“But then the wine came, one glass and then a second glass. And somewhere during that second drink, the switch was flipped. The wine gave me a melting feeling, a warm light sensation in my head, and I felt like safety itself had arrived in that glass, poured out from the bottle and allowed to spill out between us.”

— Caroline Knapp, Drinking: A Love Story

What really happens inside the brain when we drink? What explains that warm, melty feeling? And why do some people get to a place where they risk everything to keep drinking?

These are some of the questions which led me into the field of psychology and study of addiction. We are still refining our understanding of these complex issues everyday, but here is what the current science tells us.

Pleasure and the Reward Center of the Brain

*I’m not going to present a comprehensive explanation of all the brain regions and neurochemicals involved but instead focus on the role of dopamine and several areas of the brain.

Most of us consume alcohol because it produces pleasurable feelings, blunts negative ones, and seems to ease social interactions. The warm, gauzy feeling alcohol elicits is a result of increased dopamine release in the reward center of our brain. In the picture above you can see the ventral tegmental area (VTA) and nucleus accumbens (NA) which are areas that regulate pleasure, learning, memory, and addictive behaviors (1). The NA specifically is associated with liking and enjoying. Dopamine release occurs in response to natural rewards like sex and chocolate. However, everyday pleasures are no match for the manufactured pleasure of substances like alcohol (2).

For example, according to rodent studies, nicotine stimulates dopamine output in the brain 150% more than typically rewarding stimuli; cocaine 225% more, and amphetamine 1,000% more (2). Rodent studies also show that addicted rats will stimulate this brain area indefinitely to the exclusion of all other behaviors including eating and caring for young (3). Gradually, the VTA and NA impair our prefrontal cortex (PFC) which is associated with planning and decision making.

Over time, everyday pleasures will cease to produce as much reward as they once did in the presence of regular drinking. This is because the body and brain are incredibly adaptive and continuously attempt to create homeostasis (or balance) in the body. With repeated drinking, the brain will attempt to compensate for the artificially inflated sense of pleasure by producing a chemical which diminishes the the amount of enjoyment we feel from the substance (4,5,6). This process decreases dopamine transmission not just back to baseline, but below baseline (2). This is referred to as Hedonic Adaptation (7,8).

You’ve experienced hedonic adaptation when you buy a new thing (i.e., gadget, outfit, car) but over time your amount of liking wanes and soon you’re “onto the next.”

“Once dependency takes hold, your brain relies on a constant supply of alcohol to maintain neurochemical equilibrium and, over time, comes to demand ever-increasing amounts of alcohol to sustain normal activity.” As can be seen in the graph, this accounts for the widely known phenomenon of tolerance whereby over time more alcohol is needed to feel “good” or achieve the desired effect (8). Ultimately alcohol is taken to achieve a baseline feeling of “normal,” or relief from depression, as opposed to good (4). These observable changes map onto progressive changes in the structure and function of the brain (9). The longer one remains in a habitual pattern of use, the longer it will take for these brain structures to recover.

Motivation

Dopamine is released by the reward center when alcohol is consumed which accounts for the euphoric feelings and pleasure experienced by this “reward.” However, dopamine is not just associated with liking and enjoyment, but also motivation. Specifically, dopamine induces a behavioral drive and is associated with the seeking of rewards as a neural pathway. It is formed when the brain learns to remember “the way back” to the behavior that created the pleasure (4).

When early humans in hunter-gatherer societies found a patch of berries, the brain released dopamine to signal to the person “something important just happened, let me remember and learn how to get back to this pleasure” (4). This neural function ensured survival.

This pathway, though, begins to override conscious decision making by damaging the prefrontal cortex. Impaired decision-making and self-control make it more difficult to refrain from drinking both in the moment and over time.

Cravings

Cravings then are the release of dopamine signaling the drive to seek alcohol. If you’ve ever woken up feeling terrible from a hangover, disavowed drinking, and then ended up with a drink in your hand by 5pm, neuropsychology explains this phenomenon. It can become frustrating and even helplessness-inducing when this cycle repeats and the negative consequences or feelings of guilt don’t stop the behavior. Similarly, it can be dumbfounding to watch loved ones seemingly “choose” alcohol, or their substance of choice, over activities and people they formerly valued.

Its an ironic set up right? Pleasure was installed to help us remember the way back to the berries (eating is good for survival) but neurological cues to continue to consume alcohol are not good for us in the long term. Because of the potency of the reward of alcohol and functional changes over time, our brains can get hijacked into an addictive pattern.

Addiction creates a tug of war between the areas of the brain which plans not to drink and the reward center which insists on continuing the behavior.

Alcohol & Sleep

Alcohol is a central nervous system depressant that slows brain activity. The initial sedatory effect of alcohol accounts for the feeling of relaxation and is why some people think it helps them sleep. Sleep onset is shorter but sedation is not the same thing as quality sleep. For instance, alcohol suppresses REM sleep during initial sleep cycles (REM is associated with memory consolidation among other important restorative processes). Later in the sleep cycle, when alcohol is metabolized and the body attempts to downregulate this artificially inflated pleasure, it creates a stimulant-like compound which accounts for the well-known phenomenon of sleep disturbance (11). This is the brain rebounding from sedation and often people report waking up at 3am feeling alert, anxious, or having a racing mind. This also accounts for the experience of increased anxiety, or “hangxiety,” the following day.

Alcohol and Mental Health

Many people report that they drink to cope with feelings of anxiety or sadness but ironically, alcohol tends to exacerbate these issues in the long run. Alcohol is primarily a depressant which literally means it depresses mood in addition to brain activity. This can feel counterintuitive given the initial short-term euphoric effects. “Research shows that over time, drinking to cope with stress—while it may provide temporary relief from emotional discomfort—tends to enhance negative emotional states between bouts of alcohol consumption. These changes can motivate further drinking and cause an individual to become stuck in an unhealthy cycle of alcohol consumption” (9).

Also, combining alcohol with antidepressants can be dangerous because it compounds sleepiness making driving or other activities that require alertness highly risky. Combining alcohol with benzodiazepines (a common anti-anxiety drug class used for acute anxiety) can be fatal when the combination of these depressants suppress respiration.

People who reduce or quit alcohol often report significantly improved sleep, energy, cognitive functioning, and mood but these effects can take up to 60 days to realize.

Alcohol and Cancer

In addition to the risk for addiction, and the well-known risk for liver damage, alcohol use is also associated with risk for cancer (13). Isn’t it strange that most of us don’t know that alcohol is a carcinogen? And that alcohol doesn’t come with a cancer warning the way cigarettes do? Big Alcohol would prefer to keep this cat in the bag in order to protect their profits and they lobby hard to do so.

So how does alcohol lead to cancer?

“Cancer and alcohol are linked due to the way our bodies process alcohol. Once we ingest alcohol (ethanol), our bodies convert it into a toxic chemical — acetaldehyde. Acetaldehyde is primarily used to produce other chemicals. This includes acetic acid, disinfectants, drugs, and perfumes. This chemical damages DNA then stops cells from repairing the damage. In addition, acetaldehyde causes liver cells to grow at a faster rate than normal (a cause of fatty liver disease). The regenerated cells are more likely to be genetically mutated, causing cancer.” (Annie Grace, 12)

Ethanol, after all, is a component of what we put in vehicles for fuel. Its also flammable! According to the World Health Organization, it is in the same category as asbestos, radiation, and tobacco causing at least seven different types of cancer (13). Ethanol is great as a solvent which is why it is used in nail salons to remove polish. This same quality is why it destroys our gut microbiome which impacts digestion, colon health, and the immune system.

Contrary to popular belief, damage is not just done at the highest rates of consumption. In fact, moderate and light consumption is responsible for most alcohol-attributable breast cancers in women making it a definitive toxin regardless of price and quality (13).

But I heard alcohol is good for heart health!

Some rationalize drinking for the health benefits to cardiovascular functioning. While past research has suggested that moderate amounts of alcohol may be beneficial to cardiovascular functioning, more recent research indicates that any possible benefits are outweighed by the risk for cancer (13).

When reading research on the positive effects of alcohol on health, be sure to look for who funded the study (Big Alcohol has been known to fund research which creates a serious ethical violation) as well as how the study was investigated. Drug and medical device studies are about 30 percent more likely to reach positive conclusions when the research is industry sponsored (15).

Instead of obscuring the risk of alcohol on health, public-safety oriented organizations are pressing for cancer warnings to be included on alcoholic beverages, in the same way tobacco products are handled. These warnings will likely help to increase awareness and conscious decision making about one’s own alcohol use behavior and its relationship to health.

As mentioned in Part I of my article series, alcohol is one of the most dangerous drugs to withdraw from. If you have a severe alcohol use disorder, you should only attempt cessation with medical oversight.

SAMHSA 1-800-662-4357 (Confidential free help, from public health agencies, to find substance use treatment and information)

If you’re interested in cutting back or taking a break from booze, consider these resources:

Read or Listen:
- Link to Part I: The Truth About Alcohol
- Annie Grace, This Naked Mind
- Holly Whitaker, Quit Like a Woman
- Catherine Gray, The Unexpected Joy of Being Sober
- Sober Powered with Gill Tietz
Use an App
- I Am Sober
- Try Dry
- Sunnyside
Try a group

Endnotes:

Cai & Tong, “Anatomy and Function of Ventral Tegmental Area Glutamate Neurons,” Front Neural Circuits, May 2022, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9164627/
Anna Lembke. (2021). Dopamine Nation. Penguin Random House, NY.
Roy A. Wise, “Brain Reward Circuitry: Insights from Unsensed Incentives,” Neuron, October, 2002, https://www.cell.com/neuron/fulltext/S0896-6273(02)00965-0
Annie Grace. (2018). This Naked Mind: Find Freedom, Discover Happiness & Change Your Life. Harper Collins, UK.
Annie Grace. What You Need to Know About Alcohol and Depression. https://thisnakedmind.com/alcohol-and-depression/
Karkhanis & Al-Hasani, “Dynorphin and its Role in Alcohol Use Disorder,” Brain Res, February 2021, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7111141/
Koob & Moal, “Drug Abuse: Hedonic Homeostatic Dysregulation,” Science, October, 1997, https://pubmed.ncbi.nlm.nih.gov/9311926/
David G. Stewart. Etiology of Substance Use Disorders, (Seattle, 2012).
Alcohol’s Effects on Health: Research-Based Information on Drinking and its Impact. NIAAA, The Cycle of Alcohol Addiction. https://www.niaaa.nih.gov/publications/cycle-alcohol-addiction
Stacy Mosel, Alcohol and Anxiety: Does Alcohol Cause Anxiety and Panic Attacks? September 2023, https://americanaddictioncenters.org/alcoholism-treatment/anxiety
Pacheco & Singh, “Alcohol and Sleep,” November 2023, https://www.sleepfoundation.org/nutrition/alcohol-and-sleep
Annie Grace, This Naked Mind Instagram Page, https://www.instagram.com/p/ComvEl7qXdV/
No Level of Alcohol Consumption is Safe, World Health Organization, January 2023, https://www.who.int/europe/news/item/04-01-2023-no-level-of-alcohol-consumption-is-safe-for-our-health
Stacey Devine, Hello Someday Podcast, interview with Casey McGuire Davidson, episode 183, What You Need To Know About Breast Cancer And Alcohol | Hello Someday Coaching
McCambridge, J., & Mialon, M. (2018). Alcohol industry involvement in science: A systematic review of the perspectives of the alcohol research community. Drug and alcohol review, 37(5), 565–579. https://doi.org/10.1111/dar.12826

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