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Perhaps no medical topic arouses more confusion, dismay, and passion in both the public and the medical profession than alcoholism. Although alcohol is often associated with joy and celebration, ritual, and reverence, alcoholism is associated with sorrow and moral failing, disease, and death. No other disease entity can be conceived as having such extreme attributes. This is particularly evident in our country since its inception, where attitudes toward alcohol consumption have swung back and forth from liberal use to strict prohibition. The debates that stirred the American Revolution occurred more often in taverns than churches. Witness the most recent popular movie Sideways, in which wine brought out the best and worst of two friends, arousing aesthetic appreciation, love, passion, anger, and betrayal, but ultimately humor. Wine was never blamed, and sales of pinot noir increased dramatically. Contrast that movie with an earlier one, Leaving Las Vegas, that also garnered critical acclaim but with less popular appeal. It portrayed a man who was inevitably successful in drinking himself to death. At one extreme, alcohol represented bacchanalian reverence, and at the other, it represented a living hell.

We currently live in a culture that has little tolerance for risk; thus, drugs such as Vioxx and Ephedra are banned from the market because of their perceived dangers. This perception of risk is based on emotion, however, not on fact. Society's decision to ban certain substances while allowing others to be freely available has little to do with the dangers inherent in any particular substance, and it has more to do with the emotional outcry that a particular substance engenders. For example, consider the seemingly benign over-the- counter medication acetaminophen, or Tylenol. Tylenol was first introduced in 1956. About 150 acetaminophen-related deaths are reported every year in the United States alone. Add to that the associated morbidity and mortality from those requiring liver transplants from Tylenol overdoses, and the numbers become even greater. Contrast that with Ephedra, a once hugely popular drug for weight loss and bodybuilding that has been linked to a grand total of 155 deaths. The deaths from Vioxx are more difficult to calculate because these deaths are primarily from patients already suffering from cardiovascular disease and not from the direct effects of the drug itself. The estimates suggest up to 27,000 deaths since its introduction in 1999. The outrage leading to its removal had more to do with the company's refusal to acknowledge the risks than the risks themselves. Alcohol, however, is responsible for approximately 85,000 deaths annually from injuries or diseases directly related to the use or abuse of alcohol. Thus, people often judge the risks and benefits of a particular substance based more on cultural, religious, and moral beliefs than on scientific fact. Alcohol is a prime example (see Part 3 for more information about risk).

Alcohol is the single most unique intoxicant because it is a legal, nonprescription, and culturally sanctioned substance that causes more devastating effects to human lives than any other known drug, whether available by prescription or over the counter or on the street.

Alcohol is the single most unique intoxicant because it is a legal, nonprescription, and culturally sanctioned substance that causes more devastating effects to human lives than any other known drug, whether available by prescription or over the counter or on the street. Prohibition, the one attempt in American history to prohibit alcohol use, was a miserable failure, with the cure being worse than the illness. Although it successfully cut the deaths from cirrhosis in half, it came at the cost of increased crime and social unrest.

Ingesting anything — medicine, an illegal drug, or even food — is an act that entails a degree of risk.

Therefore, people should understand the risks and the alternatives before ingesting anything. Informed consent is both a legal and an ethical responsibility of healthcare providers to ensure that their patients are knowledgeable about the drugs they are ingesting, including over-the-counter medications, herbal remedies, street drugs, food, and alcohol (see Question 99 for a more detailed discussion of informed consent).

This book on alcohol and alcoholism provides necessary information for readers to make informed decisions. Examining the topic of alcohol and addiction will also provide readers with information about the influence of alcohol on their own personal well-being. Although the focus of this book is on alcohol and alcoholism, many of the questions and answers pertain to other addictive substances and behaviors as well, and thus, this book may offer some useful insight into the nature of addiction on a more general level.

We live in a time when there is a belief that scientific facts will ultimately help in legislating morality. The culture wars, whether they are fighting over health care, the environment, or other social issues, muster their troops of "scientific experts" when calling on the "facts" to forge political, legal, and moral policy. This is no more evident than the "war on drugs," in which both sides argue persuasively for the need to continue or abandon current policies.

Although the institution of medicine has accepted the concept of alcoholism as a disease, the larger culture with its personal values and beliefs, which includes healthcare providers themselves, continues to debate the issue, with many still viewing alcoholism as a moral failing. This book examines the facts of alcoholism. The following controversial perspective about alcoholism is discussed: Is it a disease or a moral failing? Hopefully a path may be developed in order to find the way out of this no-man's land, where emotions, rather than reason, have left a field littered with the broken fives of those who this horrible affliction has devastated. Because of the controversy of alcoholism as a disease or a moral failing, this book explores the controversy at length so that the reader can be properly informed about the issues and thus be better prepared to understand them in a way that is empowering rather than confusing.

Susans comment:

We celebrated when Ben recently had his 30th birthday. Nearly 6 years ago, while driving, he lost control of the car. The person behind him was very alert, stopped quickly, and found him slumped over the wheel and foaming at the mouth. When the ambulance arrived, Ben was awake but didn't remember what had happened. After many hours and a battery of tests in the emergency room, a place that would become very familiar in the coming years, the doctor explained the diagnosis of an alcohol withdrawal seizure. My reply, as well as his sister's, was "thank you, but I was interested in a medical report, not social work." According to Dr. Herrick, his psychiatrist and co-author of this book, Ben is a "malignant alcoholic" who is still alive — 30 hospital trips and 7 rehabs later.

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