Many Problem Drinkers Are Not Alcoholics

Ian Urbina of NY Times kicked off a big debate about addiction with his piece on how changes in the Diagnostic and Statistical Manual of Mental Disorders will affect diagnostic prevalence rates. The new diagnostic criteria aren’t yet finished, and I am not privy to the committee’s discussions. I can however correct one prevalent misunderstanding about how diagnostic criteria are used in the alcohol field.

A number of media stories have claimed that if diagnostic criteria are widened, everyone who drinks in an unhealthy fashion will be labelled an alcoholic. This is no more true that saying that if oncologists start diagnosing polyps then everyone who has one will be diagnosed with Stage IV cancer.

Many people who drink in an unhealthy fashion are not and will never be alcoholics. Recognizing this reality has no effect on the number of people who are diagnosed with alcoholism. In medicine, the typical term uses to describe unhealthy alcohol use isn’t alcoholism but — wait for it — unhealthy alcohol use.

All “unhealthy” means in this case is that there is a significant statistical relationship between the amount and/or frequency of the person’s drinking and some bad outcome, e.g., automobile accidents. Most people who drink in an unhealthy fashion aren’t aware that they are incurring some risk. The main intervention for unhealthy users is simple information and advice e.g., “You may not be aware that you drink more than 80% of the population and as a result have a higher risk of injuries, problems at work, and family problems than you would if you drank less. You might therefore want to consider drinking less”.

My colleague John Cunningham has shown that such information and advice processes can be done on-line by the problem drinkers in the privacy of their homes. Given solid information, quite a few cut back to a healthier level of drinking. It’s just not that simple with alcoholics, who typically need more involved intervention in order to change.

I don’t know what term the diagnostic criteria committee will ultimately use for the non-alcoholic segment of the problem drinking population. They might call them problem drinkers, unhealthy alcohol users, people with mild alcohol use disorders or the like. But the new diagnostic system will not call them alcoholics; the people who are writing the criteria are too knowledgeable to confuse two such different populations.

[Cross-posted at The Reality-based Community]

Keith Humphreys

Keith Humphreys is a professor of psychiatry at Stanford University. He served as a senior policy advisor at the White House Office of National Drug Control Policy from 2009 to 2010.