The following is the edited transcript of an interview by Bill Moyers with Marc Schuckit, M.D., on the risk factors for alcoholism. Schuckit is a psychiatrist and addiction specialist who teaches at the University of California, San Diego School of Medicine. Portions of this interview appear in the CLOSE TO HOME television series.
Moyers: You have been looking at the causes of alcoholism. Why is it important to understand how someone develops this disorder?
Schuckit: Two words: prevention and treatment. If you know the causes, it should be easier to find ways of helping people avoid the problem. And by looking at causes, maybe you can find people who have unique needs in treatment, and by meeting those needs, increase their chances of recovery.
Moyers: What are we learning about who is vulnerable?
Schuckit: To develop a problem with alcohol or other drugs, you need a combination of biological and environmental vulnerability. I'd like to study both. But it turns out that the biology is a little easier to study. So I can tell you some factors about you that will determine whether you are at higher or lower risk for alcoholism. For example, let's say that you're one of the 50 percent of Asian individuals -- Japanese, Chinese, or Koreans -- who flush when they drink. This means your face turns red and your heart beats fast and hard. It's not pleasant. In its extreme form, that negative reaction protects you from developing alcoholism quite well and in its modest form, which is found in 40% of Asian men and women, it decreases your risk a tad. But an even more important factor in predicting your risk is your family history of alcoholism.
Moyers: All right, how would you evaluate my personal risk?
Schuckit: First, I'd have to define for you what I mean by alcoholism in order to make sure we were talking about the same thing when I asked you about your relatives' drinking patterns. What I mean is a pattern of life problems related to alcohol which have a large and repeated impact. And I would give you a specific group of examples -- needing more alcohol to have an effect, getting bad shakes for a couple of days when you cut down, spending a lot of time drinking, drinking despite evidence of negative consequences, a pattern of serious consequences -- these types of things. Then, I would ask, "Are you now or do you ever plan in your life to be somebody who consumes alcohol?" If you say, "Hey, I'm never going to drink," I'd tell you that as long as you keep that promise you won't develop alcoholism and I have no data to say your increased risk of alcoholism means increased risk of developing anything else instead. Don't drink. Good. Fine. On the other hand, the second you say to me that you are a drinker or may choose to be a drinker in the future, I would tell you that your risk for developing alcoholism can't be determined absolutely, but one of the major factors is your family history. And I'd ask, "Did your mother ever have those problems in her life?"
Schuckit: Your father?
Schuckit: Do you have any grandparents who have had those problems?
Moyers: My maternal grandfather was a severe alcoholic.
Schuckit: Any others in the family?
Moyers: Two of my mother's brothers were severe alcoholics.
Schuckit: So you have some risk on your mother's side of the family. What was your mother's drinking pattern like?
Moyers: She never even tasted it. Never. Ever.
Schuckit: Okay. Now here's the problem. Your mother has a lot of alcoholism in her family. That means that your mother probably had about a four times increased risk for alcoholism compared to women in the general population. I'm using the narrow definition of alcoholism -- alcohol dependence, the severe problem pattern. The risk for alcohol dependence in women is 3 to 5 percent; her risk would have been four times that -- somewhere between 15 and 20 percent. But we don't know whether she carried the risk because she didn't expose herself on a regular basis to alcohol. That means we don't know whether she was carrying the increased risk biologically. Given her family history, I would say, your risk for alcoholism is certainly higher than the general population for males. The risk of alcohol dependence is about 10 percent for males in the general population -- 10% will develop alcoholism. If I knew that one of your parents was alcoholic or carrying whatever genes there are for the increased risk, that would mean your risk would be close to 40 percent. But I don't know whether your mom carried those genes or not. You share more than a random amount of genes with people who had severe alcoholism. Even so, my estimate would be you're probably at least double the risk for alcoholism and perhaps as much as four times the risk. So I'd advise you to be a non-drinker.
Moyers: How much higher, then, is the risk of alcoholism among the children of alcoholics?
Schuckit: Four-fold. Some would say three if you quibble, but it's basically four-fold. And if not just one but both of your parents are alcoholic, and you have it throughout both sides of your family, the risk is about 60%.
Moyers: Tell me about your study of the sons of alcoholics.
Schuckit: It's really interesting how one thing leads to another in science. The project began with some marvelous people at my alma mater, Washington University in St. Louis, including Lee Robins and George Whittaker. The first stage in that study occurred when I was a medical student and a resident. We were asking whether alcoholism is genetically influenced. We did a half-sibling study because we couldn't get adoption records in the U.S. The key question was, "Is this four-fold increased risk for alcoholism still there even if you weren't raised by an alcoholic?" The ideal way to do that is the way a guy named Donald Goodwin did in Denmark at about the same time, published a few years later. Don got actual adoption records and compared people's biological parents with their adoptive parents, determining which parents' history predicted the children's alcoholism risk. We did a similar kind of study. We looked at, for example, a father who's alcoholic and has children with several different women, but only one of those sets of kids is raised with that alcoholic biological father. So you can compare the risk for alcoholism in children of alcoholics raised by non-alcoholics versus children of alcoholics raised by alcoholics. And we found that if your biological parents experienced alcoholism, your risk for developing it was elevated, even if you were raised by non-alcoholics. That four-fold increased risk was there based on a biological parent having alcoholism. It didn't increase your risk further to be raised by an alcoholic. So the logical next question is, "If alcoholism is genetically as well as environmentally influenced, what is it that people might inherit to increase the risk?" It was important to remind myself while designing the study that it's likely to be multiple genes, not just one, which increase the risk and maybe some other genes that decrease the risk and all of those interact with environment so that it's going to be complicated. We looked for a theme. We wondered, "Is there a characteristic that people might be inheriting which increases the risk for alcoholism?" The theme we chose was something that my patients taught me. I developed the habit of asking alcohol-dependent patients to think back to their early drinking careers. "What was alcohol like when you started out?" And I've got to tell you, I expected them to say to me, "Oh, I never felt normal 'til I had alcohol. It was just nirvana." Much more often than that I got, "It wasn't much, didn't have much effect and in fact, I was pretty proud of how much I could drink and function. I became the designated driver. Maybe I shouldn't have been driving because I was drinking so much, but I was the one that they knew wasn't going to stumble after having all those drinks."
So we started a study to see whether it was possible that, as a group, children of alcoholics would show a low level of response to alcohol compared to children of non-alcoholics. You've got to start with some population, so we chose males, about 20 years old, fairly functional, who had an alcoholic father. I chose alcoholic fathers rather than mothers to avoid the potential confounding factor that alcohol itself can affect the fetus, which could be an influence but wouldn't be a genetic one. So, we looked at these men who were all drinkers but not alcohol-dependent. A high risk population for alcoholism. And for every guy in this high risk group, we selected a control counterpart, similar in age, drinking history and everything -- but with no family history of alcoholism. Over a 10-year period, we brought these people into the lab, trying various doses of alcohol, most of them the equivalent of about three to five drinks. We would give them the alcohol and then measure what happens to them. They'd fill out a check list every half hour about how high or how sleepy or how nauseated they felt during each of those half-hour intervals. We looked at both positive and negative effects. Then, we did a coordination or motor performance test where we would watch how much their body sways. If you and I were to stand and I were to measure our sway -- feet together, hands at our sides -- while everybody sways a little, if you have some alcohol, you sway a bit more. So we wondered, "Is the amount of sway increase with alcohol different in the sons of alcoholics and the sons of non-alcoholics?" And then there were some other biological measures -- how their bodies changed, including how their brain waves and their hormones changed. Basically, about 40 percent of the sons of alcoholics showed remarkably low levels of response to alcohol.
Moyers: It didn't have much effect on them?
Schuckit: Exactly. For about 40 percent, there was not much increase in body sway, not much feeling of intoxication, and their bodies, by their brainwaves and their hormones, were saying to us, "Not much happening here, guy." Now about five percent of the sons of non-alcoholics also showed that low level of response. It wasn't totally unique, so whatever was causing this effect wasn't only found in those with a known genetic risk. Up until about 1985 we were gathering these 453 men, sons of alcoholics, sons of non-alcoholics -- and testing to see if we could measure whether a higher proportion of children of alcoholics would show a low level of response to alcohol. The real question then becomes, "Does this low level of response to alcohol tell you anything about what's going to happen in the future?"
Moyers: You mean, will the people who show this low response become alcoholics?
Schuckit: Indeed. Does it predict anything? How do you find that out? You follow up with those guys. Wonderful group of guys who agreed when they first entered the study that they would be willing to at least hear from me in the future if I wanted to find out how they're doing. So about 10 years later we hired a group of interviewers, and found all 453 men almost 10 years later. And, of those 453, which to me was amazing, only three refused to take part in the follow-up. So the interviewers go out. They don't know anything about these guys. They don't know their family history of alcoholism, they don't know their level of response to alcohol, nothing about them. They sit down and they interview them about their drinking over the past 10 years, about their alcohol-related problems over the 10 years, their drug use, their mental health problems, their general life functioning. And, because not everybody remembers everything totally accurately, we also interviewed the spouse or partner or somebody else who could tell us about him. We also did blood and urine tests to see just how much drinking they were actually doing.
The punch line is that in the follow-up, those who earlier had the least response to alcohol had the highest risk of becoming alcoholic. For example, if we even just look within the sons of alcoholics -- take that group with perhaps the 30 percent or 20 percent lowest level of response to alcohol and then compare them to the sons of alcoholics who were pretty sensitive to booze, the difference was four-fold. If you were a son of an alcoholic with a pretty good sensitivity to booze and you got pretty high with a modest amount of alcohol, your risk for alcoholism 10 years later was about 15 percent -- not zero, still higher than normal, but not as high as for those with both the low tolerance and the alcoholic parent. Whereas if you were a son of an alcoholic with a very low response to alcohol in the beginning, the risk of developing alcoholism was 60 percent. That's 60 percent risk of alcoholism even though these guys had all been highly functional, they had jobs or they were in school at the time we originally tested them. The low level of response to alcohol explained a great deal of the ability of the family history to predict alcoholism.
Moyers: In other words, that early tolerance among sons of alcoholics to alcohol -- those "hollow legs," so to speak -- were a significant predictor of later alcohol abuse?
Schuckit: That certainly is what my data are saying and that's certainly what I'd make of it. I should tell you that we also now have data on daughters of alcoholics and blue collar samples as well. And, at one point in time, average age around 20, we find the same thing. In daughters of alcoholics, sons of more diverse samples of alcoholics, this low level of response to alcohol. And then, that study demonstrating that the low level predicts alcoholism over the next decade. I think all of this tells us a number of important things about alcoholism. First of all, I think that there's not one characteristic that is responsible for an increased risk for alcoholism. I don't, for a minute, think that I am studying the cause of alcoholism. I think I'm studying one of many different potential causes. One of those causes is that people who live in a heavy drinking society like ours, who try to drink like everyone else and who discover that they need pretty high doses of alcohol to get high, are at pretty severe risk for escalating their alcohol intake over time. A variety of things happen. Because they're spending a fair amount of time drinking, they're more likely to develop heavy-drinking friends. So their baseline's out of whack -- they don't know what heavy drinking is anymore because no one around them is moderate. A second thing happens. As you consume higher doses of alcohol to get the effect others do, your body is saying, "Stop this. This isn't normal." The body is adapting by creating tolerance, a need for higher doses to get the same effect. If you're still chasing that effect, you're going to find yourself continuing over time to increase the levels that you need, starting off at a much higher baseline than other people do. It's an example of one mechanism that apparently increases your risk for repetitive heavy drinking and problems. It's only one mechanism but it's got the benefit of demonstrating the following: It's not only your biology. Your biology is one part of the picture. But whether you become an alcoholic or not depends also on the environment in which you are functioning, not just the biology.
Moyers: Is the son of the alcoholic who is not greatly affected by alcohol, when he begins drinking, fooling himself? Is he saying, "Well, it doesn't affect me much so this means I can't be an alcoholic?"
Schuckit: Your guess is going to be as good as mine as to ways of interpreting that. I think that a variety of things are happening. We live in this very heavy-drinking society where showing you can handle heavy drinking is pretty highly valued. It shouldn't be, but it is. Without planning it this way, they're pretty proud of how well they can function and all the compliments they get on how well they can function. If they are also chasing the high and under the influence of heavy drinking peers, all of those combined make it a pretty risky situation for them.
Moyers: So, when we say that alcoholism is genetically influenced, what are we saying?
Schuckit: In some ways, it's really mundane. Because what we're really saying is, as with most other human conditions, genes are impacting on your risk, interacting with environment to give you a final level of risk. But, we're saying that, in this instance, genetic factors are explaining a substantial dollop of that risk. It is one of many factors that you need to look at in order to evaluate your chances of becoming an alcoholic. It raises the question of whether you should ever try alcohol at all if you have alcoholism in your family.
Moyers: If one discovers that one is the son of an alcoholic or has a genetic strain in one's family for alcoholism, there are choices to be made, and if the person knows his risk, he can make better choices?
Schuckit: That's a key point. It is similar to knowing that your mother has severe diabetes and that her sister had diabetes. It looks like it's running in that family. Now, as you're growing up, you could take that information and say, "What the heck? I'm going to do as I please because I'm going to get diabetes anyway!" That would be very unwise, because you are not predestined to get diabetes. The healthier way to look at is to say, "I can optimize the chance I won't get diabetes if I don't smoke, if I'm not overweight, if I watch my diet and if I exercise a lot." And a huge proportion of people who take those preventative steps are never going to develop diabetes, or, if they do, it'll be much later and it is likely to be much less severe. It's the same thing with alcohol. If you know that you are at risk for alcohol dependence and you have some understanding of how devastating this disease is -- no matter what your moral fiber is and what your strengths in life are -- you have a better chance of making a good decision. If you know what you're facing, you can say, "There are a bunch of cards dealt out in life, and my card is: I'm at high risk for this particular disorder. The safe thing for me to do is to avoid it. Other people can drink, I can't."
Moyers: This person is not destined to become an alcoholic?
Schuckit: No. As I've said, even if your mother and father were alcoholic and your whole family is loaded with alcoholism, the risk is still about 60%, as a rough guess. Nobody is predestined to become an alcoholic that I can think of. But everyone enters life with various levels of vulnerability -- some to diabetes, some to heart disease, some to cancer, some to alcohol dependence. And knowing something about those vulnerabilities gives you the opportunity of taking the steps to minimize the chance that this thing's going to happen to you.
Moyers: If alcoholism is so devastating, why are we so tolerant of it as a society?
Schuckit: I don't know that anyone has the specific answer, but I'll give you some thoughts. The per capita consumption today -- how much people drink in absolute alcohol per year per person is dramatically less than it was in colonial times. What that says to me is that while alcohol has, over the centuries, become an integral part of our society, we've learned to adapt to its presence. It's almost like having the Grim Reaper looking over your shoulder. You learn to adapt to that fear and try to minimize the risk to you. And, I think that people have adapted. It's part of our culture. People accept it as a normal part of our culture and dance around the issue by saying that everyone's at risk but me. When you have something that's been in your society so long and so tolerated, it's hard even to stop and think about the risks that are involved.
Moyers: What about heroin and cocaine addiction -- are there genetic roots as well?
Schuckit: It's so much easier to study the genetics of alcoholism because alcoholism is so prevalent. It's the most common of the dependencies, so it's easier to find large numbers of people to study. Also, if you're going to do genetic studies, it's a real good idea to find out information for multiple generations of a family. Alcohol's been readily available generation after generation. Heroin, cocaine, marijuana -- well, come in and out of vogue and, for most of society, didn't come into vogue until the mid-'60s. It's hard to get multiple-generation data. Another reason is that part of the predisposition might rest with how you react to the drug when exposed. It could be that there are as many people out there in society at high risk for heroin or cocaine dependence as there are for alcohol. But because of lack of exposure to the drug, they never develop their risk. Alcoholism is much easier to study regarding genetics. You ask my gut reaction, so I will fall back on a limited number of studies that are there which indicate substantial, but not overwhelmingly complete, genetic predisposition for nicotine. There are some suggestive data for cocaine and for heroin, but not much research.
Moyers: The majority of people who drink don't become alcoholics. The majority of people who take a drug don't become addicts. We really don't know why, do we?
Schuckit: We're learning more every day, I'll tell you. We have a bunch of risk factors. Are you a flusher when you drink? If you are, it doesn't protect absolutely from alcohol but it lowers risk. Are you relatively impulsive and easily bored? Probably higher risk for alcoholism. Do you have a low level of response to alcohol? Probably higher risk for alcoholism. And do you come from traditions of never drinking or never drinking to the point of drunkenness? That's an environmental factor that probably decreases any existing predisposition that's there. So there are a bunch of things that are helping increase our knowledge of what it is that makes some people at much higher risk and contributes to their development of alcoholism.
Moyers: Do you know if alcoholics have pre-existing psychological problems -- anxiety, abuse, depression?
Schuckit: A very complicated topic. It's another one of my major areas of research. I'll give you a series of statements, each of which are true, although they might sound a bit contradictory. I find no evidence that the average alcohol-dependent person is taking the alcohol to self-medicate or treat a pre-existing anxiety or depressive disorder. And I've looked a lot into the literature and we've done a fair number of studies in this area, and I believe this is true. Second, there are some psychiatric disorders that, for a variety of potential reasons, seem to be associated with a slight, but still statistically significant, increased risk for alcoholism. So if you have manic-depressive disease, the terrible lows with God-awful depression and these terrible highs where you're talking very quickly and your mind's racing quickly and you become totally disorganized, you're at higher risk for alcoholism. Manic-depressive disease -- 1% lifetime risk in the general population. Not a highly prevalent disorder. Schizophrenia, which is equally rare, also puts you at greater risk. If you are schizophrenic, there is usually an onset in the late teens to the mid-20s and it is almost a change in who you are. You withdraw from people, you don't find much emotional reaction to things. You hear voices talking to you and you believe those voices are real and think that people are plotting to harm you. Schizophrenia is associated with an increased risk for alcoholism. But perhaps it's because once you develop schizophrenia, society doesn't take care of you the way it should. You find yourself not in a hospital but on the streets, where, basically, you're around a lot of people using drugs and alcohol and so you may get into that. Others would say schizophrenics are self-medicating their schizophrenia. So yes, there are a variety of disorders that have an increased risk for developing alcoholism. They don't explain a great deal of the alcoholics, but it's there.
There are a couple of anxiety disorders that have a slight increased risk for alcohol dependence. Panic disorder is one. That's when your heart starts beating fast and hard, you have shortness of breath, and you feel like you're having a heart attack. Some of the people who have that disorder have a slightly increased risk for alcohol dependence. Another is social phobia, which also slightly increases risk. But most of the anxiety disorders don't seem to have an increased risk, so Statement Number One: The vast majority of people who develop alcohol and drug dependence do not have a pre-existing major psychiatric disorder. Statement Number Two: For most major psychiatric disorders, most of the anxiety disorders, and, in our data though not in that of some other researchers, in most severe depressive disorders, there is no increased risk for developing alcohol or drug dependence. Statement Number Three: There are some psychiatric disorders that carry an increased risk for alcohol or drug dependence, but that's not true of all psychiatric disorders.
Moyers: My uncle was on a binge once and my mother said he was drinking because he was so depressed. When he was sober, he told me he was depressed because he was drinking.
Schuckit: He has more insight than most people. And, in fact, that's probably the case. If you take a family member who has alcohol dependence and, especially while they're depressed, if you say to them, "Gee, are you drinking because you're depressed?" they're not fools, they're going to say, "Yeah, I'm drinking because I'm depressed." They probably really believe that. And there's some truth in that. But they probably got depressed because they were drinking so heavily. Alcohol can cause severe depression in anyone if the dose gets high enough. They're probably depressed because they're drinking a lot. And, now, because they've got awful judgment and they're feeling awful, they probably continue to drink, in part, because of this depression. But you want to get rid of that depression? Get them off the booze and the depression probably goes away.
Moyers: Do you think alcoholism is the same in everyone? Or, are there different ways to be an alcoholic?
Schuckit: I'll give you an analogy. Is a broken arm the same in everyone? No, it's not the same in everyone. Because some people who have a broken arm can't sit still and are pretty impulsive and very physically active and other people who have a broken arm have very low pain thresholds. They get a lot of pain syndromes and they're likely to just curl up whenever they're in pain. People are different with any disorder -- even something as straightforward as a broken arm, based on their usual style of handling things, their biology, and what else is going on in their life at the same time. So the course of alcohol dependence or any drug dependence is a combination of that biological predisposition and where you are in life and how you usually handle stress and your past experiences. Despite all of that, though, it is remarkable the levels of similarity in the course of alcoholism over time, just as there are major similarities on what you have to do for people who have broken their upper arm.
Moyers: Have you looked at the question of controlled drinking? Are there alcoholics who can learn moderate drinking?
Schuckit: The simple answer is no. There are not alcohol-dependent people who can safely go back to drinking and maintain control. Now, let me give you little bit of background. Most of us in society have this fantasy: If you're an alcoholic, it means that once you have your first sip, you're going to go crazy, and you're just going to go off on this terrible binge. Well, sometimes that happens, but most times, it doesn't. Most people who are alcoholic have jobs. Most people with alcohol dependence stop drinking regularly because they develop crises. In the midst of a crisis, they say, "I don't know that the alcohol is doing this, but I'd better stop right now just in case." Then, when they stop, they find that they don't have any DTs, none of that terrible agitated confusion which is what most people think alcohol withdrawal is like. They don't know that that's only seen in one percent of alcoholics. So they say, "I didn't have DTs," and "I was able to stop so I'm not an alcoholic. I'm going to control my drinking." Most people say this and they make rules. "I'll only drink beer." "I'll only drink after 5 p.m." "I'll only drink three drinks in an evening." They make the rules for control and, son of a gun, most of them maintain control for a limited period of time. Alcoholics can and often do control for a limited periods. A limited period could be anywhere from a couple of days to a year. But if you're a betting man and take a look at somebody with a history of alcohol dependence, when they go back into their controlled drinking, you'll have about 100:1 odds, if not more, on your side, if you say, "I don't know when, but sometime in the foreseeable future, this person is going to get back into bad trouble again." You'll be right. Almost every alcoholic I know says, "I'm different from other people. If there ever was an alcoholic who can go back to controlled drinking for the rest of their lives, it's me. And it doesn't matter that I've tried it 27,000 times before, this time's going to be different." Let me tell you, they're dead wrong. Dead is what they're going to be 15 years earlier if they try to do this. But they're dead wrong. And the odds are at least 100:1 against them.
Moyers: How can they go on trying to control it when they keep failing over and over? Are there rational reasons for their seemingly irrational behavior?
Schuckit: Let's say that this afternoon, a professor from the University of California San Diego campus comes in with severe alcohol dependence. Most people can still function fairly well despite their alcohol dependence. He (or she) sits down and talks to me. He is really likely to have this vast array of justifications about why he is different and why he's not like the other alcoholics. "In fact, don't even use that term with me, I'm not like those other people who have alcohol problems. No matter what you tell me, my course is going to be different and I'm going to be okay and I can still drink." In the course of their drinking, I think most of them say, "This isn't really alcoholism, this is a temporary problem. It's bad luck, it's unrelated to my drinking. It would've happened anyway. Or, gee, it just happened this time because I was drinking, but it'll be different in the future." I don't see how you could perpetuate alcohol and drug dependence if you didn't do that. What's remarkable to me is that the professor on campus will tell me the story using words with six syllables. And the person with a tenth grade education who also happens to be alcohol dependent will tell me virtually the same thing but in less complex words. The stories and justifications are remarkably similar in essence.
But something else regularly happens in the course of alcohol or drug dependence. It's almost like being knocked upside the head with a two-by-four. People suddenly look around and say, "Whoa, something's wrong here." They may not say something's wrong long-term, they may not say, "I'm addicted," but they do recognize that there's a problem. And, that's why the vast majority of alcoholics and drug-dependent people stop fairly regularly and stay stopped fairly regularly. Now and then, when they get that two-by-four upside the head, they say to themselves, "I can't quite do this myself. I recognize I need help" and they turn to Alcoholics Anonymous or Narcotics Anonymous or Cocaine Anonymous or they come into a treatment program. I can introduce you to people in treatment who have had something happen in their lives where most of them turned around and said, "I'm not sure of this, but I think this is out of control and I think I need help." Often, people walk into treatment not convinced that they need to stop forever. Or they say, "I'll stop Drug X, but no way am I stopping Drug Y." Now, that's what treatment's about, at least in part; it's this education about the nature of addiction and about how to take responsibility for turning your life around.
Moyers: What have you learned about denial, that refusal to see alcohol and drugs as a problem?
Schuckit: Denial is an interesting phenomenon, and, as with many things in life, sometimes it helps and sometimes it hurts. For example, I don't really think about the fact that I'm going to die someday. If I thought about that all the time and contemplated the ways that I might die and the inevitability of death, it would be pretty hard for me to function normally. I'm using denial there. And it's healthy to do so. All denial is not unhealthy or a sign of addiction and resistance. But when you have a pattern of behaviors that indicate that something fully preventable is about to hit you and you aren't doing anything to avoid it, that denial is pathological. I personally don't understand how anyone could develop alcohol or drug dependence unless they used some form of denial. Alcohol- and drug-dependent people aren't stupid. There isn't a greater proportion of immoral people amongst them than in the general population. Alcohol- and drug-dependent people have to be denying either that they have problems, or that their problems are related to drugs, or that the next time they take drugs it will cause problems again. So to me, saying an alcohol- or drug-dependent person is in denial is like saying a person sitting across the desk from me is breathing. They must have denial to have gotten them where they are or they wouldn't be where they are. It is essential to understand this, and to be compassionate about it, if you are to treat them effectively. I think that when people develop a substance dependence problem, they're really denying to themselves that the problems are occurring; in fact, they're getting to the point that the alcohol and drugs are such a central part of their life that they can hardly do anything but deny. And it is almost as if they're willing to pay any price in order to continue to use.
Moyers: Why is it so hard for them to quit?
Schuckit: There are a number of reasons. It is: "The drug makes me feel good" combined with: "When I stop taking the drug, I don't feel good at all and I can feel a lot better by getting back to the drug." Those cause not only a rational thought like, "I want the drug," but almost a reflex, like a hunger. You smell food, you get hungry. You have some reminder of the way the drug helped you feel good or the way the drug helped alleviate bad feelings, you crave drugs. There's a cognitive thought, "I want to feel good." There are less than conscious, almost reflexive feelings, "I want to not feel bad." There are all of these things going on in your life, being around people who are using a lot, who are egging you on to continue to use. You get to a point where you're saying to yourself, "Look at all these problems. If I caused all of these problems, because of alcohol or drugs, that doesn't say very nice things about me, so it really couldn't have been the alcohol or drugs in my case because I'm not that kind of a person." Now those thoughts create stress in the brain, and that leads to a feeling like, "Let's have another drink." It becomes a highly complicated series of events where there are numerous sub-conscious and conscious reminders -- friends, smells, sights, sounds, thoughts, feelings, everything -- all encouraging you to want the drug or drink. Part of why treatment is so hard is that somebody basically has to get in and cut through all this stuff and say, "I have to change now so that I want not to use more than anything in the world, and I am willing to pay almost any price to put my life back together again." It's exactly the reverse of what they were saying when they were into drugs, but now applied to abstinence. And, to teach somebody to do that, at any one moment, probably is not insurmountable. To teach them to do that so they now generalize it to other aspects of their life and that they remember it most waking moments -- that takes a lot of work. That's why treatment isn't just walking in and having somebody say, "Stop drinking. Stop using." Treatment is a whole series of things one has to learn and then apply under some sort of supervision to your life in general.
Moyers: It's getting your life back, isn't it?
Schuckit: Oh, indeed it is. And, just look at that statement. How difficult that must be. If your life has been consumed by something outside yourself and you have lost control, how difficult and what an incredible challenge it has to be to say, "I've got to do things differently now." It's basically rebuilding your lifestyle.
Moyers: Your peers -- George Koob and Steve Hyman and Alan Leshner -- have said to me that drugs change the brain of the addict. Have you found that addicts can change their brains again, can re-educate themselves, can ever again hope to have a normal, functioning brain?
Schuckit: Absolutely. There may be exceptions to this, but the vast majority of people with alcohol dependence go through this period of time where they believe they cannot possibly stop. Then, they do stop and they stay stopped and that first six months to a year, maybe a bit longer for some, is pretty rocky because their brain is not back to normal yet. And, there are so many things in their life they have to be working on. Then comes a period of time where it's almost as natural as riding a bicycle, where you basically say, "That's the old me back again." Now, who of us is the same person we were before an experience? Who can go back to what we were? Sure, everybody's different. I'm different than I was five years ago. The real question is not "Is there some lingering difference that might remain in brain chemistry?" For some drugs there might be and for other drugs there might not be. The issue is, despite my being five years older and a bit wiser -- can I right now live a normal, happy life? Well, of course I can. And the alcohol- and drug-dependent person can, even if in the worst-case scenario, their biochemistry hadn't returned completely to what it would be for other people of that age and level of experience who hadn't used drugs. There's no reason why they can't recover and be fully functional and happy.
Moyers: When you work with addicts at the treatment center, are you looking at immoral people, whose character is below average?
Schuckit: Real important question. I don't know her personally, but I tend to doubt that Betty Ford is lacking moral fiber. And there are lots of clinicians I know, physicians, psychiatrists, nurses whom I knew before they developed alcohol and drug dependence, and I sure didn't see any absence of moral fiber, any lack of ability to control themselves. I look at it as the reverse of what you're saying. What incredible moral fiber and strength it takes to admit to yourself at all that this problem is occurring, in part, related to substances, that you share some responsibility in the tremendous amount of work required to remake your life. Now, that's moral fiber.
Moyers: So, those people who come to treatment with sad faces and lots of pain in their eyes, you can say to them, "This is not the end of the road."
Schuckit: It's the beginning of the road. I mean, that sounds like such a cliche, but it is a new start. All of us have horrible things happen to us in our lives. Everybody. And when those horrible things happen to you -- somebody near to you dying in an accident, having surgery, alcohol and drug dependence -- it's how you take a look around at what's happening that counts. Do you see it as a wake-up call? You dust yourself off and you say, "I've got an incredible amount of work to do here to get things back to happiness and to normal living and I'm going to do it." And there's no reason why people with alcohol and drug dependence can't. To testify to that, you give me somebody who is alcohol- or drug-dependent who reaches a point in their lives where they say, "I'm not 100% sure, but I think there's a real problem here and I'm at least willing to listen to the need for some help." Give me your average alcohol- or drug-dependent person, who has a job, has a family, lots of troubles, but a job or family. I'll give you somebody with about a 60-70% chance of getting clean and sober for the next year. That's when most of my follow-ups are -- the next year. And that's a pretty darn good predictor of five years down the road. So I would say, "There's no reason why you can't lick this thing."
Moyers: Well, this disease hit close to home for me, and I've been to treatment centers with people who have suffered from it. When I look at the people in your treatment center, I wanted to say to them, "I wish you could see yourself 10 years from now. You will be different."
Schuckit: They will, indeed, be different, and it doesn't matter whether you're talking about somebody with a 10th-grade education or 16 years of schooling; there is no reason why they can't reach a point in their lives where they can say, "I'm going to start working on this stuff" and reach a point from there where their lives really are quite different.
Moyers: And yet we have to be realistic. We know that a lot of people fail, that many alcoholics go back to drinking and many addicts go back to smoking or using.
Schuckit: It's too bad most people don't know the research. The data shows that if we take alcohol- or drug-dependent people -- even homeless street heroin addicts, whom most people believe to be hopeless cases -- if we do nothing for them and follow them up 5 years later, 20% will be clean and sober just by spontaneous remission. So even without treatment, without any intervention, the situation is not hopeless. You add to that people who have reached a point where they say, "I think I might need help" and go to treatment. The data say not just a small proportion, but the majority, will do extremely well. I'm not dancing around what "extremely well" means; I mean clean and sober. Maybe they have a small slip here or there but for the most part, clean and sober and functional. That's the majority. The public has the wrong stereotype and they hold on to the stereotype in part because they don't want alcoholics or addicts to be anything like them. They say, "The alcoholics are those people who can't be helped. That's how I define alcoholism." And they say, "They're the people who are poking around in garbage cans, which reassures me that I couldn't possibly be an alcoholic because I don't look like that." So they set up this straw dog that only these people with horrible characteristics could possibly be an alcoholic, those awful monsters who will never get well. They're ignoring the vast majority of people who are alcohol- or drug-dependent.
Moyers: You told the medical students yesterday that it's very important to lay out the facts with people who are alcoholics. Many scientists have explained to me that drugs and alcohol change the brain, that they take over, that they're governing the life of the user now. So how can someone who is deeply alcoholic actually make the rational decisions that will lead them to get better?
Schuckit: Well, whether I am talking to you about your need to discuss a problem with your uncle or your mother, or I am talking to you as a medical student or a physician, I'd emphasize the fact almost no alcohol- and drug-dependent people stay high all the time. They stop regularly. True, it may be like spitting in the wind to talk to someone who is high and irrational and try to get them to listen to how they should change their lives. One of the keys is to bide your time and wait until one of these periods of abstinence occurs, which almost certainly will occur, often related to a crisis. When they're sober and not high, you sit down with them and you say, "I'm not going to tell you what to do because you're going to do what it is you think you need to do. And I want you to understand I'm talking to you because I'm concerned and I love you. But let me very specifically tell you what it is that's going on that is scaring me and makes me think you need help." That's what an intervention is like. I'm not sure how well it would work if the only time you intervened is when they're high on cocaine or high on heroin or drunk on alcohol. Instead, you wait for a period of abstinence.
And there's another thing that you can do, which gets the point across to them that there's a major problem. What I'm about to describe is very simple and extremely difficult at the same time. If it's somebody you care about, stop protecting them from the consequences of their alcohol or drug use. If they're picked up for drunk driving, don't go down and hire a lawyer and get them out immediately. Let there be some association of event and consequences. How else are they going to get the motivation to change? If it's somebody who is developing problems at work and the boss calls and says, "Where is John?" or, "Where is Nancy?" Don't say, "Oh, they have the flu today." Don't cover for them. I said it's difficult. But there are a variety of things that we can do to increase the chance that we can intervene at times when the person is more rational, less intoxicated, and more likely to be concerned about the consequences of using. The good news is, those periods happen regularly in almost everybody.
Moyers: But can the drunk make a good choice? Many addicts told me that they only decided to go to treatment when they had hit bottom. Even at moment of ultimate devastation, something inside is still functioning rationally?
Schuckit: I think you're underplaying the level of a person's ability to look around and say, "On the one hand, I really want that drug and it makes me feel very good. On the other hand, I'd like to have a normal marriage and be able to work and be able to relate to my kids and right now if I do the drug I don't seem to be able to keep those other things."
Moyers: The goals and values are a powerful competitor to the influence of the drug.
Schuckit: If they weren't, then how could the alcohol- or drug-dependent physician get up in the morning, go to his or her practice, do what it is that they need to do? How could they, as they often do, tell themselves, "I've got two days on call, so I'll take none. But, when I do have my next off-call period, I'm going to go back to use." There's tremendous executive functioning still remaining. There's a high level of control. If I don't spend some time talking about how that stereotype is wrong, everyone's going to assume that all alcohol- and drug-dependent people are basically craving and using the drug all the time, which is wrong, they're not high all the time and they're not non-functional all the time. They're functional, they work, they have relationships, they do all sorts of things, but they've got this "monkey on their back." They need to learn to want the rest of their lives more than they want the drug. And they're going to be able to learn that somewhere along the way, either spontaneously or with the help of treatment. But they are not totally out of control with no free will.
Moyers: I have a friend who is an alcoholic who said to me just the other day, "When I drank I was pretty smart and safe," and it seems to me that there's almost nothing you can say that can compete with that.
Schuckit: That's not really true. It's a matter of how you look at things. There are a lot of things that you can do in life which make you feel better temporarily. But if you know they can kill you in the long run, if you've experienced such consequences that you know it's a choice between the drug and your family, at some point there's free will there and you choose life, not death. Your will is not entirely compromised by the addiction. And you can be taught ways of seeing which will allow you to recognize those choices.
Most of the recovering people I've spoken with tell me, "My God, I thought I would have craving all the time." They are surprised to learn that craving isn't always there. Their ideas about what not drinking is like turn out to be completely wrong. If you can show them that, they can learn to stay sober. Craving isn't like being sucked up into the heavens by this powerful force. It can be very subtle. I think many people who are alcohol-dependent say, "I go back to drinking, but I'm not quite sure why." They don't put their finger on craving, and most alcohol- and drug-dependent people who stop don't have craving all day long.
Moyers: So you don't take craving that seriously?
Schuckit: I take craving tremendously seriously. The trouble is it's very hard to define, and that makes it very, very hard to study. Many alcoholics don't notice much craving after the initial withdrawal has past. And many of them end up going back to using alcohol and drugs for reasons they can't understand. It's not, "I had this feeling like I was being sucked into the heavens by this powerful force telling me to drink and I couldn't resist it."
Moyers: One of your peers said to me that people don't return to drinking because of craving -- they return to it because it's the only life they know.
Schuckit: The answer to anything you say about why people with alcohol and drug dependence go back is yes. They go back because they feel too good. They go back because of too much stress. They go back because there is no stress. They go back because they feel like they want to do it. They go back because it snuck up on them. It is a constant danger. There are so many complicated things that remind you why you need a drink or why you want some drugs. And many of them remind you on a subconscious level, "I would feel better if . . ." It's very hard. All you need to know is that you're vulnerable. You've had the severe problems. You can't safely use this stuff again.
Moyers: If you persuade me that my one addiction is bad, isn't it possible that I will just find another to replace it?
Schuckit: You're assuming that people are going after to treat something wrong with them. I don't have data to say that that's true at all. Let me give you the data that I do have. 453 sons of alcoholics and controls, studied at age 20, followed up again at age 35 and now at age 40, the sons of alcoholics, at high risk for alcohol dependence. But they didn't seem to be at much higher risk than the control group for cocaine dependence, amphetamine dependence, marijuana dependence, heroin dependence. There was nowhere near the level of increase, and for some of these drugs, there was no increase at all. I don't think there's an alcohol- or drug-dependent personality. People get exposed to alcohol or other drugs, some people are more vulnerable than others, and through this complex series of events, develop difficulties. But it's not a seeking to feel good or well.
Moyers: Why then do so many alcoholics also smoke heavily?
Schuckit: There is an interesting association between nicotine dependence and alcohol dependence. I don't know yet know how to explain it. Some people hypothesize that if you use alcohol and nicotine a lot together, when you take one it increases your wanting to take another. Others hypothesize that since alcohol can cause depression and nicotine can act as an antidepressant, that creates the association. And there are some who believe there may be genetic factors which increase the risk for one addiction which are located on the same gene, or close to the same gene, as the genetic factor that increased the risk for the other, so they tend to come together. You are right, they definitely come together often, although not all smokers are alcohol-dependent. Most alcohol-dependent people are nicotine-dependent. I don't understand why that association is there, but there are a bunch of theories being tested.
Moyers: There's an awful lot we still don't know.
Schuckit: Thank goodness. Or I'd be out of business.
Moyers: Is all addiction the same?
Schuckit: You'll notice that while you say addiction, I've been using the term dependence. I use that term because it's more precise -- it's defined in the psychiatric literature essentially as being compulsive use despite negative consequences -- and it's important that I be precise in the definition because people tend to mean a lot of different things when they say "addiction."
You seem to have a view of dependence which has neon lights and flashing figures going on. It's a little sexier view of dependence, or addiction, than I have. I believe there are degrees of dependence and addiction. For some people, they recognize dependence and even though the interference with life functioning is fairly modest, they're able to wake up early and say, "I got to stop this stuff." And for other people it is, "I'd rather die than give this stuff up," and they risk their lives over and over for it. There are gradations here. And the kind of overwhelming experiences we've been talking about -- where you are at risk of losing your whole life -- aren't what everybody feels in the context of alcohol or drug dependence or addiction.
Moyers: Do you have to devise treatment differently for physicians than for, say, street people? Is everybody's dependency different?
Schuckit: No, that's a jump in logic I don't agree with. You can apply the same generic approach to greater or lesser levels of intensity of a disorder and still have it work. You can treat dependence in the unemployed person or the doctor in the same way, but you may need to have different types of after-care or follow up if you want them to stay sober. For example, if the unemployed person stays out of work, it might be very hard to maintain recovery.
Moyers: Do you consider relapse a failure?
Schuckit: I don't consider it good news. But I don't consider it a failure. I view alcohol and drug dependence the same way I see somebody with a long-term problem like high blood pressure or diabetes. The goal, let's say for diabetes, is to get your weight down. You don't smoke. You exercise. You take your medications so that your blood sugar is always normal. That's the goal. And sometimes you get there, but it's not all that often. So you shift your goal. How can I help you to keep your blood pressure as low as possible, or your blood sugar as low as possible as much of the time as possible? And when there are flare-ups with alcohol or drug dependence, or where blood sugar's hitting the ceiling or blood pressure's hitting very high when those flare-ups occur, I hope that the person looks around and says, "Something's wrong here. I've got to look around and redo things again because I've got to get it under control." For alcohol and drugs that means no use. So when somebody has a slip, I wish it wouldn't have happened. In some people it never happens, but in a lot of people it does. Now, how do we get back to abstinence? Because that's what we're trying to achieve here. So when somebody has a slip, I don't say it is a failure forever. I say it is a situation right now. How do I help you to get through that situation and back on the road to recovery?
Moyers: What's your definition of success? Two months, three months, six months, two years?
Schuckit: My definition of success would be total abstinence and doing all the work to get your life going again on a normal track. It takes both. There are degrees of success, though. There are some people who make it all the way there, and there are other people who make it there for a year or two and then develop problems again, or make it almost all the way there, and don't quite make it and have to slip back and learn their lessons all over again. But each of those are steps forward. And for most long-term disorders you have your absolute goals, and then you have people who are working towards those goals, and any step toward those goals is gravy. It's what you're trying to aim for.
Moyers: Do you believe alcoholism is a disease?
Schuckit: Yes, but let me tell you how I define disease. I am a health care provider, and as a health care provider I say there are patterns of problems or symptoms which tell me there's a clinical course likely to occur. This suggests a need for certain interventions if those health consequences are to be avoided. Well, if a pattern of problems helps me to decide who's headed for severe difficulties and how to intervene in their lives, I consider it a disease. There are other people who might limit disease and say it's only a disease if it's genetically influenced. I don't think that would be very wise because many things that are genetically influenced -- like height -- are not diseases. And then there are other people who would say if it's not an infectious agent or a form of cancer, it's not a disease. Well, define it more narrowly and maybe you wouldn't call alcoholism disease. As a health care provider to me it's a disease, a disorder, a syndrome -- all synonymous.
Moyers: But how can you call it a disease when different cultures -- Irish, Jews, Native Americans, Asians -- all have different levels of it?
Schuckit: Well, one could argue that they have different genetic backgrounds as well. So I don't know if the reason why Jews have a lower rate of alcoholism is because of culture or learning or some biological attributes. The answer is a cheap one -- it's probably a combination of all those things. There is hardly a disease I can think of that isn't influenced somehow by the environment. Let's take some of the infectious diseases. Why is it that if somebody in this room, you or I, had a bad cough and we had tuberculosis and there were a bunch of people being exposed to those germs, some are going to get the tuberculosis right away, some are going to harbor it for a period of time, and others are going to be fairly immune to it? I can't think of anything as purely a biological or purely an environmental disease.
Moyers: How, in the context of the disease model, do you explain the phenomenon that if you give an alcoholic a placebo, a cocktail that has no alcohol in it, that person may act as though they are drunk and may feel, as they would with real alcohol, an intense craving for more?
Schuckit: I think you can do that with anything. Teach me something. Teach me that there's a certain behavior associated with a smell, produce that smell in the context of some vapor that might have an effect on my behavior, give me that smell again, and I will probably, at least for a short while, experience some of the effects of the vapor. There is learning that goes on and it is what I smell, what I see, what I feel, the music I hear, the ambient lighting, it's all those things that'll have an effect on how I'll respond to x, y, or z, including alcohol.
Moyers: We become conditioned to the drug we use.
Schuckit: We become conditioned to everything. I mean, I can't see some sunsets without thinking of some places that my wife and I have been together. Or I'll hear some music that will remind me of food that we've eaten or places we've been. We're conditioned to everything. That's one of the wonderful gifts that evolution has given us -- an ability to learn from our experiences, to make our lives rich with meaning.