Petros Levounis, MD, MA, is the Director of The Addiction Institute of New York and Chief of Addiction Psychiatry at St. Luke’s and Roosevelt Hospitals in New York City. Dr. Levounis is a board-certified addiction psychiatrist and Distinguished Fellow of the American Psychiatric Association. He is also the author of 4 books, including Sober Siblings: How to Help Your Alcoholic Brother or Sister-and Not Lose Yourself. Dr. Levounis serves as the Addiction Psychiatry Specialist for AOL Health’s Experts Program, where his blog addresses issues of alcoholism and addiction.
I recently spoke to Dr. Levounis about the definition of alcoholism, approaches to treatment, and the power of choice in recovery.
JH: Many people view alcoholism as a black and white issue: you either are or you’re not. Do you subscribe to this idea?
PL: I think that there are a lot of shades of gray and every individual is different; there can be all different kinds of expressions of the illness. But there does seem to be a qualitative difference in the brain – when the pleasure reward pathways get hijacked – that marks the transition to the severe form of the illness from the vast majority of people who don’t really suffer from what we call dependence or addiction.
Even within the people who do suffer from alcoholism, there is a range of severity of illness. That also should not be thought of as black or white. But what separates those with alcoholism from those who don’t has to do with the neurobiology of the system.
Dr. Alan Leshner describes a “brain switch” that gets turned on in some people when biological and sociological forces come together to change something in the brain. Once that switch is turned on, it remains on for a period of time, if not for the remainder of the person’s life.
We appreciate how differently this switch is expressed in different people and we’re somewhat aware of the multitude of expressions from problematic alcohol use to severe alcoholism, but still there seems to be a transition at some point that makes things far more serious.
JH: I often hear alcoholism discussed as a progressive disease. If you are an alcoholic, and that brain switch is turned on, does it inevitably progress?
PL: I cannot call it progressive because the word progressive brings to my mind a terminal illness, such as metastatic cancer or an ominous genetic disorder from which there is no escape. That’s not necessarily the case with alcohol dependence or alcoholism.
AA said it very nicely when they said that alcoholism is an elevator that keeps going down, but you can get out at any floor. We have tremendous amounts of evidence of many people who got out of the elevator at different floors, some of them with the help of AA, or psychotherapy, or medication, or sheer will power, or the church. All kinds of ways and combinations of ways can halt the worsening of the illness.
I think chronic-relapsing is the best way to describe it. For a lot of people, alcoholism has a chronic-relapsing quality in which there are periods of relapse and then there are periods of remission.
JH: Why are some people able to get off the elevator sooner?
PL: In life in general, when things start to go bad, most people do something about it – change something. If they don’t, things will get worse. If you have a fracture and you don’t do anything about it, chances are things are going to get worse – you might get septic and die. If you are in credit card debt and you don’t do anything about it, it will get worse. If you are gaining weight and you don’t stop eating like crazy, you are more likely to suffer from obesity. Same thing for addiction. This is common for all types of ailments people go through.
JH: So most people who are having problems with alcohol – or anything for that matter – make a change so that it doesn’t get worse. And those who don’t respond to the situation continue to worsen.
If you have crossed the line into alcoholism – as AA says, once a cucumber has become a pickle, it cannot go back to being a cucumber – there is something qualitatively different that makes going back more challenging.
JH: Why do people continue drinking rather than making a change?
PL: We don’t find the word denial clinically useful but it does have its place. People often feel that they can control their disease. That is much easier said than done.
Why would somebody not see the light earlier? It may also be because alcohol is everywhere and in some parts of the population it is considered ok to get drunk quite frequently. You look to your right and your left and it’s not frowned upon to be drunk on the weekend.
There is also something else that is unique to alcoholism. I remember a woman I encountered once who said, “I am very different than everybody else, and the difference is that when I use cocaine, I am perfectly fine. The problem is when I don’t use cocaine.” That’s exactly the problem with alcoholism: once you are on it, everything is so good and the problems seem to exist only when you’re not on it. You get the sense that if only you could control it, you would have the best of both worlds. It feels very much within reach to control your use.
JH: Alcoholism, the disease, may exist in an individual without his or her choice but each person has the choice to stop drinking, right?
PL: I think the best analogy I have is cigarette smoking. Once you are a heavy smoker, the vulnerability to go back to smoking does stay with you for a long time. Tons of people quit smoking and are able to live happy lives without smoking; but somewhere in the depths of their brains, the ability to go back to smoking is considerably higher than for people who never had a cigarette.
I think a similar thing happens for alcohol. If you have a drinking problem and you stop drinking, you can live a perfectly happy life without alcohol. But somehow your vulnerability to heavy drinking is higher than for someone who was never an alcoholic. If you were to have a few drinks after 20 years of not drinking, your risk of going back to being an alcoholic is much higher than someone who has never had an issue with alcoholism. It is possible that you would not go back to being an alcoholic again, but statistically speaking, chances are higher that you will than if you never had an issue with alcoholism – not a little bit higher, significantly higher.