Recovery Messages & News

Doctor’s Opinion Updated

By Dr. Raju Hajela

A similar version of this was presented at the Alcoholic’s Anonymous Gratitude Roundup on June 15, 2014 

The Big Book of Alcoholics Anonymous opens with “The Doctor’s Opinion”, which was written by Dr. William D. Silkworth, who specialized in treating alcoholism and treated Bill W. in New York City over 75 years ago.

Dr. Silkworth opined that the Big Book was of “paramount importance to those afflicted with alcoholic addiction.” He further stated:

“We believe, and so suggested a few years ago, that the action of alcohol on these chronic alcoholics is a manifestation of an allergy; that the phenomenon of craving is limited to this class and never occurs in the average temperate drinker… Men and women drink essentially because they like the affect produced by alcohol. The sensation is so elusive that, while they admit it is injurious, they cannot after a time differentiate the true from the false. To them, their alcoholic life seems the only normal one. They are restless, irritable and discontented, unless they can again experience the sense of ease and comfort which comes at once by taking a few drinks-drinks which they see others taking with impunity.”

The concept of allergy has evolved, as medical science has understood the functioning of the immune system better. In today’s world, an allergy is defined as a strong response from the immune system that affects the skin in the form of a rash and/or overwhelming of the autonomic nervous system, the extreme form of which is called anaphylaxis and requires emergency intervention with epinephrine to prevent death due to asphyxiation, when a substance is ingested that has that reaction in some people but not everyone. The allergy concept that Dr. Silkworth described does relate to the idea that alcohol produces a different effect in an alcoholic, which medical science has shown to be amazingly accurate. The brain of a person who has Addiction reacts differently than someone who does not have Addiction. This has been shown clearly by brain imaging and delineation of brain reward, motivation, memory and related circuitry affected by Addiction, which is affected by alcohol and other psychoactive substances.

Craving, which is also well known as an obsession of the mind, is actually a physiological phenomenon related to dysfunction in this brain circuitry that overtly produces restlessness, irritability and discontentedness.   The current, widely accepted definition of Addiction emphasizes that the brain circuitry dysfunction leads to characteristic biological, psychological, social and spiritual manifestations. Also, this makes an individual afflicted with Addiction to pathologically pursue reward and/or relief with the use of substances and other behaviors. These ideas are included in the ABCDE described in the definition of Addiction that are:

  1. inability to consistently Abstain
  2. impairment in Behavioral control
  3. Craving
  4. Diminished recognition of problems in one’s behavior and interpersonal relationships
  5. dysfunctional Emotional response

The vulnerability of someone with “alcoholic addiction” that Dr. Silkworth described, related to the “affect (change in mood) produced by alcohol”, extends much further than the physical effect of alcohol, which was recognized by the founders of Alcoholics Anonymous. Hence, the importance in Step 4 of “self-esteem, pocketbooks, security, ambitions, personal relationships and sex relations” as areas to be examined on the road to mental peace and serenity.

The three relapse related circuits that research has delineated are related to exposure of the brain to a psychoactive chemical, stress (AA recognizes H.A.L.T. – Hungry, Angry, Lonely, Tired) and environmental triggers that are well known in the AA program as slippery people, places and things.

In today’s world, there are many chemicals, prescription and non-prescription, that people need to be careful of because of their psychoactive nature, especially

sedative drugs that act on the brain exactly like alcohol, such as benzodiazepines (diazepam, lorazepam, nitrazepam, bromezepam, alprazolam etc.); and z- drugs (zopiclone, zolpidem and zaleplon). Commonly used drugs such as Gravol (for nausea or sleep) and Benadryl (sedating anti-histamine) have a depressant effect on the brain that affects the reward, motivation, memory and related circuitry. Hence, it is important for people in recovery to only take the non-sedating anti-histamines such as Claritin and Reactine. Pain medications (opioids) such as codeine, morphine, oxycodone, hydromorphone; marijuana and other hallucinogens; and stimulants such as amphetamines (including prescription Ritalin or Adderall) and cocaine. Nicotine is a stimulant as well, hence, it is not surprising that people who quit smoking in recovery also decrease their risk for relapse! Caffeine is a weak stimulant as well that can interfere with recovery because of its effects on the brain.

In summary, this Doctor’s Opinion supports and expands on the opinion of Dr. Silkworth that has become well known through the Big Book of Alcoholics Anonymous. It is essential that people in recovery truly appreciate the meaning of Step 12 – “Having had a spiritual awakening as the result of these steps, we tried to carry this message to other addicts, and to practice these principles in all our affairs” – which is to appreciate the social-spiritual nature of AA and put principles before personalities, while applying the principles in all aspects of one’s life for a happy, joyous and free life in recovery!