear reaction, at least at the present. For me, this one merits waiting for a cool down as well as some consensus building experience. Mr Christopher 21:19, 3 July 2006 (UTC)

Hmmm...should we take the 4th off and agree not to even visit the page? :) Drgitlow 21:29, 3 July 2006 (UTC)

Personally, for now, I don't plan on changing anything in the article (other than a typo or broken link) without some sort of editorial consensus, no matter how nutty the article might get. And your suggestion for taking off the 4th sounds like a plan. I'll not add the ideas I previously spoke about to the talk page until after the 4th. Mr Christopher 21:49, 3 July 2006 (UTC)

I think, though, that we can agree that it's a "health condition", which is to say a condition that effects a person's health. Does anyone have a problem with that? Robert Rapplean 21:34, 3 July 2006 (UTC)

I have used "diseased condition", meaning that the body is not functioning normally or properly. I made it so that excessive drinking causes the diseased condition, which is absolutely true, not that excessive drinking is a disease caused by biological factors, which seems to be what is the contention. —Centrx?talk • 22:07, 3 July 2006 (UTC)

Alcohol intake itself can cause disease. It can cause hepatic difficulties, dementia, and so forth if taken in sufficient quantity. What it can't do is CAUSE alcoholism, although the condition can't be identified and diagnosed in the absence of alcohol use. Push comes to shove, there will probably come a day when we can identify individuals who are predisposed to develop the condition prior to their ever using alcohol. But that day isn't here yet. And then you get into the whole "What's a disease?" issue. Let me give an example: Imagine I have a patient with Huntington's. He has the gene but no signs or symptoms of the disease yet. We know that between age 35 and 50, he will begin showing the onset. Would you say he has the disease at age 20? Or must it wait for symptoms?

Similarly with alcoholism, if I take an alcoholic and move him to an alcohol-free environment, is he still alcoholic? What if he hasn't started drinking yet, but my crystal ball shows the future and sees that he will? Is he alcoholic now? That difficulty is part of why docs don't typically relate the disease to alcohol use itself.

So I agree that excessive drinking is not a disease. But excessive drinking does not cause the condition of alcoholism either, though SOME drinking is necessary for the condition to be present. If you want my opinion, what I tell patients is that alcohol use is simply a marker for the presence of the disease, which typically is more an issue of a failure for them to have learned how to relate on an emotional and intimate basis with other people combined with some genetic issue that causes them to have an unusual response to alcohol that on a short-lived basis helps them to feel better. That's in my textbook and is educated opinion, but I acknowledge that it's my opinion and not a belief that is necessarily shared by all addiction treatment professionals. Does it have a place in this article? Up to you all...it's in the book so I suppose it could be cited. :) Drgitlow 00:49, 4 July 2006 (UTC)

Disease arguing moved to a more appropriate spot

In short, Centrx I like the introduction and think it's the closest thing we've had to NPOV yet. I have two intitiall thoughts. One is the ethanol article does not describe ethanol as a drug, there they define it as

Ethanol, also known as ethyl alcohol or grain alcohol, is a flammable, tasteless, colorless, mildly toxic chemical compound with a distinctive odor, one of the alcohols that is most often found in alcoholic beverages. In common usage, it is often referred to simply as alcohol. Its molecular formula is C₂H₆O, variously represented as EtOH, C₂H₅OH or as its empirical formula C₂H₆O.

We'd be wise to not call ethanol a drug. Otherwise I this is a good place to reach a consensus. I think it does a pretty good job of tipping it hat to the medical community's take on the issue without assuming their POV. I'm sure some of the finer points could be expanded upon or even debated but we're better off with something brief and agreed upon. It is because the opening entry is no longer claiming alcoholism is a disease (what I have been calling the "AMA POV") that I think referencing the debate introduced by Medical Man in the opening section might be misplaced. To me those viewpoints should be heard but in a more logical section. You and I share some similar concerns so if you think I'm bonkers let me know. But the opening section does not glamorize the disease concept so I'm thinking this is a good compromise. I think the overall article will read better if we correctly categorize where conflicts in opinion are strategically best placed keeping in mind we don't want to silence any voices (verifiable, reliable, etc) on the subject. Anyhow, we gotta start somewhere, might as well be at the top of the article in the opening definition. Mr Christopher 05:40, 4 July 2006 (UTC)

The reason I included the ethanol mention is so that the introduction explicitly states the mechanism by which alcoholic beverages could ever cause any harm or why they would be used despite detrimental effects. It seems obvious to us, but a child would not know and perhaps others, and it should anyway be written for the ages. Most introductions to common subjects seem rather obvious to the average intelligent reader, but it is to introduce the unfamiliar reader and to exactly define the subject. Ethanol (an unusual name too) may not be the best to link to, because that article is primarily about its chemical properties. An alternative is Effects of alcohol on the body.

Alcohol is a drug. Specifically, it has a direct, substantial effect on the physiologic function of the body. There may have been some popular mutation of the term in the last 30 years, but the fact remains that aspirin and cocaine are both drugs, and that ethanol is a psychoactive drug. Both Effects of alcohol on the body and Alcoholic beverages agree. This is not to imply any Drug War hysteria or any sinister will-circumventing influence. —Centrx?talk • 06:31, 4 July 2006 (UTC)

Medical Man Citations

Medical Man has made several citations in the last sentence of the opening paragraph, but the citations are simply a list of names rather than references. We need the actual references for (U.S. Supreme court, Fingarette, Peele, Schaler, Hobbs, Meyer, Kolata, Korhonen, Nackerud, Kelly, Doweiko, Levy, Maltzman). Drgitlow 01:28, 4 July 2006 (UTC)

Apparently, they are listed at the bottom under section References. Still, the introduction should not be cluttered with this many sources. If there is a controversy, it belongs in its own referenced section, with a statement about it in the introduction that is in reference to that section but without so many sources, many of which are rather tangential to the matter. —Centrx?talk • 03:34, 4 July 2006 (UTC)

—Reposted 07:15, 4 July 2006 (UTC)

I think part of the trouble we're having is based on terminology issues. When one of us uses a term like moderation, addiction, disease, etc., I suspect we're all thinking of different things. You're describing behavioral modification, I think. Can you post (repost?) the citation as to the efficacy of that approach for treating alcoholics?

The reason so many alcoholism treatment professionals reject the idea that alcoholics can drink in moderation is that it is completely inconsistent with the disease model. For many decades, all evidence that some alcoholics could learn to drink in moderation was dismissed as a fluke, as erroneous, or as impossible. It was rejected because it was a threat to their firm belief that alcoholics can never drink in moderation. When faced with increasingly strong evidence that some alcoholics can drink in moderation, they fell back on the lame argument that those successful people couldn't have been alcoholics or they couldn't have drunk in moderation! After all, they argued , and still do that , "an alcoholic is someone who must abstain because he or she can't ever learn to drink in moderation."

Reminds one of Freud's assertion that men could not suffer hysteria because it was defined as a disese of women. Or Jellinek's assertion that "a disease is anything the AMA says is a disease"! Or some of the arguments we've been getting trying to rebut evidence that there is no consensus about the disease concept of alcoholism in the alcoholism field.

However the NIAAA reports that about 18% of US alcoholics are now recovered (its term) and drinking in moderation (its term). [2]Medical Man 00:31, 5 July 2006 (UTC)

Problem with "intermittent or continual"

Textually, this means that any drinking at all, whether it be often or only intermittently every now and then, is alcoholism. The "excessive" is important, and something like "habitual" or "repetitive" is also. —Centrx?talk • 07:14, 4 July 2006 (UTC)

Hmmm, no, that's not the intent. I'll try to reword it. The problem is that an individual can have alcoholism but drink only rarely. A heavy drinker, on the other hand, might not have alcoholism. The disease is independent of the quantity of alcohol intake. Imagine, if you will, a binge drinker who doesn't drink for long periods of time, but then drinks to the point of oblivion, losing his job in the process and ending up in the hospital with DT's. His total alcohol intake might not be very much compared to your average college student, but he's alcoholic and the college student probably isn't. Drgitlow 13:56, 4 July 2006 (UTC)

I think the article would be incomplete without the APA's stance that lighter drinking can also be a sign of alcoholism as well as their definition of alcoholism. By introducing this in the opening paragraphs we're inviting more contention. I think there is a more logical place to put the APA's stance. To me the entry needs to be as contention proof as we can make it. Mr Christopher 15:16, 4 July 2006 (UTC)

I don't think that's the APA's position necessarily. The DSM diagnostic criteria don't address intake levels at all. I just looked through the DSM section and didn't see anything on light drinking versus heavy drinking. It's not that lighter drinking is a sign of alcoholism -- I'd never try to argue that light drinkers are, in general, alcoholics. I think in general (vast majority of the time) they are not. (We all agree on that, right?) The criteria are saying only that one need not be a heavy drinker to suffer from alcoholism. In my last edit, I tried to remove any indication of light versus heavy from the opening paragraph so that the condition is noted to be present solely based upon the effects of alcohol. I think that's consistent with the DSM definition, with the JAMA definition, and with your perspective as well, is it not? Happy 4th, by the way! Drgitlow 15:53, 4 July 2006 (UTC)

Well rain ended the fireworks display too soon but other than that things are swell this holiday weekend. Yes your latest edits to the entry are good and advance the cause of consensus building as well. Nice. I think we have made some significant recent strides. Mr Christopher 17:03, 4 July 2006 (UTC)

Definition of Alcoholism

Robert Rapplean, I hope you won't be angry that I copied this quote of yours from outside WP. I have been following the discussions and I think that you have a very valuable insight with this definition; I'd like to share it here for the sake of us who don't have doctorates but do have an interest in improving Wikipedia:

• Alcoholism is a health condition characterized by impaired control over drinking habits, preoccupation with the drug alcohol and events surrounding the drinking of alcohol, and use of alcohol despite adverse consequences. It does not refer to heavy drinking, although that is one of the primary symptoms of it.

I think that this is an excellent definition, or at least represents the beginning of one, because it is readily understandable to a layman who is looking for basic information on the topic. I think it's very important that the introductory paragraph of an encyclopedic article should:

1. be as clear and concise as possible.
2. be intellectually accessible to the majority of readers.
3. be free from controversial issues which can reasonably be dealt with later in the article.

The fact that your definition avoids "alcoholism-as-disease" would seem to be a net benefit. That 'discussion' should probably have its own section with pros and cons presented there, rather than in the introduction. Obviously I lack the academic background to contribute to this article, but I hope that what I've brought up here will help give more of a "reader's-eye view". BTW - I appreciate the fact that everyone working on this article has done so well maintaining civilty and good faith; it's a nice contrast to certain politacal and religous articles that I wouldn't touch with a 3 meter keyboard :) --Doc Tropics ^{Message in a bottle} 17:45, 5 July 2006 (UTC)

Doc Tropics ^{Message in a bottle} Welcome to alcoholism! I appreciate your contribution and hope you plan to dig in and help us improve this article. I do have a concern, though. My concern is if we are not careful we will be redefining alcoholism every other week. Before we consider yet another definition I'd like to hear who objects to the existing definition and why. I could be wrong but I think we are close to getting editorial consensus on the existing definition, though there seems to be a lingering disagreement as to whether indroducing the debate over the disease called alcoholism belongs in the opening definition or not.

But again, we can write a new definition but is there a reason to do so? I'd like to first hear the comments of any editors (including yourself, Doc Tropics) who object to the existing definition and why before we consider replacing it with something else? Does that seem fair? Mr Christopher 17:58, 5 July 2006 (UTC)

Oh gosh, I certainly wasn't suggesting a rush to undo the hard work you've put into building consensus there! It's just that from a layman's standpoint the intro seems both dense and unwieldy; from an editor's standpoint it seems that some of that info could be used to best effect elsewhere. I didn't mean to muddy the waters here, but when I found that Robert Rapplean had produced such a clear and simple definition I found it very appealing. I certainly understand your concern about "...redefining alcoholism every other week". Stability is important to an article like this, and lack of stability on an important topic is potentially damaging to WP's credibility. I have no intention of 'interfering' with the good work you've all done on this article, I was just offering up something that I had hoped would be useful. --Doc Tropics ^{Message in a bottle} 18:20, 5 July 2006 (UTC)

Doc, your suggestion was an excellent one and I explained (and you heard and understood) my reasons for not taking your suggestion, at least not yet. And please do not back peddle too far, I have read some of your Wiki contributions and we can use experienced editors like you here. And I might be smoking crack, the other editors have yet to clearly chime in on the existing definition so it's possible I am the only one who finds it acceptable. Mr Christopher 18:32, 5 July 2006 (UTC)

Don't mind your using my words at all. The reason for making this kind of change (although not specifically this change) is a matter of linguistics. Precision, conciseness, and information density are all important when creating a written work. Let me give you a few examples. Here's the current entry:

Alcoholism is the use of alcoholic beverages—which contain the drug ethanol—to the extent that such use causes physical or mental harm, or interferes with the drinker's normal personal, family, social, or work life.[1][2] Such chronic use causes a diseased condition marked by psychological and physiological disorders. Most medical clinicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors and characterized by compulsive drinking with impaired control, and preoccupation with and use of alcohol despite adverse consequences. However, the disease theory is still controversial and there is disagreement on the issue after 200 years of debate. U.S. Supreme Court decisions, books and scientific journal articles demonstrate this lack of consensus.

"the use of alcoholic beverages" is imprecise on one side and too precise on the other. Use could mean rubbing it on one's skin, for instance, thus I would replace it with the word "consumption". Also, alcoholic beverages is too precise. You don't need to specify beverages when you're consuming them, and alcoholics will drink straight grain alcohol. Everclear COULD be considered a beverage, but mostly it's an ingredient to be added to beverages, kind of like sour mix but with a kick. Thus "consumption of alcohol" would be better, and save us a couple of words. When a reader has to read too many words their attention drifts and their eyes cross.

DrGitlow: I agree that "use" is vague because it doesn't necessarily mean "imbibe." I'd be all for changing "use" to "drink," "imbibe," "consume," or some equivalent. It was a quick fix a few days ago.

Also, alcoholism ISN'T the consumption of alcohol. It's the DESIRE to consume alcohol. That's the whole "dry drunk" issue. If you're an alcoholic you can't even have one drink because it leads to binge drinking. An alcoholic who doesn't drink is still an alcoholic because any amount of drinking can result in drinking until he/she's unemployed and hospitalized. The cessation of drinking does not cure a person of alcoholism.

Also, we keep stating that the use of the word disease is controversial, and yet it appears three times in the introduction. If something is controversial, you don't use the opening paragraph to drill it into people's head. The heavy debate over whether or not alcoholism is a disease is taking over this page, and it's totally useless to those who are suffering from it instead of legislating about it. Can we please get a vote about whether or not we can move it to its own page?

Also, you're trying to pack too much information into the first paragraph, meandering over various points which are in heavy contention. The purpose of the first paragraph of a wiki article is to give the reader an operational explanation of what the topic is, not gloss over what everybody thinks about it. All of the arguments about alcoholism involve categorization, and we can get into the debates about alcohol later in the article. For the first paragraph we should provide a description of its functional impact on an alcoholic.

Thus, I would edit the first paragraph to read:

Alcoholism is a craving for alcohol that encourages the drinker to consume it beyond the point where it causes physical harm or interferes with the drinker's family, social, or work life. It is characterized by heavy drinking, but persists indefinitely even after an alcoholic maintains abstinence.

You'll notice that I completely skipped over trying to categorize it as a disease, addiction, or even a health condition because that's not nearly as important as describing it functionally. Also, I didn't specify what kind of alcohol because craving rather strictly implies consumption, and there's only one kind of alcohol we consume. In fact, ethyl alcohol is though of as the "default" alcohol, all other forms of alcohol requiring specification. We can link it to the ethyl alcohol page if people need further specification.

In the pre-Gitlow article the next section explained the terms used to describe alcoholism so that the rest of the article made more sense. The addiction article is useful, but it's necessary to break out the various forms of addiction within this specific article because alcoholism is the result of a collection of them, all of which must be treated individually. A casual reader is very likely to just gloss over a link to addiction and assume that they understand what it means.

Following that, I had it arranged (yes, that was my work) so that it progressed through the details of alcoholism in the order that they tend to impact an alcoholic and/or his family. I believe that the order was health problems, social problems, treatment options, societal impact, and political issues. Various ways to identify if you're an alcoholic would have been the first section of treatment options, but theoretically the descriptions under health and social problems would provide the reader with enough background to decide if it's worth it going off site to take a test.

When continuing the editing of this article, please keep in mind that we should be creating an article with content that is of value to the reader, not what you personally want the reader to know. Robert Rapplean 19:14, 5 July 2006 (UTC)

Here is my take on the existing paragraph sans the debate piece (which I think is not in the correct location):

Alcoholism is the use of alcoholic beverages—which contain the drug ethanol—to the extent that such use causes physical or mental harm, or interferes with the drinker's normal personal, family, social, or work life.
Mr Christopher: This is acceptable to me, and I suppose we could change the "use" to consumption, but I really think anyone reading it will know we're talking about drinking alcohol and not rubbing it on our arms. This seems NPOV to me and there is nothing subjective about it.

Robert: Can anyone point me to a text that states that a drinker needs to be actively drinking in order to be an alcoholic? To my knowledge, there is no dividing line for abstinance at which a person suddenly stops being an alcoholic. The "which contain the drug ethanol" is entirely superfluous and breaks the flow of the statement.

Such chronic use causes a diseased condition marked by psychological and physiological disorders.
Mr Christopher: This is acceptable to me. Alcohol can cause all sorts of verifiable medical conditions. This seems NPOV to me and there is nothing subjective about it.

Robert: I disagree with this because it states that chronic consumption of alcohol automatically results in "a diseased condition". This is equivalent to stating that alcholism is a disease, which violates NPOV. We could replace this with "Such chronic use can result in many physical and mental health conditions." Be sure when you write this statement that you maintain cause and effect "alcoholism" causes "overuse" causes "health conditions". Short term alcoholism among the young and otherwise healthy mostly just causes gastritis and sleeping problems.

Most medical clinicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors and characterized by compulsive drinking with impaired control, and preoccupation with and use of alcohol despite adverse consequences.
Mr Christopher: Again, I think this is a reasonable sentence. This seems NPOV to me and there is nothing subjective about it.

Robert: I'm ok with the content, but feel that the very fact that you have to include "most" as the first word suggests that it should be de-emphisized to a later paragraph.

Mr Christopher: Some points you made which I do not wish to debate with you or anyone else but I feel they are highly subjective and invite debate/contention:

Alcoholism is a craving for alcohol that encourages the drinker to consume it beyond the point where it causes physical harm or interferes with the drinker's family, social, or work life.
Mr Christopher: "Craving" is a subjective term in this context and we'll be debating a definition for it as well. In this context one does not have to even drink alcohol to be an alcoholics, they just need to "crave". This seems highly subjective to me.

DrGitlow: The use of the term "craving" doesn't work though because alcoholics don't generally have craving the way opioid addicts do. In fact, one of the reasons the World Health Organization didn't recognize alcoholism as a disease back in the 50s was because craving was one of the defining points of addictive disease (and alcoholics don't have that). Ask an alcoholic who has relapsed why he relapsed and he will generally say it was an impulsive action based on availability or proximity. That differs from opioid dependent folks who acknowledge craving. (Since the '50s, the WHO changed the requirement for craving for addictive diseaes and added alcoholism to the category).

Robert: Ok, let's roll with the idea that "craving" is subjective. I've also used "desire", and you've used "preoccupation". Any of these would work for me.

What's the difference between window cleaner and alcohol? An alcoholic can forget that window cleaner exists. Personally, I have about fifty bottles of alcohol in my basement, but I forget they exist unless something reminds me of them. Alcoholics can't do this. It's part of any recovery program to dig out all of the bottles that an alcoholic has hidden away and get them out of his reach.

Answer me this: If there's no craving, why can't he ignore a bottle of alcohol the way he can ignore a bottle of window cleaner? The level of effort an alcoholic has to go to to get his hands on alcohol is certainly a factor in relapse, but if an alcoholic doesn't crave alcohol, why does he ever drink it again?

Go to an AA meeting and ask 100 people to tell you about their last relapse. The story you'll hear repetitively will be one like these...I was in my apartment and I found an old bottle of bourbon that I'd hidden in the back of the closet; I was walking down the street and suddenly found that I was in front of a bar where I used to hang out; I went out with some new colleagues from work and they all ordered wine with dinner. Those are different stories than the ones you'll hear if you went through the same exercise at NA where the people who relapsed did so because they actively sought out the drug even after a period of abstinence. I'm not saying this is true 100% of the time, but I think it's reasonably accurate. The alcoholic drinks again for many reasons: he/she wants to be "normal," and everyone "normal" seems to drink alcohol from time to time; he/she is uncomfortable, unhappy, stressed out, irritable, and realizes that alcohol will help all those feelings go away if only for a little while; it's a recognition that alcohol will help you feel better as opposed to the type of craving one might have for food if you haven't eaten in 1-2 days. Drgitlow 01:40, 7 July 2006 (UTC)

It is characterized by heavy drinking, but persists indefinitely even after an alcoholic maintains abstinence.
Mr Christopher: No offense, Robert, but this sounds very AAish to me ("persists indefinetly"). Again, I find it highly subjective and think it invites debate/contention.

Robert: I only know people for whom the desire to drink has persisted for about five years. I'll have to see if I can dig up a few abstinant alcoholics who can give me a better long-term view of the experience. I do know, however, that the inability to drink even small amounts without danger of overdrinking persists indefinitely.

Mr Christopher: And we'll also have to define "heavy drinking" and who's definition shall we use for that? Fingarette's? And fellow editor Drgitlow has suggested "heavy drinking" is not a sign of alcoholism (at least I think so, correct me if I am wrong Stuart).

DrGitlow: And thanks, Chris, yes, heavy drinking isn't required for the diagnosis, nor does heavy drinking mean that one has the diagnosis. And the definition of "heavy" of course varies depending on gender, weight, age, and overall medical status, so it's not a useful term either diagnostically or educationally.

Robert: Ok, I'll retract the "heavy drinking". That was a spur of the moment characterization based on various studies, which generally define it something like "five or more drinks on one sitting, or drinking on five or more occassions in one week", but again that's subjective. We could use "chronic consumption of unhealthy amounts of alcohol", and possibly point to the section somewhere below which lists the side-effects of overconsumption of alcohol.

Mr Christopher:So, to me, the existing definition (without the debate piece) is less subjective and less prone for debate and having to define additional terms. You have made some very good contributions to this article and although I have not responded to all your comments, I have read them all. I am only one editor here but I think the existing definition is far less subjective and therefore will best serve our readership.

Robert: I've broken it down into individual points of contention, with point and counter point. I'm looking for additional input.

FOLLOW UP: I can see where some might object to this piece in the existing definition:

• Most medical clinicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors and characterized by compulsive drinking with impaired control, and preoccupation with and use of alcohol despite adverse consequences.

Unless we cite a poll that indicates most clinicians think alcoholism is a disease we're not presenting a NPOV. To me this is the only sentence that has some subjectivity to it and I would therefore suggest we work on that single sentence. Again, this my take on it. Mr Christopher 20:46, 5 July 2006 (UTC)

We do have that 2001 article that Medical Man brought up in which 82% of docs said alcoholism is a disease, so we could use that as a citation to meet Chris' point above if we decide that's the direction we all want to go.

It's nice to see some new names here. I think we've made some wonderful progress lately but the more input the better. I think we can end up with an article that really addresses the key features of alcoholism while creating some sections within which all perspectives can be explained.

Drgitlow 23:02, 5 July 2006 (UTC)

Request For Editorial Consensus

For now, can we agree or disagree on the following two initial sentences of of the existing definition:

Alcoholism is the use of alcoholic beverages—which contain the drug ethanol—to the extent that such use causes physical or mental harm, or interferes with the drinker's normal personal, family, social, or work life.[1][2] Such chronic use causes a diseased condition marked by psychological and physiological disorders.

Please show your approval or disaproval with your signature thusly:

• Approve <signature>
• Disaprove <signatue>

Indicate your position below this line

---

• approve Mr Christopher 23:15, 5 July 2006 (UTC)

I am not changing my "vote" but ethanol seems to be the hot topic so I thought it's worth mentioning I have already expressed my concern about ethanol and I'd be in favor of seeing it go. It could prove to be relevant elsewhere else but not in the definition. Mr Christopher 04:29, 6 July 2006 (UTC)

• Approve - relatively clear and concise, but hits the most important points. Well done :) --Doc Tropics ^{Message in a bottle} 23:55, 5 July 2006 (UTC)

Comment: after reading later contributions I agree that the hyphenated ethanol statement could be deleted or moved to help maintain continuity. --Doc Tropics ^{Message in a bottle} 03:58, 6 July 2006 (UTC)

• Approve Medical Man 01:44, 6 July 2006 (UTC)
• Approve (am OK with either "use" or "consumption")(am also OK either keeping or removing the hyphenated statement about ethanol) Drgitlow 03:52, 6 July 2006 (UTC)
• Disapprove Robert Rapplean 07:05, 6 July 2006 (UTC) I believe that the current first sentence fails to differentiate between a person who hasn't figured out that alcohol is harming them and a person who knows that it's harming them but can't quit on their own.

Oops, Robert. I earlier missed your comment about the "--which contains the drug ethanol--" being unnecessary and breaking the continuity of thought, to which I totally agree. Therefore, I don't think the current first two sentences are completely acceptable. I apologize.Medical Man 03:12, 6 July 2006 (UTC)

Medical Man, are you changing your previous "agree" to "disagree"? It's not clear to me in your comments, I'm cool either way, no need to apologize, I just want to make sure we're on the same page. And if that is the case I'd be hip to you changing your approval above and adding a comment like "previously agreed" or something for clarity.

Chris- Thanks for your understanding. I don't want to slow up the good progress that's recently been made and I think drgitlow's suggestion below neatly solves the problem.Medical Man 15:49, 6 July 2006 (UTC)

Robert, I read your latest comments and agree with you on much of it. I do not believe this will be the final word on the definition but to me it will give us a "beta" version, one that isn't exactly the way I would personally write it but it does not offend the senses. I view it as a editorial compromise that does not compromise the integrity of the article. I think the average reader would find it sensible. I agree it is imperfect and if we fail (in this round) to get consensus on the first two sentences we'll simply try again. Mr Christopher 04:08, 6 July 2006 (UTC)

I want to be clear, I was mainly taking about the first two sentences in my comments to you above, Robert Rapplean. Since that is what I am currently proposing we agree or disagree on. I too have some issues with some of the rest of it that I'll view and seek comments on after we decide about the first two sentences. Sorry if I seem anal, just wanting to be clear. Mr Christopher 04:12, 6 July 2006 (UTC)

I agree the "which contains the drug ethanol" breaks up the sentence badly, but something in reference to "drug" or "ethanol" or "Effects of alcohol on human body", or whatever that article is called, should remain. —Centrx?talk • 07:23, 6 July 2006 (UTC)

Centrx, I agree in that that ethanol belongs at least somewhere in the article. Since this seems to be an editorial sticking point, at least as it is currently written and in the opening sentence/definition, would you feel comfortable if we either put it elsewhere in the article or put it on ice for the time being where we can revisit the merits of it being in the opening definition later? And by the way, you're being an exception sport about us all sitting here nitpicking your handy work. I appreciate it. Mr Christopher 15:05, 6 July 2006 (UTC)

FYI there is some good stuff on ethanol in the Alcoholic Beverage article! Mr Christopher 15:17, 6 July 2006 (UTC)

It's unfortunate that alcohol is a generic term that refers to a variety of chemical substances that include ethanol, when really the only one we're concerned with here is ethanol. I suppose a more precise term would be Ethanolism. I don't suppose we could be single-handedly responsible for changing the terminology (though we could certainly try). Given that alcoholism is really talking only about ethanol use (consumption), it seems that we could change the first line to read "Alcoholism is the consumption of ethanol-containing beverages to the extent that such use...." Drgitlow 15:22, 6 July 2006 (UTC)

I agree with drgitlow's suggestion, which is both accurate and solves the problem.Medical Man 15:49, 6 July 2006 (UTC)

I don't want to be a stick in the mud but it still seems odd to me. In view of what FloNight added below, and as a compromise, how would you folks feel about us not putting the ethanol portion in the definition section, but instead make it the subject of the section following the definition where we could elaborate on the subject? So in effect we'd have

• Alcoholism - here is our handy definition of alcoholism - yadda yadda
• Alcohol - this is what constitutes alcohol, the key term here would be ethanol (yadda yadda).

Does that seem reasonable? Mr Christopher 16:55, 6 July 2006 (UTC)

To address my most recent comments, there is good stuff about ethanol on the alcoholic beverages article, but sadly it is not well cited. Stuart, on the ethanol topic I'd lean towards us handling it in a similar fashion on the alcoholic beverages article. Obviously I want to cite it better than what we see there but I think giving ethanol it's own section (within the article, not a spin off) makes sense to me. Mr Christopher 15:28, 6 July 2006 (UTC)

As for specialized terminology, we can still use the word "alcohol" rather than "ethanol", and either link it to Ethanol or to Effects of alcohol on the body. To clarify though, don't let this argument hold up the process of streamlining the introduction by removing this clause, at least temporarily. —Centrx?talk • 21:32, 6 July 2006 (UTC)

Regarding the nature of alcoholism

Question for Robert: You're right, it doesn't address that issue at all. I know that the distinction is important, but do you think it's absolutely necessary to address it in the very first sentence? I'm a fanatic about preserving useful information and I don't think anyone is suggesting that this point be excised, just shuffled around a bit. Could we, for the sake of our Hypothetical Reader, simply clarify that point later in the article? I'm hoping that if we can achieve even a general consensus on the intro it will give us a fresh start on collaborative editing and help the article move forward :) --Doc Tropics ^{Message in a bottle} 16:12, 6 July 2006 (UTC)

I'm afraid this is a bit of a sticking point with me. This definition states that drinking=alcoholism. If that were the case, there would be no studies which measure time until relapse. Once you stop drinking, you'd be cured. Because of this, I think that the first sentence dangerously mischaracterizes the problem.

The essential problem with alcoholism isn't that the alcoholic drinks. The problem is that they can't stop drinking. It's the urge to drink regardless of obvious consequences that identifies an alcoholic, not the actual consumption. This is an essential fact about alcoholism that must be understood for a person to understand alcoholism. I'll go even further to say that this is one of the biggest misunderstandings in the public regarding alcoholism, and results in the greatest amount of mistakes in its treatment outside of the medical field. I'm afraid I can't accept any description that doesn't address this. Robert Rapplean 17:11, 6 July 2006 (UTC)

Thanks for taking the time to make such a thorough reply; I understand and respect your postion on this. Flonight has given us an excellent guideline in a new section just below this. Let's try to find an intro that will satisfy everyone, but still be accessable to an "average" reader. To help get started can you give us an example of what you think would be a better wording for the intro? Since it seems that the rest of it is (mostly) acceptable to everyone, can we still use that as a framework and just add the necessary distinction? --Doc Tropics ^{Message in a bottle} 17:38, 6 July 2006 (UTC)

I think this can be achieved with a very minor change, thus:

Alcoholism is the urge to consume alcoholic beverages to an extent that results in physical or mental harm, or interferes with the drinker's normal personal, family, social, or work life. The resulting chronic use can result in many psychological and physiological disorders.

Opinions? Robert Rapplean 18:27, 6 July 2006 (UTC)

• Approve - This version seems to incorporate the suggestions made in discussions of the previous version and it seems very readable to me. I tried to bluelink "chronic", "psychological" and "physiological", but the results were non-useful and I didn't save that copy. --Doc Tropics ^{Message in a bottle} 18:58, 6 July 2006 (UTC) Addendum - I tried to bluelink from this page but didn't get the tags right. The bluelinks from the article page are good. --Doc Tropics ^{Message in a bottle} 19:07, 6 July 2006 (UTC)

Comment - I have temporarily stricken my Approval pending resolution of Mr Christopher's concerns (see below).

The opening sentence has two cites for reliable sources, those sources are other online encyclopedias. It's worth noting neither of them use the term "craving" or "urge" in their definition of alcoholism. Those references are well worth reading and are pretty NPOV in my opinion (at least the definition, they get a bit goofier as they go deeper in the subject). Robert, what reliable sources do you have to support this sentence you are suggesting? And as far as my own opinion goes, I am not in favor of using terms like "urge" or "craving" in the opening definition and feel things like urges and cravings (and things like the idea of time abstinence) belong elsewhere in the article. If you have not already, I really suggest folks read the two existing references and see exactly how other online encyclopedias handle this subject. My $.02. Mr Christopher 18:50, 6 July 2006 (UTC)

Ok, let's do some citing. NIAAA attempts to explain craving mechanisms, American Academy of Family Physicians describes craving as a symptom, Alcohol Craving in Problem and Occasional Alcohol Drinkers from the Oxford Journal of Medicine, What Is Craving? Models and Implications for Treatment from Alcohol Research & Health, Fall, 1999. I have to admit that this entire argument has caught me rather flatfooted. It's almost like trying to explain to people that pain is a symptom of a broken leg. Where would you go to cite articles about that? If alcoholics don't crave alcohol, why is it so hard for them to stop drinking? Robert Rapplean 20:09, 6 July 2006 (UTC)

Now we come to the heart of the matter...Robert made a wonderful comment above: alcoholism is NOT about the fact that the alcoholic drinks. Here's the best part, though: it's not about the alcohol at all. What I'm about to say isn't what I'm looking for the article to say; it's mostly opinion. Alcoholism is a condition in which the disease is all about the individual's discomfort when they're NOT drinking, discomfort that is so omnipresent and harsh that when the individual discovers that alcohol helps them feel better, albeit briefly, they continue to drink despite the hardship that such use brings. That's what leads to what I always tell alcoholics at their intake visit: once you stop drinking, then we'll start treating your alcoholism. That's when we'll be able to work on getting you to feel better.

Done with opinion now. I'm really sincere about our need to stay away from the term "craving." Although you WILL be able to find plenty of citations in which educated scientists speak of craving and alcohol in the alcoholic, for the most part such studies come from people who were originally trained in opioid dependence, or who don't distinguish among the various addictive conditions. Those of us who focus in the sedative/alcohol dependence world recognize that the sedative/alcohol dependent patients don't have "craving," at least not in the way that most people would define the term. Alcoholics use impulsively or chronically but not out of a craving. Drgitlow 23:30, 6 July 2006 (UTC)

Common ground

I think we're very close to something useable and it's just a matter of a couple of words. Let's try to find the common ground between these two:

1. Alcoholism is the consumption of alcoholic beverages—which contain the drug ethanol—to the extent that such use causes physical or mental harm, or interferes with the drinker's normal personal, family, social, or work life. Such chronic use causes a diseased condition marked by psychological and physiological disorders.
2. Alcoholism is the urge to consume alcoholic beverages to an extent that results in physical or mental harm, or interferes with the drinker's normal personal, family, social, or work life. The resulting chronic use can result in many psychological and physiological disorders.

What about this:

• 3. Alcoholism is the consumption of, or preoccupation with, alcoholic beverages to an extent that such use causes physical or mental harm, or interferes with the drinker's normal personal, family, social, or work life. The resulting chronic use can result in many psychological and physiological disorders.

Opinions? --Doc Tropics ^{Message in a bottle} 20:23, 6 July 2006 (UTC)

Note that "addictive medical condition" is one of two major meanings, the other being "chronic excessive drinking". A person who no longer drinks could be considered an "alcoholic" under the first meaning, while a frequent, heavy, deleterious drinker who does not appear to satisfy the medical diagnosis can still be considered an "alcoholic" under the second meaning.

Clearly, it seems that the medical diagnosis is currently prevalent in the field, but the fact remains that all general sources do include that other meaning and it is not necessarily clearcut to distinguish between the two.

The primacy of the medical diagnosis may also be a recent phenomenon: The OED, 1989, whose definition appears to be primarily based on the 19th-century meaning, has alcoholism: "The action of alcohol upon the human system; diseased condition produced by alcohol." All of the quotations, spanning 1852 to 1882, indicate the "excessive drinking" meaning, not the "addictive medical condition" meaning. If the article is to be specifically about the modern medical definition, then that needs to be explicitly stated, and the other definition still warrants mention as it is the origin of this meaning. —Centrx?talk • 21:53, 6 July 2006 (UTC)

It sounds like we need to add a section for "Historical treatments of Alcoholism", or maybe "Historical views of Alcoholism". It seems reasonable that the main article would deal with contemporary views, but there is a lot of historical info that would be interesting and useful. --Doc Tropics ^{Message in a bottle} 22:18, 6 July 2006 (UTC)

There's no question that alcoholism has been redefined over the years. One of the reasons for the 1992 JAMA article was as an attempt to bring consensus to an area that had previously been fraught with multiple perspectives. If anyone had said that there's poor consensus in defining alcoholism, I'd be the first to agree. Still, I think it is reasonable for us to use more recent definition sources, at least for the first paragraph, then potentially explore earlier ones later in the article. The '92 definition does not talk of excessive use or of craving or of urges. The first paragraph above labelled "1." works. So does the third one, because preoccupation is spoken of in the DSM-IV definition. The second one doesn't quite fit. When you get right down to it, alcoholism is the repeated use of ethanol despite one's best interests. But we can't really say that, can we? Drgitlow 23:38, 6 July 2006 (UTC)

Heh, heh...if we could write the whole article at that level we'd be done in an hour. It seemed that there were hang-ups with both versions 1 and 2 so I tried to distil the commonalities into #3. --Doc Tropics ^{Message in a bottle} 00:40, 7 July 2006 (UTC)

I think you did an excellen job, Doc. Does everyone else find definition #3 to be acceptable?Medical Man 01:15, 7 July 2006 (UTC)

Agreed! Yes. Drgitlow 01:30, 7 July 2006 (UTC)

Agreed! (#3 is excellent and has my full support) Mr Christopher 14:34, 7 July 2006 (UTC)

Agreed. Robert Rapplean 23:35, 7 July 2006 (UTC)

Needless to say, I'm thrilled that we seem to be achieving something like consensus on this. I'm just waiting to hear from R. Rapplean before making any changes to the article itself. I'd also like to hear from Centrx, but he's a busy guy and his contributions may be infrequent. My thanks to all of you for being willing to work together and compromise for the sake of the article. --Doc Tropics ^{Message in a bottle} 15:38, 7 July 2006 (UTC)

In a brief exchange on his Talkpage, Centrx?talk expressed "no serious objections" to the proposed intro and suggested that we might as well proceed. I'm going to make the change in the article now, but if anyone, especially Robert Rapplean (who didn't have a chance to comment yet) does have a serious objection, then we can revisit it. Otherwise, I think we're ready to tackle the next sentence :) --Doc Tropics ^{Message in a bottle} 18:06, 7 July 2006 (UTC)

As mentioned I am in favor of door number three, but based on the history of this article, I'd really like to get Robert's opinion/buy off on this prior to making any changes. Again, based on the history until Robert buys off I do not feel we have consesus and for us to make changes without his opinion, if nothing else, looks bad. Mr Christopher 18:21, 7 July 2006 (UTC)

Sorry for taking so long to get back to this - had a bit of a busy 24 hours. I believe that this is a workable compromise, although I'm not the least bit opposed to "alcoholism is the repeated use of ethanol despite one's best interests". We could fill in the details in later sentences. Robert Rapplean 23:35, 7 July 2006 (UTC)

Thanks Robert. I agree that we can fill in the details later in the article, both on that, and other topics as well. I think this constitutes "full consensus" for our little workgroup (O we band of brothers) so I'll go ahead and make the change. --Doc Tropics ^{Message in a bottle} 23:40, 7 July 2006 (UTC)

"Marked by...disorders" means both that it results in these disorders, but also that it can be caused by these disorders, such as with a depressed person using alcohol to drown his sorrows. That is, the disorders may be found together with alcoholism, not only as a direct result of it. —Centrx?talk • 01:16, 8 July 2006 (UTC)

Manual of style: lead section

Manual of style, a guide not a policy suggests:

In general, specialized terminology should be avoided in an introduction. Where uncommon terms are essential to describing the subject, they should be placed in context, briefly defined, and linked.

Thought this might help. You all are making real progress. Keep up the good work. --FloNight ^talk 15:40, 6 July 2006 (UTC)

Intro, second half

I'll copy in the remainder of the intro below this (I took the liberty of bluelinking "disease"). I wanted to offer an observation about cites: Cites are a good thing in any article and a necessity in a complex article, but the presence of 7 cites at the end of a single sentence suggests that a rewrite might be in order for the sake of clarification. Regarding the actual content of these sentences, I have no problems with what's being expressed there, but this is where your collective expertise is so important: is there a general consensus that this is a good representation of the issue?

• Most medical clinicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors and characterized by compulsive drinking with impaired control, and preoccupation with and use of alcohol despite adverse consequences. However, the disease theory is still controversial and there is disagreement on the issue after 200 years of debate. U.S. Supreme Court decisions, books and scientific journal articles demonstrate this lack of consensus.

Yes, why don't you pare down the references to what you think appropriate. Thanks,Medical Man 18:58, 7 July 2006 (UTC)

I'm going to be in a meeting for the rest of the afternoon, but I'll check in this evening. If no one else has started by then I'll have a go at it. If all 7 cites are necessary (I haven't read through all yet) then I would look at simply re-arranging things so that it's a bit tidier. My initial thought is that having more than 2 cites per statement ends up confusing rather than clarifying the issue. --Doc Tropics ^{Message in a bottle} 19:14, 7 July 2006 (UTC)

Gentlemen, I do not feel we have consensus yet on the first section/sentence yet that sentence has now been changed in the article which puts Robert in an awkward position should he object to it. I can't speak for Robert and I think "preoccupation" is an excellent compromise but he has yet to chime in and has expressed specific concerns regarding the opening sentence/para. Respectfully, can we wait for consensus on the first section before pressing on to the next? Mr Christopher 19:24, 7 July 2006 (UTC)

No problem. And I don't think Robert should feel diffident about voicing any objection(s) he might have.Medical Man 20:09, 7 July 2006 (UTC)

My apologies if I jumped the gun. I reverted myself until we have full consensus. --Doc Tropics ^{Message in a bottle} 20:53, 7 July 2006 (UTC)

Thank you both :-) Mr Christopher 20:55, 7 July 2006 (UTC)

While waiting for RR to get back to us, I followed the link to MOS which Flonight provided for us (above) and based on the guidelines there, I have a sketchy proposal for the second half of the intro (not even the actual words yet; just an idea about what needs to be there):

1. Trim down what we have now to simply mention the epidemiology/controversy exists. Save all the details for the main body of the article.
2. New sentence re: diagnosis and treatment. As above, this should be a brief mention without going into details.
3. New sentence re: societal impact, politics and public health.

This is just my first thought after reading through things again. Any input? --Doc Tropics ^{Message in a bottle} 23:28, 7 July 2006 (UTC)

Let me back up a little and rewrite this (without compromising my thoughts at all) segment. Obviously, there will be disagreement and we'll need to compromise...one problem here is the definition of "medical." Rather than trying to define that, I'd stick with using terms like "physicians." The other problem is this whole "controversial" thing. I know MM has posted extensive references to there being a controversy, but even the Supreme Court isn't a medical resource and the other evidence cited is not from peer-reviewed literature in the medical field. The fact that sociologists have a different perspective is important to underscore. The fact that the legal system has a different perspective is also an important area to cover. But we shouldn't confuse people into thinking that their physicians are uncertain or are still arguing about something that they've long ago agreed upon. That's been my whole gripe from the start. MM has made clear to me how extensive the controversy is, but it still hasn't crossed the line from the lay public into the physician community.

Here's where we're starting:

• Most medical clinicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors and characterized by compulsive drinking with impaired control, and preoccupation with and use of alcohol despite adverse consequences. However, the disease theory is still controversial and there is disagreement on the issue after 200 years of debate. U.S. Supreme Court decisions, books and scientific journal articles demonstrate this lack of consensus.

I'd go here:

• Addiction Medicine specialists consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors (I'd leave out the rest of the sentence because we just gave the definition in the last paragraph). However, the disease theory is still controversial outside the physician community and there is disagreement on the issue after 200 years of debate. U.S. Supreme Court decisions, books and scientific journal articles demonstrate this lack of agreement.

Drgitlow 23:43, 7 July 2006 (UTC)

I actually think that the 3rd sentence is essentially "details" that should appear in the main text rather than intro. I'm also wondering if we can "dumb-down" the first category a bit; I'm not at all sure an average reader will grok Addiction medicine specialists and WP doesn't have a page by that name to explain it. What about this:

• While Addiction Medicine specialists consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors, the disease theory is not universally accepted, and still considered controversial by some practicioners, even after 200 years of research and debate.

I'm not convinced I'm giving enough to each side here, but I've got a pretty thick skin, so go ahead and slap me around :) --Doc Tropics ^{Message in a bottle} 00:07, 8 July 2006 (UTC)

Healthcare professionals, Physicians, Addiction Treatment Professionals, Addiction specialists, Doctors, Clinical specialists in addiction, Clinicians, Addiction Therapists, Addiction Counselors...every one of those is a different group of people, but I provide this list just so we can pick and choose what we want to say. Addiction medicine specialists are board-certified addiction specializing physicians, just as Family Practitioners are physicians who are board-certified in Family Practice. But I think you're right that it's not a known entity like Internist or Surgeon or Psychiatrist. Even within medicine, many doctors think that addiction specialists are psychiatrists...they're not. About 40% of addiction specialists are indeed psychiatrists but the rest aren't. You're just trying to get me to start a new article on Addiction Medicine, aren't you?! :) Drgitlow 00:54, 8 July 2006 (UTC)

(Couldn't resist...started an Addiction Medicine page!) Drgitlow 01:00, 8 July 2006 (UTC)

LOL, it worked didn't it? I've added the shiny new bluelink and changed my contrib to match. --Doc Tropics ^{Message in a bottle}

I do not know if it is accurate, but a previous argument was that physicians agree on 'disease' but that alcoholism counselors were much more divided? —Centrx?talk • 01:22, 8 July 2006 (UTC)

That's roughly the impression I have at this point, but I'm waiting to hear more from the actual experts. --Doc Tropics ^{Message in a bottle} 02:16, 8 July 2006 (UTC)

I'd like to make the following observations:

• It doesn't seem accurate to say that "physicians agree" that alcoholism is a disease given the fact that at least one in five doesn't agree and with some evidence that the proportion of those who disagree may be higher. I think we could honestly say that the majority agrees.

• It would seem to be incorrect to assume that the AMA speaks for American physicians. Its membership has declined over the years and is currently only about 244,000 of the 800,000 active US physicians. At best, it can be said to speak for only about 30.5% of active US physicians.

• If we get too narrow in our reference group and report something like "X% of American psychiatrists whose practice is primarily devoted to treating alcoholics define alcoholism as a disease...," then we've provided an unintentionally misleading definition for readers.

• I think the evidence supports a statement to the effect that smaller proportions of other treatment professionals accept the disease concept. If we try to be too specific about different categories within that rubric (see Drgitlow's list above and his observation about physician confusion about who does what to whom) we'll complicate matters and confuse readers -- and perhaps ourselves!

Here’s a suggested revision based on Drgitlow’s draft: Most physicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors. The disease theory remains controversial, however, especially outside the physician community and there is disagreement on the issue after 200 years of debate. Medical Man 03:40, 8 July 2006 (UTC)

Wow MM, great input and many excellent points! In fact, they tie in neatly with something I wanted to bring up. There is some heated discussion on WP regarding systemic bias and "U.S.-centrism" in our articles. I think that the more we can "globalize" this article the wider its appeal will be. I'm not suggesting something silly like dropping all cites from the AMA...but maybe we could avoiding referencing too many American organizations in the main text, or try to tie-in with some international organizations. This is just a little something to think about, I don't see it having a major impact either way. Your latest revision of the intro looks good to me; the syntax of the second sentence seems a little awkward because it has been revised so many times, so I might suggest a minor tweak there. Otherwise, I'm good with it! And I'm putting it in bold below this so it doesn't get lost. --Doc Tropics ^{Message in a bottle} 04:02, 8 July 2006 (UTC)

Thanks, Doc. I'm surprised that there's controversy about the obvious US-centric focus of most articles. In the controversies section of our article we can mention the fact that the disease theory generally receives less support in many other parts of the world. This pan-world matter is something we may want to keep in mind as we work on the piece.Medical Man 16:27, 8 July 2006 (UTC)

• Most physicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors. The disease theory remains controversial, however, especially outside the physician community and there is disagreement on the issue after 200 years of debate. Medical Man 03:40, 8 July 2006 (UTC) reposted by Doc Tropics ^{Message in a bottle} 04:04, 8 July 2006 (UTC)

Medical Man is absolutely correct to say that while the AMA may be the "voice" of American Medicine, it no longer has adequate membership to put the necessary oomph into its message. That said, the way the AMA develops policy is through a representative system made up of delegates from medical state and specialty societies. THOSE societies have much greater membership, and the specialty societies are probably much closer to 100%. So the AMA policy was established based upon a vote of the delegates from the other societies, not internally by its own members. One of the really strange things about the AMA is that if you're an AMA member but NOT a member of a state or specialty society, you actually have no voice at all within the AMA policy-making body. Another oddity is that the AMA could have no members at all yet would still represent American Medicine due to its house of delegates. That's a big reason why the AMA remains a powerful lobby in Washington (for good or bad) despite their primary membership being what it is.

I disagree with Medical Man's statement about physicians in which he notes that at least one in five doesn't agree. That was the result of a single non-random survey and an unvalidated source. I'm not saying it's not possible that the survey results aren't representative of physicians in general, but I'm saying it's highly unlikely. The type of survey that was conducted is the usual step that might be taken prior to conducting a research-oriented random survey.

But...and here's the best part...I'm pretty comfortable with MM's suggested revision. I'd probably amend the last sentence slightly to read: The disease theory remains controversial primarily outside the physician community, where there is disagreement on the issue after many years of debate. Drgitlow 04:05, 8 July 2006 (UTC)

• Medical Man 03:40, 8 July 2006 (UTC) reposted by Doc Tropics ^{Message in a bottle} 04:04, 8 July 2006 (UTC) and by Drgitlow 04:07, 8 July 2006 (UTC)

I would like to propose a one word edit to Drgitlow's streamlined revision:

Most physicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors. The disease theory remains controversial primarily outside the physician community, and there is disagreement on the issue after many years of debate. Medical Man 16:27, 8 July 2006 (UTC)

By the way, is it at all controversial that alcoholism falls into the addiction category? Don't we want to say that alcoholism is one of the addictions, and that most physicians also consider it a disease? Or is that getting way too picky? Drgitlow 04:10, 8 July 2006 (UTC)

Heh, heh, I would not have said "...way too picky", but now that you mention it... :) Seriously, remember that our Hypothetical Reader has (at best) a high school education. As long as we can communicate the basic ideas in an understandable manner we'll be doing good. I'm quite content to go with either your version, or MM's, unless someone else wants to incorporate more changes into either one. --Doc Tropics ^{Message in a bottle} 04:18, 8 July 2006 (UTC)

Drgitlow, I think your hunch that the point might be a little too involved (I won't say picky) is correct. Perhaps that would be one of the many controversies discussed elsewhere in the article.Medical Man 16:27, 8 July 2006 (UTC)

I am going to make a suggestion in a new section below this one. This will in no way compete or take away from the existins tactical discussion you folks are having here. 06:02, 8 July 2006 (UTC)

Doc, I agree that we try to keep potential readers in mind. As you indicate, their reading level may not be so high as we might assume. We will probably have failed is we don't accurately and effectively communicate with most readers, many of whom will probably be junior and senior high school students.Medical Man 16:27, 8 July 2006 (UTC)

I'm comfortable with MM's edit of the two sentences above. Drgitlow 18:05, 8 July 2006 (UTC)

So what we have so far is:

Alcoholism is the consumption of, or preoccupation with, alcoholic beverages to an extent that such use causes physical or mental harm, or interferes with the drinker's normal personal, family, social, or work life.[3][4] The resulting chronic use can result in many psychological and physiological disorders. Most physicians consider alcoholism an addiction and a disease influenced by genetic, psychological, and social factors. The disease theory remains controversial primarily outside the physician community, and there is disagreement on the issue after many years of debate.

I'm going to recuse myself of this portion of the discussion. I believe I've already more than adequately made my point that the disease discussion is a categorization of the problem, not an actual description or explanation of it, and will not significantly benefit the audience of this article. As such, it should exist as a subsection, or even in a separate article. That said, I believe that the rest of you are well on your way to consensus and I'll leave that decision to you. Robert Rapplean 20:16, 8 July 2006 (UTC)

I am in great disagreement over the change in direction of this definition. We went from describing what alcdoholism is and somehow got side tracked into an article about doctors opinions and non-doctor opinions and we're making some all inclusive claims again. That sort of thing erodes credibility. Again, I think we'd be wise to discuss an objective othwerwise we're going to get side tracked as it appears we are doing now. Just my $02. Mr Christopher 00:38, 9 July 2006 (UTC)

That's OK...let's back up then. I think Chris and Robert have important points here. Why don't the two of you rewrite the first few sentences to satisfy your point about our being sidetracked. If I understand, the first two sentences are OK, and then the next two need to be removed from the intro, with the topic revisited elsewhere in the article. So what should be the next two sentences of the introduction instead?Drgitlow 23:22, 9 July 2006 (UTC)

Important points to cover

Instead of attempting to hack prose, let's have a bit of brainstorming regarding what pieces of information people would want to know regarding alcoholism. I'll start it out. Robert Rapplean 18:27, 10 July 2006 (UTC)

• Is or results in uncontrollable drinking
• is not entirely under the drinker's control
• Has many causes, all of which work towards encouraging a drinker
• Has many treatments, few of which can boast high success rates
• Is very controversial
• Most people have strong opinions which prevent them from considering the whole picture (so get multiple opinions if you want a balanced viewpoint)
• Is not completely understood by anybody

I'd do this a little bit differently, as follows:

1. A functional definition of alcoholism
2. The epidemiology of alcoholism
3. The typical course of a case of alcoholism
4. Available treatment methodologies and their outcomes
5. Brief discussion of related conditions (alcohol-induced mood disorder, etc.)
6. Possible causes (and I'm putting this down lower because it's an area that has no definitive explanation and many potential explanations)
7. Controversies

It is important to recognize that nearly all disease states have extensive controversy - what is the REAL cause of juvenile diabetes, for example. You'll see extensive controversy in the scientific literature regarding the RIGHT way to progress scientific research to determine how to cure diabetes (something we haven't achieved yet because we still don't know the entire mechanism). And yet the entry about diabetes doesn't say "is not completely understood by anybody" or "is very controversial." If we're really putting together a NPOV, then it's important to truly be neutral. The medical field is as comfortable with its position on alcoholism as it is with hypertension or cancer, which is to say there is much uncertainty accompanied by confidence regarding the current approach and treatment methodologies as being the best currently available. This isn't an article about the controversies; rather it is an article about alcoholism. I'd therefore suggest that we keep the controversies but not place them throughout an otherwise well-educated entry. Drgitlow 20:19, 10 July 2006 (UTC)

I agree that we need to keep controversies in perspectives. On the other hand, I think there's good reason why there haven't been great controversies (at least beyond the research community) about juvenile diabetes. JD has no history of being considered the result of moral failure, inadequate willpower, degenerate character, or lack of religious faith. Those who suffer dibetes haven't been accused of wasting their family income, abusing their spouses, neglecting their children, costing the taxayer unnecessary expense for treatment, or engaging in violence and crime because of their disease. Concern over diabetes has never led to a national prohibition against the manufacturing, distribution or sale of sugar. And the list of differences goes on and on.Medical Man 02:55, 11 July 2006 (UTC)

On #2, Could you better define epidemiology for me? Robert Rapplean 22:49, 10 July 2006 (UTC)

Sure. Epidemiology is a branch of public health which covers the study of incidence, distribution, and control. Typical areas of epidemiologic research include the percentage of the population impacted by a given condition, the distribution pattern and possible cultural and geographic implications, the cost of not treating to the public, the cost of treating to the public, and so forth. So a typical entry for epidemiology of a disease might say: "x% of people suffer from abc, with y% of those individuals ultimately dying of their illness. A greater percentage of those in the northeast have abc than those in the southwest. It is unclear as to whether this is the result of environmental conditions or of other factors. Due to extensive complications of abc, the cost of treatment averages $z per patient per year." and so on. Drgitlow 23:13, 10 July 2006 (UTC)

The article should also address the etiology or cause(s) of alcoholism. Epidemiology is typically the first step in trying to understand a disease. However, we have much better confidence in our understanding once we know the actual physiological proceses at work. HIV/AIDS provides a good example. The first step was epidemiological; who was suffering the disease, where did they live, where did the disease spread geographically and demographically, what common characteristics did suffers have, etc. But that was preliminary. Next came research to understand the physiological processes at work. That then permitted good pharmacological research on the disease.Medical Man 02:55, 11 July 2006 (UTC)

Ok, I think we need to take a step even further back and ask who our audience is. I think we can rule out medical professionals -- they have much better references for such a thing. As such, I think that the epidemiology should be deprioritized because that's largely useful to people who have to deal with many cases of it. It shouldn't be entirely removed, though, because it is of interest to our audience from the perspective of "how common is this". We also want to include social impact, obviously, and be able to give an overview to someone who wants to volunteer to facilitate for groups that help alcoholics.

Instead of "The typical course of a case of alcoholism", can we approach that from the perspective of "How to identify alcholism"? I think that the content would be very similar, but that the later would be a question that your typical reader would want answered.

I definitely like the "available treatment methodologies and their outcomes", but as Medicine Man hinted at above, I feel that we need to first describe the many factors involved with a person's decision to drink, and that they all need to be addressed for a treatment to be effective. Can we move "Current theories on the causes" above that? We should definitely mention that the lack of ability to identify a single cause makes treatment of it very difficult and often unsuccessful. Although this information isn't firm, I think it's important to know before people consider available treatments.Robert Rapplean 17:59, 11 July 2006 (UTC)

1. A functional definition of alcoholism
2. How Alcoholism is identified
3. Current theories on the causes
4. Available treatment methodologies and their outcomes
5. Epidemiology (includes societal impact), but we should use a more reader-friendly word
6. Brief discussion of related conditions (alcohol-induced mood disorder, etc.)
7. Controversies
8. History

I don't disagree with your rearrangement, but I'm worried. How alcoholism is identified depends in large part upon how it is defined, which depends upon which model one follows. Under the medical model, alcoholism is diagnosed, fairly simply, with reference to the disease description in any of a number of textbooks (such as the DSM-IV). Those who disagree with that model, however, would have other approaches which, in some cases, don't include diagnosis at all. So we might want to go this route:

1. A functional definition of alcoholism
2. Theory 1

1. Who supports this theory
2. How to identify
3. How to treat
4. Potential complications

1. Theory 2

1. How to identify
2. How to treat

and so on until you get to the controversies section. Drgitlow 19:15, 11 July 2006 (UTC)

I only disagree with this because it suggests a false dilema about which theory is most accurate. Pretty much everyone agrees, for instance, that peer pressure and believe that alcohol consumption provides value to a person's life are definitely components in the addiction. The moral incompetence theory, on the other hand, has wide acceptance and poor scientific support. Pharmacological extinction has the reverse condition. Nonetheless, I happen to know various people who would probably fall into all three categories, and require treatment for each of them. Additionally, treatment methods don't just target a single cause. AA, for instance, goes head to head with the moral issue, and treats the neurochemical addiction by providing its members with "supplementary fortitude". Antibuse treats the neurochemical addiction via counter-stimulation when the drinker drinks. I believe that the Betty Ford clinics treat the physical dependence through detox, and provide life counciling to try to convince the person that they don't want to drink, and then teach the person how to distract themselves from the craving. Pharmacological extinction relieves the person of the craving naturally, and deals with the dependence by allowing the drinker to reduce his intake over time.

All of this means that there's significant overlap between the theories, so we can't seperate them out as cleanly as that. This is why in the original article I separated out the three forms of addiction that alcohol causes, and then was planning on describing how each treatment deals with each form of addiction. Does that make sense?

As far as "how it's defined" is concerned, I think we can stick with "continued drinking after negative consequences become obvious" and describe how to identify it from that perspective. A person who doesn't drink any more but still has the urge probably doesn't need US to tell him how to identify it. Robert Rapplean 21:57, 11 July 2006 (UTC)

And that brings us back to another key question: who are the readers that this is being written for? You're right that some people will come here because they're wondering if they're alcoholic. But others will come because they want to know what the history is of the term (which we haven't really discussed at all); still others will be concerned friends and family members looking to make sure their loved one takes the path most likely to result in improvement. That's why I think we have a responsibility to not only be fair to the Wiki methodology but also to present information in a manner most likely to be useful.

Your original approach is concerning to me only because it suggests that alcohol causes alcoholism. While alcohol is indeed a necessary ingredient without which someone could never become alcoholic in the first place, it doesn't cause the onset of the disease through biochemical or behavioral alteration. If an individual is a social drinker, we can't turn them into an alcoholic through provision of alcohol. On the other hand, if someone has never before had alcohol, we have to assume they have about a 10% chance of being alcoholic (but not knowing it because they've never had alcohol). Does alcohol turn those 10% into alcoholics? Not in a medical sense - they were there to begin with but didn't know it. But in a generic sense, perhaps one could make that argument. ??? Drgitlow 03:48, 12 July 2006 (UTC)

Ok, I've added "history" as a section for this article. I agree with your comments in that paragraph, and feel that the direction we're headed covers them. Let me know if you feel otherwise.

I'm not sure why my direction suggests that. Could you elaborate? I do feel that uncontrolled drinking is the primary indicator of alcoholism. There are others, of course, but they all stem from uncontrolled drinking. I also think that the 10% genetic propensity for alcoholism is one of the things that could truly be referred to as a disease. Call it "Alcoholism Predisposition A", or something similar in medical jargon if you will. It's only a predisposition, though, and doesn't bloom into alcoholism unless the person gets into the habit of drinking. Essentially, drinking and "AP A" must both exist in the same person for the condition to develop. How can we convey that? How medically supported is that? Robert Rapplean 15:38, 12 July 2006 (UTC)

I think the best way for me to answer that is by example. I got called once to a college fraternity identified by the school as being a place where alcohol use was "out of control." In interviewing the students, I found that nearly all of them drank great volumes of alcohol from time to time. Many of them drank with abandon during parties and at other times. Only a few (about 15%) were alcoholic, based upon repeated use of alcohol despite hardship (grades dropping below their acknowledged abilities, losing girlfriends, being put on academic probation, arrests secondary to public intoxication, etc.) and some of these individuals were drinking less in total quantity than some of their friends who had no such problems. If I had tried to diagnose these students because of uncontrolled drinking, I wouldn't have had a clue. There's no question that some of those students who drank a lot but hadn't had problems yet might end up being diagnosable, but at the time they weren't.

In my book, all those who have alcoholism have the genetic propensity (whatever that turns out to be precisely) because I believe this disease to be genetically moderated, but I can't readily prove my contention. All I can do is point to studies (such as the Shedler/Block studies) that indicate significant differences in children between those who eventually end up with substance use disorders and those who don't.

And the condition isn't about a habit. Alcoholics drink differently than others from their very first drink when they recognize what the alcohol does to/for them. Talk to 50 alcoholics...they not only remember their first drink, but recall it with a smile and a sparkle in their eye. Talk to anyone not an alcoholic...their recollection is about the same as if you asked them when the first time was that they had cranberry juice. Who knows? It didn't mean anything to them. And if it didn't mean anything, then it can't cause a problem. Drgitlow 01:28, 13 July 2006 (UTC)

I can barely stand alcohol, and I remember that my first drink was gin out of a glass soda bottle when I was 15. Some friends of mine in highschool went to a park, and one of the girls was dating a 23 year old, who brought the gin. Although I got drunk, I merely remember it as being dizzy and confused. I have an exceptional memory, though, so that doesn't in any way disprove what you said.

The college issue that your describing is an excellent example of what we might call "Alcoholism Predisposition B", which is social circumstances that provide a very high psychological benefit to drinking. Everybody has their personal set of scales in which they value experiences, and people who are fresh out from under their parent's thumb have an unusually high valuation of new social experiences. It isn't unusual, uncommon, or unexpected that some of these teenagers value new social experiences more than they value their educational experiences. Alcohol is a social lubricant in that it makes dealing with unfamiliar people much easier, and as such runs rampant under these conditions.

It's drinking alcohol beyond the point where it is causing obvious, chronic damage to your life. This is still a form of alcoholism, even though its root cause isn't the aforementioned "AP A". It's just that this form of alcoholism requires a completely different form of treatment, and goes away quickly when the person is removed from the encouraging environment. There is significant overlap between sufferers from AP A and AP B because they are mutually supporting. We might even go on to categorize things like "AP C", where the person drinks as a coping mechanism for unpleasant or stressful life circumstances and other psycho/social maladies. Personally I like to lump them in as being a psychological addiction, but then again I'm not trying to treat them.

So, again, we definitely CANNOT call heavy drinking alcoholism unless it's causing obvious, chronic damage to the drinker's life. Once that qualification is met, though, it becomes alcoholism regardless of the cause. Robert Rapplean 16:10, 13 July 2006 (UTC)

You've got an interesting definition going. It's not the standard in the field, but it's pretty reasonable, and your last paragraph is entirely correct. Drgitlow 21:07, 13 July 2006 (UTC)

Well, the entire idea of a genetic propensity for a neurological addiction throws a lot of the "standard in the field" on its ear, I'm afraid, and the evidence I keep digging up seems to support it. I've certainly bent no shortage of my neurons over trying to sort this all out.

So I think we're finally coming to an agreement on how to characterize "active" alcoholism. I'd like to temporarily table the discussion of "passive" alcoholism (where a person needs a support group to help them resist the desire to drink) and "remissive" alcoholism (where a person has reverted their drinking conditioning, but could return to alcoholism if they drink without an opioid antagonist in their system) for a later time in favor of going back to discussion what direction the article should head in after the initial description of alcoholism.

1. A functional definition of alcoholism
2. How Alcoholism is identified
3. Current theories on the causes
4. Available treatment methodologies and their outcomes
5. Epidemiology (includes societal impact), but we should use a more reader-friendly word
6. Brief discussion of related conditions (alcohol-induced mood disorder, etc.)
7. Controversies
8. History

Running with being able to identify alcoholism as "continued consumption of alcohol dispite obvious, chronic damage to the drinker's life.", I think we can start with the various cannonical methods of recognizing it, maybe with a summary that characterizes the obvious symptoms for non-doctors.

OH, my wife also mentioned that kids doing book reports are also among our target audience. I don't think that adds anything to the details, but does effect our language and usage level somewhat. Robert Rapplean 22:46, 13 July 2006 (UTC)

Robert, you speak of active, passive, and remissive alcoholism. These terms are not part of the medical perspective on alcoholism. From a medical perspective, one either has the disease or one does not. As in hypertension, an individual taking antihypertensives may bring his blood pressure back to normal. Thirty years later, that individual may still have normal blood pressure if he's been taking his medications. He still has the disease of hypertension. But it's been properly treated and the individual will not have the morbidity or mortality rates that one would expect from a case of untreated hypertension. Similarly, an alcoholic receiving proper treatment and not drinking will have morbidity/mortality rates that are close to normal. I suppose one might put descriptors upon the different states - a hypertensive taking anti-hypertensives, a diabetic on insulin therapy with normal hemoglobin a1c measures, an alcoholic who isn't drinking - all are in the same place with respect to their illness, but they still have the illness. I understand that you're still approaching this from a non-disease perspective and are therefore taking a different route to get to the descriptions, but it's tough for me to imagine that we're going to get a consensus if we're ultimately at odds about definition, cause, treatment, and beneficial outcomes. I'm not sure what the 'right' thing to do is, however. Drgitlow 02:39, 21 July 2006 (UTC)

The "active, passive, and remissive" conditions are my words for three states that an alcoholic can be in, which really need to be differentiated. An active alcoholic is currently drinking more than is healthy for him. A passive alcoholic is someone who suffers from a strong desire to drink (obsesses about it), but is abstaining for whatever reasons. A remissive alcoholic is someone who has extinguished the desire to drink, but can re-develop it if they drink without an endorphin blocker. Technically they are all alcoholics, but their condition is in a different state and needs to be handled differently from a treatment perspective. What terminology would you like to apply to these? Robert Rapplean 03:29, 21 July 2006 (UTC)

I absolutely understand how you're defining your terms, and it's not a bad categorical approach, but it isn't a standard. In medicine, the terms used are partial remission and full remission, both of which can be either early or sustained. The remission states refer to the presence or absence of disease symptoms, so they don't refer to whether someone has stopped drinking, although you can generalize that an individual in full remission is likely not drinking at all. I actually prefer your terminology, since it is MUCH more clear and would probably be used accurately by clinicians and easily understood by the lay public. But I don't think this article is the place to introduce new terminology not generally used in the field. If, on the other hand, there's a citation you could use to indicate that these terms have been suggested as a new approach, that would work. Drgitlow 04:54, 26 July 2006 (UTC)

Comments on Developing a Strategy

I think we'll be more effective in the tactical discussion (what words do we use to explain alcoholism) if we have a clear set of objectives for the remaining definition first. So rather than talk about what to write in this section, let's talk about what our objective is for the remaining definition section. If we first have an objective then I think finding the words will come much more naturally. It would be worth reviewing what we have agreed upon to give us an idea of how to approach finishing the definition. I'll have some thoughts on the subject but I plan on not being here much over the weekend. I'm not saying wait for me, only that I might not be around much. Anyhow, it's something to think about and what we have agreed upon I think is very respectful to the reader and non-confrontational. I think the reader would so far say "Ok, they're not trying to sell me anything and what they're saying makes sense" and want to continue reading. So far the introductory definition seems quite credible to me. 06:14, 8 July 2006 (UTC)

I agree that we've made some real good progress and have a "credible" definition. I'm also open to anything that will help us move forward. Unfortunately, I'm going to be out of town for about a week so I'll have to leave it to the rest of you. And I can just see you all breathing a big sigh of relief at my upcoming vacation: Finally, some peace and quite around here, they say. Seriously, keep up the good work, all of you. :) --Doc Tropics ^{Message in a bottle} 06:52, 8 July 2006 (UTC)

Formatting

I've made several minor edits, mostly for the sake of formatting, and I think I see a need for many, many more. I really don't anticipate these will be "controversial" since the changes are largely cosmetic in order to Wikify the article, but if I accidently turn something into nonsense feel free to revert it and mention it here. --Doc Tropics ^{Message in a bottle} 21:12, 20 July 2006 (UTC)

I just moved or deleted the first 9 cites in order to keep them with (what I think is) the proper text, and to reduce redundancy. I'm hoping someone will review this carefully because it was a bit of a headache and I may have goofed. I did it in 2 rounds of editing, clearly marked, so it should be easy to correct. --Doc Tropics ^{Message in a bottle} 12:20, 21 July 2006 (UTC)

OK, that didn't go well. I totally bolluxed it and had to revert myself. I'll try again when I haven't been awake for 20+ hours. --Doc Tropics ^{Message in a bottle} 12:25, 21 July 2006 (UTC)

Do we really need to be Citing another encyclopedia?

In reviewing the cites in our first paragraph, both of the remaining cites are to other encyclopedias (Medline Plus Medical and Britanica). I think that it's a very poor showing that, for our first paragraph, we have to point to another encyclopedia and say "See, they think so, too!" After some consideration, I think it would be a better policy to back up our opening section with the rest of the article, and if we need to back up individual statements in the rest of the article, then we should find more authoritative sources than other encyclopedias. Unless someone protests, I'm going to remove those two references. Robert Rapplean 17:15, 23 July 2006 (UTC)

I agree (although I thought Medline was a Journal rather than an Encyclopedia). It really bothers me to see refs to EB anywhere; I'm sure we can do better. Once you've taken care of those two, would you like to sort through 3 - 9? I tried to reduce and reposition those more appropriately; maybe you'll have better luck :) --Doc Tropics ^{Message in a bottle} 17:21, 23 July 2006 (UTC)

I realized that Medline self-identifies as an encyclopedia so I went ahead and removed the first two cites. They're still available in the history of course, so if anyone really wants to replace them it's easy enough. I couldn't find a specific WP:POLICY against citing other encyclopdias, but I strongly agree that our intro should stand on its own and we should think carefully about citing other encyclopedias anywhere, ever. --Doc Tropics ^{Message in a bottle} 01:21, 24 July 2006 (UTC)

I also removed a broken link from the next section. --Doc Tropics ^{Message in a bottle} 01:53, 24 July 2006 (UTC)

Tobacco, not alcohol, is most widely abused substance

46 million US adults are smokers and most are addicted says the CDC. Tobacco smoke contains at least 43 carcinogens. The CDC estimates that male smokers lose an average of 13.2 years of life and females lose an average of 14.5 years of live because of smoking the numerous health problems it causes.

For these reasons, the Alcoholism article is in error, the qualification is not "weasel words" and the reference is not a "nonsense link." Non-smoker 01:24, 24 July 2006 (UTC)

The referrence was a nonsense link because it had absolutely no bearing on the article at all; if you want to use a link like that to prove a point it can be done here on the Talkpage, but not in the article. I removed the weasel words because "alcoholism affects over 15 million people" is a verifiable fact, not an estimate. I realize that you are new to WP and I'm sorry if my initial response seemed harsh to you. Since we're in the process of trying to reduce the cites in this article, it was largely a case of bad timing. Please don't get frustrated, this article has been under construction for a while :) --Doc Tropics ^{Message in a bottle} 01:45, 24 July 2006 (UTC)

XXXXXXXX

I'm not trying to prove a point only to correct a verifiable error on the Alcoholism page.

The 15 million alcoholics is only an estimate, not a verifiable fact. (And where is the reference supporting it?) All we have are estimates of the incidence of any diseases or behaviors because no census (to my knowledge) has been taken of these diseases or behaviors. A CDC estimate is an official estimate of the U.S. government. So it appears that to be in every way as strong a statistic as the 15 million estimate. So over 45 million is roughly three (3) times 15 million.

In what way am I wrong?Non-smoker 02:55, 24 July 2006 (UTC)

Sorry for the confusion about "prove a point"; I was trying to explain that if you disagree with a point in the article you could post the link that you used on the Talkpage to discuss it, but I'm sure you understand that linking to a website about smoking isn't appropriate in an article about alcoholism. Since I'm really just a humble simple> woefully undereducated editor I'm hoping that one of our resident eggheads subject-matter experts will address the balance of this : ) --Doc Tropics ^{Message in a bottle} 03:40, 24 July 2006 (UTC)

Hi, there. This is one of the resident eggheads. Non-smoker, you are quite correct that tobacco smoking is a bigger problem than alcoholism, but let me disect the terminology here. I'm going to quote a few numbers here to start us off:

Alcoholics: about 15 million (as per the NIAAA)

Tobacco smokers: about 45 million (let's assume you're right)

Alcohol drinkers: about 200 million (as per SAMSA)

For alcohol, there is a clear distinction between alcohol users and alcohol abusers. Most of us just plain don't have a problem with it, and can occasionally drink it safely on a regular basis with no hint of long-term damage. Most of us do not suffer from the addiction that it causes in others.

Tobbacco doesn't have that quality. 100% of all tobbacco smokers will get addicted over time. Nicotine supplements and replaces choline in such a way that our body forgets that it needs to make its own. Also, there is no way to smoke tobacco safely. Even small amounts of it will increase your risk of cancer by small amounts, while large amounts of it will increase your risk of cancer by large amounts. Thus, you could make the argument that all tobacco use is a drug abuse problem.

Where the real problem comes in is that there is no standard definition for the term "abuse" because it's a term that's been used too much by people with political agendas to mean "use of something that I don't approve of". Once you tie a term to morality it takes on a relative quality necessary for a line that people draw immediately beneath themselves to identify who they are superior to. Thus, in our current culture, drinking alcohol and smoking tobacco become "use" while alcoholism becomes "abuse".

I do know that tobacco induced medical costs far exceed alcohol induced medical costs, although it would take some doing to dig up the numbers, and the total cost of alcohol would also need to include property damage, divorce bills, and similar difficult to pin down expenses. Can anyone else give some input on this? Robert Rapplean 17:52, 24 July 2006 (UTC)

Thanks RR, I knew I could count on one of the editors here to reply in more depth and detail than I'd be able to. My strongest objection to Non-smoker's changes was the addition of the cite which linked to a smoking-related website. I may well have been overreacting when I deleted the text that was added; my primary concern was trying to manage the size and scope of this article at a time when we're trying to trim extraneous details. If other editors feel that the text was appropriate, I won't object again. I do think that we need to be concerned about the overall size and readability of this article however, and any further additions should be carefully scrutinized. --Doc Tropics ^{Message in a bottle} 18:08, 24 July 2006 (UTC)

The page says that "alcoholism is the most common substance abuse problem." But that is simply wrong if 15 million are addicted to alcohol and 46 million are addicted to tobacco. Why not say that "alcoholism is one of the most common substance abuse problems"? That would seem to be accurate. Are you going to let an error stand to avoid linking to a page citing the source of a statistic? That seems like a strange priority.Non-smoker 19:03, 24 July 2006 (UTC)

In retrospect I have no significant objection to the sentence reading "alcoholism is one of the most common substance abuse problems." That phrase would be acceptable, but the link is not. Citations in an article about alcoholism should link to the topic of alcoholism, not websites about cigarette smoking, heroin addiction, crystal meth, or any other unrelated topic. Please feel free to re-insert your original phrasing, but I hope you won't add the link again without consensus to do so. Thanks for engaging in discussion; even when we don't agree, this is far more productive than edit-warring and reverts :) --Doc Tropics ^{Message in a bottle} 19:20, 24 July 2006 (UTC)

As for the addition of the word "estimated", since we don't actually state a number down to any precision it can safely be assumed that it's an estimation. All numbers of that form are an estimation, simply because you can't exactly take a weekly nation-wide survey and ask everyone if they're an alcoholic. Numbers for tobacco users are a little easier to pin down because health insurance keeps tabs on it, but lying about smoking for health insurance purposes is common, and those who don't have life insurance are more likely to smoke than those who do, so those numbers are similarly suspect. I favor leaving out the "estimated" because it can be presumed, but will look to see if Wikipedia has a policy on that kind of concept.

The cites, on the other hand, are another issue. We're definitely trying to eliminate cites in the opening paragraphs. Also, the page that is referenced doesn't say anything about alcoholism. I'd agree that it doesn't belong in the article, although it can be mentioned on the talk page in order to make a point.

I'd like to be a little more specific than calling it one of the most common. I'd really like to get across that it's many times more prevalant than opiate addictions, for instance. I'm sure that we can come up with some kind of wording that relays that without overlooking the problems that smoking causes. Robert Rapplean 19:43, 24 July 2006 (UTC)

I noticed that Non-smoker decided to update this himself. I like the statement, but think that it may be a sweeping generalization. I'm willing to leave it as it is, though, until we have the time to dig up more specific information on the rates of various substance abuse problems throughout the world. Robert Rapplean 04:24, 25 July 2006 (UTC)

I'd like to make several points regarding this discussion. The first is that there are many people for whom nicotine/tobacco use does not become an addiction. While all tobacco use is "bad" with respect to causing health-related consequences, one can make the same argument for alcohol (although alcohol in small quantities is said to be helpful from a cardiac perspective, it is harmful from multiple other perspectives, including hepatic, neurologic, etc.). There are many who smoke cigarettes "once in a while" when they go to social occasions or when they're with someone else who smokes, yet do not become addicted for whatever reason. This is a subject of ongoing research to determine why some people get addicted to nicotine quickly while others do not. There's no question that alcohol addiction is a MUCH greater problem in terms of cost to society and # of people afflicted than ALL other substance addictions combined - except for nicotine, as pointed out above. Drgitlow 04:47, 26 July 2006 (UTC)

My experience with tobacco smokers is that nicotine addiction takes several months of continuous smoking in order to set in. Unlike alcohol, nobody sucks down their first Camel and says "I gotta get me some more of that!", they think, "That's not so bad, and now I fit in with the cool crowd!". The psychological/social addiction sets in first, giving time for the physical addiction to get its grip. I smoked myself for about three weeks just because I was curious and I didn't get addicted, but the trial period was too short for that to be meaningful. The primary reason that the factors of nicotine addiction are so difficult to pin down is because the signal to noise ratio is so high. The cost/benefit formula for the initial picking up of the habit involves nearly intangible benefit and negligible cost, so it's often swamped by other considerations.

I will admit, though, that my statement of 100% nicotine addiction is based on those who have picked up smoking. It may be that the unaddictable percentage just forget to purchase the next pack at some point, but I've never met anyone who has smoked for a while and then just lost interest. I'll have to start asking that specific question. I don't think that anybody has done a study where they take x non-smokers, ask them to smoke a pack a day for a year, and then find out how many of them can easily quit, so I think that the evidence is out either way.

But back on topic, can we say "Second only to nicotine addiction, alcoholism is one of the world's most costly drug use problems."? Robert Rapplean 16:00, 26 July 2006 (UTC)

Identification and Diagnosis section

I've moved all of the diagnosis information into one place. I'd like to change this heading to something less technical, preferably something like "Identification", specifically to avoid controversy over whether this is a medical, behavioral, or spiritual problem. Also, many of the entries here refer to concepts that aren't discussed in this article, and we need to fix that.

Could we have a bit of brainstorming about the various ways of identifying an alcoholic? I'd like to put each major method under its own subheading. Obviously the DSM and CAGE models belong there.

I'd also like to expand on my first paragraph that describes the difficulties involved in diagnosis. Can we put a section in previous to it that describes the various addiction factors that contribute to alcoholism? I think that would properly belong in the "extended definition" section of the article. Robert Rapplean 22:39, 20 July 2006 (UTC)

I'll leave the technical end of things to our panel of experts, but the changes you've made so far look good to me; it's a better format for the info I think. I also agree that "addiction factors" does belong in the extended definition (unless it gets so long that it deserves its own section). It seems we've re-established enough goodwill that you could go ahead and edit, just be prepared to discuss if anyone objects. Happy editing! --Doc Tropics ^{Message in a bottle} 02:15, 21 July 2006 (UTC)

The CAGE isn't a diagnostic test. It is simply a screening test used to identify those individuals likely to have alcoholism. As an analogy, to diagnose primary hypertension, one might conduct a screening test of measuring blood pressure. A single result of an elevated blood pressure may have many causes, one of which is primary hypertension. The DSM definition of alcohol dependence is a diagnostic definition for the disease of alcohol dependence (DSM's term for alcoholism). The 1992 JAMA article's definition of alcoholism is another diagnostic definition for the disease. From a medical standpoint, a physician will ask a series of questions designed to determine whether an individual's intake of alcohol has led to adverse outcomes in a repetitive manner. If the answer is 'yes,' then the individual is alcoholic. If 'no,' then intake of alcohol may be either nonpathologic or causing something other than alcoholism. For instance, let's say an individual comes in to see me complaining of significant anxiety, but has NO other problems. And let's say that individual honestly reports drinking 2-3 beers each day. That patient possibly has an alcohol-induced anxiety disorder. I then tell the patient that their anxiety, which is causing significant discomfort, may be a result of alcohol intake. I recommend cessation of alcohol use and a re-examination in 1 month. If in one month the patient has not stopped drinking despite the possible adverse reaction, now I must consider alcoholism as one possible diagnosis. Drgitlow 02:30, 21 July 2006 (UTC)

An interesting example Dr. G, and well written. Keeping in mind our Hypothetical Reader (who is still working towards a high school diploma), is it possible to clarify the difference between screening and diagnosis within the article a bit? It seems that the different techniques could probably stay in the same section since, to a layman, the difference appears to be a rather minor one? I think this actually sums up a challenge facing the article overall: We really need to bring the overall level down a bit to make it more accessible to our HR, but without dumbing it down so much it turns into nonsense. --Doc Tropics ^{Message in a bottle} 02:48, 21 July 2006 (UTC)

This is definitely an important distiction, and one of the reasons why I wanted to rename the section "Identification" instead of "diagnosis". Remember that our target audience doesn't contain a lot of medical professionals, so if it gets to the diagnosis stage we probably just need to give a brief overview of "how do them doctor guys know, anyway?" As such, the screening is a good tool that people can use in order to help them decide that maybe they really do need to see a doctor about this, and as such is perfect for our audience. Robert Rapplean 03:29, 21 July 2006 (UTC)

OK, who forgot to log in? :) I went waaay out on a limb and unilaterally changed the section header to "Identification and Diagnosis", although "Screening and Diagnosis" might also be appropriate. --Doc Tropics ^{Message in a bottle} 03:27, 21 July 2006 (UTC)

Doh. That was me. I own that IP address, so I should make it a synonym to my name. Robert Rapplean 03:29, 21 July 2006 (UTC)

Diagnosis

The current diagnosis section opens with a sentence that reads that diagnosis of alcoholism is difficult. I'm not sure what that statement is, whether it's an opinion or a value judgment in and of itself, but it's certainly not true for an addiction medicine specialist. Alcoholism is our bread & butter -- making the diagnosis is about as easy as pulling weeds. Can we reword that? Drgitlow 18:16, 23 July 2006 (UTC)

Rewording might be appropriate, if handled with care. I just read through that section again and it seems to be refering to "borderline" cases, but that isn't clearly stated. If you can clarify that without delving too deep into "specialist stuff" it would be perfect :) --Doc Tropics ^{Message in a bottle} 18:24, 23 July 2006 (UTC)

I believe that this can be fixed by changing the leading word "diagnosis" to "identification". I agree that diagnosis isn't terribly hard. If a person tells you that they have trouble not drinking then that pretty well settles it (oversimplification, I know). The difficult part comes in when other people are trying to decide if their loved ones are alcoholics. This usually involves attempting to apply the observer's priorities on the drinker, which is more often than not a mis-match. This is where the difficulty comes in. Again, trying to keep the non-medical-professional audience in mind. Does that make sense? Robert Rapplean 04:40, 25 July 2006 (UTC)

It makes sense to me, and I'm probably the lowest-common-denominator around here :) I also tweaked a couple of words in the opening sentence of this section. --Doc Tropics ^{Message in a bottle} 04:51, 25 July 2006 (UTC)

RR, your latest change to "Identification and Diagnosis" does an excellent job of clarifying! It's a good use of NPOV languange that should be understandable to everyone, and hopefully agreeable to all the editors as well. This is exactly the kind of cleanup that the article needs. --Doc Tropics ^{Message in a bottle} 15:55, 25 July 2006 (UTC)

Treatment Discussions

Curing by moderation (Reposted comment from archive)

There is reason that healthcare professionals have a tough time accepting any treatment that involves continued drinking. The Pendery article in Science in 1982 (Science. 1982 Jul 9;217(4555):169-75.) essentially blew the moderation movement out of the water by demonstrating that over the long-term, patients who truly had alcoholism and who tried to drink in moderation either a) died of alcohol-related disease, b) ended up with significant morbidity due to alcohol-related disease, or c) had successfully entered abstinence. One method of diagnosing the disease is to simply see whether a patient tries to control their alcohol intake; if they do, they probably have alcoholism (noone tries to control their orange juice intake -- if they did, one would think there's something wrong). Drgitlow 16:53, 3 July 2006 (UTC)

You're mistaking pharmacological extinction with moderation. Moderation is an attempt to use personal habits and willpower to attempt to decrease one's drinking habits to a more healthy level. Pharmacological extinction is an attempt to reverse conditioning placed upon a person's neurochemistry by providing stimulus, but by blocking the reward mechanism. I agree and accept that moderation doesn't work, but there is a great deal of evidence indicating that PE does. Robert Rapplean 21:45, 3 July 2006 (UTC)

Regarding Pharmacological Extinction

I think that the countersite on pharmacological extinction needs to be more closely examined. PA isn't an attempt at moderation, and the cited study is dated 1982, before PA was developed, which was around 1992. PA is based on observations that overdrinking prone rats have overactive endorphin systems. Endorphin is our body's chemical mechanism for making us want to perform behaviors like sex, exercise, and fighting, which aren't terribly productive or efficient in their own right but which provide notable benefits in the long run. It has been demonstrated that the consumption of alcohol releases endorphins in our system, so the theory is that alcoholism is caused by the inappropriate rewarding of our neurological system when we drink.

Pavlov demonstrated that providing a stimulus coupled by a reward causes conditioning, but he also proved that providing the stimulus without the reward causes the extinction of that conditioning. Bell without food results in cessation of salivation over time. For alcoholism the bell is all of the sensations involved with drinking alcohol, and the reward is an endorphin reward to our neurons. Naltrexone is an opioid antagonist. In short, it blocks our bodies from being rewarded when we drink. Thus, if we drink alcohol while on naltrexone, our neurons unlearn their drinking impulses.

So, again, it has nothing to do with attempting to moderate drinking, it has to do with providing stimulus without reward so that the urge to drink is extinguished. Thus, any study which involves moderation without naltrexone use has nothing to do with this. Similarly, any study which involves naltrexone (or nalphamene, or noloxone) coupled with abstinence or abstinence encouraging therapies (like AA) similarly demonstrates nothing about PE. If you would like a complete list of the studies which have been performed involving opioid antagonists, let me know. I have a list that was updated around Nov 2004. Robert Rapplean 02:13, 5 July 2006 (UTC)

Robert, the PE approach is a behavioral modification approach combined with neurochemical findings. And I see your point about it leading to abstinence through a process which involves some continued use of alcohol for the behavioral modification to occur. It's a fascinating idea. My understanding of it is that it works theoretically as follows:

Alcohol causes the production of endorphins. In some individuals, alcohol causes endorphins to a greater extent than usual. This causes those individuals to have a reduced ability to refuse alcohol (because, simply put, the alcohol is too enjoyable for them to refuse even if it causes them hardship). Naltrexone, among other drugs, stops the endorphins from getting their message through by antagonizing the neurotransmitter system involved. Therefore, if you give the naltrexone and these individuals drink, they will no longer feel the enjoyment they once did. Behavioral modification will result due to the lack of positive feedback and the drinker will ultimately be able to stop drinking on his or her own.

While liver toxicity is an issue with naltrexone, the doses necessary here would be low enough as to present a low risk of hepatic damage (in general), even when combined with alcohol. I reviewed the Sinclair paper from Alcohol & Alcoholism 36(1)2-10. 2001 that discusses this in greater detail. What Sinclair reports is something that hasn't been replicated well in US trials since the US trials haven't followed his instruction that naltrexone be given simultaneously with alcohol. This provides a potential explanation as to why the US trials for naltrexone have been less than successful. All very interesting and deserving of additional study. Drgitlow 02:43, 5 July 2006 (UTC)

This is almost correct. Right idea, but the theory states that it's a neurochemical effect, not a behavioral one. In order to clarify, I want to Quote Dr. Sinclair directly:

"On the other question, you are correct that mixing naltrexone and disulfiram together will not work. Many people would expect it to, but this expectation is based on the incorrect common sense understanding of behavior (CUB). CUB says that a person sits and contemplates what behaviors will bring pleasure and what will bring pain, and then choose to make the behavior expected to produce the most net pleasure. Inherent in this view is the idea that pleasure and pain add together algebraically. Like pleasure has positive numbers and pain has negative. So if you have behavior that produces something good (+2) but then you shock the person for doing it (-3), the end result is the algebraic sum -1, so the person will avoid doing that. If you only give a little shock (-1), the sum is +1 and the person will continue doing it. If you really wollop them (-5), then the sum is -3 and the person will avoid the behavior completely. This seems so logical. It is the basis for our legal system, the basis for economic, the basis for how most people raise their kid, and the basis for how most people treat others. It is, however, definitely incorrect.

"It has been the basis for how we treat alcoholism. And we have been punishing alcoholics with -5s and even -10s, but it almost never has worked.

"There is the classic statement that the effect of punishment depends upon which end of dog you inflict it upon. The reaction to pain is to find a response that gets rid of the pain. So punishing an alcoholic is most likely to drive them out of treatment. It does not get rid of the craving.

"According to CUB there is no mechanism of extinction. Naltrexone works, CUB says, because the patient is told that he will get no pleasure from drinking, so they do not bother. That was the logic that caused them to put in the instructions for naltrexone that the heroin addict is told first that they will get no pleasure and second that they may die if they drink while on naltrexone. You remember that this was completely ineffective.

"Making a response and not getting the normal positive reinforcement extinguishes the behavior. Adding punishment only makes the patient want to get out of the treatment. If you were to look in the brain, you would find, I believe, that after taking naltrexone and then drinking, that there is a process going on that weakens the pathways producing drinking. If you look in after drinking (without naltrexone) and then getting beat up in a fight, you will find the pathway causing drinking is being strengthened - the endorphins are still there producing the reinforcement. At the same time pathways the cause getting out of that bar and avoiding fights are also being strengthened. End result, the guy continues drinking but someplace else."
-Dr. John David Sinclair, Jan 21, 2006

The reason I want to make this distinction is because people's lives give them -10s when they drink. They lose their jobs, their spouses, their property, and can wind up in a gutter. This doesn't make them stop drinking alcohol, even though sensibly and obviously the net effect is quite negative. It just tells them that they need to get help, and sometimes even that isn't enough, which is why they have interventions. There's more to it than an intellectual assessment of the benefits.

Robert Rapplean 04:43, 5 July 2006 (UTC)

References Section

Hey, folks. The references section has gotten out of control as an unreadable mishmash of cites that may or may not actually be pertinant to something that is still in the article. Could you help me out here? I'd like to maintain a permanent section in the talk page that specifically lists the significance of each reference to the article at large. Many of these articles are not readily accessible, so I'd like to create a guide to their significance so the reader doesn't have to go digging into a bunch of medical journals to figure out what the purpose of the cite is. I'm going to use this site from Dr. Sinclair as an example of how I'd like to see the cites explained. In the article I'd like to see them ordered based on the position of the text in the article that they support. Robert Rapplean 16:42, 22 July 2006 (UTC)

I think this is an excellent idea, and without question, something needs to be done. It appears that many of the cites are redundant in the sense that they point to articles which say essentially the same thing. I'd like to suggest a couple of ideas, but I'll wait for input from others before taking any actions:

1. Eliminate some of the redundant cites.
2. Try to avoid referencing the websites of individuals, even if they are MDs. I think these don't have as much credibilty as the numerous journals we can link to.
3. If any sentence actually needs more than a single cite, that might indicate that we need to rewrite the sentence for clarity.

--Doc Tropics ^{Message in a bottle} 17:30, 22 July 2006 (UTC)

I think that this is a very insightful piece of input, Doc. In fact, I'd like to see the second two points embodied as long-term policy. Robert Rapplean 16:45, 23 July 2006 (UTC)

Sinclair, J. D. (2001) Evidence about the use of Naltrexone and for different ways of using it in the treatment of alcoholism. Alcohol and Alcoholism 36: 2-10. An invited review in the Oxford Journal of Medicine which describes the pharmacological extiction treatment, its effectiveness in treating alcoholism, and the relative (read: poor) effectiveness of the use of naltrexone in other treatment methods. Belongs attached to "Alcoholism:Treatments:Pharmacological Extinction"

• O’Malley, S. S., Jaffe, A. J., Chang, G., Rode, S., Schottenfeld, R. S., Meyer, R. E., and Rounsaville, B. (1996). Six-month follow-up of Naltrexone and psychotherapy for alcohol dependence. Archives of General Psychiatry 53: 217-224.
• Månsson, M., Balldin, J., Berglund, M., and Borg, S. (1999) Six-month follow-up of interaction effect between Naltrexone and coping skills therapy in outpatient alcoholism treatment. Alcohol and Alcoholism 34: 454

• Tonnesen H, Hejberg L, Frobenius S, Andersen JR. Erythrocyte mean cell volume--correlation to drinking pattern in heavy alcoholics. Acta Med Scand. 1986;219(5):515-8. (Medline abstract)

• Schwan R, Albuisson E, Malet L, Loiseaux MN, Reynaud M, Schellenberg F, Brousse G, Llorca PM. The use of biological laboratory markers in the diagnosis of alcohol misuse: an evidence-based approach. Drug Alcohol Depend. 11 June 2004 ;74(3):273-9. (Medline abstract)

• Ewing, John A. “Detecting Alcoholism: The CAGE Questionnaire” JAMA 252: 1905-1907, 1984

• U.S Supreme Court, Traynor v Turnage, 485 U.S 353 (1988) at 535-550

• McKelvey v. Turnage, 792 F.2d 194 (D.C. Cir. 1986) and Traynor v. Walters, 791 F.2d 226 (2d. Cir. 1986)

• Korhonen, M. Alcohol Problems and Approaches: Theories, Evidence and Northern Practice. Ottawa: National Aboriginal Health Organizations, 2004 [3]

• Schaler, J. A. Thinking about drinking: the power of self-fulfilling prophecies. The International Journal of Drug Policy, 1996, 7(3), 187-191 [4]

• Doweiko, H. E. Concepts of Chemical dependency. NY: Brooks-Cole, 1996.

• Anton RF, O’Malley, SS Ciraulo DC, Cisler RA. Couper D, Donovan DM, Gastfriend DR, Hosking JD, Johnson BA, LoCastro JS, Longabaugh R, Mason BJ, Mattson ME, Miller WR, Pettinati HM, Randall CL, Swift R, Weiss RD, Williams LD, Zweben AZ, for the COMBINE Study Research Group (2006) Combined pharmacotherapies and behavioral interventions for alcohol dependence: The COMBINE Study: A Randomized Controlled Trial JAMA. 2006;295:2003-2017.

Cites which seem to belong to the Disease article

• Kolata, G. Alcoholic genes or misbehavior? The Supreme Court is due to decide whether alcoholism is a disease or a character flaw. Psychology Today, May, 1988 [5]

• Nackerud, L. The disease model of alcoholism: a Khunian paradigm. Journal of Sociology and Social Welfare, 2002 [6]

• Heavy Drinking: The Myth Of Alcoholism As a Disease, Herbert Fingarette, PhD (University of California Press, 1988)

• The Diseasing of America: How We Allowed Recovery Zealots and the Treatment Industry to Convince Us We Are Out of Control, Stanton Peele, PhD (Jossey-Bass, 1999)

• Kelly, D. Understanding the Nature of Alcoholism (2001). Discusses the disease controversy. [7]

• Levy, M.S. The disease controversy and psychotherapy with alcoholics. Journal of Psychoactive Drugs, 1992, 24(3), 251-256. [8]

• Maltzman, I. Is alcoholism a disease? A critical review of a controversy. Integrative Physiological and Behavioral Science: The Official Journal of the Pavlovian Society, 1991, 26(3), 200-210 {

[9].

• Hobbs, M.D., Ph.D., T. R. Managing alcoholism as a disease. Physician’s News Digest, February, 1998 [10]

• Meyer, Roger E. The disease called addiction: emerging evidence in a 200-year debate. Lancet, 1996, 347, 162-166. [11]

Things which impact the entire article

APA vs APA

I'm not sure how to handle the APA's in this article. I've made reference to the American Psychiatric Association in my entries. MedicalMan has made reference to the American Psychological Association in his. Both organizations use the abbreviation APA and some of our current paragraphs use the APA abbreviation as well. Readers won't know which APA we refer to. It's annoying, but I suggest we spell out each such reference to be certain readers (and we) know whom is being cited. Drgitlow 04:17, 1 July 2006 (UTC)

Likely that American Psychological Association is the more commonly recognized use of APA. Agree that writing out each one is necessary in this case. FloNight ^talk 15:39, 1 July 2006 (UTC)

Systemic geographical bias

The article has been Tagged for "Systemic Bias", specifically "U.S.-centrism". Ironically, I had voiced this concern previously and was considering how to best address the problem. Unfortunately, the editor who added the tag didn't offer up any suggestions (which I consider a bit sloppy; adding a tag without any follow-up is actually a dis-improvement). My only idea so far is to check out the World Health Organization and see if they offer more "global" statistics, and I haven't actually done so yet. Can anyone suggest other possible resources for globalizing the article? --Doc Tropics ^{Message in a bottle} 20:48, 24 July 2006 (UTC)

LOL, I was just going to change the end of the first paragraph, but had an edit conflict with Nonsmoker. Rather than make rapid changes to the article let me offer this proposed change for commnets: --Doc Tropics ^{Message in a bottle} 20:59, 24 July 2006 (UTC)

• Alcoholism is the most common substance abuse problem in most developed nations, and affects more than 15 million people in the United States alone.

I agree that this article suffers from US-centrism, but considered that to be a concern entirely secondary to attempting to hammer out the information that doesn't change from one location to the next, for instance the symptoms and treatment thereof. That's the problem with drive-by tagging like that - it doesn't take the opportunity to determine what the current discussions are about and seems to insist that this be taken care of before we take another step.

Your sentence looks good to me, go ahead and insert it. Robert Rapplean 21:54, 24 July 2006 (UTC)

I agree that the "bias" issue is secondary to other content-oriented considerations, that's why I haven't put much effort into it yet. I really would like to bring this article up to GA or FA status, so we'll need to address it eventually, but we seem to be making good progress in other areas right now. Since RR and I have made a number of changes recently I'll hold off on the one I suggested above until we get more input. --Doc Tropics ^{Message in a bottle} 22:41, 24 July 2006 (UTC)

[Jacob] Having not commented, yet used Wikipedia extensively, this conversation gave me the push to begin. Enough said, while I am not in a position to comment on the above debate, I would strongly argue that the page Alcoholism should contain something similar to a 'Cultural Perceptions of Acceptable Alcohol Consumption' section in the begining or at the end to put the discourse into a global or at least Western context (examples of both are available). The point should not be to dispute medical facts on the negative effects of alcohol, but rather show that perceptions of alcohol consumptions vary widely from country to country. So, using the CAGE test many many Scandinavians would be alcoholics. While they might be, it might also be the case that societies and cultures deal differently with heavy (weekend) alcohold consumption and their societies are not falling apart. This is arguably a subjective point of view. Yet, for instance, the official Danish PR body of the ministry of health (Sundhedsstyrelsen) recommends a maximum intake of 21 (14 for females) units of alcohol (a 33 cl bottle of beer is one unit and so is a shot of strong alcohol (vodka, snaps etc)) per week. From the Wikipedia page I get the view that such recommendations would make officials in other Western countries shake their heads in disbelief. As said, this serves not to dispute medical facts or ruling beliefs, but merely to put this hotly debated topic into perspective. Finally, making such a section should also not be a 'trojan horse' to say that North Americans (or others) are too strict in their definitions, but - again - just to show how societies and individuals deal with the abundance of alcohol and the cultural acceptance of indulging in such abundances differently. Documenting such the above points would be fairly easy.

Hi, Jacob, and welcome to the conversation. I hope you don't mind that I moved your paragraph to this topic, it really seems to belong here. This would be very useful in taking some of the geographic bias out of the Identification section. I think that the proper way to present this would be to give examples of the two extremes (for instance, places in the middle east where any alcohol is sinful), and then give a general feel for what kinds of people have what kinds of social tolerances for alcohol. I'm a bit tied up with other information gathering activities, but would anyone else like to take a whack at that? Robert Rapplean 04:21, 26 July 2006 (UTC)

There are a few issues here: the first is that we can't confuse what should go in the Alcohol article as opposed to what should go in the Alcoholism article. Alcoholism, the condition defined by the World Health Organization, is akin to all other health conditions in that it is not defined by virtue of culture, country of origin, or any other parameter other than being human. Just as one either has hypertension or not, independent of whether a particular race has a lower or higher than human population average for blood pressure, one either has alcoholism or not, again independent of the usual intake of alcohol among one's peers. The fact, of course, is that the likelihood that one suffers from alcoholism is nil if there's no alcohol around, as is common among particular cultural groups.

Maximum or minimum recommended intake levels are indeed defined differently by different groups, and with much controversy among various cultures, but those issues apply to alcohol, not to alcoholism. I'd therefore vote that we leave that topic out and rather focus on the defining aspects of alcoholism. I recognize, as we've discussed here, that there are differing definitions - but I don't believe there are any who would define the condition based upon cultural factors. Worst case scenario is that of an individual who has lost his home, finances, and health as a result of his alcohol intake - an alcoholic in any culture. Drgitlow 04:42, 26 July 2006 (UTC)

Having slept on it, I have to agree with Dr. Gitlow. One of the things that is tough to understand about alcohol is the relationship between alcoholism and drinking. Drinking doesn't cause alcoholism, but alcoholism does cause drinking. There's a verifiable unidirectional causal relationship there. The only berring that this might have on the article would be that it's more difficult to spot alcoholism in cultures where heavy drinking is common and socially acceptable, and over-diagnosed where it isn't acceptable. In St. Louis, Missouri, for example (which works extra hard because it isn't "officially" in the bible belt), someone who regularly drinks heavily on the weekend will often be considered an alcoholic, even though true alcoholics would consider five days of sobriety a major victory. In your typical US college town it's difficult to tell the difference between someone who just can't let go of the bottle and someone who has no sense of how much money their parents are wasting on their lack of desire to attend classes.

In general I'd say that it warrents a mention, but that an in-depth examination of this, while good information, doesn't really fit in this topic. Can I have opinions from other editors, please? Robert Rapplean 15:38, 26 July 2006 (UTC)

Conversation between editors

Regarding recent edits

I'm going to attempt to rearrange the talk page so that it has major sections which reflect the major sections of the article itself, in the same order. I archived the discussion about moving the Disease topic, but need to put a placeholder at the top telling people that all discussion about that topic should be addressed there. I'd like to suggest that we have effectively resolved the differences that required us to go into mediation, and comments pertaining to that can also go into the archive. Robert Rapplean 15:44, 22 July 2006 (UTC)

Please be more careful

drgitlow, please be more careful in honoring Chris with edits I made. Because you chose to highlight Dr. Benjamin Rush's view that alcoholism is a disease, I think it essential to point out his view that Negroidism is also a disease because this helps the reader understand his conception of disease.Medical Man 01:46, 3 July 2006 (UTC)

I didn't highlight Dr. Benjamin Rush's view. I never wrote a sentence about Dr. Rush. I thought that was there before I ever got here, but I can check back in the history. Drgitlow 03:54, 3 July 2006 (UTC)

Yup...it was added on April 9 by someone without a user signature. After I started working on this, but not me. Drgitlow 04:09, 3 July 2006 (UTC)

Alcoholism Discussed in Popular Media by Alcoholism Experts

Did anyone catch this 20/20 investigative report on the alcoholism disease debate or participate in the chat below it?

Treatment Wars: The 20/20 Report

What Is Alcoholism?

I didn't catch the show but I want to read the full transcripts. The investigative approach to it by a major news source is an interesting angle. Mr Christopher 04:37, 11 July 2006 (UTC)

I'd put "alcoholism experts" in quotes, since I don't see that there were any alcoholism experts involved in either the 20/20 report or the chat. It's an interesting discussion and report, but please don't confuse the popular media and those who actively involve themselves with the public debate as being qualified experts in the field.

Let me give another example from a completely different field. Here in the northeast, there is an ongoing debate as to whether a wind farm should be built in Nantucket Sound off Cape Cod. Self-proclaimed experts have written editorials and participated in debates, some very much in favor and some very much opposed. As a citizen with absolutely no knowledge as to whether this is an economically or environmentally appropriate approach to take, I'd very much like to hear from the real experts. But I have difficulty distinguishing the people who really know from the people who know nothing but think they know a great deal, or from the people who simply are trying to make a point but who know how to use the media to accomplish their task. I fear that is what happens with alcoholism and it brings us back to our whole controversy issue again. Is there a controversy in the media? Yes, absolutely. Is there a controversy among the community of medical experts in the field? Nope. Drgitlow 17:40, 11 July 2006 (UTC)

Had the participants in the 20/20 piece defined disease early-on, they may not have had so much disagreement about that issue. Of course, there was also controversy about other issues such as treatment options and effectiveness.

Drs. Alan Marlatt and Nick Heather are both highly regarded experts in alcoholism research and treatment. Years ago Nick Heather ignited the heated and continuing debate over whether or not some alcoholics can learn to drink in moderation. Based on evidence that they can, some treatment profesionals have established alternatives to the traditional abstinece only model.

Obviously, we can't sweep such controversies under the rug and thereby shortchange our readers of information they should have.Medical Man 20:39, 11 July 2006 (UTC)

I'm afraid both Alan Marlatt and Nick Heather are psychologists, not physicians, and therefore don't tend to approach issues using a medical ethic. Whether they're seen as "highly regarded experts" is an opinion. The drinking in moderation approach really ignited with the Sobells, and I invite you to see this article for an interesting perspective: http://www.habitsmart.com/cntrldnk.html

You'll like Dr. Westermeyer's take on the issue, and while I disagree with his conclusion, his historical description covers the bases. He feels the Sobells were ultimately vindicated, but many disagree - and that's yet another controversy in this field.

I can see why you feel comfortable about there being a controversy, and I've come to totally understand your perspective. Indeed, there appear to be strong viewpoints held by sociologists, strong viewpoints held by psychologists, and strong viewpoints held by physicians, all of which appear to be at odds with one another. These groups have different diagnostic strategies, differing opinion regarding treatment outcomes (because they're all treating different things based on different definitions, and looking for different outcomes based upon differing strategies as to what is a "good" outcome), and differing opinions regarding the mechanism of the problem. So even the question as to who is a highly regarded expert is up for grabs - in my opinion, to be an expert in a disease state, you'd need to have certain qualifications. But of course circular reasoning comes into play there; if alcoholism is not a disease, then my specified qualifications wouldn't matter. I've said before that there isn't a controversy - and I stand by that to the extent that within the field of qualified medical experts in addiction medicine, there is no controversy about alcoholism's status as a disease. But...

We could have several VERY different articles, "Alcoholism - The Medical Disease," "Alcoholism - The Social Problem," and so forth. And maybe that's the best way to go. Drgitlow 21:56, 11 July 2006 (UTC)

Talk Page Discussion

At this point, I think what is happening is that the editors are working together to build consensus and to discover directions for the article with which all can agree and/or compromise about. After the serious disagreements that we had originally, we've come a long way. I admire the fact that we've all stepped back, are taking a breather, and are simply discussing perspectives for now without fighting about the article. And though the new template at the top of the page is correct, a couple of more days of discussion prior to getting back to the work at hand seems reasonable to me. Other thoughts? Drgitlow 22:00, 11 July 2006 (UTC)

I'm just checking in real quick from the cruise ship. It looks like you're doing great work here :) --Doc Tropics ^{Message in a bottle} 22:17, 11 July 2006 (UTC)

Mirror site?

I was looking for a definition of alcohol toxemia and found this instead [[12]]. A quick look at the article and the associated talkpage [[13]] indicates that it's very up to date. I assume it's a "mirror", but the website appears to be at least semi-commercial (note the HUGE ads?). Can anyone shed some light on this? --Doc Tropics ^{Message in a bottle} 18:16, 25 July 2006 (UTC)

This is a spam link. The first link randomly fails to actually go to the alcoholism article and displayes a page full of advertisements for bible software instead. Nice spotting. How do we report such things? Oh, I fixed the alcohol toxemia to link to Effects of alcohol on the body, which is redirected from Alcohol poisoning. Robert Rapplean 20:26, 25 July 2006 (UTC)

Actually, it's worse than that. It isn't even a mirror. I made a change and accessed their site, and it immediately had the change in its version. They're directly querying Wikipedia and re-presenting the information as their own. That's really underhanded. Robert Rapplean 20:40, 25 July 2006 (UTC)

I thought it seemed really strange; I'll ask someone to take a look. Thanks for fixing the link, I got distracted and forgot :) --Doc Tropics ^{Message in a bottle} 21:02, 25 July 2006 (UTC)

I sent a message to the dev team, and they blocked the offending IP address. Brion sends his thanks for catching this. Robert Rapplean 21:24, 25 July 2006 (UTC)

Quick work! And I did something useful! :) --Doc Tropics ^{Message in a bottle} 21:42, 25 July 2006 (UTC)