Alcohol

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 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 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 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 could be unnecessarily restrictive (apart from the Canadian one sounding sexist) for some people 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 familiar with the pathological use of alcohol a la DSM-V, but also a lot of the horrifying human tragedies that drinking can cause. I know the definition of a “standard drink”, and have understand 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 had to set those Canadian guidelines or the psychiatrist committees that wrote the DSM-V, because, had they made their definitions anything but fairly 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. Don’t get me wrong! These objections would come from important serious respectable and reasonable points of view, in my opinion. So the people setting the standards had no choice but to be way over on the safe side. I’m glad it isn’t me.

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. 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 more than the 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 have a good grasp on what it takes for me not to die of something else.

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 control over your drinking may be very different for different people. For an unfortunate 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. 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 importantly: 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.

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 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. And unlike most alcohol statements I think it’s important for me to say you will never again enjoy the fun of drinking.

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.

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 amounts to about double the Canadian standard. And here’s what I’m doing now: two days of abstinence, two days of one standard drink at 5 PM, then three days of two standard drinks starting at five.

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.

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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