Tag: alcoholism

06/25/24

Increasing Your Awareness of Alcohol Misuse

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Here’s a random statistic for you, according to Capital One. Did you know that Americans spent $3.9 billion on alcohol (mostly beer) for the Fourth of July in 2022? So, what’s the problem with that? Well, the CDC published a study in March of 2024 that estimated an average of 138,000 people died annually from alcohol-related causes in 2016-2017, which increased to 178,000 in 2020 to 2021. The causes included motor vehicle accidents, alcohol poisoning, cancer and cirrhosis.

The PBS News Hour said the main factor for this increase was the COVID-19 pandemic. Alcohol became easier to purchase with the rise of home delivery services, according to Dr. Michael Siegel, of Tufts University. The stress, loss of life from the virus, and isolation from family and friends contributed to mental health struggles that led many people to self-medicate with alcohol. He thought this rise in alcohol-related deaths was “most likely to hold steady,” unless the U.S. takes actions like raising taxes on alcohol to bring down consumption, which has worked in other countries. According to NIAAA, the 2022 National Survey on Drug Use and Health (NSDUH) said 29.5 million people over the age of 12 (10.5%) had an alcohol use disorder in the past year.

The CDC has something called ARDI, the Alcohol-Related Disease Impact Application, where you can see national and state estimates of alcohol-related health impacts, including alcohol-attributed deaths, years of potential life lost, and estimates of the proportion of death from various causes attributed to alcohol. For example, in Pennsylvania there were a total of 6,624 deaths due to excessive alcohol use. Among the chronic causes of death, 787 were due to alcoholic liver disease (520 from cirrhosis), 699 due to hypertension in a total of 1,472 deaths caused by heart disease and stroke. Among acute causes of death there were 382 from motor vehicle traffic crashes, 371 from suicide, and 291 from homicide.

The CDC study of deaths from excessive alcohol use from 2016-2021 is here. The study found that the annual number of deaths from excessive alcohol use increased nationally by more than 29% from 2016-2017 to 2020-2021. There were 12,719 deaths from alcoholic liver disease, and 37,317 from heart disease and stroke. Acute causes of death included 15,055 from motor vehicle crashes, and 9,801 from suicides.

There were increases in the alcohol-related deaths for all age groups. The article suggested that over one in eight total deaths of adults aged 20-64 were from excessive alcohol use. Death rates were highest in men and adults aged 50 to 64, but are increasing more rapidly among women and younger adults. See the following graphs taken from the CDC study.

The nearly 23% increase in the deaths from excessive alcohol use that occurred from 2018–2019 to 2020–2021 was approximately four times as high as the previous 5% increase that occurred from 2016–2017 to 2018–2019. Increases in the availability of alcohol in many states might have contributed to this disproportionate increase. During the peak of the COVID-19 pandemic in 2020–2021, policies were widely implemented to expand alcohol carryout and delivery to homes, and places that sold alcohol for off-premise consumption (e.g., liquor stores) were deemed as essential businesses in many states (and remained open during lockdowns). General delays in seeking medical attention, including avoidance of emergency departments for alcohol-related conditions; stress, loneliness, and social isolation; and mental health conditions might also have contributed to the increase in deaths from excessive alcohol use during the COVID-19 pandemic.

The prevalence of binge drinking among adults aged 35-50 was higher in 2022 than in any other year of the past decade, and could contribute to future increases in alcohol-related deaths. Binge drinking is a pattern of drinking that brings your blood alcohol content (BAC) to .08% or higher. This happens when a woman has four or more drinks or a man has five or more drinks within 2 hours. The CDC said most people who binge drink are not dependent on alcohol. Binge drinking is most common among younger adults aged 18-34 and more common among men than women. See the following graph.

A small percentage of adults who drink account for half of the 35 billion total drinks consumed by US adults yearly. Twenty-five percent of binge drinkers do so at least weekly, and 25% consume at least 8 drinks per occasion. Proven strategies to prevent excessive alcohol use and the related harms include: increase alcohol taxes; enforce laws prohibiting alcohol sales to minors; hold retailers accountable for harms the result from illegal serving or selling alcohol; avoid the privatization of alcohol sales; maintain limits on the days and hours when alcohol can be sold; and regulate the density of alcohol retailers. See “Excessive Alcohol Use” by the CDC.

See the following CDC data table for the number of drinks consumed on an occasion when people binge drink (the black circle is for Washington DC):

Older Adults Are Drinking More Alcohol

The rise in drinking is particularly concerning for people 65 and older, with greater health impacts. Dr. George Koob, the director of the National Institute on Alcohol Abuse and Alcoholism, said this is a particular concern for women. He said Baby Boomers (born between 1946 and 1964) have always tended to drink more, as well as use other drugs, “so the percentage of older people who drink is going up.” The number of people who binge drink, develop alcohol use disorder, and die from alcohol is on the rise. This could place an increased burden on our healthcare system, according to Dr. Koob.

Bodily changes as you age make you more susceptible to some of the harms from drinking alcohol. Your tolerance for alcohol drops. People in their 70s aren’t going to react to alcohol in the same way they did in their 30s. There is a decrease in the enzyme that metabolizes alcohol, meaning the response to a drink will be stronger in older people as their metabolism gets slower. There is a reduction in the percentage of water in the bodies of older people, leading to a higher blood alcohol concentration.

There is also a larger impact on the driving performance, reaction time, memory and balance in older than younger drinkers. “Balance is particularly a problem considering that the leading cause of injuries among adults ages 65 and older — and studies suggest falls while intoxicated tend to be more severe.” Ninety percent of older adults are taking at least one medication regularly, and combining them with alcohol can be risky. Dr. Koob said a study found that older adults are more likely to experience depressed breathing than young adults from a combination of alcohol and opioids. And alcohol can weaken the body’s ability to fight off infections, like with COVID-19.

It can be harder to spot problem drinking in older adults who are retired, live alone or socialize less, as the signs are less overt. The current Dietary Guidelines for Alcohol given by the CDC are one drink or less daily for women and 2 drinks or less daily for men. Less is better, according to Dr. Koob:

We believe that people at any age could benefit from stepping back and taking a look at their current relationship with alcohol. We also think that cultivating alternatives to alcohol use for relaxation, socializing, and dealing with stress can result in less alcohol use and better health.

April is Alcohol Awareness Month and older adults are at a heightened rick of alcohol misuse due to a variety of environmental, medical and social factors. See the Alliance for Aging Research for an interview with Dr. Koob. Embedded in the article is a YouTube video of the interview.

10/4/22

It Bites Like a Serpent

Because it gives such a vivid picture of compulsive drinking, Proverbs 23:29-35 is a favorite passage of mine.

image credit: iStock
image credit: iStock

29 Who has woe? Who has sorrow? Who has strife? Who has complaining? Who has wounds without cause? Who has redness of eyes?

30 Those who tarry long over wine; those who go to try mixed wine.

31 Do not look at wine when it is red, when it sparkles in the cup and goes down smoothly.

32 In the end it bites like a serpent and stings like an adder.

33 Your eyes will see strange things, and your heart utter perverse things.

34 You will be like one who lies down in the midst of the sea, like one who lies on the top of a mast.

35 “They struck me,” you will say, “but I was not hurt; they beat me, but I did not feel it. When shall I awake? I must have another drink.”

Not only does this passage truly capture the out-of-control drinking of an alcoholic, it also displays the rich imagery of biblical Hebrew in the process. The description of unmanageability and negative consequences would fit right in with the personal stories in the AA Big Book or on one of the modern recovery blogs.

The passage begins with a series of rhetorical questions that lays out the unmanageability suffered by alcoholics and problem drinkers throughout the ages: woe, sorrow, strife, complaining, wounds without cause and red eyes. Who has all things? “Those who tarry long over wine.” The litany of questions also suggests someone who is familiar with the negative consequences from “tarrying over wine.” It seems that the author knew of what he wrote from personal experience.

According to R. Laird Harris in the Theological Wordbook of the Old Testament, wine was the most intoxicating drink known in ancient times. The reference to mixed wine suggests a process of first evaporating wine with a high sugar content; then mixing it with more wine to get a higher alcoholic content in the “mixed wine.” Even in Old Testament times problem drinkers knew how to maximize their high with the “hard stuff.”

The imagery of verse 31 is wonderfully seductive: red, red wine that sparkles in your cup and goes down smoothly. But watch out! It bites like a serpent and stings like an adder. The message then and the message today is the same for an alcoholic. The seductive appeal of sparkling wine is just as dangerous as a biting serpent.  And if you do not listen to the warning , you could end up dead.

Now we enter into the heart of a drunken stupor: your eyes see strange things; your heart utters perverse things. Watch this YouTube video of Robin Williams describing how alcoholics “see strange things and utter perverse things.” Nothing much had changed there.

The imagery in verse 34 is of being on a ship in the midst of a storm. Tossed about by the waves, one minute you are in the midst of the sea; the next at the top of the mast. In Psalm 107:27, sailors in a storm are said to be reeling like drunken men. Drunkenness is feeling like you are on a storm tossed ship. Can anyone relate? Like a storm, drunkenness must be “ridden out;” endured until the end. And you are powerless to calm the seas and end the storm.

The drinker says that he was struck, but not hurt (35a); beaten, but he did not feel it (35b). When you’re drunk, pain fails to register. Sometimes you don’t even remember what hit you. The terror of the strange things seen and perverse things uttered is like a dream: when will he awake? And if he does, more wine becomes the goal: “I must have another drink.”

Wine leads to negative consequences for those who pursue it; and the aftermath of a drunken storm leads right back to wine. A bleak, hopeless circle is depicted. The main point of the passage is then: Do not look at wine; it bites like a serpent and leads to an unending circle of sorrow.

So why do we do it? Why do humans turn to wine and other intoxicants? Ronald Siegel suggested in his book, Intoxication, that pursuing intoxicants is a “fourth drive,” following hunger, thirst and sex.

“History shows that we have always used drugs. In every age, in every part of this planet, people have pursued intoxication with plant drugs, alcohol, and other mind-altering substances. . . . This ‘fourth drive’ is a natural part of biology, creating the irrepressible demand for drugs.”

I think Leo Tolstoy is closer to the truth. In his essay “Why Do Men Stupefy Themselves?” he said:

“For man is a spiritual as well as an animal being. He may be moved by things that influence his spiritual nature, or by things that influence his animal nature. . . . People drink and smoke, not casually, not from dullness, not to cheer themselves up, not because it is pleasant, but in order to drown the voice of conscience in themselves.”

In the end, the apostle Paul had it spot on. In Romans 7:21-23 he said: “So I find it to be l law that when I want to do right, evil lies close at hand. For I delight in the law of God, in my inner being, but I see in my members another law waging war against the law of my mind and making me captive to the law of sin that dwells in my members.”

Originally posted on 8/1/2014.

10/26/15

Doubling Up Your Drinking

© willeecole | stockfresh.com
© willeecole | stockfresh.com

Would you like to be able to double the amount of alcohol that enters into your bloodstream when you drink? Let’s say you consume the equivalent of two standard drinks containing one ounce of alcohol. Your blood alcohol level (BAL) would double and you would likely exceed the legal driving limits in thirty minutes. Oh, and you would feel drunker as well. Does this sound crazy? Yet that is exactly what happens to someone who has had gastric bypass surgery.

A recent 2015 study, “Effect of Roux-en-Y Gastric Bypass Surgery,” published in JAMA Surgery evaluated the physical and subjective effects of ingested alcohol on individuals who had received a common from of gastric bypass surgery called Roux-en-Y gastric bypass. The find is from a small study of 8 obese women who had undergone the surgery and 9 obese women who had not yet had the surgery. All the women consumed the equivalent of two standard alcoholic drinks or two placebo nonalcoholic drinks in two 10-minute drinking sessions.

HealthDay reported that the researchers measured the blood alcohol concentration (BAC) levels of the participants. “Drunkenness” was measured by matching each participant’s behavior to an “Addiction Research Center Inventory.” BAC levels rose much faster in the bypass group and peaked at levels twice those seen in the non-bypass group. The BAC levels of the bypass group also exceeded legal driving limits for thirty minutes after consuming their second drink. “BAC levels never exceeded legal driving limits among the non-bypass group.”

Feelings of drunkenness were also greater in the bypass group. Using criteria developed by the U.S. National Institute on Alcohol Abuse and Alcoholism, the researchers concluded that just two drinks were the equivalent of a binge-drinking episode with the potential risk of an alcohol use disorder. Dr. Samuel Klein, one of the study’s authors, said:

This surgery literally doubles the amount of alcohol that immediately enters your bloodstream. . . . And it also increases the patient’s long-term risk for alcoholism, because the risk for a binge episode of drinking goes up. And we know that binge drinking increases the risk for going on to develop alcoholism in the future.

Although Klein and his team used a more rigorous methodology than had been used before, the study’s finding isn’t new. Dr. John Morton, chief of bariatric and minimally invasive surgery at the Stanford University School of Medicine, said this was a well-known phenomenon.  “It’s about physiology,” he said. There is an increased sensitivity to alcohol because the surgery removes alcohol receptors in the stomach. These receptors are also found in the liver. “And if you bypass and remove a portion of either of these, you have a change in blood alcohol levels.”

ScienceLine reported on a woman who lost 180 pounds within a year of her gastric bypass surgery in 2009. She started ordering wine in place of dessert at dinner so she wouldn’t sit there ‘”twiddling my fork” while others ate their dessert. The occasional glass of wine became more often and she spent the next two years fighting an alcohol use disorder. She began drinking at home alone, two bottles of wine per occasion. She began hiding bottles from her husband, driving while drunk and blacking out when drinking. She discovered injuries she didn’t remember getting.

A 2012 study, “Prevalence of Alcohol Use Disorders Before and After Bariatric Surgery,” found that while alcohol use disorder (AUD) symptoms were not significantly different one year after the surgery, they were significantly higher in the second postoperative year. The presence of an AUD in the year before surgery substantially increased the odds of an AUD in the first two postoperative years. “Regular alcohol consumption prior to surgery also independently increased the likelihood of postoperative AUD.” One in 8 participants reported consuming at least three drinks per typical drinking day; and 1 in 6 participant said they drank at a hazardous level in the second postoperative year.

A 2013 Swedish study, “Alcohol Consumption and Alcohol Problems After Bariatric Surgery” did a long-term follow up of over 2,00 obese patients who had three types of bariatric surgery: vertical banded gastroplasty (VBG), banding and gastric bypass. The follow up time of the study ranged from 8 to 22 years. Alcohol consumption standards established by the World Health Organization (WHO) were used to assess the risk levels of alcohol consumption during the follow up period.

During the follow up time, 93.1% of the surgery patients and 96.0% of the controls reported alcohol consumption classified as low risk by the WHO. However, in comparison to the control group, the gastric bypass group had an increased risk of alcohol abuse diagnoses, alcohol consumption at least at the WHO medium risk level, and related alcohol problems. VBG also increased the risk of these conditions, while banding was not different from controls.

Another 2013 study, “Substance Use Following Bariatric Weight Loss Surgery,” looked at the course of substance use (alcohol, cigarettes, recreational drugs, and composite substance use), as measured by the Compulsive Behaviors Questionnaire. Participants completed questionnaires preoperatively and 1,3, 6, 12 and 24 months after surgery. There were no significant changes in participant’s reported frequencies of cigarette smoking or recreational drug use. However, there was a significant increase in alcohol use for participants who had undergone RYGB surgery, the same Roux-en-Y gastric bypass as reported above in the 2015 study by .

Because patients have a reduced tolerance for alcohol after RYGB surgery, they may experience the rewarding aspects of alcohol use sooner and more frequently, which may contribute to the increase in frequency of alcohol use after LRYGB surgery.

Steph Yin for ScienceLine noted that many patients are unaware of the risk of an alcohol use disorder when they get gastric bypass surgery. And scientists aren’t clear themselves on why the risk exists. An early theory was that of addiction transfer. People adopt new addictions after weight-loss surgery because they can no longer fulfill their food addictions. However, evidence like that above in “Effect of Roux-en-Y Gastric Bypass Surgery” suggests there may be an anatomical explanation. Namely that metabolic and hormonal changes triggered by gastric bypass leave patients particularly vulnerable to alcohol use disorders. It’s possible, said Yin, that both are right. Or maybe it’s something else entirely. We just don’t know at this point.

According to James Mitchell, a doctor and professor of neuroscience at the University of North Dakota, “Whether it’s addiction transfer or something else going on, we really don’t know at this point.” What is certain is that the high rates of alcohol use disorders in postoperative gastric bypass patients cannot be attributed to chance.

11/10/14

A “Cure” for Alcoholism

Stockfresh image by stevanovicigor
Stockfresh image by stevanovicigor

There is an alleged “cure” for alcoholism. Yes, “cure.” It’s called “The Sinclair Method.” It actually encourages individuals to drink, but only after taking naltrexone or nalmefene before they start drinking. Naltrexone and nalmefene are opiate agonists (drugs that blocks opioid receptors in the brain). The theory is their use before drinking will reduce the neurological “reward” after drinking. The “cure” claim is that this reduction eventually leads to the extinction of the person’s desire to drink because they no longer catch the same buzz when they drink.

This is not a joke. The Sinclair Method has its own facebook page; it is promoted in a new documentary, “One Little Pill,” which also has its own facebook page. The original research was done by David Sinclair, and published in the journal, Alcohol & Alcoholism in 2001. You can see the original article here or here. Sinclair believes that drinking alcohol is a learned behavior. Some individuals (partly for genetic reasons) get so much positive reinforcement from drinking, that the behavior becomes too strong for them to control. “They cannot always control their drinking; they cannot ‘just say “no”.’  And society calls them alcoholics.”

The use of the Sinclair Method is said to remove “the neural changes that have caused alcoholism—the over-strengthened pathways of neurons that have developed in the brain, causing alcohol craving and excessive drinking.” The basic premise of the treatment method is that addiction is a learned behavior that has become so entrenched that the addict can no longer control it. “Alcohol drinking produces reinforcement and is learned through that reinforcement.”

Sinclair’s method is the subject of a book by Roy Eskapa, The Cure for Alcoholism. Eskapa said the book’s title means what it says: “Addiction to alcohol can now be cured—not through abstinence, but by always taking a medication an hour before drinking alcohol.” The reduction in cravings is progressive, with the strongest effects in evidence three to four months after beginning to use the Sinclair Method. “The benefits continue increasing indefinitely so long as you take naltrexone if and when you drink.”

Eskapa claimed that the Sinclair Method does not need to be done in conjunction with “extensive counseling.” He based this on his understanding of a study called Project COMBINE. “As a result of this study, naltrexone is no longer just for large clinics specializing in alcohol problems; now, any licensed doctor can ethically and safely prescribe naltrexone for problem drinking.” Citing clinical trials in Finland and the U.S., he said that naltrexone treatment was only effective when it was taken at the same time that alcohol was being drunk. “Until now, most doctors and addiction experts were unaware that to cure alcoholism, one has to drink alcohol while naltrexone is in the bloodstream.”

What the COMBINE study actually found was that all treatment groups experienced a large increase in the percentage of abstinent days, a factor of three times greater. The treatment groups for naltrexone alone, treatment alone and the combination of treatment and naltrexone had comparable outcomes. It did not conclude that treatment wasn’t needed.  What it said was: “Medical management of alcohol dependence with naltrexone appears to be feasible and, if implemented in primary, and other, health care settings, could greatly extend patient access to effective treatment.”

Before you seek out a doctor to prescribe naltrexone (nalmefene is not approved by the FDA for use in the U. S. at this time), let’s look at this alleged “cure.” First, alcoholism is reductionistically conceived as a learned behavior. And the treatment or “cure” is the systematic application of a behavior modification technique known as extinction. Now, the science behind extinction, and the reduction in drinking by using the Sinclair Method is clear. When you positively reinforce a behavioral stimulus, the individual person (or hamster) will do the behavior more. When you stop positively reinforcing the behavior, it will decrease in frequency. This systematic decrease is extinction. Here is a short YouTube primer on the four basic elements of classical conditioning, if you’re interested.

So here’s the kicker. The “cure” is contingent upon continuing the extinction process. In other words, you need to continue taking the medication an hour before you plan to drink . . . forever. But you can resume drinking for the positive reinforcement of the high simply by not taking your pill. So the “cure” is also contingent upon the motivation level of the potential drinker to take the drug before drinking. This is not a “cure” for alcoholism in my way of thinking.

Alcohol in high enough concentrations in the blood stream can cause unconsciousness, stop your breathing leading to cardiac arrest and other physical problems. The physiological effects from alcohol in your blood stream continue to occur even if the neurological reward for drinking is neutralized. The Sinclair Method does not stop these other effects from occurring. It simply neutralizes the reward from drinking and gradually extinguishes the cravings to drink. It does not metabolize the alcohol in your system.

Understanding what is actually treated by the Sinclair Method is slippery. Eskapa’s book title says it’s a “cure” for alcoholism. But he speaks about “alcohol drinking” being positively reinforced to the point that some individuals (excluding those with a genetic predisposition) cannot control their drinking and are called alcoholics.  Alcoholism is more than just a learned behavior or an out-of-control behavioral reinforcement strategy. It’s not something that pharmacological extinction can remove or cure. “It’s like a switch, clickin’ off in my head. Turns the hot light off and the cool one on, and all of a sudden there’s peace”  (“Brick” from: Cat on a Hot Tin Roof).