When I was an intern in Newfoundland in 1976, all the specialists and trainees were assembled in a room at the hospital one morning to hear a hepatologist (internal medicine liver subspecialist) from Harvard tell us about liver disease. Once he had finished his talk, an old internist in the back row put up his hand and asked the question most people want to hear answered: How Much Can You Drink? The hepatologist if I remember mumbled something incomprehensible.

There are lots of places these days where people looking for the answer to that question can go. Conservative psychiatry (the American Diagnostic and Statistical Manual of Mental Disorders – the DSM-V) has gone back to a list of alcohol-related behaviours (there are 11 of them), and grading problem drinking as mild, moderate, or severe depends on how many you have. A couple of the milder ones are craving alcohol, and spending a lot of time thinking about or obtaining alcohol (I’m pretty sure I have those two so I am in the the Mild Alcohol Use Disorder category. Oh hell).

The Canadian Government said I think about 10 years ago that they allowed: “10 standard drinks a week for women, with no more than 2 drinks a day, most days, and 15 standard drinks a week for men, with no more than 3 drinks a day, most days.” But recently the Canadian Centre on Substance Abuse in a “study” commissioned by the Canadian Health Ministry has drastically reduced those recommendations, now saying that six or more drinks per week result in significant health risks.

I looked for the trials and published studies that informed this approach and couldn’t find any online although I know they must exist. The cancers associated with increased alcohol use are throat, esophagus, and stomach, all illnesses known to be heavily associated with tobacco use. I’ve looked into the evidence for diet and health and written a book on the subject and it’s clear to anyone reasonable that “lifestyle” association with illness is fraught with technical and logical problems and has to take into account what we can only call life’s enjoyment. And in a lot of ways if you look at the world like a statistician does people who drink a lot are entirely different people than the ones who drink nothing or next to nothing.

I discussed these fairly tight recommendations for alcohol use with my colleague and friend James MacCormack. James is a doctor of pharmacy and one of the most respected experts on healthcare research in the province, possibly in the country. He told me that the evidence that the new six drinks per week “guidelines” were “irresponsible”. His main basis for this comment was that, “They are all addiction specialists.” I imagine leaping to common sense over the top of silly science I like the idea “When you’re a hammer, everything looks like a nail.”

If you want to review a sensible article by an academic evidence expert go and find Vinay Prasad’s post on the subject What is the Truth about Alcohol Consumption dated January 13, 2025. https://www.drvinayprasad.com/p/what-is-the-truth-about-alcohol-consumption Bottom line: the evidence is bad science and everybody has to make up their own mind.

I drink alcohol (and have since I was 16 years old) for the same reason most people do: I just love it, both the taste and the drug effect. But I’m a doctor and so have to be familiar with the pathological use of alcohol a la DSM-V, but I’ve also seen in my practice a lot of the horrifying human tragedies that drinking can cause. I know the definition of a “standard drink”, and understand both the former and the “new” Canadian guidelines for how much alcohol you’re supposed to consume.

I have always avoided the kind of administrative jobs that put a doctor or any expert directly in the path of responsibility in the event of a catastrophe. I don’t envy whoever set the old Canadian guidelines or the psychiatrist committees that wrote the DSM-V, but have the same scepticism about the scientific integrity of the proponents of the “new” Canadian guidelines as I do about people who are fundamentalists about diet and health. Had guidelines-writers made their definitions anything but prohibitive, they would have been drowned in public opprobrium from the news media, Mothers Against Drunk Driving, and the relatives of people harmed by alcohol. Dead because of alcohol. And that opprobrium is seriously right in its way but with so many things it’s only part of the story.

Don’t get me wrong! These objections two drinking would come from important serious and reasonable points of view, some from people who have lived the horror of a drunk-related death. I think bless their hearts people setting the standards have no choice but to be way over on the safe side. I’m glad I’m not one of them.

Having no such responsibility, here is my approach to being reasonable about drinking.

A few ground-rules-setting facts:

1. The acute (“immediate”) effect that drinking alcohol has on you depends on your weight more than your gender, but also on a bunch of imponderables that used to be referred to as “holding your liquor”, which is a biological and psychological variable I don’t understand.

2. Alcohol’s longer-term effect on your body and brain is subject to a bell curve that leaves some people (certain Asians, many other ill-defined groups, and many millions of individuals) at one end or the other. There are very elderly people who drank excessively all their lives and lived to over 100, there are young people, kids, who died of alcohol abuse. The averages don’t make much sense to any of us.

3. What happens to people who drink (and to everybody in general) is subject as well as to biological variability to contingency, common sense, type of employment, age, circumstances like friends, family, and wealth, a welter of ideology, the luck of the draw.

4. A standard drink is approximately 17 mL or about 14 mg of absolute alcohol, which is contained in 5 ounces of wine, 12 ounces of beer, or 1.5 ounces of hard liquor. Measure it! You might be surprised.

5. Making decisions about drinking should be made thinking carefully about whether you are a teenager, a 30-year-old mum, Or a lonely older person looking for help with a clear understanding of your own situation about statistical risks, balanced against whatever joy alcohol brings.

Here’s my hope for myself, what I have tried to teach my kids, and what I think is a reasonable way to look at your relationship with alcohol.

First, on the negative side:

1. If you are unusually sensitive to alcohol’s effects, or if alcohol is so compelling for you that you are always getting into trouble with it and can’t control your drinking, leave it alone.
2. If you do drink, control your drinking, because if you can’t, you have to stop or it will kill you.

But on the positive side, controlling your drinking means:

1. Dying of something else. You have to drink little enough that you don’t get cirrhosis of the liver or a fatal digestive hemorrhage, have a deadly alcohol-related motor-vehicle accident, or get such bad alcoholic brain disease that it shortens your life.

The direct relationship of alcohol to risks of cancer, heart disease, and stroke are questionable because of the quality of the studies supporting it and tiny quantities of increase in risk. To be clear, you have to discover the amount of drinking you can get away with without getting seriously sick or otherwise dying because of it. And some of that decision will be social: what kind of “drinker” do you want to be? What were your parents like? It varies according to the individual.

I suspect for most people your tolerable and “safe” drinking level is more like the “old” Canadian guidelines, and somewhere between the DSM-V’s Mild and Moderate Alcohol Use Disorder.

I’m sorry to disappoint you for not setting a standard here. All I can say is that I believe I have have a not-bad guesstimate of what it takes for me not to die of something else compared to my enjoyment of alcohol, and I do control my alcohol consumption.

2. Avoiding PROBLEM DRINKING. I need another paragraph to define this.

Problem Drinking is in my opinion drinking that causes important life-changing problems: a serious motor vehicle accident that is your fault as a result of being drunk, one of the illnesses referred to above under “dying of something else” or another alcohol-related disease, destroying an important relationship (dear friend, marriage, sibling, parent, child) that clearly happens because you were drunk, losing a job because of drinking, being known among your family or friends as somebody who drinks too much and often makes a fool of him or herself, or just understanding that you are captured by alcohol and can’t escape even though you really badly want to.

AND your Problem Drinking continues in spite of any of these things.

What it takes to accomplish control over your drinking may be very different for different people. For some people it may mean no alcohol at all, or just a tipple on special occasions. Others may be able to drink the “old” Canadian guidelines (or more) regularly and still — being honest with themselves — not have what I’ve called Problem Drinking. Be careful my friends…

The important thing in my mind about Problem Drinking is not for most people exactly the problems it causes (divorce, hospital, death, financial ruin, loss of self-respect) although all of these things are horrifying if they happen), but the choice an ordinary Problem Drinker must face between stopping drinking, and descending into an alcoholic nightmare.

I want to make this point very clear: Stopping drinking for people who really enjoy alcohol is not trivial. My own experience has been effectively and importantly limiting my alcohol intake for no other reason than that I don’t want to stop. 

There are now medications that limit addiction. See your doctor. It could make the most important difference you’ve ever experienced in your life.

If you love alcohol and can’t control it, whether to stop or not is a very serious decision. If you do stop (and make no mistake: if you are a Problem Drinker you must) you could be excluded from social events and circles, and face the rest of the life staying away from alcohol in the face of temptation. It’s okay. You can stop drinking forever and still have a fabulous career, a terrific sexual and friendly marriage, and huge persisting personal satisfaction.

My best advice: don’t let yourself be a Problem Drinker.

CONTROL YOUR DRINKING, or you’ll have to STOP. But exactly how much you can drink and get away with depends on your honest and sober understanding of your own circumstances.

September 2021

Since posting that advice about alcohol something remarkable has happened to me. My wife Robin the love of my life decided she needed to lose weight, and signed up for a weight loss program. This cost a fair bit of money, but she lost the 30 pounds she wanted to as of a few weeks ago. I was thrilled partly by her new much-younger looks, but mostly by a return of brightness in her eyes and straight-shooting participation that reminded me of both of us when we were a lot younger.

That program involved quitting alcohol altogether. To support her, I did the same thing for about three weeks. I was expecting that me feeling better after three days of abstinence in my usual old alcohol program would double down to feeling like I was 26 years old: no more seeing double, dizziness, can’t lift heavy objects, not remembering people’s names, taking time to figure out what the hell I was doing.

That didn’t happen. The shit of it was that most of those problems were just changes of aging. At about two weeks of abstinence I didn’t feel any better than I’d been feeling after three days of the same. But something happened as I approached the third week. I almost hesitate to say this because it will sound like a testimonial of religious faith: My Inner Life Became More Coherent.

I honestly found I could carry on thinking about what the hell I was doing (as opposed to suddenly through some sort of ADHD “breaker, breaker” switch of topic losing the thread) for reasonably long periods of time. This may not be any big deal for a lot of people who can carry on thinking about the same old thing but don’t really get a lot of benefit out of it, but for me it made a pretty nice difference.

Okay. What kind of drinking was I doing before this big epiphany? Three days of abstinence (Monday Tuesday Wednesday), then four days of four or five standard drinks starting at 4 PM every other night of the week. This 16-drink system amounted to about double the “old” Canadian standard. And here’s what I’m doing now: two days of abstinence, then five days two standard drinks starting between 5 and 6 PM.

Am I maintaining my “inner life coherence”? Mmm… kind of. And God help me I push the “standard drink” just a bit, pouring a 2 ounce cocktail at 5 PM. But something, thanks to Robin’s weight-loss thing, has big-time changed. I don’t get drunk! And I’ve noticed a few people around me including Lord love them my kids are understanding that too much drinking is crazy and harmful and they are also cutting back.

 I’ve heard it’s harder to moderate than to abstain. I’m not sure if I can accomplish it. But I will keep my millions of readers posted here about how things go. God bless.

January 2023

Now after a year or so of that most recent drinking program I think the “inner life coherence” is going okay, but what surprises me is that I don’t want to drink anymore after those two (and a bit) drinks five days a week. That usually occurs right after dinner.

Addiction experts have told me that that kind of moderation is quite rare. All I can say is that it really surprises me. I had no idea I could do that. And it’s not taking a whole lot of effort either: when I do drink four or more drinks in an evening I really don’t feel very good in the morning. Which warns me off overdoing it except on rare special occasions.

Who’d have thought?

August 2023.

To expand a bit on what I’ve said about the “new” Canadian guidelines for alcohol, readers of my book on diet and health Forbidden Food will appreciate that you can’t do a respectable scientific study of the effect of lifestyle on health. Even I don’t question that heavy cigarette smoking will probably shorten your life and likely make the last years of it unpleasant which is a seriously sad and pathetic thing. But there is no properly-proven harm from eating as much white sugar as you like. Sorry.

With alcohol when I find the studies that the Canadian Substance Abuse people are relying on I’m sure they will show a lack of scientific rigour (nobody but nobody would try, or be allowed, to put hundreds of people on an alcohol-drinking research farm for enough years to compare them to a randomized control group of supervised teetotalers. This by the way is what Dr Vinay Prasad is proposing.) Also the likelihood, based on flawed studies, of getting sick or dying sooner than you otherwise would if you drink regularly and moderately will be minute.

Stay tuned.

January 13, 2025.

Back to Dr. Prasad’s article. Here are his recommendations (I wish mine had been as honest and practical. I particularly like his number 13):

1. Parents should introduce their kids to alcohol before they go to college. Ideally good wine with dinner, properly paired. First introduction should not be a frat party.

2. Never drink a drink you don’t like. If it’s poorly made, or you hate it, don’t drink it. Throw it away.

3. Don’t count your drinks. That’s antithetical to the pleasure of drinking, and a buzz kill.

4. The best drink is the one immediately before dinner.

5. Good food should be served with good wine or beer, as appropriate. Brandy and sherry at the end of a meal.

6. Jalapenos and habaneros have no business in alcohol.

7. Don’t drink and watch TV.

8. Don’t drink alone, unless you’re meeting someone later and need liquid encouragement.

9. Learn how Beer, Wine, and Scotch are made. For drinks you like, learn how they are made. Learn to mix good cocktails. You should know at least 25 off the top of your head.

10. Pour a bunch of drinks, for instance, several types of whiskey or wine, and learn to appreciate the differences. Do it with a blindfold on. Don’t say peaty, unless you know what that means.

11. If you love red wine take Sommelier training.
12. Have your last drink at least an hour before bed.
13. You can come to my dinner party and not drink, but you won’t be coming back.
14. If you wake up with headaches and can’t work/ call in sick, you have a drinking problem and should cut back or cease.
15. If you are having outburst at your children or spouse, same as above.
16. Drink with friends. Drinks pair best with laughter.
17. Marijuana when used in moderation can reduce alcohol consumption.
18. If you have acetaldehyde dehydrogenase deficiency, don’t drink. This cancer risk is insane. Use marijuana instead. THC soda’s if you want.
19. If you like red wine, put 6 bottles (at varying price points 10-200 dollars) of the same grape (e.g. Cabernet or Syrah or Petit Verdot) in paper bags, hide the label, open all 6. Let everyone try all the wines, and write down notes on taste. Try to guess the prices.
20. A long run deserves a cold beer.
21. Alcohol should be thought of like other foods. There are reason why some alcohol is served before meals, with steak, with dessert, by the fireplace. These traditions can include the chemical properties of fatty red meat and the tannins in red wine. These should be learnt and understood.
22. You can learn more about alcohol from a chef than an epidemiologist. And more from a Sommelier than the Surgeon General.
23. People who don’t drink because they seek longevity will likely live a short, miserable life.
24. Some people tell me they feel bad when they drink, what should they do? Well, if you don’t even like drinking than don’t do it, but perhaps there are things you haven’t learned about wine and spirits.
25. As yourself if you know what “Terroir” means with respect to wine. If no, then there is a lot to learn in this life.

Dr Sloan is back…

This so far is as good as I’ve seen from somebody who enjoys alcohol and has serious training in epidemiology. Caution: I don’t know how much clinical experience Dr. Prasad has had with alcohol trouble, if he’s dealt with alcohol accidents in the ER, cared for cirrhosis ends-of-life, or even had a terrifying alcoholic family, he might be a little less relaxed. Of course his proposals sound unscientific and not-directive. Me? I think alcohol creeps into life itself: for some reason we humans love it and hate it.