The Doctors Opinion on Alcoholism – Revisited (November 2011)

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 http://www.dawnfarm.org/programs/education-series.

1. THE DOCTOR’S THE DOCTOR’S
OPINIONOPINION
An explanation of addictive illness found in the An explanation of addictive illness found in the
“Big Book” of Alcoholics Anonymous“Big Book” of Alcoholics Anonymous
Dawn Farm Lecture SeriesDawn Farm Lecture Series
November 15, 2011November 15, 2011

2. Herbert Malinoff, MD, FACP, Herbert Malinoff, MD, FACP,
FASAMFASAM
Specialist in Chronic Pain and Addictive Illness Specialist in Chronic Pain and Addictive Illness
Medical Director, Pain Recovery Solutions, PCMedical Director, Pain Recovery Solutions, PC
Attending Physician, Saint Joseph Mercy Hospital, Ypsilanti, MIAttending Physician, Saint Joseph Mercy Hospital, Ypsilanti, MI
Clinical Faculty, University of Michigan Medical Center, Dept. of Clinical Faculty, University of Michigan Medical Center, Dept. of
AnesthesiologyAnesthesiology
Consultant to Michigan Pain Specialists, Ann Arbor, MIConsultant to Michigan Pain Specialists, Ann Arbor, MI
Secretary, American Society of Addiction MedicineSecretary, American Society of Addiction Medicine
4870 Clark Road W. Suite 2014870 Clark Road W. Suite 201
Ypsilanti, MI 48197Ypsilanti, MI 48197
734/434-6600734/434-6600

3. Declarations of Potential Conflicts Declarations of Potential Conflicts
of Interestof Interest
The content of this presentation is The content of this presentation is
non-commercial and does not non-commercial and does not
represent any conflict of interestrepresent any conflict of interest

4. ObjectivesObjectives
Discuss Dr. Silkworth’s explanation of Discuss Dr. Silkworth’s explanation of
alcoholism as a twofold disease, affecting alcoholism as a twofold disease, affecting
mind and bodymind and body
Relate Silkworth to the modern Relate Silkworth to the modern
neurobiolgy of addictive illnessneurobiolgy of addictive illness
Identify therapy for alcoholism as Identify therapy for alcoholism as
promoted by Alcoholics Anonymous and promoted by Alcoholics Anonymous and
its relationship to Dr. Silkworth’s opinionits relationship to Dr. Silkworth’s opinion
Still have time for questionsStill have time for questions

5. BORING

8. Alcoholism 101, Revisited

9. 490% Ever drank
460% Current drinkers
4>40% Temporary problems
410-20% Abuse
43-10% Dependence
Alcohol Prevalence

10. >Regard Addiction as a moral problem
>1% of medical school curriculum
>Fail to adequately screen
>Believe interventions are ineffective
JAMA, 2003:290, 1299

12. William Silkworth, M.D.William Silkworth, M.D.
Psychiatrist at Towns Hospital 1930’sPsychiatrist at Towns Hospital 1930’s
Thought alcoholism a twofold illness (mind Thought alcoholism a twofold illness (mind
& body)& body)
Gave Bill W. Step 1 (the problem)Gave Bill W. Step 1 (the problem)
Published in Published in Journal-LancetJournal-Lancet, 1939, 1939

15. The Problem The Problem
Determines the Determines the
SolutionSolution

16. The Solution makes The Solution makes
no sense without an no sense without an
understanding of the understanding of the
problemproblem

17. What is the What is the
problem…..NOT problem…..NOT
Lack of willpowerLack of willpower
Lack of moral characterLack of moral character
Lack of understanding or Lack of understanding or
educationeducation
Alcohol and/or drugsAlcohol and/or drugs

18. The Problem:The Problem:
Lack of WillpowerLack of Willpower
(weak)

19. The Solution: “Just Do It”The Solution: “Just Do It”
Avoid barsAvoid bars
Avoid drinking buddiesAvoid drinking buddies
Avoid liquor storesAvoid liquor stores
Think of baseball Think of baseball

23. The Solution:The Solution:
LecturesLectures
BooksBooks
Tapes & VideosTapes & Videos
Self-Knowledge Self-Knowledge

25. The Problem:The Problem:
Lack of KnowledgeLack of Knowledge
(dumb)

30. The Problem:The Problem:
Deep Psychological Deep Psychological
ProblemsProblems
(crazy)

31. The Solution:The Solution:
CounselingCounseling
PsychotherapyPsychotherapy
Medication (tranquilizers) Medication (tranquilizers)

34. 10,000 Pounds of Insight 10,000 Pounds of Insight
Isn’t Worth 1 Ounce of Isn’t Worth 1 Ounce of
Behavior ChangeBehavior Change

35. The Problem:The Problem:
Lack of CharacterLack of Character
(bad)

36. The Solution:The Solution:
A solemn oathA solemn oath
A better code of moralsA better code of morals
A better philosophy of lifeA better philosophy of life
Organized religionOrganized religion

38. The Problem:The Problem:
Alcohol & DrugsAlcohol & Drugs
I have a “drug problem”
I have a “drinking problem”

39. The Solution:The Solution:
Abstinence (Dry)Abstinence (Dry)
RestlessRestless
IrritableIrritable
DiscontentDiscontent
ResentmentResentment
FearFear
Shame & GuiltShame & Guilt

41. Alcohol Problem vs.Alcohol Problem vs.
AlcoholismAlcoholism

42. Then What Then What ISIS the the
Problem?Problem?
An allergy of the body and an An allergy of the body and an
obsession of the mindobsession of the mind

43. Allergy to AlcoholAllergy to Alcohol

45. Definition of AllergyDefinition of Allergy
““An abnormal reaction to any An abnormal reaction to any
beverage, food, or other beverage, food, or other
substance” substance”

46. The Brain’s DesignThe Brain’s Design
Because the brain is so wondrous that Because the brain is so wondrous that
most of us assume it has an elegant most of us assume it has an elegant
design.design.
In fact, the brain is a kludge (A kludge in In fact, the brain is a kludge (A kludge in
the words of Jackson Grandholm is “an ill the words of Jackson Grandholm is “an ill
assorted collection of poorly matched assorted collection of poorly matched
parts, forming a distressing whole”).parts, forming a distressing whole”).
From the work of David Linden, Ph.D., described in The Accidental Mind

47. The Reward CircuitThe Reward Circuit

50. What is the “Abnormal What is the “Abnormal
Reaction?” Reaction?”
getting drunk repeatedlygetting drunk repeatedly
getting sick repeatedlygetting sick repeatedly
getting into all kinds of trouble getting into all kinds of trouble
repeatedlyrepeatedly
This does not happen to This does not happen to
“social drinkers”“social drinkers”

51. ““The only relief we have to The only relief we have to
suggest is entire abstinence”suggest is entire abstinence”
““The Doctor’s Opinion”, The Doctor’s Opinion”,
Alcoholics AnonymousAlcoholics Anonymous p. xxx p. xxx

52. Can’t start drinkingCan’t start drinking
Rx: “entire abstinence”Rx: “entire abstinence”

53. Alcohol vs. CarrotsAlcohol vs. Carrots

57. ObsessionObsession
“ “Compulsive preoccupation Compulsive preoccupation
with a fixed idea”with a fixed idea”

58. ““They are restless, irritable They are restless, irritable
and discontented, unless and discontented, unless
they can again experience they can again experience
the sense of ease and the sense of ease and
comfort…..”comfort…..”
The Doctor’s Opinion, The Doctor’s Opinion,
Alcoholics AnonymousAlcoholics Anonymous pp. pp.
xxviii-xxixxxviii-xxix

59. How do we manage How do we manage
primitive drives?primitive drives?
The primitive parts of our brain control the The primitive parts of our brain control the
less primitive (basic drives change our less primitive (basic drives change our
thoughts, we are not rational beings)thoughts, we are not rational beings)
Thus, as long as they are in control our Thus, as long as they are in control our
thoughts will not changethoughts will not change
–““Live your way into sober thinking rather than Live your way into sober thinking rather than
trying to think your way into sober living”trying to think your way into sober living”

60. InsanityInsanity::
Alcohol vs. a hot stoveAlcohol vs. a hot stove
““Being unable to judge or Being unable to judge or
comprehend the comprehend the
consequences of ones consequences of ones
actions.” actions.”

62. Can’t stop startingCan’t stop starting
Rx: “Personality change Rx: “Personality change
sufficient to recover…”sufficient to recover…”

63. Allergy + Insanity =Allergy + Insanity =
Can’t start drinking (allergy)Can’t start drinking (allergy)
Can’t stop starting (insanity)Can’t stop starting (insanity)
PowerlessPowerless

64. firm resolve
??restless
??irritable
??discontent
THE CYCLE OF
ADDICTION
one drink
Allergy Insanity
??drunk
??sick
??all kinds of trouble
a spree

68. Robert Holbrook Smith, MDRobert Holbrook Smith, MD
“Dr. Bob”“Dr. Bob”
UM Med (1908-10)UM Med (1908-10)
Akron SurgeonAkron Surgeon
Co-founder of Alcoholics AnonymousCo-founder of Alcoholics Anonymous
Treated over 5,000 Alcoholics Treated over 5,000 Alcoholics
Current AA membership 2.8 millionCurrent AA membership 2.8 million
24+ million copies of 24+ million copies of Alcoholics AnonymousAlcoholics Anonymous
sold since 1939sold since 1939

70. Step 1: THE PROBLEMStep 1: THE PROBLEM
HopelessHopeless
HelplessHelpless
IncurableIncurable
““We admitted we were We admitted we were
powerless…powerless…

72. Step 2: THE SOLUTIONStep 2: THE SOLUTION
No human power could relieve No human power could relieve
our alcoholismour alcoholism
God could and would if he were God could and would if he were
soughtsought
““Came to believe”Came to believe”

74. The Actions Which Bring The Actions Which Bring
About the Solution About the Solution
Don’t DrinkDon’t Drink
Go to meetings Go to meetings
Get a sponsorGet a sponsor
Work steps 4-9 Work steps 4-9
Prayer Prayer
One day at a time One day at a time