We need to change the way we think about alcoholism

We need to change the way we think about alcoholism.

Scientists know how to explain most of the components of addiction, which I study from a systems neuroscience perspective. But I've found that because of the way we do science, focusing in on narrow approaches to a problem, we've lost sight of how to synthesize our research and explain the bigger picture. Alcoholism is a melting pot of society, culture, race, and biology – and that's just for starters – so explaining the illness isn’t as cut and dry as having a few too many drinks too often.

The way we currently explain alcoholism relies heavily on biology and genetics and minimizes social and cultural explanations for the illness. I believe that approach has created problems for the future of addiction research. By changing how we look at alcoholism, we can learn to better support those who are affected and begin to ask more compelling, interesting research questions.

Alcoholism originated in the early 19th century as dipsomania, Greek for “thirst-mania,” to describe an uncontrollable craving for the drink. Around 50 years later, in 1849, the term alcoholism was introduced by Swedish physician Magnus Huss to more specifically refer to the adverse effects of excessive alcohol intake.

As researchers and physicians began to better understand physiology, the brain, and society in the next century and a half, the term became problematic. It was too broad and couldn't be used effectively as a medical definition that identified those with an illness and ruled out those who didn't have one. Understanding if four drinks at lunch was dysfunctional behavior, or just another Tuesday at the office, was guesswork. And making that determination was dependent on geography, race, industry, and gender.

In an effort to better define the negative outcomes of drinking, leading researchers and physicians created a new set of definitions. In 1980 and 1987, respectively, they added Alcohol Abuse and Alcohol Dependence to the Diagnostic and Statistical Manual (DSM) to isolate problem drinking into stricter diagnostic categories. The move validated the condition in the medical field by giving it a universal diagnostic standard. Then, after a series of reviews, the committee that architects the DSM decided they didn’t like those terms, and merged the categories in the fifth version of the DSM, creating Alcohol Use Disorder (AUD) in 2013.

Changing the name was meant to signify that scientists are using a modern lens, powered by advances in our understanding of disease in general, to think about problem drinking and addiction. With the rise of genomics, the process of analyzing human DNA that became possible in the early 2000s, researchers began to think they had found the golden ticket to explaining all disease. Genetic predisposition was supposed to determine the causes of our diseases, uncover the biology behind what they did to our bodies, and lead us in the right direction to create cures. Thus, the idea that alcoholism was a disease that was mainly nature and some nurture was born. This explanation thrived even when it became clear that genes alone really don’t explain disease all that well.

In some ways, thinking about alcoholism as a purely biological disease was a fantastic and desperately needed change, because it helped ease the image of dysfunction typically associated with alcohol use. But I believe the move to apply modern disease theory to studying an illness like Alcohol Use Disorder was problematic, too: it largely removed the social and cultural components of understanding the illness.

By changing the narrative to "it's just genetics," or, "it's a brain disease you can't control," I'd argue we stunted important sociological research on Alcohol Use Disorder by silently writing off possible social and cultural attributions to the disease. Even though those lenses can be problematic, I don't think erasing them entirely is helping: researchers have shown that this “disease like any other” language in the light of modern medical advances does absolutely nothing for erasing the stigma associated with alcoholism and mental illness in general.

Thankfully, we are improving our understanding of the relationship between genetics and society. One of the interesting candidate genes for Alcohol Use Disorder is called GABRA2. If you have a specific mutation on that gene, it appears that you could be at a higher risk of developing Alcohol Use Disorder. And it's found in about a third of the population.

To figure out what this means in practice, my former professor at Indiana University, Dr. Brea Perry, decided to put all this genetics data through a social lens. She and her colleagues hoped to learn more about how social ties and theory applied to the genetics of alcoholism.

By using a group of research participants, their family history, and their genetic data, they were able to put together a group of high-risk individuals with the GABRA2 mutation and a group of low-risk individuals without it. After an exhaustive review of social theories and applying social hypotheses to genetics, they found a wildly compelling piece of data: social factors, such as support from family, seemed to wipe out increased genetic risk for Alcohol Use Disorder.

This isn't to say that social support will cure AUD, but that social treatments can ease genetic risk. In other words, it shows a tangible social and cultural component of the illness that can help mitigate genetic factors.

So while social definitions of disease have historically stigmatized sufferers by making their suffering seem like a personal shortcoming, our go-to move to avoid these stigmas has ended up hiding the social components of the illness. This approach for chronic illnesses, as in the case of AUD, is often insufficient.

Adding social and cultural understanding to strict biological processes is necessary – and effective. Support programs help manage disease and should be part of the ongoing national debates around healthcare funding and treatment.

Our only way to move treatment for Alcohol Use Disorder – and many other conditions – forward is to understand it as a multi-disciplinary condition. That will bring funding, policy, and treatment to groups that need it the most, all while changing cultural narratives about who drinks and why. With this, we truly can start to reverse stigma while helping those who have suffered all the more for it.