Nicole Hefner, Victoria Pearson
Politics of Health
Professor Callahan-Kapoor
April 3, 2017
Alcoholism
Definition and Background
The prevalence of alcohol in the United States is greater than that of any other drug, with over 86% of US adults reporting having consumed alcohol at least once in their lifetime. Although the majority of alcohol consumption is non-problematic, immoderate use may put individuals at risk of developing Alcohol Use Disorder (Alcoholism: Natural History and Background). Over 17.6 million US adults suffer from alcohol abuse or dependence, and alcoholism is the third leading lifestyle-related cause of death in the country (NCADD, 2015). Alcoholism is defined by the Encyclopedia Britannica as “excessive and repetitive drinking of alcoholic beverages to the extent that the drinker repeatedly is harmed or harms others” (Keller and Vailant, 2017). Contemporary medical perspectives recognize alcoholism as a chronic, progressive disease influenced by a matrix of genetic, psychosocial, and environmental factors (JAMA). Heredity, peer or cultural influence, preexisting psychiatric conditions, economic misery or affluence, and availability of alcohol have been identified as specific risk-factors (Keller and Vaillant, 2017).
The term alcoholism has been used in both formal and informal contexts to describe problematic, atypical, or even chronic drinking behaviors. However, as of 2015, Alcohol Use Disorder (AUD) and its associated diagnosis has been established by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) as the clinically approved standard for categorizing severe drinking. Therefore, self-reported alcoholism and popular discourse about alcoholism may occur in or out of the presence of an actual AUD diagnosis. Alcoholism has four classic symptoms: craving, loss of control, physical dependence, and tolerance (Foundation for a Drug Free World, 2017). Long-term physical dependence on alcohol can result in withdrawal symptoms including seizures, disorientation, and visual and auditory hallucinations. In addition to withdrawal side effects, alcoholics are twice as likely to die via suicide, homicide, fire, and drowning and 4.5 times as likely to die in a motor accident (Keller and Vaillant, 2017).
Clinical Diagnosis
Alcohol Use Disorder is comprised of 11 diagnostic criteria, including answering “yes” to having “had times where you ended up drinking more, or longer than you intended” and “wanted a drink so badly you couldn’t think of anything else” (Alcohol Use Disorder). Other behavioral indicators of AUD include regularly drinking more than intended, trying to cut down or stop drinking and being unable to, and giving up activities that were important or gave pleasure in order to drink (Alcohol Use Disorder). Notable changes were made to the diagnostic criteria for AUD between the DSM-IV and revisions in the DSM-5. A study conducted by the Veterans Association evaluating primary care patients with self-reported frequent drinking indicated that 73% of participants met AUD criteria for both measures. However, the DSM-V identified 13% more patients with AUD than the DSM-IV alone (ASCP). The most notable change to the diagnostic measures was the integration of alcohol dependence and alcohol abuse, which were mutually exclusive categories in the DSM-IV. In turn, alcohol abuse is now treated as a continuum encompassing individuals whose conditions vary in severity (Takahashi).
Historical and Social Context
Alcohol has been produced and consumed for thousands of years, dating back to societies in ancient Egypt, China in 7000 BCE, and India in 3000 BCE. In the 16th century, alcohol was used for medicinal purposes, and in the following centuries, it was consumed as a safer alternative to water which often carried pathogens (Foundation for a Drug Free World, 2017). The world alcoholism originated in the 18th century, during which medical constructions of alcohol-related problems appeared (Scull, 2014). By the 19th century, popular attitudes toward alcohol began to shift, and religious revivalism provoked movements for local prohibition and temperance. In January 1919, the 18th amendment was ratified, outlawing the manufacture, sale, and transportation of alcohol. However, this did not eradicate the demand for alcohol and precipitated the practice of bootlegging – the illegal production and sale of liquor – and established speakeasies (secretive drinking establishments). Illegal economies flourished, and bootlegging led to the foundation of organized crime whose prevalence persisted even after the end of prohibition. In the face of public dissent, drastic rises in smuggling, and illegal activity, prohibition was repealed in December 1933 through the ratification of the 25th amendment (“Prohibition,” 2017).
Today, heavy drinking is on the rise, up 17% since 2005. These rates are not equal among all populations, and dramatic increases in alcohol consumption has affected women in particular. The rate of binge drinking in women increased by 17.5% between 2005 and 2012, in comparison to only 4.9% in men. Though the percentage of binge drinkers has increased significantly in the past decade, the overall percentage of Americans who regularly consume alcohol has stayed constant; 56% of US adults said they drank any alcohol both in 2005 and 2012 (NBC).
Alcoholism in the United States disproportionately affects certain racial groups, including African Americans and Native Americans. Sherman Alexie, a famous Native American novelist and poet, describes Native Americans as “having an epidemic rate of alcoholism.” Alexie named his brother, sister, both parents, and all of his cousins, uncles and aunts as either active or recovering alcoholics. He even described some of the negative consequences of this culture of alcoholism, stating, “my classmates, you know, three have died in alcohol-related accidents. My brother has had five best friends die in alcohol-related accidents. And we’re not atypical” (Sherman, 2013). Numerous Indian communities have experienced social and cultural devastation attributable to alcohol abuse. Problems that stemming from alcohol abuse include historical trauma, social and cultural factors, poverty, and domestic abuse. Many policies and programs have been implemented in the past to try to help the alcoholic problem in Native American communities, but so far there has been minimal evidence of their efficacy. This may be due to the inconsistency of these policies and the lack of evaluation (Beauvais, 1998).
Sherman Alexie, image from Konigsberg, Etic. “In his Own Literary World, a Native Son Without Borders.” The New York Times, October 20, 2009. Accessed April 2, 2017. http://www.nytimes.com/2009/10/21/books/21alexie.html
The Native American Context
The Native American community’s first exposure to alcohol occurred during colonization. Soldiers regularly engaged in excessive drinking, and the natives were exposed to their habits. Thus, excessive consumption formed the natives’ conception of normalized drinking behavior. This issue was compounded by the notable lack of mechanisms for coping with the negative consequences of drinking, including alcohol dependence. As European contact continued, “there was a progressive development of high-dose, prolonged collective binge drinking as a central element in many new native drinking cultures” (Frank, Moore, and Ames, 2000).
Alcohol became a profitable trade good because of its inexhaustible demand, it was relatively lightweight for its trade value, and it is nonperishable. At first alcohol was used as a tool of diplomacy, but over time its use in treaty parleys and other official negotiations became nearly universal (Frank, Moore, and Ames, 2000). Shortly, alcohol became a sign of success and a symbol of status among Native Americans.
Economic, cultural, and social factors were the initial influence in establishing a culture of alcoholism among Native Americans. Since then, there have been many efforts to enforce prohibition on reservations all over the country. These alcohol addictions have been passed on from generation to generation and are still prevalent today.
Treatment Perspectives
There are various perspectives on the most effective treatment for alcoholism. Treatment options can be placed into three categories: physiological, psychological, and social. Physiological treatments consist of safe alcohol detoxification and withdrawal. This is often done under medical supervision to maximize patient comfort and minimize life-threatening side effects of withdrawal, such as seizures or strokes. The drug disulfram is one experimental method for preventing relapse after alcohol withdrawal. Once ingested, alcohol is converted by the body to acetaldehyde. Disulfiram works by blocking the metabolism of acetaldehyde, causing people to become nauseated and vomit when they drink alcohol. The intended result is to create an aversion to alcohol by forming an association between drinking and these undesirable side effects. This drug has not yet been proven effective in preventing relapse.
Psychological treatments such as group therapies and individual techniques aim to address an individual’s underlying psychoneuroses. Through emotional stabilization, individuals may experience decreased desires to drink. Proponents of psychological treatment maintain that its efficacy is drastically influenced by how advanced the alcoholic condition is when these cognitive treatments are introduced. They assert that as the brain loses its plasticity, it becomes increasingly difficult to end an addiction to alcohol.
Lastly, social treatment of alcoholism includes four kinds of non-medical interventions. First is external community supervision requiring the participation of the alcoholic in order to keep their employment. Second is the replacement of the habit of drinking with another compulsive habit. Third is finding community support in therapeutic or religious communities or in romantic relationships. Finally, the fourth involves forming a spiritual commitment to facilitate abstinence.
The most popular example of a social treatment of alcoholism is Alcoholics Anonymous (AA). AA is a “12-Step fellowship” in which participants use spiritual principles and a “program of action” as a means to achieving sobriety. Participants agree to abstain indefinitely from alcohol consumption and maintain active participation within the fellowship. Treatment is voluntary, free, and non-medical. AA defines alcoholism as a “threefold disease”, defined by the presence of three characteristics: mental obsession; physical allergy; spiritual malady. The mental obsession characterizes an uncontrollable compulsion to drink. Physical allergy is defined as a hypersensitivity unique to alcoholics which causes the “phenomenon of craving”. Finally, the concept of a spiritual malady supports the assertion that will power is not sufficient to achieve complete abstinence from alcohol. The principal tenants of the program include attending AA meetings; having a sponsor (i.e. sober mentor); having faith in a self-defined conception of god, or higher power; completing the 12 steps (Alcoholics Anonymous).
Each of these treatment plans, physiological, psychological, and social, have advantages, and people often have differing opinions on which they believe is the most effective (Keller and Vailant, 2017)
Prohibition has been the most prevalent policy for treating alcoholism in the Native American population, though it has been proven ineffective. In 1832 the U.S. Congress passed legislation banning the sale of alcohol beverages to Indian people. This was repealed in 1953, and in turn tribes were afforded the choice to retain prohibition. Two-thirds of reservations are legally “dry”, however, this has not had a significant effect on the prevalence of alcoholism within their communities. Researchers have found few notable differences between “wet” and “dry” reservations. In fact, some research suggests that a Native American is more likely to abuse alcohol if he or she grows up on a “dry” reservation (Beauvais, 1998).
Substance abuse prevention programs are commonly found in Native American communities. Unfortunately, most of these programs have not been evaluated for efficacy, so their success is undocumented. In addition, the specific details of these programs are rarely published or made public (Beauvais, 1998). The select programs that have been evaluated show some degree of efficacy in reducing substance abuse, but in contrast to the immensity of this issue, it is necessary to continue working to create more effective programs.
Relation to Politics of Health
Alcoholism is linked to the issue of medicalization, which is categorization of a behavior as an illness which necessitates medical intervention. Before the 18th century, drinking alcohol was considered a completely normal and non-problematic behavior. But as Andrew Scull notes in his encyclopedia of mental illness, “the end of the 18th century marks a period of increasing linkages with [drinking alcohol and] mental illness in . . . the United States” (17). Physicians brought attention to the fact that certain liquors caused destructive behaviors like madness, murder, and suicide when overconsumed. These views spread throughout the 19th century, during which time the term “alcoholism” arose. A Swedish doctor coined the term to mean a chronic condition of inebriates, referring to the most severe form of alcohol abuse resulting in toxicity. During the 1900s, alcoholism, or alcohol dependency, as many medical officials called it, was recognized as a medical condition in need of treatment. Alcoholics Anonymous arose in the 1930s to help alcoholics end their addictions, and the World Health Organization held committees on alcoholism under the larger category of Committees on Mental Health (Scull, 2014). In the last two centuries, alcoholism underwent medicalization, evolving from a normal habit that might cause some unwanted effects to being a mental health condition requiring treatment.
Native Americans, who have had a drinking culture for hundreds of years, have the highest alcohol-related death rate of all ethnic groups in the United States, in part caused by their political history (Frank, Moore, and Ames, 2000). Contemporary reservations are afflicted with issues such as domestic violence, health disparities, rape/sexual assault, dropout, and suicide; Native Americans have identified alcohol as a coping mechanism (Sherman, 2013). This group has a traumatic past characterized by oppression, removal from their original homeland, forced relocation to small reservations, and the denial of rights afforded to other American citizens. Until the Indian Civil Rights Act of 1968, Native Americans were not legally entitled to free speech, press, and assembly; protection from unreasonable search and seizure; and right to a jury trial for offenses punishable by imprisonment (Wikipedia – native American civil rights). Native Americans had minimal means to earn a salary, making poverty and poor social conditions an additional risk factor for alcoholism and drug addiction (Bentley, 2013). The abysmal history of structural violence and oppression suffered by Native Americans sheds light on the fact that they are the group with the most prevalent alcoholism in the United States today.
Bibliography
“Alcoholism: Natural History and Background.” National Institutes of Health. 2017. Accessed April 1, 2017. https://pubs.niaaa.nih.gov/publications/HealthDisparities/Alcoholism1.htm
“Alcohol Use Disorder.” National Institute on Alcohol Abuse and Alcoholism. Accessed April 1, 2017. http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-use-disorders.
Beauvais, Fred. “American Indians and Alcohol.” Spotlight on Special Populations 22, no. 4. (1998). https://pubs.niaaa.nih.gov/publications/arh22-4/253.pdf
Bentley, Andrew. 2017. “Alcohol: It’s difference for Native Americans.” Partnership with Native Americans. Accessed February 12, 2017. http://blog.nativepartnership.org/alcohol-its-different-for-native-americans/
Fox, Maggie. “Americans are drinking more.” NBC News. 2015. Accessed April 1, 2017. http://www.nbcnews.com/health/health-news/americans-are-drinking-more-lot-more-n347126
John W. Frank, Roland S. Moore, Genevieve M. Ames. 2000. “Historical and Cultural Roots of Drinking Problems Among American Indians.” Public Health Then and Now. Accessed February 12, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446168/pdf/10705850.pdf
Keller, Mark and George E. Vaillant. 2017. “Alcoholism.” Encyclopedia Britannica. Accessed March 31, 2017. https://www.britannica.com/science/alcoholism
“Prohibition.” Encyclopedia Britannica. March 23, 2017. Accessed April 1, 2017. https://www.britannica.com/event/Prohibition-United-States-history-1920-1933
Scull, Andrew. 2014. Cultural Sociology of Mental Illness: An A-to-Z Guide. Thousand Oaks: SAGE Publications, Inc. 2014. eBook Collection (EBSCOhost). EBSCOhost (accessed March 31, 2017).
Sherman Alexie, interview by Bill Moyers. Moyers and Company. “Sherman Alexie on Living Outside Cultural Borders.” April 12, 2013.
The Editors of Encyclopedia Britannica. 2017. “Prohibition.” Encyclopedia Britannica. Accessed April 1, 2017. https://www.britannica.com/event/Prohibition-United-States-history-1920-1933
The National Council on Alcoholism and Drug Dependence (NCADD). 2015. “Facts About Alcohol.” Accessed April 1, 2017. https://www.ncadd.org/about-addiction/alcohol/facts-about-alcohol.
“What is alcoholism or alcohol dependence.” Foundation for a Drug Free World. Accessed April 2, 2017. http://www.drugfreeworld.org/drugfacts/alcohol/what-is-alcohol-dependence.html
Wikipedia contributors, “Native American civil rights,” Wikipedia, The Free Encyclopedia. Accessed April 2, 2017. https://en.wikipedia.org/w/index.php?title=Native_American_civil_rights&oldid=773009714
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