Drug and alcohol abuse

  A similar set of arguments holds for drug and alcohol abuse. Both can be associated with mental illness and both can also cause mental illnesses. Fine for psychiatry to be involved then. But are drug or alcohol abuse mental illnesses in themselves? The rebranding of addictions as illnesses was a humanitarian impulse in the 1940s after the founding of Alcoholics Anonymous in 1939, to provide help to detoxify addicted individuals and support sobriety. The world’s largest self-help groups (Alcoholics Anonymous, AA, and Narcotics Anonymous, NA) both consider addiction a lifelong illness, although they rely on personal and spiritual support rather than medical treatment.

  AA and NA view the addict as fundamentally different from other individuals, never able to use drugs or alcohol sensibly. Within psychiatry, however, there are divided views. Many view addiction as an illness to be treated like any other mental disorder. Others see drug and alcohol abuse as dangerous habits that can lead to mental illnesses but are not themselves illnesses, and ultimately are the responsibility of the individuals themselves. The medicalization of substance abuse is criticized as a distraction from effective public health measures such as raising the price and restricting access. Both of the latter have been shown to reduce drinking and drink-related illnesses and deaths.

  Offering help such as prescribing medicines to cope with withdrawal and support to build up a sober lifestyle are uncontroversial. Concerns arise from the use of compulsion which is common to a limited degree in most countries. In much of Scandinavia, Eastern Europe, and Russia, however, there has been extensive use of specialized mental hospitals for longer term detention and treatment of alcoholics and drug addicts. Can this be justified? The consequences of heavy drinking or drug abuse can undoubtedly be disastrous, even fatal. But many of us make foolish decisions and suffer the consequences – smoking is probably more dangerous than drinking but we don’t compulsorily treat smokers. The confused thinking and poor judgement when intoxicated is also a questionable justification for psychiatric intervention as the express purpose of becoming intoxicated is to alter judgements by blurring an unattractive reality.

  Increasing sophistication in genetics and epidemiology has helped identify those who are at greater risk of alcoholism and drug abuse. There are well recognized ethnic variations in the ability to tolerate and metabolize alcohol. These findings strengthen the contention that these are not simply personal choices but disorders, much in the same way that schizophrenia is a disorder – we just don’t yet know as much about it as we do about schizophrenia. Some even propose that self-destructive drinking and drug use must be the result of a mental illness. Clearly the issue is still open and psychiatric engagement with drug and alcohol abusing patients will continue to attract some controversy.