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The Science of Loss of Control

Posted on April 23, 2026, tagged as

In 1973 I gave my first lecture on the disease concept of alcoholism to a group of patients in treatment in Janesville, Wisconsin. The material I drew on for the talk was the scientific literature on the subject at the time, my study of the Alcoholics Anonymous (AA) program, and my clinical experience working with patients.  I should mention that in four years of medical school I had only one lecture on addiction. A guest lecture was delivered by Dr. Harris Isbell, then director of the federal addiction research and treatment facility in Lexington, Kentucky. I actually remember one thing that he said that day. He told us that the data for the statement that ten percent of alcoholics who quit drinking abruptly will have withdrawal seizures comes from a study done at Lexington. In this study they allowed everyone on the alcohol ward to drink as much as they wanted for two weeks, and drink they did. Alcohol access was then abruptly halted, and over the next few days ten percent of the patients had seizures. (I am happy to say that such a research study would not be approved today.) Now over fifty years later, I can say that I could give the same talk today and be accurate on all points. Scientific inquiry since that time has supported this point of view. As mentioned in my accompanying book review of The Urge: Our History of Addiction, addiction has been subjected to highly competent scientific study by very smart people and has confirmed what common sense tells us is obvious. Addiction affects the brain, and some residual effects remain even after prolonged abstinence. Some of these alterations put such people at risk of loss of control if they return to drinking.

I used to define addiction in this lecture as follows: “Addiction is an illness in which the afflicted individual has lost the ability to control his or her use of addictive substances or behaviors, resulting in problems in the areas of physical or mental health, and of spiritual or social well-being. And, early in the course of the illness, and sometimes throughout the lifetime of the individual, they are in denial about having this disease.”  (I use the words illness, sickness, disease, and malady interchangeably.)  I went on to say that there are two types of loss of control. The first is where use of alcohol, a drug, or a behavior such as gambling leads to excessive use and therefore, adverse consequences. One drink calls for another. This is entirely different from what people without this disease experience. Such unafflicted people stop drinking when it is reasonable to do so. The other type of loss of control occurs when a person makes promises to quit, is sincere about such promises, and then after some period of time returns to drinking, gambling, etc. anyway. 

Dr. Fisher in his book says that AA is inconsistent about calling alcoholism a disease. I disagree.  Bill Wilson, a cofounder of AA, has written a lot and everything he says is not entirely consistent, but an impartial reading of the book Alcoholics Anonymous, the foundational text of the program, could not be more clear on this subject. Alcoholism is a disease. I believe addiction is so complex that people could come to other conclusions including that it is a moral defect, weakness of will, a psychological impairment, a bad habit, a spiritual sickness, or a condition in which one yields to the temptation of an evil supernatural being. And some of these are not necessarily mutually exclusive.

We have a choice about how we think about something, and my truth may not be your truth. The importance of how I think about something lies in how it affects me and the people around me, and how it affects the decisions I make. The actual reality may be more complex than we would like it to be. The importance of how one thinks about addiction depends upon one’s situation. If one is an alcoholic, for example, it is critical for that person to know that returning to drinking will most likely lead once again to loss of control. There is a widely held belief among AA people that “once an alcoholic always an alcoholic.” Psychiatric literature, based on attempts to make a scientific study of the irreversibility of alcoholism, is not as absolute. There are varying conclusions, but studies reflect that no more than 10 per cent of alcoholics can return to controlled drinking, and the truth is probably far less. (My argument in support of “once an alcoholic always an alcoholic” is that in these studies they may have included people who were not accurately diagnosed and were not really suffering from the disease of alcoholism.)  But let’s say for the sake of argument that this percentage is accurate, that around ten percent of alcoholics could safely return to controlled drinking. How could any doctor justify supporting a treatment plan that is certain to fail ninety percent of the time? A patient who enjoys risky behavior may well defy sound advice and try controlled drinking, but there is always the chance that they will never stop, or that their consequences may become more severe. 

So, I believe that those in the treatment field must recommend total abstinence as a goal of therapy. Admittedly, for some patients addicted especially to opiates or methamphetamine some form of harm reduction therapy must precede full abstinence. And for opioid dependence control of cravings and normalization of life often relies on prescribing of medications such as naltrexone, buprenorphine or methadone. Being too rigid in approaching the solution to any problem can be a handicap. Thomas Henry Huxley stated that one should follow one’s reason as far as possible, and once having done so, accept the limits of one’s knowledge. Further research will undoubtedly provide the answers to some of these questions. In the meantime, we must utilize the best information available and use common sense.