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It is a pleasure to reply to such well-considered and well-articulated commentaries. All were in general agreement that the chronic relapsing disorder construct limits understanding of both the nature of alcohol problems and the development of effective means of help. Tucker [1] and Moskalewicz [2] also focus on related but different issues. Tucker takes issue with the conceptualization of dependence itself, while Moskalewicz interrogates wider biomedicalization and examines more distal historical influences [3]. We are in full awareness that we have taken the concept of dependence as a given in ways which these two commentators critique. We chose this focus for debate carefully, however, being concerned by the apparent recent influence of the chronic relapsing disorder construct on research, clinical service provision and public health initiatives.

Andreasson [4] adds a new element that was missing from our original account by incorporating public understanding of the nature of addiction into his persuasive depiction of a vicious circle. We agree strongly. While we were more concerned by what leaders in the addiction field were communicating to generic professionals, we omitted consideration of what the field as a whole does to engender greater public understanding of the nature of dependence and related problems [5]. Indeed, it may not be excessive to consider this the greatest failure of the field, as such promotion of cultural change might be expected to contribute to greater numbers avoiding dependence or resolving it more quickly [6].

‘For Debate’ papers inevitably call into question what is known in the area concerned. It is tempting to be pessimistic about the limited development of the epidemiology of alcohol dependence. This should be resisted. Ours is not a systematic review, and may be useful for hypothesis generation for both primary and secondary research concerned with the onset and persistence of dependence, patterns of relapse and the contributions of other problems and social contexts. The heart of our invitation to debate is about the how the chronic relapsing disorder construct is used, and whether this is useful for research, policy and practice.

It remains our view that this is a useful focus for debate and therefore it is somewhat disappointing that we have not yet succeeded in eliciting perspectives opposed to our own. Looking at, for example, the latest statement by the American Society of Addiction Medicine on the nature of addiction [7], it is obvious that there are many addiction researchers who would disagree with our perspective. We also encourage debates on variations of similar themes such as those suggested in these commentaries, as well as research studies that address novel ways of understanding the causes and course of alcohol dependence (e.g. [8]).

Declarations of interest

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  2. Declarations of interest
  3. References

Support to CAMH for salary of scientists and infrastructure has been provided by the Ontario Ministry of Health and Long Term Care. The views expressed here do not necessarily reflect those of the Ministry of Health and Long Term Care. John Cunningham is also supported as the Canada Research Chair on Brief Interventions for Addictive Behaviours. Jim McCambridge is supported by a Wellcome Trust Research Career Development fellowship in Basic Biomedical Science (WT086516MA).

References

  1. Top of page
  2. Declarations of interest
  3. References