Understanding the Difference between Alcohol Abuse and Addiction

 

The term addiction was pretty much eliminated from diagnostic terminology with the release of DSM-IV in 1994 (the later DSM-IV-TR released in 2000 did not revise any diagnostic criteria, but simply updated descriptive material in the text). The term substance dependence was believed to be a more descriptive term than addiction, and it was adopted until 2013 when DSM-5 was released. With this release, the entire scheme for diagnosing what most of us think of as “addiction” was changed.

The terms addiction, dependence, substance use disorder (e.g., alcohol use disorder) are all used interchangeably in this article for simplicity. Even though many people still use the terms alcohol abuse and alcohol addiction interchangeably, they refer to two different syndromes.

Technically, the difference between substance abuse and substance dependence relates to the number and type of potential diagnostic criteria a person meets. The criteria were formed such that chronic drug abuse problems were perceived as potentially less dangerous or less serious than drug dependence (drug addiction); however, individuals with drug abuse still experienced serious repercussions as a result of their use. These repercussions were considered signs that the individual had a serious problem even if that person did not meet the diagnostic criteria for an addiction.

In terms of alcohol usage, a person who would be diagnosed with alcohol abuse would be experiencing significant repercussions as a result of alcohol usage; however, the length of time and the issues the person experienced were not as longstanding or severe as a person who would be given a diagnosis of alcohol dependence (alcoholism).

 
To qualify as alcohol abuse, a person must display at least one of the following issues within a timespan of one year:

• Recurrent alcohol use leads to the person not fulfilling major responsibilities at work, school, or home.
• The person repeatedly uses alcohol in situations where it is physically dangerous (operating machinery, driving a car, etc.).
• The person’s alcohol use leads to legal problems.
• The person continues to drink alcohol despite having the problems listed above and/or problems continue to worsen as a result of drinking.

 

 

Essentially, someone with alcohol dependence would most likely have an issue with abuse. However, someone who only meets the diagnostic criteria for alcohol abuse would not necessarily qualify for a diagnosis of alcohol addiction (alcohol dependence).

For the vast majority of cases, it is probably safe to say that the road to alcohol addiction began sometime in the past, with the person suffering from alcohol abuse, even if the alcohol abuse disorder had never been diagnosed.

A person would qualify for a diagnosis of alcohol dependence (alcohol addiction) if three or more of the following issues are displayed within a year:

• Tolerance, which consists of the need for more amounts of alcohol to become intoxicated or to get the desired effects, or a significantly diminished effect occurs from using the same amount of alcohol
• Withdrawal, which consists of either a characteristic withdrawal syndrome, or using another substance or alcohol to get rid of, or to avoid experiencing, withdrawal symptoms
• Unsuccessful attempts to cut down on drinking
• Drinking alcohol in larger amounts or for longer periods of time than originally intended (e.g., not being able to have only one or two drinks from a full bottle of alcohol)
• Important activities related to one’s social life, work, or leisure time are either given up or reduced as a result of alcohol use
• Spending a great deal of time trying to obtain alcohol, using alcohol, or recovering from the effects of alcohol use
• Continuing to drink alcohol despite realizing that recurrent problems occur or are worsened by drinking

 
For the vast majority of people who develop an addiction to alcohol, their problem did not start overnight or develop in a matter of just a few weeks. For most individuals, the pattern begins with occasional normal use, the development of an abuse issue, and then either the inability or unwillingness to stop using alcohol despite numerous signs that the person has a problem (numerous signs would indicate an alcohol dependence issue). The key issue becomes the person’s inability to stop using alcohol despite a number of negative issues associated with the alcohol use.

It is also important to note that the person does not have to develop an actual physical dependence on the drug (e.g., display tolerance and withdrawal symptoms), as is seen in many depictions of alcoholism in the media; however, developing a physical dependence on the drug is part of the criteria for addiction. One could easily be diagnosed with alcohol dependence (alcohol addiction) without experiencing significant withdrawal symptoms once drinking stops; however, as one develops physical signs of tolerance and withdrawal, the spiral of addiction quickly begins to get out of control.

 

The National Institute on Alcohol Abuse and Alcoholism defines heavy drinking as drinking five or more drinks on the same occasion for five different days in any 30-day period. This certainly increases the risk for abuse, but unless the above criteria for alcohol abuse are also met, heavy drinking alone is not sufficient to diagnose an alcohol abuse problem.

Binge drinking is defined by the National Institute on Alcohol Abuse and Alcoholism as using an amount of alcohol in a two-hour period that raises one’s blood alcohol concentration to 0.08 percent. This is about the equivalent of five or more drinks for an average man and four or more drinks in an average woman within a time period of roughly two hours. Someone who binge drinks would not meet the criteria for alcohol abuse unless the person displayed one or more of the diagnostic criteria for abuse in a period of one year. Simply binge drinking at parties, without other repercussions, would not qualify for a diagnosis of alcohol abuse. Likewise, unless the person met three of the diagnostic criteria for alcohol dependence in a period of one year, the person would not qualify for a diagnosis of alcohol addiction.

The research on binge drinking indicates that people who binge drink on a regular basis are more likely to suffer negative consequences as a result of their binge drinking. Many of these individuals also display significant changes in the central nervous system as a result of their behavior. It is generally rare to have an individual repeatedly engage in binge drinking behavior and not experience any negative repercussions from that behavior, such as missing work or relationship issues; however, it is conceivable.

 
Since addiction comes from abuse, it is relevant to look at different types of alcohol addiction to understand how different types of abuse develop. A 2007 study in the journal Drugs and Alcohol Dependence identified five different types of individuals with alcohol dependence. These five subtypes listed, from the largest to smallest groups are:

• The young adult type is the largest subtype of alcoholics in United States. According to the research, they most likely qualified for alcohol dependence at around age 20, tend to be binge drinkers, and drink less frequently than other subtypes of alcoholics. Their average age is around 24 years old.
• The young antisocial type is the second biggest group. This group tended to start drinking as teenagers, around age 15, and met the criteria for alcohol dependence at around 18 years of age, much earlier than the other subtypes identified in this study. These individuals also have a tendency to be diagnosed with antisocial personality disorder, a personality disorder that often is associated with criminal behavior. The average age for this group is around 26. They do not overlap with the young adult type.
• The functional type is generally working adults who are middle-aged, educated, have good jobs, higher incomes than the other types, and relatively stable relationships. This group tends to drink every other day or even more, often consuming five or more drinks when they do drink.
• The intermediate familial type constitutes a group about as large as the functional type. These individuals generally begin drinking in their late teens (by age 17) and would qualify for a diagnosis of alcohol addiction in their early 30s. Nearly half of the individuals in this group have relatives who are also alcoholics.
• The chronic severe type is the smallest group. This group mainly consists of men and has the highest divorce rate of other groups. These individuals frequently use other illicit drugs in addition to their alcohol use.

This study dispels a good many stereotypes associated with alcoholism and also identifies the general patterns associated with chronic alcohol dependence.

 

The designations of substance abuse, substance dependence, and addiction are no longer used as diagnostic labels in the latest edition of the clinical manual that is used to diagnose psychiatric disorders in the United States. Instead, the terms abuse and dependence are replaced with the term substance use disorder. There are three levels of substance use disorder:

• Mild substance use disorder, which in part is supposed to correspond to the older substance abuse notion
• Moderate substance use disorder, which includes most of the diagnoses of addiction or substance dependence
• Severe substance use disorder, which corresponds to individuals who have very severe addictions

The reasons for this change were based on the large body of research that the committee reviewed.  The criteria that were originally included in the substance abuse category in DSM-IV (or DSM-IV-TR) were removed altogether and are no longer used as diagnostic criteria.  The 11 criteria that were used for the substance dependence diagnosis were retained in order to make this new designation.

The substance use disorder concept combines the old abuse and dependence criteria and designates the abuse aspect as being less severe by designation of having fewer symptoms present.  As a person moves towards a more severe alcohol use disorder (addiction), that person meets more of the 11 criteria.

The release of DSM-5 generated quite a bit of controversy regarding many of its changes. It remains to be seen if the current approach offers any specific advantages to more traditional notions of substance abuse and substance dependence (addiction).