What is the difference between being an alcoholic and an alcohol abuser? Is the latter a "functioning alcoholic?" Do they both need the same kind of treatment?

-- J.

Technically, the difference between an alcoholic and an alcohol abuser is the difference between alcohol DEPENDENCE and alcohol ABUSE. Alcohol dependence (or alcoholism) is a more severe problem than alcohol abuse. However, alcohol abuse is also unhealthy, and it can develop into alcohol dependence.

The essential feature of both alcohol dependence and alcohol abuse is continued drinking despite significant alcohol-related problems. In alcoholics, the drinking pattern may include tolerance (the need for greatly increased amounts of alcohol to become intoxicated or to achieve the desired effect, or markedly diminished effects with continued use of the same amount of alcohol) and withdrawal (physiological, behavioral and cognitive changes that occur when the body levels of alcohol decline in someone who has maintained prolonged heavy drinking). Alcohol-dependent individuals will often drink to relieve or avoid withdrawal symptoms.

You don't have to demonstrate alcohol tolerance or withdrawal to meet diagnostic criteria for alcohol dependence -- although if you demonstrate both tolerance and withdrawal, you've got two of the three criteria required for a diagnosis of alcohol dependence according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (or DSM-IV), the "bible" of psychiatric diagnosis. An individual can be diagnosed as alcohol dependent if he or she demonstrates any three of the following (or one of the following if both tolerance and withdrawal are present):

• He or she drinks in larger amounts or over a longer period than he or she planned.
• He or she expresses a desire to cut down or control drinking, and has tried unsuccessfully to do so.
• He or she spends a great deal of time obtaining alcohol, drinking or recovering from the effects of drinking.
• He or she reduces or completely gives up important work or social activities because of alcohol use.
• He or she continues to drink despite recognizing that drinking causes or worsens physical and/or psychological problems.

Alcohol abuse, in contrast, is characterized by a problematic pattern of drinking in which drinking causes recurrent and significant adverse consequences. Those consequences may include:

• failure to fulfill major responsibilities such as work, school or domestic tasks
• recurrent drinking in hazardous situations (such as while driving)
• recurrent drinking-related legal problems (such as arrests for disorderly conduct while drinking)
• continued drinking despite persistent or recurrent social or interpersonal problems caused or worsened by drinking (such as fights or marital arguments)

Perspectives on the appropriate treatment for alcoholics and alcohol abusers vary. The majority opinion is that alcoholics should stop drinking altogether, through addiction treatment programs or community support groups such as Alcoholics Anonymous or Rational Recovery. I suspect most mental health professionals would also recommend that an alcohol abuser with a family history of alcoholism stop drinking altogether, to avoid developing alcohol dependence.

Some psychologists, however, believe that alcohol abusers or "problem drinkers" can learn to modify their drinking to healthy levels, a process called "controlled drinking." Thus, they provide counseling and education to teach alcohol abusers skills to lessen their drinking and prevent adverse consequences. There is some controversy about controlled drinking, however, with many mental health professionals believing it may feed into the typical abuser's denial of having a real problem.