Thursday, 19.04.2018

Reply (Paul Devenyi)

This is a reply to this comment

Peter Martin was a very talented research fellow in the institution I used to work. I am pleased to see that he developed into a very talented and highly respected psychiatrist. His response  is eloquent, making many good points. I don't believe he is violently opposed to what I said, but he certainly has a more optimistic view about the future of addictions and their treatments, than I have. I highly respect that.

The comparison between alcoholism and type 2-diabetes is often made. Yes, insulin resistance is the underlying disease along with several other factors (genetic, immunological). If, as in Martin's example, we compare the control of diabetes as a chronic disease with that of alcoholism, the latter is so far behind that similar outcomes in diabetes would give our health care system the shivers.

I agree with Peter that "loss of control" defines addictions more than for example cirrhosis defines alcoholism; when addiction reaches the "loss of control" stage, we can really talk about a disease. I am glad Peter is optimistic that "addiction may be modified throughout a patient life using pharmacological and behavioral strategies". I think pharmacological approaches failed so far perhaps behavioral ones might produce some success.

As to "pre-morbid characteristics" being predisposing factors, I never came to term with "addictive personality". I still think addiction will be largely determined by the family a patient comes from, by cultural determinants and values of his social milieu and the peer group he associates with. Genetic factors underlying addictions have been proposed, but the evidence so far has been weak.

I still believe that "social engineering" represented by educators, the media, police, judges, social agencies, etc. could have more impact on the prevalence and perhaps the outcome of addictions, than the medical profession.

As to Peter's alcoholic who is "placed on an island where there is no alcohol, will he/she be cured or will other behaviors emerge that replace the alcohol?" As Peter, I don't know the answer either. My guess is that even after many years if escaping from the island, he/she will drink in an uncontrolled fashion again. In the meantime, if the island has a medical school, he/she may become a psychiatrist.

Peter, thanks again for your reply and I am heartened by your overall optimistic approach that an old cynic as I, doesn't have.

Paul Devenyi
October 3, 2013