Disease Model

Substance Use Disorder – is a medically recognized disease.

The American Medical Association recognized alcohol dependence in 1956.  Alcohol dependence fits the disease model because it is a dysfunctional state with characteristic form.

Use of some drugs, including alcohol, may cause dependency.  The medical term for this dependency, or addiction, is Chemical Dependency.  In order for a chemical to be addictive, it must possess three properties.  It must be:

• mind-altering or mood changing
• euphorigenic
• reinforcing – that is taking the chemical stimulates taking more of the chemical.

Chemical dependency is a chronic condition, meaning that it is permanent and prone to relapse. It is also primary, meaning it exists independently and is not secondary to some other underlying mental illness. And, it is progressive, meaning it gets worse over time.

Current understanding of this disease is that it is significantly influenced by genetic predisposition. For alcohol, this predisposition is believed to affect about 40-60% of those who are alcohol dependent.  Approximately 10% of the population has the genetic predisposition. It is present across all lines of race, gender, intelligence, and occupation.  Other risk factors include age of first exposure to addictive substances, environment, and psychological trauma.

The chemical processes that occur in the brain of the individual who is genetically predisposed are significant and different than the activity in a “normal” individual. When using an addictive substance, the activation of the brain’s centers of pleasure and wellbeing is so rapid and strong the individual almost immediately develops a strong emotional attachment to the drug. Over time, this emotional attachment is accompanied by a physical need. For alcoholics, sudden abstinence from alcohol can result in physical withdrawal symptoms ranging from headaches, sweating, and shaking hands to seizures, convulsions, and death. As mentioned previously, dependency (or addiction) is manifested in three ways:

• Loss of Control
• Compulsive use
• Continued use despite adverse Consequences.

These characteristics are sometimes referred to as the three C’s of addiction.

Loss of Control

Loss of control means the loss of predictability. That is, a chemically dependent individual cannot predict three things when faced with taking a drink or a drug:

• will they use?
• how much will they use?
• what behavior will result?

Loss of control is the most typical symptom in the early stages of the disease but is difficult to identify because it may be present intermittently.

For the pilot population, loss of control may also be masked because of the strict rules and regulations associated with alcohol use as it relates to flying. FAA’s 8-hour “bottle to throttle” regulation, and company rules which often prohibit drinking alcohol within 12 or 24 hours of a duty period, affect the pilot’s drinking behavior. Often problematic drinking, or early signs of dependency, is evident in “binge” drinking behavior. Binge drinking is defined as 5 standard drinks in a setting for a male or 4 standard drinks for a female. Such drinking behavior may be evident even when not associated with flying periods. For airmen, loss of control usually first manifests as drinking more than intended, or as a violation of company or FAA limits on consumption.

Compulsive Use

A compulsion is an irrational repetitive act that is done despite a firm intention not to do it. It arises from an obsession which is an omnipotent thought, so powerful it takes precedence over other very powerful thoughts, even survival-type thoughts. This compulsive behavior is why alcoholics will risk their jobs, health, relationships, and every other aspect of their lives in order to get a drink or continue to drink. In short, it means alcoholics are powerless to make a rational choice and drinks the way they do not because they want to, but because they haveto.

Continued Use Despite Adverse Consequences

For the alcoholic who has not yet reached the chronic stage of the disease, he may still choose to abstain from drinking. However, once alcohol is induced into the individual’s system, the three C’s once again become manifest. So, for most alcoholics, the problem isn’t stopping their drinking, it’s staying stopped. If a person continues to drink despite adverse consequences, one can be assured the person is beginning to enter a disease state.

Similarly, the three C’s are present in those addicted to drugs other than alcohol. Often the use of prescription medications can lead to symptoms of dependency for those who are genetically predisposed. Using addictive medications not in accordance with the doctor’s orders, using medication that is not prescribed for that individual, or using medication that is not warranted by the presence of the associated symptom are all signs of possible abuse/dependency. And, like alcoholics, addicts will protect their supply, rationalize their behavior, and exhibit denial about their misuse.