The Truth About Alcohol
We see it everywhere, right? This is the society we inhabit, where drinking is glamorized across our media and alcohol is the most prevalent drug consumed. But what is this ubiquitous depiction of alcohol not telling us?
The Facts
Most of us are aware of the dangers of what have commonly been referred to as “hard drugs” like cocaine, heroin, opiates, and methamphetamine. What is astonishing is that alcohol is both legal and socially considered one of the most benign drugs when in fact it kills more people than opioids and other drugs combined (1). We’ve even been prescribed a glass of wine daily for heart protection (2,3), but this year the World Health Organization declared that in fact no amount of alcohol is safe (4,5).
The stats (6,7):
Alcohol contributes to at least 40% of emergency department visits (healthcare professionals have told me this number is closer to 70%) and 22% of accidental overdose deaths making alcohol the fourth-leading preventable cause of death in the US
Driving under the influence accounts for 13,384 deaths or a third of overall driving fatalities
Alcohol use, which increases impulsivity, is involved in 21% of suicides
Alcohol is one of the most dangerous drugs to withdraw from, with the possibility of seizure, nervous system dysfunction, elevated heart rate, abnormally high body temperature, hallucinations, and in worst cases death
Alcohol’s Ripple Effect
The costs to society go far beyond these outcomes. On top of the many unnecessary deaths, “countless people are impacted by alcohol’s ripple effects including the consequences of car crashes, increases in violence and assault, jobs lost, families fractured, and children’s lives made unstable by a parent’s dependence on a drug” (1). These children are often exposed to higher rates of emotional, physical, and sexual violence; housing instability; poverty; and physical health issues (8).
Based on my clinical experience, other lasting effects of being a child of an addicted parent include:
Parentification
Taking on adult roles before it is developmentally appropriate
Difficulty regulating emotions
Lacking a parent who can teach adaptive coping skills and reliably validate your experiences and emotions
Loneliness and depression
Hypervigilance in relationships
Difficulty trusting others
Waiting for the proverbial “shoe to drop” when others behave unreliably or let you down
One’s own risk for developing addiction
These negative outcomes may make sense at the severe end of alcohol use by a parent, but even moderate drinking in front of your kids sends the message “Drinking is good, fun, and an acceptable way to deal with stress.”
The Language of Addiction
The language we have historically used to characterize problems with alcohol, words like “alcoholism” and “alcoholic,” have unfortunately misled many in their understanding of addiction.
The term “alcoholic” often invokes images of a man huddled under a bridge grasping a paper bag containing malt liquor. This creates a false sense of safety for those with unhealthy drinking patterns who do not resemble the guy under the bridge (9).
Addiction to alcohol has had different definitions across time even in the psychiatric diagnostic manual:
“abuse” formerly captured binge drinking or overuse (a focus on quantity)
dependence captured the pattern of drinking (a focus on frequency) in addition to highlighting the compulsive nature of use
the diagnosis has also typically included a measure of impairment linked to the number of alcohol-related problems or consequences the individual has faced
Notice the connotation of the term “abuse.'“ We do not use this word when referring to other conditions like binge eating. We say “overeating” or eating disorder rather than abusing food. We say “diabetes” rather than abusing sugar. Unfortunately drinking problems are one of the most highly stigmatized mental health problems in spite of being one of the most common issues.
Historically it was difficult to define what an “acceptable” versus problematic pattern of alcohol use was. Common sense was to avoid heavy drinking which the NIAAA (The National Institute on Alcohol Abuse and Alcoholism - unfortunately this organization has maintained old terms) defines as:
For men: four drinks on any day or 14+ drinks a week
For women: three drinks on any day or 7+ drinks a week
Keep in mind that a standard drink is a 1.5 ounce shot, 5-ounce glass of wine, and a 12-ounce beer which is often smaller than the drinks we pour at home.
Alcohol use disorder (or AUD) replaced the diagnoses of abuse and dependence in 2013 (10). AUD takes the phenomenon out of its former dichotomy (you are either an “alcoholic” drinker or not) and places addiction to alcohol on a spectrum based on symptoms and consequences experienced including:
drinking more than you planned or for longer than you intended
unsuccessfully trying to cut down or stop drinking
trying to moderate but unable to stick to your rules
e.g., you plan not to drink on Mondays but find yourself coming up with “exceptions” (e.g., “today was a stressful day”)
wanting a drink so badly, you couldn’t think of much else
intrusive thoughts and the irresistible urge to drink (aka cravings)
more than once got into situations while or after drinking that increased your chances of getting hurt
giving up other important activities in favor of drinking
Meeting just 2 of the criteria with the presence of distress or impairment qualifies for a mild AUD. Impairment includes consequences of drinking like missing work due to a hangover or not being able to remember an event. Cravings or intrusive thoughts about drinking qualify as distress as does unsuccessfully trying to cut down. The full list of criteria can be found here.
If you’re someone with a frequent habit of drinking with few consequences, you may consider the concept of “Gray Area Drinking” which Jolene Park coined in 2017. It captures the daily habit of drinking alcohol in social settings or at home. She says for example, “there is no definitive rock bottom, but you drink as a way to manage anxiety and then regret how much – and how often – you drink” (11).
While many people can exist in this area for a long time without encountering major consequences, this area may be riskier than you think, especially now that we understand the associated health risks and how alcohol progressively affects the brain (the link to Part II: How Alcohol Affects the Brain will go live in December).
Many people who drink alcohol think their consumption falls within the “acceptable” range for alcohol use, but your drinking pattern could be riskier than you realize.
According to NIAAA, 29.5 million people in the US met criteria for AUD in the past year. While heavy drinking in college is considered a “normal” or typical rite of passage, those who engage in frequent, binge drinking may meet criteria for and are at increased risk of developing an AUD over the course of their lifetime (12).
Disease Model and Beyond
Early models of addiction painted a picture of AUD as a disease that you either inherited or didn’t. The benefit of the disease model was that it made the medical world take the condition seriously and reduced moral stigma (i.e., people with alcohol problems were no longer considered “weak-willed losers”). A major drawback of the disease model, which AA still uses, is that it invokes a sense of powerlessness over change. For some, this ultimate surrender allows them to recover where for others feeling helpless interferes with recovery efforts.
While controversial, many treatment practitioners in the psychology world have moved on from the disease model. We now understand the complex causes of the condition to include a combination of genetics, trauma history, and alcohol use exposure. All these factors combine to influence a person’s vulnerability to overuse.
Sadly, the alcohol industry would prefer that the problem remain situated within an individual who is improperly using alcohol due to a disease or moral failing.
By using the slogan “consume responsibly,” Big Alcohol evades responsibility by insisting that if people just drink correctly, nothing bad will happen. This messaging “prevents drinkers from observing their own relationship with alcohol and provides a false sense of security” (11).
What is more accurate and useful is to understand how the behavior of drinking (something most of us do) can lead to addiction. Newer models have conceptualized AUD as a learning disorder where the habitual use of alcohol (to enhance experiences, to socialize, or to cope with stress) is an over-learned behavior (13). This greatly enhances our ability to treat AUD and de-stigmatizes addiction as a condition that does not just belong to the degenerate but can in fact happen to anyone.
Once addiction is underway, it is hard to stop because of the way the brain works. Our neurological reward system gets hijacked which leads to needing more of the substance to experience the positive effects. Annoying intrusive thoughts may emerge (e.g., “Is it five ‘clock yet?”) and negative consequences may begin to stack up.
The more time accrued in a pattern of addiction, the more difficult it is to stop. In 2022, leading addiction experts “released an opinion paper urging the field to adopt a diagnosis of “pre-addiction” for people with mild to moderate substance use disorders (SUDs). Much as the concept of prediabetes improved early intervention for people at high risk of diabetes, the authors concluded that a concept of pre-addiction could improve diagnosis and treatment for those at risk of AUD and other SUDs” (1,14).
So if alcohol is this dangerous, then why do we drink?
In the acute intoxication phase, alcohol creates a “buzz” that can feel euphoric. As a depressant, it can be a potent relaxant which is why so many people use it to “take the edge off.” The problems arise in how our bodies deal with alcohol (see Annie Grace’s explanation) and the consequences of drinking (e.g., DUIs, conflict within relationships, alcohol-related injuries, reduced productivity, hangovers). People drink to enhance experiences (consider how much alcohol you see at a concert or football game), as a social lubricant (“liquid courage”), or to cope with life problems and unwanted emotions. Using alcohol habitually and learning to rely on these effects is where problems arise.
How do I know if I am addicted to alcohol or engaging in a risky pattern of drinking?
If you google this, you will probably get many different self-report quizzes and possibly differing answers. Many will conclude ambiguously “you may have a problem.” The self-reflection questions below may be more useful to you. A professional can certainly help you explore the function and consequences of drinking in your life and how it is serving you (pardon the pun) but ultimately you are the only one who can decide if alcohol is working for you or not.
Perhaps consider these questions regarding your relationship to alcohol:
How has the pandemic changed how I’m using alcohol?
Am I okay with how alcohol shows up in my life?
Is alcohol giving me what I want?
Do I feel free or stuck?
Do I regularly negotiate with myself about drinking? Does trying to moderate my use take up a good deal of my mental energy?
Is alcohol negatively impacting my life?
Is there anything I want to do to improve my relationship with alcohol and the effects on my life?
Read more:
Links to my forthcoming articles on Alcohol & the Brain and Women & Alcohol will go live in December and January respectively.
Women & Alcohol - how does alcohol specifically effect women and why are more women drinking than ever before? What are my risks of cancer when consuming alcohol?
Alcohol & The Brain: How exactly does alcohol affect the brain in short- and long-term ways?
I’m Ready to Make a Change:
Explore Quit Lit
Annie Grace, This Naked Mind
Holly Whitaker, Quit Like a Woman
Catherine Gray, The Unexpected Joy of Being Sober
Use an App
Try Dry
Try a group
Find treatment near you
SAMHSA 1-800-662-4357 (Confidential free help, from public health agencies, to find substance use treatment and information)
References:
Kristin Weir, “More People in the U.S. Die of Alcohol-Related Causes Than from Opioids and Other Drugs: Psychologists Are Working to Change That,” APA Monitor, June 2023, https://www.apa.org/monitor/2023/06/tackling-risky-alcohol-use
Mandy Oaklander, "Here’s What Happens When You Drink Red Wine Every Night,” Time, October 12, 2015, Here's What Happens When You Drink Red Wine Every Night | Time
Leandra Cohen, “Tell It To Me Straight: Is Wine Ruining Me or Saving Me?” Repeller, June 20, 2018, I Just Want to Know Once and For All If Wine is Good For You (repeller.com)
World Health Organization, “No Level of Alcohol Consumption is Safe for our Health,” News Release, January 4, 2023, No level of alcohol consumption is safe for our health (who.int)
GBD 2016 Alcohol Collaborators, “Alcohol Use Burden for 195 Countries and Territories 1990-2016, https://www.thelancet.com/article/S0140-6736(18)31310-2/fulltext
NIH, “Alcohol’s Effects on Health,” NIAAA, 2023, Alcohol-Related Emergencies and Deaths in the United States | National Institute on Alcohol Abuse and Alcoholism (NIAAA) (nih.gov)
SAMHSA, Preliminary Findings from Drug-Related Emergency Department Visits, 2021
Whitaker, H. (2021). Quit like a woman the radical choice to not drink in a culture obsessed with alcohol. The Dial Press.
https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-use-disorder-comparison-between-dsm
Jolene Park, “Gray Area Drinking,” https://grayareadrinkers.com/about-jolene-park/
NIAAA, 2023, Drinking Levels Defined | National Institute on Alcohol Abuse and Alcoholism (NIAAA) (nih.gov)
Maia Szalavitz, Unbroken Brain, Picador St. Martin’s Press, New York, 2016
McLellan, Koob, & Volkow, “Preaddiction - A Missing Concept for Treating Substance Use Disorders,” JAMA Psychiatry, 2022, https://ww2.uthscsa.edu/artt/AddictionJC/2022-07-11-McLellan.pdf