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Editorial Comment 6/11: Final response, contribution of volume and frequency to the diagnosis of alcohol use disorder (AUD)

by William Haning, MD, DFAPA, DFASAM | Jun 07, 2019
Editorial Comment:  Final response, contribution of volume and frequency to the diagnosis of alcohol use disorder (AUD)

In last week’s ASAM Weekly (04 June 2019), Dr. Raymond Anton and co-authors replied to a guest editorial by Dr. Stuart Gitlow, in reference to a Clinical Psychiatry News 21 February report from the December 2018 meeting of the American Academy of Addiction Psychiatry (AAAP).   As is customary in an exchange of letters, Dr. Gitlow’s response is provided below, in conclusion:

“I greatly appreciate the effort and scholarly interest that has gone into Anton et al.'s finely crafted response. I believe the two sides have a difference of underlying presumption. I believe addictive disease stems from a combination of genetic and environmental factors that lead the individual, eventually, to a flawed discovery that a substance (or similar substrate) represents the best possible solution to an underlying discomfort. This is consistent with ASAM’s definition of addictive illness. The APA’s definition of addiction, however, is based upon the behaviors and observed signs that follow that discovery by the individual. In essence, we have individuals with late-stage disease who are identified by DSM-5 and who are therefore identified utilizing signs/symptoms that are not present early in the course of the illness. As a result, I see drinking in AUD to be not only a symptom, but one of the late symptoms of the illness, while Anton et al describe it as a “cause of the disease,” something supported by the definition in DSM due to the fact that without alcohol use, one cannot have an alcohol use disorder. I’ve always said that cessation of alcohol use for an individual with alcoholism allows us to begin to treat the alcoholism, as at that point we’ve done nothing but eliminate the substance the person is using to treat his or her underlying discomfort. The discomfort is the result of the disease, not of alcohol use. The discomfort is addictive illness and is the driving force behind the addiction, which either has not yet begun, or which is now in the rearview mirror. 

“I do understand and appreciate Anton et al.’s perspectives, and I believe they stem in large part from a belief (which may yet be true) that if alcohol were to disappear from the planet’s surface, no one would have alcohol use disorder, whereas I believe that alcohol use disorder is in fact present prior to the first use of alcohol, but simply is not identified in those individuals due to their failure to display what, under DSM, are required symptoms. If alcohol and analogues were not present, all the people with alcohol use disorder would simply be uncomfortable but would never fall down the rabbit hole as a result of their discovering sedatives. Ultimately, the question here revolves around whose definition of addictive disease we believe. Although we like to think that the addiction field and the psychiatric field, both of which I feel are my brothers and sisters, represent one large group, I believe the differing disease definitions are driving very different research efforts, for they give rise to very different questions, and answers that have one set of meanings for one side and another set for the other side. 

“I am ever hopeful that we can eventually resolve these issues with continued scientific exploration and resulting discovery.

- Stuart Gitlow, MD, DFASAM”

- W. Haning, MD, DFASAM