What’s the difference between an alcoholic and an addict?

Image courtesy of Pete Linforth at Pixabay.

When I first found myself in rehab I became aware of a distinction: alcoholics vs addicts. I had never thought about it before. It seemed like semantics. Alcoholics drink alcohol. Addicts take drugs.

But over time I started to notice an emotional charge to this distinction.

“At least I’m not a junkie, I’d never steal,” I heard from alcoholics.

“At least I’m addicted to a real drug,” or something similar from some addicts. “Alcohol was never my problem.”

I decided this distinction could work for me. As long as I didn’t drink and use at the same time I would always be clean or sober.

I could drink and go to an NA meeting and be clean. I could use and go to an AA meeting and be sober.

It had a beautiful symmetry to it. A loophole that offered a way out of addiction.

But I never got to try this wonderful idea.

Before it got off the ground I ran into the rather insoluble problem that I couldn’t have one without the other.

I had enthusiastically parroted, “Alcohol is a drug” at recovery meetings. And I believed it, but with caveats. I emphasised the “a”.

Alcohol is a drug, but it’s not the drug… It’s not my drug.

I was so not an alcoholic that I didn’t even have to try to not drink alcohol. It would probably just happen.

Unfortunately I learned the hard way.

I was back home after time away getting clean. Healthy. Revitalised. Beloved job beckoning.

Struggling to sleep one night, and buzzing with anxiety, I thought to myself:

“I’ll go downstairs. If the drinks cupboard’s open I’ll have one drink to help me sleep. If it’s locked I won’t, because I don’t really need it anyway.”

It was locked.

The drink was so unimportant that I got a knife and levered the cupboard open. One drink became most of a bottle. Before long I was rifling through clothes and drawers just in case there were a few stray crumbs of anything left over from before.

That was the start of a quarter year that nearly killed me.

“Alcohol is a drug,” felt different after that.

 

Defense Mechanisms

Working in addiction treatment the distinction came up again. And again.

I’m an alcoholic, not an addict. Or vice versa.

Is it a meaningful distinction? Does it help or hinder?

Doug Sutherland, a psychotherapist, suggests it can be detrimental to recovery in the sense it “highlights difference. It allows us to say, “that’s not me.””

Sometimes it’s easier to focus on what you’re not than on what you are. The motivation to use defense mechanisms such as deflection is understandable when recognising where you’re at is so uncomfortable.

“I consider myself an addict whose drug of choice happened to be alcohol,” says Sutherland.

“When clients say to me I’m an alcoholic not an addict, I ask them what their definition of a drug is.”

“Is it a chemical compound? Well, yes. And is ethyl alcohol a chemical compound? Yes. Of course it is, it’s just in a solution form instead of a powder.”

“And it happens to be legal so the alcoholics don’t get criminalised in the same way as other drug users.”

Alcohol is a drug

When you strip away all the socio-cultural baggage, of course alcohol is a drug like any other.

It hits the GABA receptors like benzodiazepines. And like all addictive drugs and behaviours, its craving is mediated by dopamine, the molecule of desire.

Alcohol induces physical dependence. In fact it is one of the few drugs from which withdrawal can be fatal. Coming off opiates is unpleasant but coming off alcohol can kill you.

(Yet, in my experience working in addiction treatment,  the alcoholics are more likely to refuse or forget their detox meds. The heroin addicts are more likely to be camped outside the office waiting for theirs.)

In the DSM-5, the mental health diagnostic benchmark, “alcohol use disorder” is a subcategory of “substance use disorder” with the same diagnostic criteria.

When you shift from asking “which substance?” to “why the substance?”, the answers are often strikingly similar.

Many would argue that, at the root of it all, the cause is essentially the same: emotional pain and a lack of other coping strategies to deal with it.

And the impact on families is pretty similar too. They experience the same insomnia, depression, anxiety and despair, regardless of the substance.

But nonetheless the distinction persists

When asking friends and colleagues what the difference is, I got a range of responses, from “there’s no difference” to “massive difference”.

One non-addicted friend, Charlie, said: “I’d say there’s no difference – both are forms of substance dependency and the only reason we distinguish between them at all is because alcohol has historically been more socially validated than other forms of substance dependency.”

Another non-addicted friend, Max, said: “To me, an alcoholic is just an addict to alcohol. I’d guess we have a separate word for it because alcohol is the sanctioned drug of our civilization, so addiction to it is more common.”

But Djordje, who self-identifies as both an addict and an alcoholic, says:

“There are differences for sure. I thought for years that was not the case but what I found so far is a massive difference between the two fellowships (Alcoholics Anonymous and Narcotics Anonymous).”

“First with behaviour: addicts are involved in more street crime then alcoholics.”

“Second, most alcoholics have or had jobs, whereas addicts mostly couldn’t keep up their jobs.”

“The alcoholic thinks he is not a junkie and the addict thinks he is not an alcoholic.”

“Both are in denial, they have the same problem, they compare to each other and can’t see their problem.”

“Addicts think differently than alcoholics…”

That sparked my curiosity. My initial reaction was skepticism.

Same again when another friend who self-identifies as both addict and alcoholic suggested that addicts tend to be more immature.

I could think of plenty of examples to confirm and dis-confirm those views.

But I wasn’t up for doing an empirical survey.

Fortunately other people already had.

Horses for courses

Alcohol is a drug. But drugs have various effects. Therefore one might expect people to choose different drugs for different reasons.

That’s the argument of Edward Khantzian’s self-medication model. Different people are trying to medicate different kinds of psychological distress, and therefore end up with a different drug of choice.

He suggests: 

Stimulant-abusers are “high energy” sensation seekers, or depressives trying to escape that flatness. 

Opioid-abusers are looking to soften rage, aggression or depression, sometimes linked with loss, disappointment or trauma.

Abusers of alcohol and other depressants are trying to escape internal tension caused by cutting themselves off from their emotions with rigid defense mechanisms.

A recent study roughly supported the opiate and depressant descriptions, suggesting:

“There is building evidence that a denial-based defensive system is characteristic of alcohol abusers.”

(No doubt alcoholics would deny this. And there’s plenty of studies that would too.)

Another experiment showed alcoholics lagged opiate addicts in a key emotional intelligence metric- the ability to recognise emotional expressions.

Detoxed alcoholics performed worse than detoxed opiate addicts. The alcoholics even lagged opiate addicts still on methadone maintenance.

Alcohol users also show deficiencies in recognising emotions from voice rhythm and intonation, reflecting a theory that the brain regions involved in such tasks (the frontal lobes), are particularly vulnerable to alcohol toxicity. 

But in a Latvian study alcoholics topped addicts of other drugs in several emotional intelligence metrics, such as empathy and self-actualisation.

Alcohol users have shown deficiencies in irony in numerous studies. I initially misread that and thought they meant anaemia. But they really do mean irony. And humour more broadly too. Although I’m sure there’s a few alcoholic comedians who might disagree…

Unfortunately I couldn’t find any direct comparisons of humour and irony deficiencies between users of alcohol and other drugs: there’s more research available on alcohol specifically because it’s been studied more extensively. Although one study highlighted deficiencies in recognising sarcasm among opioid misusers.

These studies might be interesting, and they certainly hint at differences between those addicted to alcohol and those addicted to other drugs. But taken as a whole they paint a mixed, incomplete and sometimes contradictory picture. 

Do addicts really commit more crimes than alcoholics?

When you perceive alcohol as a drug like any other, the legal and socio-cultural distinctions seem flimsy. But their consequences are real.

In the US roughly 450,000 people are in prison for non-violent drug crimes. For alcohol? Zero. Drug possession convictions can lock you out of the labour market in many countries. The arbitrariness of this is highlighted by Professor David Nutt’s renowned study that ranks alcohol as the most damaging drug to society. 

And with legal differences come price differences. The cost of addictions to some illegal drugs like crack and heroin racks up faster than addiction to a legal drug like alcohol (depending on what you’re drinking, of course.) And this contributes to different stereotypes; that addicts resort to more extreme and questionable economic pursuits.

Is there any truth in this?

Studies of prisoners’ substance use and crimes in Sweden and Canada did show a link between illicit drug use and acquisitive crime. But they also showed alcohol was a bigger risk factor for violent crimes, particularly fatal violence.

It’s not that alcohol users necessarily commit less crimes; they may have a tendency to commit different crimes.

Who would you least like as a neighbour?

Evidently there are differences in the level of stigma experienced by addicts and alcoholics. Addicts claim the unenviable top spot for most stigmatised mental health condition.

Alcoholism can be more easily glossed over or minimised with a euphemism; “He likes a drink” plus a knowing wink. “He likes a bit of smack,” *knowing wink*, does not have quite the same minimising effect.

But alcoholics are not far behind addicts in most stigma metrics, such as being blamed for their condition and being stereotyped as dangerous and unpredictable.

The similarities in stigmatisation are perhaps more striking than the differences.

Identification

There are distinctions. But many of them are subtle and questionable and scientific studies of the differences are often conflicting.

Is there even any point in drawing a distinction??

Some alcoholics suggest there is, in the interests of “identification”. Being able to relate to people’s stories is, for many, what opens the door to recovery.

Justin, an alcoholic, says he struggled to identify with addicts, and found it important to gravitate towards more like-minded alcoholics.

“One of the biggest differences I’ve noticed between addicts and alcoholics (in a very generalised way) is in our pasts.

I think drugs overtake your personality and make you dysfunctional within society much faster than alcohol. Drugs almost have you sprinting towards un-manageability. Whereas hitting bottom in alcoholism is more of a slow burn.

I started doing cocaine seriously at 17 and I quit because my life had become unmanageable by 22. I started drinking at 11 and didn’t hit bottom until 34.

Even though drugs were a huge part of my past, alcohol is what brought me down. I had a successful 15 year career and for the most part a happy 11 year marriage. I never had to struggle for my poison. I always had a full bar at home, bars and liquor stores around the corner and money in the bank. I couldn’t relate to needing to commit petty crime and going to insane lengths to score and get high.

This all became apparent to me when I started attending meetings. I found it very difficult to relate to most addicts.”

Singleness of Purpose

This resonates with Alcoholics Anonymous’, “singleness of purpose”, embodied in its Fifth Tradition: “Each group has but one primary purpose—to carry its message to the alcoholic who still suffers.”

In February 1958 AA co-founder Bill Wilson was already grappling with that point of intersection between alcoholism and addiction to other substances. He wrote in the AA Grapevine that he could  “see no way of making non-alcoholic addicts into AA members.”

But he continued:

“Suppose, though, that we are approached by a drug addict who nevertheless has had a genuine alcoholic history. There was a time when such a person would have been rejected. Many early AAs had the almost comical notion that they were “pure alcoholics”- guzzlers only, no other serious problems at all. When alcoholic “ex-cons” and drug users first turned up there was much pious indignation. “What will people think?” chanted the pure alcoholics. Happily, this foolishness has long since evaporated.

One of the best AAs I know is a man who had been seven years on the needle before he joined up with us. But prior to that, he had been a terrific alcoholic and his history proved it. Therefore he could qualify for AA and this he certainly did.”

Neither addict, nor alcoholic

So you can be a terrific alcoholic and a terrific drug addict too.

But some would argue that first and foremost you’re a terrific person, and the labels addict and alcoholic can compromise that.

Half a century after Bill Wilson wrote that there’s a growing movement to not just toss out the debate but to toss out the terms.

SMART Recovery, for example, rejects such labels entirely.

The CBT-based self-help group argues that “alcoholic” and “addict” are stigmatising, demeaning terms that generate a sense of worthlessness and powerlessness and prevent many from seeking help in the first place.

Clinical psychologist Brian Sherman, writes on the SMART Recovery website:

“By continuing to use the term “addict” and “alcoholic,” treatment providers are doing a disservice to their patients and potentially negating progress towards destigmatization and successful long-term treatment.

It has been years now that the field of clinical psychology did away with stigmatizing terms such as “schizophrenic”, “manic-depressive”, or “autistic.” Why then does the field of addiction remain so far behind?”

He suggests instead using terms such as: “person with a substance use disorder” or “person suffering from addiction”. He concludes:

“People are people first, before they develop an addiction. The “addict” label suggests the whole person is the problem, rather than the problem being the problem.”

Same same, but different

Some people find the labels empowering. For many, saying “I’m an alcoholic” or “addict” resonates with the achievement of sobriety. Others are more empowered by discarding them.

Some find the distinction between “alcoholics” and “addicts” important for identification. But for others, that distinction is food for defenses that help to minimise the extent of the problem and the scope of the changes necessary.

The alcoholic/addict distinction, many argue, is a misleading impediment to treatment: “I’m one but I’m not the other.” But some suggest the differences might be substantial enough to warrant individualised treatment for users of alcohol compared with other drugs.

Language is evocative. Labels can drive motivation or diminish it. They impact on self-identity. So ultimately it’s important to choose whatever works for you and enables you to get down to the real work of making positive changes.