Date Published: January , 2012
Publisher: Blackwell Publishing Ltd
Author(s): John A Cunningham, Jim McCambridge.
This ‘For Debate’ paper starts by recognizing the growing trend towards considering alcohol dependence as a chronic relapsing disorder. We argue that the adoption of this model results from focusing on those in treatment for alcohol dependence rather than considering the larger number of people in the general population who meet criteria for alcohol dependence at some point in their lives. The majority of the general population who ever experience alcohol dependence do not behave as though they have a chronic relapsing disorder: they do not seek treatment, resolve their dependence themselves and do not relapse repeatedly. We suggest that caution is therefore needed in using the chronic relapsing disorder label. Our primary concerns are that this formulation privileges biological aspects of dependence to the detriment of psychological and social contributions, it inhibits much-needed developments in understanding alcohol dependence and leads to inefficient distributions of public health and clinical care resources for alcohol dependence. We invite debate on this issue.
There appears to be a growing acceptance that alcohol dependence is a chronic relapsing disorder [1–8]; but is this description an accurate label to apply? Does it capture the core features of this problem [9–12], and is it useful? In this ‘For Debate’ paper we will explore why this term may be attractive, as well as its limitations. We suggest that the majority of people with alcohol dependence do not behave as though they have a chronic relapsing disorder. Further, we will argue that conceiving of alcohol dependence as a chronic relapsing disorder may be detrimental to our attempts to understand the nature of this phenomenon, and to decisions on what to do about it.
The principal source of the chronic relapsing disorder model of alcohol dependence may be neurobiology research. There have been several high-profile papers, published by leaders in the field in influential journals [1–4], describing addiction as a brain disease and as a chronic relapsing disorder, and the two can be easily conflated. Neurobiology has made great strides in understanding the impact of substances of abuse on the brain, and these findings have advanced a fundamentally biological explanation of addiction. However, as has been discussed eloquently by Kalant , there are limitations to how far neurobiology can take us towards understanding a problem that has social and psychological as well as biological roots. The neurobiological chronic relapsing disorder perspective tends towards reductionist rather than integrative conceptions of dependence. In addition, we argue that this emphasis on the biological component of an intrinsically interdisciplinary problem results from and reinforces an emphasis on the more severe end of the continuum of dependence problems. It is usually those with severe dependence who are under study in neuroscience. This focus may narrow rather than broaden our understanding, as it implies a categorical separation of the addicted (or the alcoholic) from the non-addicted (the favoured terms within neuroscience), because some people have this problem while others do not. This is at odds with clinically based attention to severity of dependence, prevailing conceptions of the nature of dependence itself, and also what is known in population health sciences.
Our approach to alcohol dependence comes primarily from a population health perspective. That is, when the course of alcohol dependence is examined for the entire population of people who meet criteria for this disorder, do they behave as though they have a chronic relapsing disorder? The majority of people who meet criteria for alcohol dependence at some point in their life: (i) do not seek treatment [18–21]; (ii) resolve their alcohol dependence without any formal treatment or similar help [19,22,23]; and (iii) do not relapse repeatedly to alcohol dependence [19,22,24,25]. We stress here that this is not to say that some people with alcohol dependence do not relapse repeatedly and that a chronic care model of treatment would be ill-advised for this subpopulation—just that most people who experience alcohol dependence do not relapse again and again. If we want to understand the nature of alcohol dependence, or other addictive behaviours, then it is important to examine the full range of people experiencing the problem, thus including but not restricted to those with severe dependence only.
Is there a middle ground between these two views of alcohol dependence that may be appreciated when one considers the component terms—chronic, relapsing and disorder? For many people who experience alcohol dependence, there is indeed chronicity in the sense that this is not just a short-lived episode responsive to some sort of quick fix. Alcohol dependence usually takes many years to develop and be maintained [26–34] before it is subsequently overcome by most people on their own [19,22,23]. Drinking behaviour is dynamic and modified by a multitude of influences at different levels of intervention among those who are alcohol-dependent. Difficulties in controlling consumption are characteristic of many of those who have dependence and are fundamental to our understanding of it, and great suffering is involved in their personal struggles to limit the associated harms. Relapse in the sense of setbacks in these struggles is not at all unusual. Finally, alcohol dependence is clearly a disorder in diagnostic terms and disordered in the sense that it conflicts with deeply held values and goals and does damage to them .
The different perspectives held by addictions researchers with a clinical versus a population health perspective are not new. Room  referred to these as the two worlds of alcohol problems at a time early in the development of the modern epidemiological study of alcohol dependence. These different perspectives have far-reaching consequences, because the picture that is derived of alcohol dependence is very different depending on the researcher’s or policy maker’s orientation. Fundamentally, it comes down to how we define the population with alcohol dependence—does it consist of only those who are seen in treatment or does it comprise everyone who meets criteria for alcohol dependence in the general population? If one restricts the perspective to just those in specialized addictions services then it may be useful to regard alcohol dependence as a chronic relapsing disorder, although even here severity of dependence has long been accepted to be a key determinant of likelihood of relapse . When the scope of alcohol dependence is widened to include all those who meet diagnostic criteria within an epidemiological survey then the concept of a chronic relapsing disorder does not seem as applicable. It is important to be clear that this broader epidemiological perspective emphasizes the need to be appreciative of the full continuum of alcohol problems (up to and including severe alcohol dependence), and not any sort of false dichotomy between those who alcohol dependent and those who are not.
Caution is needed when using the chronic relapsing disorder term, as the value of this perspective is diminished when one considers the problems probably attendant on its careless application. Restricting attention to those with ‘complicated alcohol dependence’, which may be a better way of thinking about and referring to this population, has profoundly adverse consequences for both science and clinical and public health interventions. Insufficient attention has been paid to the entire distribution of those with alcohol dependence. We believe that a chronic relapsing disorder model is not a useful conception for understanding the experience of the majority of people who have difficulties with alcohol dependence at some point in their life and that the influence of age and age-associated problems linked to dependence would benefit from further elaboration. Further, adopting a chronic relapsing disorder model may lead to an imbalance in considering the factors contributing to alcohol dependence, shifting focus away from psychological, social and environmental contributors towards an overemphasis on neurobiological perspectives. In addition, it is unclear whether a chronic relapsing disorder perspective serves some other useful purpose, such as leading to reduced stigma for those with alcohol dependence or to increasing the likelihood of accessing effective treatment. Until there is some evidence that adopting this model of alcohol dependence provides researchers, practitioners and policy makers with significantly more benefits than it does potential harms, we suggest that alcohol dependence itself should not be regarded as a chronic relapsing disorder.