Cunningham & McCambridge's [1] thoughtful analysis excavates long-standing questions about conceptualizing and pursuing the intertwined, but distinct, goals of advancing scientific knowledge about alcohol misuse versus positioning alcohol services within clinical and public health care. Their sound basic argument would benefit from further qualification distinguishing the utility of the dependence concept for these related, but not identical, enterprises.

Dependence has been defined variously as a clinical diagnostic category, a syndrome, a continuum reflecting problem severity and biological involvement and, most recently, a chronic health disorder [2]. Like the earlier disease concept of alcoholism [3], these conceptions, especially McLellan's [2], have value in positioning services in the health-care system for patients who experience withdrawal and relapse and who make multiple quit attempts. Such patients often require repeated treatment before achieving stable sobriety, typically abstinence. The thesis is persuasive that serious alcohol dependence should be managed like other chronic health problems (e.g. diabetes, hypertension) with long-term monitoring and stepped-care interventions and, accordingly, reformed reimbursement schemes and evaluation metrics.

Despite benefits for advancing long-term care of people with serious alcohol problems, a generalized chronic care model breaks down quickly in two key directions. First, it has little relevance for guiding interventions outside specialty health care. It does not fit with the robust success of screening and brief interventions for resolving mild to moderate alcohol problems in non-specialty settings [4]. It serves little purpose for guiding public health programs for risky drinkers and problem drinkers who do not seek clinical care and comprise the majority of drinkers with problems [5,6]. As Cunningham & McCambridge noted, a population perspective indicates that a spectrum of interventions encompassing clinical, community-based and telehealth interventions is needed to close the gap between need and service access.

Secondly, a singular characterization of alcohol misuse as a chronic disorder offers little guidance for—and indeed risks misdirecting—scientific investigation of the demonstrated heterogeneity of alcohol-related problems. Cunningham & McCambridge argued convincingly that pursuing this research agenda serves the development of an essential range of services. Much like cancer, ‘alcoholism’ is not one disease, but probably a spectrum of disorders with different characteristics, courses and causes that merit different interventions. Treatment options for other serious health problems have often advanced rapidly when the disorder spectrum was well differentiated. Alcohol interventions will probably benefit from similar refinement.

The original dependence syndrome [7] is one severe ‘type’ along the spectrum of alcohol use disorders that has straightforward implications for service delivery [2]. Fully expressed, alcohol dependence appears to be the converging phenotypic expression of an accumulation of many upstream determinants and processes that are heterogeneous across and within individuals. Despite its clinical utility, alcohol dependence is not a good organizational umbrella under which to investigate these upstream variables that dynamically influence the initiation, development, maintenance, recovery and relapse of alcohol-related problems. There is much we do not know about milder forms of risky drinking, and focusing on alcohol dependence perpetuates a ‘pathology’ bias in research that favors studying a homogeneous severe type of the disorder [5].

Debate also continues over whether alcohol abuse should be viewed as a less severe diagnostic category than alcohol dependence, or whether presentations that fall short of a dependence diagnosis should be characterized along several continuous dimensions, rather than categorized hierarchically based on apparent severity [8,9]. Similarly, more research is needed on transitions over time among abstinence, low-risk and high-risk drinking patterns for different population segments (e.g. by gender and age and during pregnancy) and on how to develop and deliver a range of accessible, appealing services to match the needs of different risk groups at different points in problem development or resolution [6].

Understanding population variability in alcohol use and misuse is fundamental to broadening services for alcohol-related problems. The science of behavior change is based increasingly on disciplinary pluralism that recognizes that no single perspective is adequate in isolation as a scientific model [10]. Moreover, clinical and public health perspectives are not mutually exclusive [11]. Rather, alcohol misuse encompasses an extensive, nuanced set of behaviors and consequences, which all have a place on the research agenda. An over-generalized alcohol dependence concept discourages this agenda. If constrained within its boundary conditions of utility in health systems and clinical work, it is a useful organizing framework.

Declaration of interests