GIMedia Review

Physicians may miss the diagnosis of alcohol dependence in more than half the patients they see, according to Beyond the Influence. For general practitioners who hope to close that gap, this book is a fine resource that distills the plethora of information about this complex disease into a single volume.

An update of Ketcham's Under the Influence (Bantam, 1984), it is coauthored by practitioners in the field of recovery, one of whom is a recovered alcoholic. Written for both health professionals and lay readers, the text is straightforward, with chapters that are documented by a 38-page reference section, which cites studies and statistics from major alcohol research centers and government agencies in the country. It includes information on the biological etiology of alcoholism, identification of alcoholics in early as well as late stages of alcoholism, traditional and alternative therapies, and social implications of alcoholism, the marketing of alcohol, and government policies.

By citing recent neurological and biochemical studies on both animals and humans, the authors substantiate the disease model of alcohol dependence in Part I, The Problem. Beyond the Influence brings new light to the discussion of genetic defects that may result in an individual's predisposition to alcohol dependence. The dopamine D2 receptor (DRD2) gene, for example, is sometimes popularly referred to as the “alcogene,” the mutated gene that is suspected of playing a role in alcohol dependence. However, the authors point out that researchers identify it instead as a “reward gene” because it governs other compulsive and pleasure-seeking behaviors such as carbohydrate bingeing, abnormal sexual activity, display behaviors (e.g., Tourette's Syndrome) and compulsive gambling. Other clinical trials mentioned in the book concur with research cited recently in Substance Abuse: The Nation's Number One Health Problem, produced by Brandeis University for The Robert Wood Johnson Foundation (February 2001). Both books, for example, upend the belief that people simply drink because of unpleasant social situations or because they are depressed or anxious. Rather, they encourage physicians to view alcoholism as a disease that can cause depression, relational difficulties, and unemployment because of its “widespread disruption” of brain chemistry.

With respect to the disruption of brain chemistry, the authors focus most of their discussion on TIQs (tetrahydroisoquinolines), which have a “central role in neurological addiction.” The book describes the mechanisms by which TIQs are opiate-like by-products of the interactions between neurotransmitters and acetaldehyde, alcohol's metabolite, and how these mechanisms have been extensively studied in animal models of substance abuse. The TIQ theory is used to explain cravings and uncontrolled drinking behavior in humans: the production of TIQs in the brain, it is presumed, must lead to more of a craving for these addictive substances, which alcohol provides, and sets up a vicious cycle that alters a drinker's brain chemistry. Although the discussion on TIQs is compelling, it is unfortunate that mention is not given to other studies that have been done—on humans, rather than animals—concerning the relationship between brain levels of TIQs and the propensity for alcohol dependence. However, the authors say it well when they concede that “nothing… is simple in alcoholism, and the addictive potential of TIQs is only one piece in the complicated puzzle of addiction.”

Once the authors establish the neurobiological bases for alcoholism, they make a distinction between those who are alcohol dependent and those who are alcohol abusers (non-alcoholics who drink heavily). According to the authors, controlled drinking programs will not help an alcoholic; however, by acknowledging that physiology makes controlled drinking impossible, alcoholics feel supported in their need to recover, rather than ashamed that they lack willpower. (Actually, when it comes to willpower, alcoholics statistically show higher rates of compliance with their treatment plans than patients diagnosed with diabetes or heart disease.) Unfortunately, as the book notes in a section on “the managed-care bugaboo,” some insurance policies still do not cover alcoholism because it is designated as a mental health disorder, rather than a physiological problem—an injustice that physicians might help to rectify.

While Beyond the Influence shows the biological root of alcohol dependence in Part I, Part II, The Solution suggests for treatment not only drug therapy, but therapies that have psychosocial and spiritual dimensions: individual, group, and family therapy; Alcoholics Anonymous meetings; and meditation, to name a few. To ignore the behavioral and psychosocial aspects of alcohol dependence would be tantamount to not treating it at all; however, evidence in this book for the success of such treatments is more anecdotal than that given for the biologic bases of the disease: it includes case studies from coauthor Arthur P. Ciaramicoli, a clinical psychologist and psychology instructor at Harvard Medical School, and other practitioners in the field of recovery.

Notwithstanding a lack of empirical evidence for certain treatments, Part II of this book is most helpful to general practitioners in providing the tools to diagnose and treat patients with alcohol dependence. If physicians will forgive explanations to a lay readership (e.g., the difference between a sign and a symptom), they will find the chapter Am I an Alcoholic? helpful in sensitively diagnosing early- and middle-stage alcoholics before they hit bottom and deceptively high-functioning, late-stage alcoholics, who engage in demanding careers. Such diagnoses may be difficult, the authors admit, particularly in view of the estimated 10% of physicians in the United States who are themselves alcoholics. Other helpful tools for treating an alcoholic patient include: a compendium of six diagnostic questionnaires, such as the popular CAGE questionnaire; a description of how to plan and implement an intervention to get an alcoholic into treatment; an explanation of the symptoms of long-term withdrawal (i.e., protracted withdrawal syndrome), that can occur months and even years after quitting; strategies for helping patients remain sober, including an awareness of the physical and emotional symptoms of an impending relapse; a description and assessment of the major pharmacological approaches to treatment, such as the use of disulfiram, naltrexone, acamprosate, and the selective serotonin reuptake inhibitors; as well as chapters on nutrition and exercise for patients in recovery; and descriptions on successful alternative therapies, such as acupuncture. The chapter on treatment gives detailed descriptions of patients' options, down to specific programs in the United States and their weekly schedules and costs.

In Part III, The Future, the authors describe the political, legal, and social milieu in which alcohol dependence and its treatment unfold in the United States. Here the authors do not tread gingerly in their critique about the legislative and judicial policies that may contribute to the problem of alcohol dependence in the United States, and they scathingly and courageously attack the “Big Alcohol” industry or “booze merchants” in much the same way that Big Tobacco has been assaulted.

This is a fascinating book, a blend of science and other disciplines, replete with an eclectic mix of references, shocking statistics on alcoholism and drinking patterns in the United States, proverbs, and quotes from renowned authors in both the sciences and humanities. Moreover, the book is filled with interesting, useful, but little-known facts about alcohol. For example, did you know that carbonation in alcoholic beverages speeds the rate of absorption of alcohol by irritating the pylorus and opening it prematurely? Beyond the Influence is recommended for alcoholics and their loved ones, for therapists and physicians, or anyone, in fact, who might wonder, “Am I?”