The Doctors Opinion on Alcoholism – Revisited (November 2011)


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This program describes a physician's view of alcoholism, as presented in the literature of Alcoholics Anonymous and updated with the modern neurobiology of addictive illness. It includes a discussion of Dr. Silkworth’s explanation of alcoholism as a twofold disease, affecting mind and body, how Dr. Silkworth's opinion relates to the modern neurobiolgy of addictive illness, and identification of therapy for alcoholism as promoted by Alcoholics Anonymous and its relationship to Dr. Silkworth’s opinion. The program is presented by Dr. Herbert L. Malinoff, MD; addictionologist. This program is part of the Dawn Farm Education Series, a FREE, annual workshop series developed to provide accurate, helpful, hopeful, practical, current information about chemical dependency, recovery, family and related issues. The Education Series is organized by Dawn Farm, a non-profit community of programs providing a continuum of chemical dependency services. For information, please see

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  • I, however, am eager to test Wilde's description of absinthe's effects: "After the first glass, you see things as you wish they were. After the second glass, you see things as they are not. Finally you see things as they really are, and that is the most horrible thing in the world."
  • Summary; addictive drugs activate the reward system via increasing dopamine neurotransmission In this last slide, the reward pathway is shown along with several drugs that have addictive potential. Just as heroin (morphine) and cocaine activate the reward pathway in the VTA and nucleus accumbens, other drugs such as nicotine and alcohol activate this pathway as well, although sometimes indirectly (point to the globus pallidus, an area activated by alcohol that connects to the reward pathway). While each drug has a different mechanism of action, each drug increases the activity of the reward pathway by increasing dopamine transmission. Because of the way our brains are designed, and because these drugs activate this particular brain pathway for reward, they have the ability to be abused. Thus, addiction is truly a disease of the brain. As scientists learn more about this disease, they may help to find an effective treatment strategy for the recovering addict. LIPOPROTEIN RECEPTOR AND OPIATE RECEPTOR FAT AND OPIATES IN DIET.
  • The Doctors Opinion on Alcoholism – Revisited (November 2011)

    1. 1. THE DOCTOR’S OPINION An explanation of addictive illness found in the “Big Book” of Alcoholics Anonymous Dawn Farm Lecture Series November 15, 2011
    2. 2. Herbert Malinoff, MD, FACP, FASAM Specialist in Chronic Pain and Addictive Illness Medical Director, Pain Recovery Solutions, PC Attending Physician, Saint Joseph Mercy Hospital, Ypsilanti, MI Clinical Faculty, University of Michigan Medical Center, Dept. of Anesthesiology Consultant to Michigan Pain Specialists, Ann Arbor, MI Secretary, American Society of Addiction Medicine 4870 Clark Road W. Suite 201 Ypsilanti, MI 48197 734/434-6600
    3. 3. Declarations of Potential Conflicts of Interest <ul><li>The content of this presentation is non-commercial and does not represent any conflict of interest </li></ul>
    4. 4. Objectives <ul><li>Discuss Dr. Silkworth’s explanation of alcoholism as a twofold disease, affecting mind and body </li></ul><ul><li>Relate Silkworth to the modern neurobiolgy of addictive illness </li></ul><ul><li>Identify therapy for alcoholism as promoted by Alcoholics Anonymous and its relationship to Dr. Silkworth’s opinion </li></ul><ul><li>Still have time for questions </li></ul>
    5. 5. BORING
    6. 8. Alcoholism 101, Revisited
    7. 9. <ul><li>90% Ever drank </li></ul><ul><li>60% Current drinkers </li></ul><ul><li>>40% Temporary problems </li></ul><ul><li>10-20% Abuse </li></ul><ul><li>3-10% Dependence </li></ul>Alcohol Prevalence
    8. 10. >Regard Addiction as a moral problem >1% of medical school curriculum >Fail to adequately screen >Believe interventions are ineffective JAMA, 2003:290, 1299
    9. 12. William Silkworth, M.D. <ul><li>Psychiatrist at Towns Hospital 1930’s </li></ul><ul><li>Thought alcoholism a twofold illness (mind & body) </li></ul><ul><li>Gave Bill W. Step 1 (the problem) </li></ul><ul><li>Published in Journal-Lancet , 1939 </li></ul>
    10. 15. The Problem Determines the Solution
    11. 16. The Solution makes no sense without an understanding of the problem
    12. 17. What is the problem…..NOT <ul><li>Lack of willpower </li></ul><ul><li>Lack of moral character </li></ul><ul><li>Lack of understanding or education </li></ul><ul><li>Alcohol and/or drugs </li></ul>
    13. 18. The Problem: Lack of Willpower (weak)
    14. 19. The Solution: “Just Do It” <ul><li>Avoid bars </li></ul><ul><ul><li>Avoid drinking buddies </li></ul></ul><ul><ul><ul><li>Avoid liquor stores </li></ul></ul></ul><ul><ul><ul><ul><li>Think of baseball </li></ul></ul></ul></ul>
    15. 23. The Solution: <ul><li>Lectures </li></ul><ul><ul><li>Books </li></ul></ul><ul><ul><ul><li>Tapes & Videos </li></ul></ul></ul><ul><ul><ul><ul><li>Self-Knowledge </li></ul></ul></ul></ul>
    16. 25. The Problem: Lack of Knowledge (dumb)
    17. 30. The Problem: Deep Psychological Problems (crazy)
    18. 31. The Solution: <ul><li>Counseling </li></ul><ul><ul><li>Psychotherapy </li></ul></ul><ul><ul><ul><li>Medication (tranquilizers) </li></ul></ul></ul>
    19. 34. 10,000 Pounds of Insight Isn’t Worth 1 Ounce of Behavior Change
    20. 35. The Problem: Lack of Character (bad)
    21. 36. The Solution: <ul><li>A solemn oath </li></ul><ul><ul><li>A better code of morals </li></ul></ul><ul><ul><ul><li>A better philosophy of life </li></ul></ul></ul><ul><ul><ul><ul><li>Organized religion </li></ul></ul></ul></ul>
    22. 38. The Problem: Alcohol & Drugs <ul><li>I have a “drug problem” </li></ul><ul><li>I have a “drinking problem” </li></ul>
    23. 39. The Solution: Abstinence (Dry) <ul><li>Restless </li></ul><ul><ul><li>Irritable </li></ul></ul><ul><ul><ul><li>Discontent </li></ul></ul></ul><ul><li>Resentment </li></ul><ul><ul><li>Fear </li></ul></ul><ul><ul><ul><li>Shame & Guilt </li></ul></ul></ul>
    24. 41. Alcohol Problem vs. Alcoholism
    25. 42. Then What IS the Problem? <ul><li>An allergy of the body and an obsession of the mind </li></ul>
    26. 43. Allergy to Alcohol
    27. 45. Definition of Allergy <ul><li>“ An abnormal reaction to any beverage, food, or other substance” </li></ul>
    28. 46. The Brain’s Design <ul><li>Because the brain is so wondrous that most of us assume it has an elegant design. </li></ul><ul><li>In fact, the brain is a kludge (A kludge in the words of Jackson Grandholm is “an ill assorted collection of poorly matched parts, forming a distressing whole”). </li></ul>From the work of David Linden, Ph.D., described in The Accidental Mind
    29. 47. The Reward Circuit
    30. 50. What is the “Abnormal Reaction?” <ul><li>getting drunk repeatedly </li></ul><ul><ul><li>getting sick repeatedly </li></ul></ul><ul><ul><ul><li>getting into all kinds of trouble repeatedly </li></ul></ul></ul>This does not happen to “social drinkers”
    31. 51. “ The only relief we have to suggest is entire abstinence” “ The Doctor’s Opinion”, Alcoholics Anonymous p. xxx
    32. 52. Can’t start drinking Rx: “entire abstinence”
    33. 53. Alcohol vs. Carrots
    34. 57. Obsession “ Compulsive preoccupation with a fixed idea”
    35. 58. “ They are restless, irritable and discontented, unless they can again experience the sense of ease and comfort…..” The Doctor’s Opinion, Alcoholics Anonymous pp. xxviii-xxix
    36. 59. How do we manage primitive drives? <ul><li>The primitive parts of our brain control the less primitive (basic drives change our thoughts, we are not rational beings) </li></ul><ul><li>Thus, as long as they are in control our thoughts will not change </li></ul><ul><ul><li>“ Live your way into sober thinking rather than trying to think your way into sober living” </li></ul></ul>
    37. 60. Insanity : <ul><li>Alcohol vs. a hot stove </li></ul>“ Being unable to judge or comprehend the consequences of ones actions.”
    38. 62. Can’t stop starting Rx: “Personality change sufficient to recover…”
    39. 63. Allergy + Insanity = <ul><ul><ul><ul><li>Can’t start drinking (allergy) </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Can’t stop starting (insanity) </li></ul></ul></ul></ul></ul>Powerless
    40. 68. Robert Holbrook Smith, MD “Dr. Bob” UM Med (1908-10) <ul><li>Akron Surgeon </li></ul><ul><li>Co-founder of Alcoholics Anonymous </li></ul><ul><li>Treated over 5,000 Alcoholics </li></ul><ul><li>Current AA membership 2.8 million </li></ul><ul><li>24+ million copies of Alcoholics Anonymous sold since 1939 </li></ul>
    41. 70. Step 1: THE PROBLEM <ul><li>Hopeless </li></ul><ul><ul><li>Helpless </li></ul></ul><ul><ul><ul><li>Incurable </li></ul></ul></ul>“ We admitted we were powerless…
    42. 72. Step 2: THE SOLUTION <ul><li>No human power could relieve our alcoholism </li></ul><ul><li>God could and would if he were sought </li></ul>“ Came to believe”
    43. 74. The Actions Which Bring About the Solution <ul><li>Don’t Drink </li></ul><ul><li>Go to meetings </li></ul><ul><li>Get a sponsor </li></ul><ul><li>Work steps 4-9 </li></ul><ul><li>Prayer </li></ul><ul><li>One day at a time </li></ul>