What it means to have an alcohol use disorder, and what you can do about it. Most people know that consuming too much alcohol is bad for your health, yet excessive drinking remains the third leading preventable cause of death in this country. It’s a disease that affects some 17 million U.S. adults, a staggering one-fifth of whom are “functionally dependent,” meaning they don’t fit stereotypical ideas about how an alcoholic looks or acts.
“What it means to be a functional addict is that you can be addicted to drinking and still continue to function in certain domains, “ says Stephen Ross, MD, director of substance abuse in the department of psychiatry at NYU Langone Medical Center. “Functional addicts can drink heavily once they get home from work and yet are still able to get up the next day and go to work. They may not function optimally, but they can do their job.”
Who Is the Functional Alcoholic?
Married. Forty-something. Mother. Employed. These are some of the words that describe an alcohol-dependent patient treated by Mark Willenbring, MD, president and founder of Alltyr Clinic, a St. Paul, Minnesota-based addiction treatment clinic.
“She was drinking to relieve chronic pain and stress…[but] didn’t like how her drinking was affecting her, and she was unhappy with her lack of consistent control,” says Dr. Willenbring about his patient. “Also, her past experience with alcohol use disorder in the family made her more sensitive to over-drinking.”
The typical functional addict is middle-aged and educated, holds a steady job, and has a family. Outwardly, they seem to have their personal and professional lives under control, even as they consume increasingly dangerous levels of alcohol. Most functional addicts are in denial: They don’t recognize they have a problem and, as a result, they don’t seek any treatment.
Compounding the problem is that functional alcoholics’ friends and family may encourage their dependence by ignoring the problem. “There is a certain amount of enabling that goes on,” Dr. Ross says. “Mom may drag dad up to bed every night, and the kids grow up thinking it’s okay for dad to pass out every night.”
Alcohol dependence is roughly 60 percent genetic and 40 percent environmental, Willenbring says. People with a family history of alcoholism should watch their drinking very carefully or abstain altogether.
About one quarter of functional addicts have had a major depressive illness at some point in their lives, according to the National Institute on Alcohol Abuse and Alcoholism.
“If you are a functional alcoholic, you may not recognize that you are experiencing anxiety or depression. Escalating anxiety and depression can lead to problematic drinking in the future.” says Scott Krakower, DO, assistant unit chief of psychiatry at Zucker Hillside Hospital in Glen Oaks, NY.
“Very often when someone is drinking too much and having trouble cutting down, there is a co-existing problem like anxiety or depression,” Willenbring says.
For people with anxiety and depressive disorders, alcohol consumption can disrupt their treatment and create a vicious cycle. “Alcohol can interfere with the medication so your anxiety problem grows worse,” says David Streem, MD, an addiction specialist at the Cleveland Clinic.
Knowing When There’s a Problem
Spotting alcoholism in yourself or someone else can be tricky, especially when one is functioning well at home and work. One telltale sign is an inability to curtail drinking once you’ve started.
“You may set limits and then go over them,” Willenbring says. “You may say you are only going to drink on weekends but then drink most days of the week.”
Even for functioning alcoholics, constant drinking eventually impairs their ability to function properly. “You may notice that things are getting a little harder for you,” says Krakower. “It gets increasingly difficult to get the job done. I always ask my patients: Are you functioning well or could you be functioning better?”
The World Health Organization recommends that all individuals be regularly screened by their doctors for the presence of an alcohol use disorder, but many doctors neglect to do this. As Willenbring points out, “most doctors are not taught how to diagnose or manage alcohol use disorders.” That’s why it’s so important to know when someone needs medical help and raise the issue with a healthcare provider.
“People with functional alcohol dependence are almost always aware of and distressed by their impaired control over drinking, [but] they don’t seek help because the options usually available are so stigmatized, unpleasant, expensive, and disruptive, such as rehab,” Willenbring says. “If assessment and treatment are more accessible, attractive, and affordable, they will seek help at a much higher rate than they do now.”
It’s often external circumstances brought on by drinking that force people into treatment, according to Ross. “Maybe the person gets a DUI [Driving Under the Influence driver’s license suspension], or a liver test at the doctor’s office turns up abnormal,” he says. “The person may go to work smelling of alcohol so the boss brings it up, or maybe the wife threatens to leave if he doesn’t get help.”
Treatment depends on the severity of the problem. Many individuals can benefit from outpatient treatment and support groups like the Alcoholics Anonymous (AA) 12-step program. As Ross points out, outpatient treatment can have a big advantage over inpatient treatment.
“It lets you learn to be sober in the environment that you live and work in,” Ross says. “Anyone can get sober in a rehab facility where there are no cues that make the person want to drink. But when you get sober in a normal environment, the triggers that make you want to drink are still there.”
Cost and access may be factors in choosing the right treatment, but affordable and even free options are available. The Substance Abuse and Mental Health Services Administration (SAMHSA) provides a locator map listing behavioral health treatment facilities nationwide. SAMHSA also provides a directory of state agencies for substance abuse services.
There are a variety of anti-relapse drugs such as naltrexone that can be effective, Streem says. “These medications can have a good outcome…but it’s not like you just take a pill and then there’s nothing else you need to do.”
Willenbring says his patient “has done very well” with anti-relapse medications and counseling. “Once her pain was treated with appropriate medication, she has successfully abstained from alcohol,” he says.
As Krakower points out, there’s no one-size-fits-all treatment. “I don’t know if either outpatient or inpatient treatment is more advantageous, but more likely we have not found a great solution for treating this as, unfortunately, many patients are being missed,” he says. “Hopefully, future primary-care initiatives will help to identify patients earlier so they can get some treatment.”
Last Updated: 2/10/2015. By Dr. Sanjay Gupta
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