As the opioid epidemic rages on in this country, awareness has been raised about the problem of substance abuse in general, including alcoholism. Some people worry that they may be drinking too much, but don’t know how to tell for sure. Others think that they have a problem, but they don’t know how or where to seek treatment.

One problem in making this judgment is that alcoholism can be a “progressive disease.” Authors Katherine Ketcham and William Asbury have identified three stages: early-, middle-, and late-stage alcoholism. Often people do not experience serious consequences until the final stage, and the first two stages can last 2 months or 40 years, depending on the individual.  Many people can seem to “handle” their excessive drinking for years, until suddenly they cannot: in the late stage, alcohol is metabolized differently, so that even if you were previously someone who could “hold their liquor,” that may not remain true.

The “disease” model of alcoholism, introduced by Jellinek in the mid- 20th century, was very helpful in that it removed some of the stigma and shame associated with it. This idea has dominated much of our thinking about diagnosis and treatment for many years. Also dominating the landscape has been Alcoholics Anonymous, founded by two men who met in a hotel and resolved to help each other to stop drinking. AA relies on the idea that some people are powerless over alcohol and must refrain from it altogether, with support from a group of fellow “recovering alcoholics.”

The medical community continues to use the disease model, and evidence shows that some people have a genetic predisposition to be at risk for alcoholism. The diagnostic manual known as the ICD-10 has the following criteria for the alcohol dependence:

Three or more of the following manifestations should have occurred together for at least 1 month or, if persisting for periods of less than 1 month, should have occurred together repeatedly within a 12-month period:

■ a strong desire or sense of compulsion to consume alcohol;

■ impaired capacity to control drinking in terms of its onset, termination, or levels of use, as evidenced by: alcohol being often taken in larger amounts or over a longer period than intended; or by a persistent desire to or unsuccessful efforts to reduce or control alcohol use;

■ a physiological withdrawal state when alcohol use is reduced or ceased, as evidenced by the characteristic withdrawal syndrome for alcohol, or by use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms;

■ evidence of tolerance to the effects of alcohol, such that there is a need for significantly increased amounts of alcohol to achieve intoxication or the desired effect, or a markedly diminished effect with continued use of the same amount of alcohol,

■ preoccupation with alcohol, as manifested by important alternative pleasures or interests being given up or reduced because of drinking; or a great deal of time being spent in activities necessary to obtain, take, or recover from the effects of alcohol;

■ persistent alcohol use despite clear evidence of harmful consequences, as evidenced by continued use when the individual is actually aware, or may be expected to be aware, of the nature and extent of harm.