Clinical Review

Science, medicine, and the future: Substance use disorders

BMJ 1997; 314 doi: (Published 31 May 1997) Cite this as: BMJ 1997;314:1605
  1. Marc A Schuckit, director of Alcohol Research Centera
  1. a Department of Psychiatry, Veterans Affairs Medical Center and University of California, San Diego, CA 92161, USA


    Consumption of alcohol and other intoxicating drugs has serious public health implications relevant to a wide range of people. Recent decades have seen large advances in the understanding of substance intoxication and subsequent problems. The progress was made possible, in part, by developments in the definition and identification of the relevant phenotypes. The American and World Health Organisation diagnostic systems have been made more precise, resulting in more agreement on the definition of dependence.1 2 Researchers have also recognised the need to identify and study separately subgroups of dependent people with psychiatric and behavioural syndromes that occurred outside and within the context of their substance use disorder.1 3 This article focuses on the recent developments that have improved our understanding of genetic factors that contribute to the risk for alcoholism and our knowledge of the cellular actions of some drugs of abuse and on discoveries that are likely to have direct effects on future clinical management of our patients.

    Genetics of alcohol dependence

    The process of development and perpetuation of dependence on a substance is highly complex.1 4 The original social, behavioural, and biological factors that contributed to the repeated consumption of high levels of these substances set the stage for the development of further problems. Subsequently, additional social factors (for example, attitudes towards substance consumption and intoxication) combine with additional biological factors (such as acute or protracted withdrawal syndromes) to contribute to the perpetuation of the dependence (fig 1). Recent animal and human studies have focused on potential genetic contributors to various characteristics that might increase or decrease the risk of alcoholism. These include the isoenzyme patterns of the main enzymes that metabolise alcohol (alcohol and aldehyde dehydrogenases), as well as the organism's reaction to the drug.3 4

    Fig 1

    Factors that may affect development of alcohol dependence

    Possible future developments

    • Genetic identification of …

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