It’s that time of year when heavy boxes (nine pounds) arrive with the fruits of last season’s labor. The 76th (!!) edition ofConn’s Current Therapy is now in print, and with it my chapter on alcohol use disorder.1 I’ve been the chapter author since 2022.
Many thanks to my old partner, Tim Scanlan, M.D., for passing my name along to the editorial team at Elsevier. And also to my editors Rick Kellerman, M.D., and Kevin Travers.
I’ve been invited back for 2025. I plan to add a section on ambulatory withdrawal management.2 I’ve also been mulling over whether risks related to alcohol truly “start from the first drop.”3 Finally, the updated edition ofThe ASAM Criteria, which appeared in late 2023, likely requires brief mention. ✸
Why does your car stop at a red light? Sure, you press the brake, but do you really think about it? For experienced drivers, the answer is no — it just seems to happen on its own.
A vaguely appreciated or unsensed cue (e.g., stoplight) causes a driver to bring their vehicle to a stop. Photo: Ludovic Simon, et al.
This is the miracle of the brain: it can automate processes so you don’t need to consciously think about them. But this is also the challenge of addiction. Unhelpful mental scripts keep executing themselves, even when you sincerely want them to stop.*
What causes the scripts to execute? TheBig Book contains various clues that have since been verified by modern science. The biggest drivers are
Negative affect
Stress
Cues
The Big Book famously describes those with addiction as “restless, irritable and discontented.” This is the best description of negative affect that I have ever seen.
Stress occurs when “environmental demands tax or exceed the adaptive capacity of an organism.”
Cues are environmental triggers — “people, places, things” — that have previously been paired with drug use. Sometimes you are consciously aware that cues are present, for example, you notice bottles of wine in a restaurant. But in many cases, they are unsensed. The brain registers the cues but there is no conscious appreciation that they are there.
The vignette in Chapter 3 of the Big Book brings this all together. Jim, the salesman, reported, “I felt irritated” after a dust-up with his boss. (Negative affect) He might have been stressed over a sales goal. He stopped at a roadhouse to grab a sandwich. The place “was familiar for I had been going to it for years.” (Cues) Despite “no intention of drinking” and “no thought of drinking,” Jim inexplicably “ordered a whiskey and poured it into [my] milk.”
Because “addictive behaviour appears to involve processes outside of the sufferer’s personal consciousness by which cues are registered and acted upon by evolutionary primitive regions of the brain before consciousness occurs.” Spooky functional imaging studies have shown this to be true.
The holidays often involve negative affect and stress. And there are often a lot of cues, both sensed and unsensed, in holiday environments. This “perfect storm” can initiate a behavior chain that often leads to unintended problem behaviors (alcohol or drug use).
I will be talking with my patients about countermeasures for the next month. ✸
* St. Paul lamented, “I do not understand my own actions. For I do not do what I want, but I do the very thing I hate” (Romans 7:15; NRSV). This gets into the realm of reversal learning, which is part of the neurobiology of addiction.
I had the privilege of authoring the chapter on Alcohol Use Disorder in Conn’s Current Therapy 2023, the venerable textbook that has now been through 75 (!!) annual editions. With a little luck, you should be able read it via Google Books (Section 10: Psychiatric Disorders, Page 823).
I’ve been asked to return for the 2024 edition. If space permits, I may include a section on ambulatory medically managed withdrawal (“detoxification”), which is feasible for many patients.
Many thanks to Rick Kellerman, M.D., for involving me in this most rewarding project! ✸
Postscript [03/03/2023]. It’s always fun to receive the physical copy in the mail. The book weighs in at around 9 pounds per the label on the box in which it arrived.
I had the great honor of authoring the chapter on Alcohol Use Disorder inConn’s Current Therapy 2022, the venerable textbook that has been through 74 (!!) annual editions. With a little luck, you should be able read it via Google Books (Psychiatric Disorders, Page 803).
I’ve been asked to return for the 2023 edition. I plan to include some important new research on non-abstinent recovery (“progress, not perfection”). I’ll also be adding a section on how to actually deliver motivational enhancement therapy (a/k/a motivational interviewing) and cognitive behavior therapy (CBT) during brief sessions like office visits in primary care.
Many thanks to Rick Kellerman, M.D., for involving me in this most rewarding project! ✸
