THE DISEASE MODEL
The American Medical Association recognized alcohol dependence in 1956. Alcohol dependence fits the disease model because it is a dysfunctional state with characteristic form.
Use of some drugs, including alcohol, may cause dependency. The medical term for this dependency, or addiction, is Chemical Dependency. In order for a chemical to be addictive, it must possess three properties. It must be:
- mind-altering or mood changing
- reinforcing – that is taking the chemical stimulates taking more of the chemical.
Chemical Dependency includes alcoholism and any other drug dependency. Chemical Dependency manifests as a loss of control, compulsive use, and continued use despite adverse consequences. Chemical Dependency is sometimes referred to as addiction. Psychoactive chemicals that are addictive fall into six categories:
Narcotic pain relievers, e.g. Morphine, Codeine, Demerol, Dilaudid, Percodan, Talwin, Darvon, Methadone, Fentanyl, etc. Heroin is often substituted as a less expensive alternative.
Alcohol, sleeping pills, and minor tranquilizers, plus Barbiturates and Benzodiazepines such as Valium, Librium, Ativan, Xanax, Restoril, Halcion, etc. The “Z-drugs", such as Ambien (zolpidem) and Sonata (zaleplon) are also included.
Amphetamines, by prescription such as methylphenidate, e.g. Ritalin, Cylert, Adderal, and Dexedrine. Includes Cocaine, Nicotine, and Caffeine which are the most widely used legal stimulants with addictive properties.
Also called Hallucinogens and Dissociatives includes LSD, PCP, Mushrooms, and Mescaline.
Marijuana (pot) in all its forms including hasish. Syntheic cannabinoids include K2 and Spice. Two cannabinoids are available by prescription, dronabinol and nabilone, in very restricted situations.
Volatile hydrocarbons that are sniffed such as gasoline, toluene, paint thinner, and airplane glue.
Contrary to what many believe, and what is often portrayed in the media, there are many more injuries, medical problems, and deaths from the use/misuse of legal drugs in America than to the use of illegal drugs. Each day in the United States approximately 10 people die from illegal drug use. In 2018, nearly 200 Americans died per day of drug overdoses, two-thirds of which were due to opioids that are most available by prescription, while there are more than 300 alcohol related deaths per day, and over 1000 daily deaths attributable to nicotine addiction.
Some drugs are, of course, more addictive than others. Stimulants, such as methamphetamine and cocaine, are considered to be the most addictive “street” drug. The addictive potential of other common drugs in decreasing order are: heroin, nicotine, narcotic pain relievers, other stimulants, alcohol, sedative/hypnotics, perceptual distorters, and marijuana.
There are also misconceptions about who suffers from alcoholism. Less than 5% of alcoholics are in the chronic stages of the disease and live “under a bridge.” Most alcoholics are still quite functional. They often exercise regularly, are engaged in productive work, and live with other family members. Over time, for the alcoholic, the normalcy of these areas of life deteriorates. He or she often becomes socially isolated, physically ill, and emotionally stressed while experiencing financial difficulties, legal problems, and spiritual conflict. In many cases, the alcoholic experiences one or more of these problems before his dependency becomes apparent in the workplace.
Chemical dependency is a chronic condition, meaning that it is permanent and prone to relapse. It is also primary, meaning it exists independently and is not secondary to some other underlying mental illness. And, it is progressive, meaning it gets worse over time.
Current understanding of this disease is that it is significantly influenced by genetic predisposition. For alcohol, this predisposition is believed to affect about 40-60% of those who are alcohol dependent. Approximately 10% of the population has the genetic predisposition. It is present across all lines of race, gender, intelligence, and occupation. Other risk factors include age of first exposure to addictive substances, environment, and psychological trauma.
The chemical processes that occur in the brain of the individual who is genetically predisposed are significant and different than the activity in a “normal” individual. When using an addictive substance, the activation of the brain’s centers of pleasure and wellbeing is so rapid and strong the individual almost immediately develops a strong emotional attachment to the drug. Over time, this emotional attachment is accompanied by a physical need. For alcoholics, sudden abstinence from alcohol can result in physical withdrawal symptoms ranging from headaches, sweating, and shaking hands to seizures, convulsions, and death. As mentioned previously, dependency (or addiction) is manifested in three ways:
- Loss of Control
- Compulsive use
- Continued use despite adverse Consequences.
These characteristics are sometimes referred to as the three C’s of addiction.
Loss of Control
Loss of control means the loss of predictability. That is, a chemically dependent individual cannot predict three things when faced with taking a drink or a drug:
- will they use?
- how much will they use?
- what behavior will result?
Loss of control is the most typical symptom in the early stages of the disease but is difficult to identify because it may be present intermittently.
For the pilot population, loss of control may also be masked because of the strict rules and regulations associated with alcohol use as it relates to flying. FAA’s 8-hour “bottle to throttle” regulation, and company rules which often prohibit drinking alcohol within 12 or 24 hours of a duty period, affect the pilot’s drinking behavior. Often problematic drinking, or early signs of dependency, is evident in “binge” drinking behavior. Binge drinking is defined as 5 standard drinks in a setting for a male or 4 standard drinks for a female. Such drinking behavior may be evident even when not associated with flying periods. For airmen, loss of control usually first manifests as drinking more than intended, or as a violation of company or FAA limits on consumption.
A compulsion is an irrational repetitive act that is done despite a firm intention not to do it. It arises from an obsession which is an omnipotent thought, so powerful it takes precedence over other very powerful thoughts, even survival-type thoughts. This compulsive behavior is why alcoholics will risk their jobs, health, relationships, and every other aspect of their lives in order to get a drink or continue to drink. In short, it means alcoholics are powerless to make a rational choice and drinks the way they do not because they want to, but because they have to.
Continued Use Despite Adverse Consequences
For the alcoholic who has not yet reached the chronic stage of the disease, he may still choose to abstain from drinking. However, once alcohol is induced into the individual’s system, the three C’s once again become manifest. So, for most alcoholics, the problem isn’t stopping their drinking, it’s staying stopped. If a person continues to drink despite adverse consequences, one can be assured the person is beginning to enter a disease state.
Similarly, the three C’s are present in those addicted to drugs other than alcohol. Often the use of prescription medications can lead to symptoms of dependency for those who are genetically predisposed. Using addictive medications not in accordance with the doctor’s orders, using medication that is not prescribed for that individual, or using medication that is not warranted by the presence of the associated symptom are all signs of possible abuse/dependency. And, like alcoholics, addicts will protect their supply, rationalize their behavior, and exhibit denial about their misuse.
Denial is a subconscious defense mechanism used to avoid bad news. It is not a manner of thinking limited to Chemical Dependency. If a patient were told by his physician that he only had 6 months to live, it would be typical for the patient to react by saying the doctor must be mistaken and that he wanted a second opinion. This is denial.
In the case of Chemical Dependency, the person using the drugs or alcohol enjoys the experience. If he or she were to acknowledge that use of the drugs or alcohol created problems in his or her life, it would be a normal and sane response to limit or stop his or her use. Since the alcoholic or addict doesn’t want to stop using, they play a psychological trick on themselves and deny the cause and effect relationship of using and having problems. This denial is so strong, consistent, and common that it is considered a defining characteristic of the disease of Chemical Dependency.
It is important to understand that denial is not lying. It is not a conscious distortion of the facts. It is a subconscious mechanism that distorts reality as it relates to the person’s chemical use. The alcoholic or addict simply sees no problem with using their drug of choice. In fact, they often distort reality to the point they reverse the relationship saying their problems cause the chemical use, and not vice versa.
There are reasons other than denial that could be invoked to explain continued chemical use despite adverse consequences. One might presume that alcoholics and addicts are simply stupid, or immoral, or lack will power, or have some other primary mental illness. Thorough investigation reveals, however, that none of these other explanations suffice. Alcoholics and addicts are no different than the general population in any of these characteristics. Of course, chemically dependent people may behave stupidly, or immorally, or as if they were insane, but this behavior is either directly attributable to being impaired by the chemical, or was created over time as a result of their disease. Their impairment is related to changes in the brain structure and biochemical process of dependent persons.
So, what does the presence of denial tell us about the alcoholic and addict? It tells us that we’re dealing with people who are sick. Recognizing that the chemically dependent person is sick is an important step in determining the proper method of dealing with the problem. It also encourages us to have compassion for people we might otherwise judge more harshly.
One’s understanding of the disease of chemical dependency can be determined by how one answers the following questions:
- Is a person alcoholic because they drink too much? or;
- Does a person drink too much because they are alcoholic?
The correct answer is #2: a person drinks too much over a long period of time because they are alcoholic.
While many people misuse alcohol while learning how to imbibe properly and moderately, over time the negative consequences of misuse result in a reduction in overindulgent behavior. For some people, however, the negative consequences are denied and excessive consumption continues. When this denial is accompanied by loss of control, compulsive use, and continued use in spite of adverse consequences, we know the disease of Chemical Dependency is present. In this event, a medical solution to the problem is warranted. HIMS seeks to provide medical assistance to pilots suffering from the disease of Chemical Dependency with dignity and confidentiality.