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 specialist) 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 a couple of places these days that people looking for the answer to that question can go to. 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 depending on how many of those behaviours 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 this would put me into the category of Mild Alcohol Use Disorder).

The Canadian Government says about amount of alcohol 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.”

I think those authoritative pronouncements are unreasonably restrictive (apart from the Canadian one sounding sexist) and I’ll tell you why in a minute.

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 pretty well familiar with the pathological use of alcohol a la DSM-V, a lot of the horrifying human tragedies that drinking can cause, the definition of a “standard drink”, and those 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 it was that had to set those Canadian guidelines or the psychiatrist committees that wrote the DSM-V, because, had they made their definitions realistic, they would have been drowned in public opprobrium from the news media, Mothers Against Drunk Driving, and the relatives of people harmed by alcohol, all from important serious respectable and reasonable points of view, in my opinion. So they had no choice but to be way over on the safe side.

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

A few ground-rules-setting facts:

1. The effect that an amount of 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 that nobody can really define.
2. Alcohol’s 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.
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, and 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.

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. So 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. 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. How much is that? It varies according to the individual. I suspect for most people it’s around 2 to 3 times the Canadian guidelines, and somewhere between the DSM-V’s Mild and Moderate Alcohol Use Disorder.

But I believe I know how much it is for me.

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 this as well: your Problem Drinking continues in spite of any of these things.

What it takes to accomplish this control may be very different for different people. For an unfortunate very small few it may mean no alcohol at all, or just a tipple on special occasions. Others may be able to drink twice the Canadian guidelines or more regularly and still — being honest with themselves — not have what I’ve called Problem Drinking.

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. Stopping drinking for people who really enjoy alcohol is, I want to emphasize heavily, not trivial.

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 will be forever until you die unhappy in an important way, excluded from a variety of social events and circles, and unless you’re lucky or some sort of a saint among non-drinkers, otherwise just be boring to others and to yourself.

There is no alternative: 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.


About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 40 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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