[CANCER RESEARCH 39, 2836-2839, July1979] 0008-5472/79/0039-0000$02.0O The Disease of Alcoholism1 Stanley E. Gitlow Mount Sinai School of Medicine, New York, New York 10029 Abstract ance to all of the remaining hypnotic drugs despite the possi bility that none of the other drugs listed in Table 1 has ever A pharmacological view of narcotic addiction and alcoholism, been tried. Setting the issue of tolerance aside for the moment, or sedative addiction, serves as a basis for the further exami let us examine dependence. Not only may the narcotic drugs nation of these complex illnesses. The disease called alcohol produce physical dependence and the incumbent withdrawal ism (sedativism) consists, however, of much more than just a syndrome upon discontinuation of the agent, but a cross-de chronic or periodic addiction to a sedative drug. The urgent pendency exists between the various members of the narcotic need to understand the psychological and societal parameters group. Thus, one may replace one narcotic with another and of this illness is underscored by the likelihood that alcoholism thereby prevent the withdrawal syndrome from appearing. This represents the major factor in the cause of death of young results in a variable degree of cross-addictability, the patient adults (<45 years) in the United States today. Its further role addicted to one narcotic agent being relatively willing to main as a carcinogen is only recently achieving adequate examina tam his addiction by use of any other narcotic despite the fact tion. that minor preferences may exist. As with the narcotic group, the sedative group also demonstrates physical dependency Although plaguing mankind since antiquity, 2 major illnesses and cross-addiction within the group of soporific drugs. Thus, of addiction continue to exact their terrible cost without either one may replace an ethanol i.v. drip with pentothal without broad understanding of their nature or appropriate efforts permitting the withdrawal syndrome to appear and without directed toward their control or eradication. Perhaps the more seriously inconveniencing the patient's feeling of well-being. recent of these, involving many thousands of Americans, has Patients with alcoholism discovered the cross-addictability of been accompanied by sociopathic behavior with its resultant the sedative drugs much earlier than the medical profession. strain upon the legal mechanisms for dealing with ethical so As early as 25 years ago, it was apparent that many affluent, cietal problems. It has been called ‘‘drugaddiction,'‘although urban patients with alcoholism were establishing dependence the illness involves addiction to only the narcotic compounds upon sedative agents other than ethanol. During the past (morphine, meperidine, methadone, heroin, etc.). The other, quarter of a century, the incidence has risen from about 35% involving millions of victims in the U. S. alone, entails addiction to somewhat in excess of 50%. to any one or a combination of sedative-soporific drugs (Table In questioning the existence of the so-called ‘‘addictiveper 1) and has been called, also inappropriately, alcoholism. The sonality' ‘some20 years ago, it was startling to realize the media, perhaps because of the long social use of alcohol, have rarity with which one observed either a crossing over from one quite consistently confused the 2 addictions by referring to group of substances to the other or the simultaneous use of alcoholism on the one hand and drug addiction (grouping sedative and narcotic agents, except in those instances involv narcotics with solid sedatives) on the other. Of course alcohol ing physicians and nurses wherein drug availability might well is a drug, and, more seriously, this view obscures the basic have played a special role. With the advent of methadone nature of the disease of alcoholism as well as the critical programs, however, cross-addiction between these 2 major relationship among sedative drugs in general. From a phar classes of drugs became either more frequent or more visible. macological standpoint, the 2 groups of drugs are quite dis Even then, alcohol or other sedative abuse among patients parate. Narcotics will classically produce analgesia without taking methadone for the treatment of their narcotic addiction substantive sedation whereas sedative-hypnotic drugs can only achieved no more than a 35 to 40% incidence. The majority of produce significant analgesia after eliciting a somnifacient re such addicts failed to turn to the sedative drugs despite the suIt. There are certain similarities to the addictive state pro fact that methadone in no way interfered with their doing so. It duced by each of these groups, however. The narcotic agents might also be stressed that there is no substantive cross can elicit a 20-fold increase in tolerance, and there is cross tolerance or cross-dependency between the sedative drugs on tolerance among the various drugs of this group. Thus, when the one hand and the narcotic agents on the other. The ad one has achieved considerable tolerance to methadone, there dictive illness that we discuss is that to sedative drugs. The is simultaneously increased tolerance to heroin and the other material which follows is largely the clinical bias emanating drugs in the narcotic group. In the case of the sedative drugs, from in excess of 25 years of treatment of many hundreds of tolerance can be established, but it can rarely achieve more patients suffering from this illness. than a 2-fold increase. Cross-tolerance within the group of Alcoholism is a disease (3) characterized by the repetitive sedative agents also occurs, having first been observed during and compulsive ingestion of any sedative drug, ethanol being the 19th century when physicians attempted to anesthetize the just one of these, in such a way as to cause interference in town drunk with the then new agent, diethyl ether. The fact is, some aspects of the subject's life, be it in the area of interper when one is tolerant to alcohol, there is simultaneously toler sonal relationships, job, marriage, or physical health. It is absolutely critical to appreciate that this definition does not in any way specify which sedative agent is used, the frequency I Presented at the Alcohol and Cancer Workshop, October 23 and 24, 1978. Bethesda,Md. of its use, or the amount ingested. Thus, patients with this 2836 CANCERRESEARCHVOL. 39 Downloaded from cancerres.aacrjournals.org on September 30, 2021. © 1979 American Association for Cancer Research. The Disease of Alcoholism Table1 technically correct would be that of ‘‘sedativism'‘(2)if, only to drugs emphasize that patients with this illness may replace alcohol Ethanol with not only any one of its variant beverages but with any Chloral hydrate other soporific drug as well. Alcoholics often refer to Librium Barbiturates (short, medium, and long acting) Paraldehyde as simply ‘‘theverydriest martini. ‘‘Themajor differences Glutethimide (Doriden) resulting from such a replacement reside only in their relative Ethchlorvynol (Placidyl) caloric content and perchance their odor. Less facetiously, we Methyprylon (Noludar) Benzodiazepines (Librium, Valium, etc.) should recognize that the alcoholic who has switched from Meprobamate (Equanil, Miltown) ethanol to benzodiazepines may well have leaped from the Bromide frying pan into the fire. Except among adolescents, there is Diethyl ether Chloroform little of a rewarding social milieu during pill taking, and the alcoholic, by passing this particular barrier of social accept ance, may simply have indicated something more about the illness come in all sizes, shapes, and colors. They may be 8 or severity of his compulsion and the unlikeliness with which he 80 years old. The amount ingested per year might be consid might respond to therapeutic efforts. Obviously, the term al erably less than even the most modest social drinker's yearly coholism is perfectly adequate as long as we all realize that intake. Alternately, one may observe substantive tolerance and nothing more than historical coincidence favored it over chlor a regular daily ingestion of enormous quantities of soporific alism, barbism, or paraldehydism. Since the colorful stores, drugs. The key issue in the definition is that of ingesting a packages, and advertisements dealing with sedative use con sedative agent despite the fact that previous experience should sistently limit their attention to ethanol as opposed to the other have more than clearly demonstrated a serious untoward result sedative drugs, let us examine this particular drug as a proto from the drug. One need drink but twice per year, and, if such type of the group. drinking is associated with motor vehicle operation, or lion An understanding of the clinical pharmacology of ethanol (1) taming, the modest incompetence of excessive sedation could is essential to the comprehension of the disease of alcoholism. well yield catastrophic results. It also must be stressed that the We need concern ourselves minimally with the action of this subject must have had ample opportunity to observe the unto substance upon any tissue in the body other than that of the ward results on one or more previous occasions before such brain. It may be facetious, but it is true that no one ingests this behavior could fall within the confines of this diagnosis. As with chemical for what it does to his liver. Fortuitously, ethanol is so many other diseases, this particular one has a spectrum of rapidly absorbed and achieves appreciable central nervous severity, that associated with the least severe aberration and system levels within a short time after it is ingested. At that function obviously being the most difficult to diagnose. In its point, it yields its primary and major pharmacological effect, mildest form, functional impairment might fail to appear in any that of sedation. There is considerable popular confusion con area other than that of lost potential.