What makes an alcoholic? Definitions changing

The holidays are over. Resolutions are wearing thin. It's a time of year when many people wonder if they have a drinking problem.

More than 30 percent of Americans engage in risky drinking at some point in their lives, according to the National Institute on Alcohol Abuse and Alcoholism. But there's no consensus on exactly what an "alcoholic" is. Even Alcoholics Anonymous relies on alcoholics to diagnose themselves.

Researchers have made up dozens of screening tests over the years. According to one developed for Johns Hopkins University Hospital years ago that still pops up on the Web, I'm "definitely an alcoholic" because I answered yes to at least three of 20 questions: I "crave a drink at a definite time of day" (evenings, mostly) and drink alone (sometimes) and drink to "escape from worries or troubles" (doesn't everyone who drinks?).

But Alcoholscreening.org says I'm "below the range usually associated with harmful drinking or alcoholism" since I have only a glass or two of wine when I drink.

Drinking patterns

The authoritative American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV, separates alcohol abuse from alcohol dependence, based partly on the problems the drinking causes. You qualify for a diagnosis of "abuse" if you've done any one of these in the past year: drunk alcohol in hazardous situations, like driving; kept drinking despite social or interpersonal problems; had legal problems related to alcohol or failed to fulfill major obligations at work, school or home because of drinking.

You've moved on to "dependence" if you've done any three of these seven: drunk more or longer than you intended; been unable to cut down or stop; needed more alcohol to get the same affect; had withdrawal symptoms without it; spent more time drinking or recovering; neglected other activities or continued to drink despite psycholigical or physical problems.

Experts long believed that abuse progressed to dependence, which almost inevitably became chronic and relapsing -- but that was based on observing severely addicted people in treatment programs. Several large new surveys have shown that drinking patterns in the general population are much more varied, with milder forms of dependence. Some 43 percent of daily heavy drinkers don't fit into either DSM-IV category, even though they are setting themselves up for serious health and addiction problems.

"Some people will abuse alcohol -- driving drunk, for example -- but they only drink heavily once a month. They can remain stable for a long time and not progress to dependence," says Mark L. Willenbring, director of the division of treatment and recovery research at the NIAAA. "And people can be dependent and not have abuse problems at all. They're good parents, good workers. They watch their weight. They go the gym. Then they go home and have four martinis. Are they alcoholics? You bet. And the goal is to get treatment for these folks that is acceptable and attractive and effective."

To that end, some experts want the DSM-V -- the new edition now being compiled -- to combine abuse and dependence into a single "alcohol-use disorder" that ranges in severity. The aim is for simmering problems to be spotted sooner.

As one former counselor says, "The conventional wisdom held that alcoholics had to hit bottom before they could get better. We'd like to raise that bottom so that people don't have to fall as far before they get help."

Many heavy drinkers are very high-functioning -- until they can't function anymore. "Alcoholics can be high achievers in the short run, because they're driven and compulsive," says Charlie, a New York attorney who, like all AA members, wants to remain anonymous. Charlie was drinking about a fifth of Johnnie Walker most nights when it began to show. "I'd tell my secretary I was in a meeting with a client, but I'd be home and only starting to feel human by about noon. Then I'd try to do eight hours of work in four hours," he says. This went on for seven years, until he finally went into rehab. He's been sober now for 26 years.

Too much, too fast

Charlie says many heavy drinkers, especially those who grew up around alcoholics, set a private benchmark in their denial. "They say to themselves, 'As long as I'm not making a fool of myself in a bar, or drinking in the morning, or as long as I'm still showing up for work, then I'm not an alcoholic.' "

NIAAA officials say that in recognizing a drinking problem, the label "alcoholic" is less important than harmful patterns of drinking, defined as drinking too much, too fast or too much, too often.

Too much, too fast means having more than four drinks in two hours for men, and more than three in two hours for women. That's a level that makes people legally drunk and impairs brain function. (A standard U.S. drink is 12 ounces of beer, 5 ounces of wine or a 1½-ounce shot of 80 proof spirits.)

Even if you stay within those limits, you can be drinking too much, too often, if you have more than 14 drinks a week for men, and more than seven for women. That's the kind of chronic use that raises risks of health problems, including liver and cardiovascular disease, pancreatitis, dementia, depression and numerous cancers.

How those drinks are distributed is also important. "If you drink seven drinks in two days, that's hazardous -- you're drunk two days a week," says Ting-Kai Li, the NIAAA's director. "If you drink two a day for seven days, that's not harmful."

Counting drinks very carefully to stay within the limit can be a sign of trouble too, says Ruth. "The glass keeps getting bigger and bigger or you forget to add the mixer." She suggests trying to go 30 or 60 days without drinking. "If it doesn't bother you, you're OK. She suggests trying one of AA's public information meetings. "If you're not an alcoholic, you can't catch it from them," she says.

Your family doctor is another place to start. The NIAAA recently issued a guide for primary-care physicians (www.niaaa.nih.gov/guide) to enlist their help in spotting alcohol problems. It starts with a single screening question: How many times in the last year have you had more than five drinks (four for women) in a day? If the answer is even once, doctors are advised to discuss the risks of harmful drinking with their patients, along with steps patients can take to cut back, including new medications to help curb alcohol cravings.

The encouraging news from the NIAAA's recent research is that many people do cut down or quit on their own. "That's the real mind blower," says Willenbring. "Only about 15 percent of the people who develop alcohol dependence in their lifetime have the severe, relapsing form. Most people -- 72 percent -- have a single episode (of addiction) lasting on average three or four years and then they go into remission and stay there. A lot of them are abstaining." For many people, that spate of heavy drinking happens in college -- the peak years are 18 to 24, says Willenbring. "Then they mature out of it and get on with their lives."

For those who don't, alcoholism, however it's defined, is still a profound problem, and the third leading cause of preventable death in the U.S., after smoking and obesity. But being aware of your risks and cutting down now if you need to may prevent you from becoming one of those statistics.