Dry January: a history of assessing alcohol use disorder 

Rebellion Dogs January 2024 

click to Read or download a PDF: Dry January - making exploring our drinking habits hip

In mid-1970s Montreal AA, almost every Alcoholics Anonymous group literature table had a yellow trifold that included:

• The AA phone number for meeting information or someone to talk to, 
• “Just for Today” – the AA philosophy that was practical, secular, bit-size approaches to deal with predictable challenges to maintaining sobriety. 

• The John Hopkins Hospital 20 Questions about alcohol use.

Like the Narcotics Anonymous offering of the same namesake, read at most NA meetings I attend, the “Just for Today” offering I found in early AA is a common-sense approach to 12-Step fellowship life, philosophy and hacks for challenges that are certain to come to the newly sober. Next blog I think I will look at “Just for Today” and how it has aged. Stay tuned… 

To kick off 2024, for our DRY JANUARY blog, why not review how alcoholism, alcohol use, alcohol use disorder is measured, from the age-old 20 questions of yester-century to the DSM-5? Even for those of us in long term sobriety, it’s a new year, some like to review or return to basics, and/or think about the obvious pattern we see every year at this time: in the rooms and on the streets, we are in the presence of neophytes and the sober-curious. Attendance at meetings picks up this time of year; post holiday, infrequent 12-step members are “back in the gym (or back to school)” and newcomers arrive, unsure but searching. 

While many join the living sober ranks to kick off the year, not everyone needs to stop forever. Dry January encourages everyone to reflect. As a means of mental and physical renewal to kickoff the year, a period of sobriety helps many refresh from a period of excess. Some may find something about sobriety that inspires a lifestyle change, others will look forward to returning to the bar. The line between living/partying hard vs. stumbling over the line into problematic alcohol or other substance/process activities is a pause for concern. It is also controversial. Reduce harm, abstinence, keep the party going, many strongly feel one way or another.  Let’s talk.

Do You Have an Alcohol Use Disorder?[i] 

The 20 Questions is a test was developed by Dr. Robert Seliger of Johns Hopkins in the 1930s to help people self-assess whether they have a drinking problem. This is not a professional screening tool … It is, however, a useful tool to help determine if your alcohol use is becoming problematic. What I often find fascinating is the type of questions asked; never am I asked how much I drink in a drinking session and how frequently are my drinking activities? The test seems to screen physical effects of alcohol use, psychological factors, and social consequences of drinking. 

A Three-fold approach, biology, psychology, social impact

The biopsychosocial model of addiction doesn’t rely strictly on the disease or behavioral model; evaluating our substance use status: it’s complicated. From a layperson/peer-to-peer perspective, we hear that addiction is a threefold predicament—physical, emotional, mental. Or some will call it, physical, mental, spiritual. Either way, the point is that after all these years, we still don’t have blood test that will tell someone if they are or will be an addict. The biopsychosocial model looks at the genetic link, neurochemical differences, behavioral differences, —the hyperaroused,  anhedonic, depressive alcoholic—degree of social consequences, and other genetic and personality type factors.[ii]

While healthcare professionals from treatment counselors to family doctors do utilize sophisticated assessment measures, many of us come to AA on our own, urged by family, or from a discussion we have with an AA member we know; so not everyone gets the professional assessment treatment. This self-evaluation, found online and still at some 12-step meetings, is a helpful tool for any of us ambivalent about do we or do we not have a real problem or how severe it may be.

Ask yourself the following questions and answer them as honestly as you can.

1. Do you lose time from work due to drinking?                                              

2. Is drinking making your home life unhappy?                                               

3. Do you drink because you are shy with other people?                              

4. Is drinking affecting your reputation?                                                           

5. Have you ever felt remorse after drinking?                                                  

6. Have you gotten into financial difficulties as a result of drinking?           

7. Do you turn to lower companions/inferior environments when drinking?  

8. Does your drinking make you careless of your family’s welfare?                  

9. Has your ambition decreased since you started drinking?                             

10. Do you crave a drink at a definite time daily?                                                 

11. Do you want a drink the next morning?                                                          

12. Does drinking cause you to have difficulty in sleeping?                                

13. Has your efficiency decreased since you started drinking?                          

14. Is drinking jeopardizing your job or business?                                                

15. Do you drink to escape from worries or trouble?                                           

16. Do you drink alone?                                                                                          

17. Have you ever had a loss of memory (blackout) because of drinking?       

18. Has your physician ever treated you for drinking?                                         

19. Do you drink to build up your self-confidence?                                              

20. Have you ever been to a hospital or institution on account of drinking?   

If you answered YES to any one of the questions, this indicates you MAY have a problem with alcohol.

If you answered YES to any two, CHANCES are you have a problem with alcohol.

If you answered YES to three or more, you should seek additional evaluation of your use of alcohol.

In healthcare settings such as hospitals, clinics, and addiction treatment centers, this test is used, although not always as a stand-alone, to screen for alcohol use disorders. It can also be utilized by mental health professionals, such as therapists and counselors, to evaluate the drinking habits and potential alcohol-related problems of their clients (as a symptom, comorbidity or coping mechanism).

The test is regarded as a valid and reliable screening instrument for identifying individuals who may be struggling with alcohol use disorder, and it can assist healthcare providers in initiating early intervention and treatment for those who require it. You can read it and score it on your own. I was confronted with it, others find it, surprisingly on the bedside table or in your briefcase—signs you may now be living with an Al-Anon member.

We will look at a more “comprehensive evaluation.” But this is what I found on an AA literature table many places I attended, when new. I would offer it to others, sometimes asking them, as was done with me. Some questions refer to more than one of this threefold-disorder (biopsychosocial) idea, but all of them reference at least one of three. Eight questions include the physical/health consequences of alcohol use, eight cover mental/psychological issues, and eight look at social/work/family troubles. 

When I first answered these questions as a teenager with alcohol and other drug problems, I was fighting the diagnosis of being an alcoholic. I wanted it to tell me—and everyone hassling me—that I was a victim of bad luck and a series of serious misunderstandings, but not an alcoholic. Of course, that’s not what the results found. Even minimizing my more dramatic issues and omitting others, I passed with flying colors. I thought, “What a gyp. ‘three or more out of 20 and I am probably alcoholic!’ The fix is in; wouldn’t it be great to get through school getting passes for 3 or more right answers in a quiz of 20 questions? I didn’t want to be teetotaler; anyone who parties hard would be called an alcoholic from this sham.”

My first experience was confrontational, someone else accusing me of having a drinking problem. I felt defensive; better results come from curious inquiry or not having someone else breathing down your neck as you go through the questions. On the other hand, someone loved me enough to confront me. “I would rather step on your toes than walk over your grave,” as they say.  

The AUDIT (Alcohol Use Disorders Identification Test)[iii] detects hazardous drinking and alcohol abuse. Furthermore, it has a greater sensitivity in populations with a lower prevalence of alcoholism. One study suggested that questions 1, 2, 4, 5, and 10 were nearly as effective as the entire questionnaire.

AUDIT Questions and Scoring System:

1. How often do you have a drink containing alcohol?

2. How many drinks containing alcohol do you have on a typical day when you are drinking?

3. How often do you have 6 or more drinks on 1 occasion?

4. How often during the past year have you found that you were not able to stop drinking once you had started?

5. How often during the past year have you failed to do what was normally expected of you because of drinking?

6. How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

7. How often during the past year have you had a feeling of guilt or remorse after drinking?

8. How often during the past year have you been unable to remember what happened the night before because you had been drinking?

9. Have you or has someone else been injured as a result of your drinking?

10. Has a relative, friend, or a doctor or other health care worker been concerned about your drinking or suggested you cut down?

Evaluators as part of training are forewarned that people with addiction will minimize or deny, when being confronted; I know I did. In the diagnostic process, these questions often accompany blood and urine texts that may tell a more objective story. 

What is the DSM-5[iv] and what does it say about alcohol (and other drug) use?

For people born after 1952, there has always been a Diagnostic and Statistical Manual. It was controversial. DSM still is, let’s say, a conversation starter. Science invites criticism as part of the error and correction process. The biggest issues with the DSM-5 are that:

1. It leads to cultural bias.
2. It lacks scientific basis.
3. It pathologizes shared human experience.
4. The National Institute of Mental Health (NIMH) does not use it for researching mental health.
5. It promotes a pharmaceutical approach to treatment.
6. Essentially anyone can be diagnosed with a lifetime disorder.[v]

Widely recognized in the DSM-5 is the prevalence of comorbidity; where we find mental health disorders—post traumatic stress disorder, depression, anxiety etc.—we find more alcohol use disorder (and other mind-altering substance misuse). Visit the DSM-5 (see endnotes) and search “alcohol use disorder”—137 hits come up. The great chicken and egg question comes up in clinical settings and peer-to-peer meetings. Does our environment and biochemical markers predisposing us to mood/mental health hardships [the chicken], cause addictive responses as coping mechanisms [the egg]? Are mental health symptoms [the egg] just a side-effect of my substance or process addiction [the chicken]; will “drying out” and recovery diminish my depression or anxiety to non-chronic levels? The chicken and egg model is art and philosophy, which helps us make sense of, or context for, science. You can’t have an egg without a chicken! True that, and you can’t have a chicken without an egg! Hence, no consensus can be arrived at in the, “Which came first?” question.

Some aspects of process addiction are recognized in the DSM-5, “Alcohol use disorder and other substance use disorders may also be comorbid with anorexia nervosa, especially among those with the binge-eating/purging type (DSM5 p. 345),” as an example. Other process addiction experiences are discounted or otherwise ignored. Our individual experiences may not be identified in this clinical tool kit—Gambling Disorder, in; as far as love and sex addiction, the sexual dysfunction characteristics (p 423) disappoint many who suffer from, or treat sexual compulsion, anorexia, attachment disorders, etc. For instance, intimacy avoidance may be mentioned as a symptom of anxiety, hypoactive sexual desire disorder (442) may be isolated within a sexual dysfunction. 

I don’t find the “that’s it” moment reading the manual or the holistic biopsychosocial experience I hear in meetings that include declining quality of life resulting in fantasy, pornography, acting out, attachment disorders, shame, loneliness and fear, so easily expressed in podcasts and in National Association of Addiction Professionals (NAADAC) seminars/workshops. The whole story and all our nuances are not affirmed in the “official” manual. 

Frankly, I hear more “what is wrong with” vs. “why I rely on” discussion around the Diagnostic and Statistical Manual. However, if I was not predisposed to being a person with addiction to gambling, I would bet there will be a DSM-6.

Under diagnostic criteria in the DSM-5 for problematic alcohol use (pp 490-497):

“Alcohol use disorder is defined by a cluster of behavioral and physical symptoms, which can include withdrawal, tolerance, and craving. Alcohol withdrawal is characterized by withdrawal symptoms that develop approximately 4–12 hours after the reduction of in-take following prolonged, heavy alcohol ingestion. Because withdrawal from alcohol can be unpleasant and intense, individuals may continue to consume alcohol despite adverse consequences, often to avoid or to relieve withdrawal symptoms. Some withdrawal symptoms (e.g., sleep problems) can persist at lower intensities for months and can contribute to relapse. Once a pattern of repetitive and intense use develops, individuals with alcohol use disorder may devote substantial periods of time to obtaining and consuming alcoholic beverages.

Craving for alcohol is indicated by a strong desire to drink that makes it difficult to think of anything else and that often results in the onset of drinking. School and job performance may also suffer either from the aftereffects of drinking or from actual intoxication … individuals with an alcohol use disorder may continue to consume alcohol despite the knowledge that continued consumption poses significant physical (e.g., blackouts, liver disease), psychological (e.g., depression), social, or interpersonal problems [domestic violence, DUI and other crime, child abuse, antisocial behavior] …”

The diagnostic criteria addresses the spectrum of alcohol/substance disorder, instead of you might be, you probably are, who are you kidding—you’re a text-book addict, DSM offers mild (2-3 symptoms), moderate (4-5 symptoms) and severe (six or more) markers and suggests that once these criteria are no longer present, our disorder is, in my layperson understanding and language, “arrested.”

Read them and weep (or debate or identify) invite your friends, have a Zoom meeting …

1. Alcohol is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
4. Craving, or a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
10. Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. b) A markedly diminished effect with continued use of the same amount of alcohol.
11. Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol or b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Dryish January (moderation management)

For DRY JANUARY-lite fans, the world wide web offers Dryish January. Sunnyside Co offers a mindful-goal-oriented approach, neither anti-abstinence, nor anti-indulgence. There are questionnaires and apps for moderation management as well; many just want to cut down for the first month of the year. 

DRYISH JANUARY click Here self assessment and goal oriented alcohol use/non-use

Passion is such that there is infighting between in-groups. Safe supply and harm reduction advocates and their abstinence-based sibs sometimes get into it with each other. We are family is my position. My abstinence isn’t in disagreement with your moderation management. And inside each of these camps, there is some scrapping as well. Oh, the narcissism of small differences—because I am cursed with it, I can and do see it in others. 

“Live and let Live,” people. I will try to do the same. I have never seen a case of bad sobriety. You might not like so-and-so’s recovery but the whole community appreciates it; consider the alternative. And reduced harm is reduced sorrow, reduced suffering, reduced poverty and death and sickness and abuse. Who in hell is against less suffering?

Mystery Beyond Mastery

I have said before that when I first pondered, “Am I or am I not an alcoholic?” I would not have believed that in 2024 a DNA or blood test still can’t conclusively identify people who really shouldn’t drink from the free-pass crowd. The Cleveland Clinic reports that, “Gene mutations that increase your likelihood of developing a genetic condition later in life can sometimes be detected through predictive and pre-symptomatic testing by looking for changes in your genes that increase your risk of developing certain diseases. These include certain types of cancer such as breast cancer.”[vi] To restate what I hope is obvious—not a doctor, not a scientist—copy and pasting the words “gene mutation” doesn’t suggest I grasp the breadth of what is offered. 

But so far, what we see is what we get and while science continues to expand and enhance the medical complexes resources to help us, there will remain, at least for now, mystery beyond mastery. I don’t say that like it’s a bad thing. What has been accomplished, the still unconquered unknown, both speak to me as a layperson. Gut-feeling and folk-wisdom can’t be sent to the curb, replaced by medical/scientific certainty—not just yet anyway. 

Channeling Living Sober (A.A. World Services), there is no “‘right’ way or ‘wrong’ way. Each of us uses what is best for [ourselves] without closing the door on other kinds of help we may find valuable at another time. And each of us tries to respect the others’ right to do things differently.”

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