The Drug Epidemic Nobody Talks About

U.S. death rate from alcohol-related liver disease is soaring.

"Deaths from liver disease have increased sharply in recent years in the United States, according to a study published in the British Medical Journal. Cirrhosis-related deaths increased by 65 percent from 1999 to 2016, and deaths from liver cancer doubled, the study said. The rise in death rates was driven predominantly by alcohol-induced disease, the report said.

"Over the past decade, people ages 25 to 34 had the highest increase in cirrhosis deaths — an average of 10.5 percent per year — of the demographic groups examined, researchers reported.

Here's a link to the Washington Post article.

Harm Reduction Advocate Takes on the Abstinence Question

A guest editorial on “clean and sober” vs “drinking less.”

One of the most divisive issues in the harm reduction movement is the question of abstinence versus controlled drinking. This rift has come to symbolize differences over the AA philosophy, the disease model, the role of will power, and other issues related to addiction. Those who find the disease model unconvincing at best, and some sort of fraud at worst, are more likely to bristle at the notion that total abstinence is the only course available to the addict in treatment. But disease model proponents point out that, for most alcoholics, not drinking at all turns about to be easier than drinking a little. Still, for heavy drinkers who are not addicted to alcohol, cutting down often makes the most sense.

Kenneth Anderson of the harm reduction group HAMS has written an article on the abstinence question which is as straightforward and free of special pleading as any I’ve seen from the harm reduction movement. Bear in mind that I don’t agree with all of the opinions expressed in this guest post, and remain convinced that for most people who abuse alcohol regularly, sustained abstinence is the best policy. But I definitely believe it’s worth a read.


Drinking Again
By Kenneth Anderson

If you have successfully resolved your problems with alcohol via long term (6 months or more) abstinence from alcohol then HAMS urges you to use great caution before you consider drinking again. Studies (NIAAA 2009) show that about half of persons with Alcohol Dependence resolve the problem by quitting completely. HAMS is always supportive of total abstinence as a recovery goal; since the “A” in HAMS stands for Abstinence we like to say that “Quitting drinking is our middle name.” Harm reduction strategies are aimed at those who are unwilling, unable, or not yet ready to abstain from alcohol. This includes people who have attempted abstinence and ultimately not succeeded at it but instead have gone on major benders after short abstinence periods. It also includes those who have never attempted abstinence or who currently have no interest in abstinence. Increased trauma produces increased drinking (Denning & Little 2011). The more resources people have intact, the better their odds of achieving recovery–whether abstinent or non-abstinent recovery. Harm reduction helps keep people’s resources intact enabling them to recover more quickly and easily than if they lost all.

If you are succeeding at abstinence and your alcohol related problems have disappeared or are disappearing then we strongly urge you to continue with what you find to be working–i.e. abstinence. However, if you have already decided that you are going to dink again then HAMS is a safe place to experiment with controlled drinking and you will be far safer here than if you attempt this on your own with no support at all.

If you are wavering and have not yet decided whether or not you wish to drink again then we strongly suggest that you do a Cost Benefit Analysis (aka a Decisional Balance Sheet) which compares the pros and cons of continuing to abstain with the pros and cons of drinking again. We also suggest that you write out a list of alcohol related losses and problems and a list of what you have gained as a result of abstinence from alcohol.

Some people are more likely to succeed in drinking again than others:

People whose drug of choice was not alcohol. If you went to rehab for heroin or some other drug which was not alcohol you were probably told that you were cross addicted to all mood altering drugs and that you must never drink again or you would relapse. The simple fact is that this is not true. You may well have noticed your rehab counselors using mood altering drugs like caffeine and nicotine all the time and not calling this a relapse. The fact is that if you try to use alcohol as a direct substitute for heroin and get as drunk as possible all the time instead of shooting heroin then you will certainly have alcohol problems. However, if you get your life together and become a whole new person with a whole new life there is no chemical reason in your brain why you should not have an adult beverage at times. Opioids are directly cross-tolerant with each other; they are only slightly cross-tolerant with alcohol. Other drugs like speed are not cross tolerant with alcohol at all.

We do, however, very strongly recommend that if you are an ex drug user who is choosing to drink in moderation that you track your drinks by charting. Keeping a drinking chart will help you keep your drink numbers under control and let you know if you are starting to slip out of bounds. If you find your drinking is showing a tendency to “creep” up more and more you might wish to opt to return to abstinence from alcohol. We also strongly suggest that you do your experimenting within the safety net of a HAMS group and that you write out a Cost Benefit Analysis.

Another group who may tend to succeed with drinking again are those who were sowing a lot of wild oats in high school or college and wound up in rehab or an abstinence program in their teens or early twenties. If you are now in your forties you might have matured a great deal and no longer be interested in being the wild man. If you now find that moderate drinking is appealing to you but the thought of being a drunk teenager throwing up on your date’s shoes at a party is repulsive to you then you may well find success at becoming a moderate drinking. Again we suggest that you do your experimenting within the safety of a HAMS group and that you chart and do a Cost Benefit Analysis.

If you had a long drinking career and a long history of alcohol related problems then the odds of returning to controlled drinking are greatly reduced. The longer the drinking career and the more problems the lower the chances of successful controlled drinking.

If you think that you have a shot at becoming a successful controlled drinker, then write down what it is that has changed in your situation that you believe will make you a successful controlled drinker this time around. If nothing has changed then it may well be excruciatingly difficult to try to use the HAMS harm reduction and moderate drinking tools to become a controlled drinker. Not only may you find that your odds of success are low, but you may also find that staying within the moderate drinking limits you have set for yourself is a form of torture and that abstinence is far simpler and more pleasant.

HAMS harm reduction strategies are not a magic bullet which can turn everyone into a successful controlled drinker. For many, many people abstinence remains the best choice. Abstinence is simple and clear cut and avoids the problem of shades of gray

And whether you opt to continue to abstain or you choose to drink again, always remember that you and no one but you are responsible for your choices.


REFERENCES:

Denning P, Little J. (2011). Practicing Harm Reduction Psychotherapy, Second Edition: An Alternative Approach to Addictions. The Guilford Press.

NIAAA (2009). Alcoholism Isn’t What It Used To Be. NIAAA Spectrum. Vol 1, Number 1, p 1-3. (PDF)


Photo Credit: http://www.rehabinfo.net

Are You Okay?

A variety of drinking tests: the good, the bad, and the silly.

Here’s a short, no-nonsense questionnaire that uses your weekly drinking habits to produce an at-a-glance comparison of how your intake stacks up against others your age and sex. For example, your result might say: “Only 4% of the adult male population drinks more than you say you drink.” Which is food for thought, at least. Join Together (sponsored by The Partnership at DrugFree.org and Boston University School of Public Health) provides this service.

Here is the Mayo Clinic alcohol use self-assessment test, which says with refreshing frankness: “This assessment can’t diagnose you with an alcohol use or abuse problem, but it can help you evaluate your drinking and understand whether you may benefit from seeking help.” Tends to be a bit stern on the drinks-per-day end of things, but otherwise it’s quite straightforward.

Then there is the venerable Michigan MAST Test, first offered in 1971, and revised regularly every since. It’s showing its age a bit as a clinical tool, but here is a link to the 22-question self-administered version: TEST

Iondesign’s Drink-O-Meter is a whimsical test that makes a sober point: “Why not take our test to calculate the state of your kidneys, wallet, and quantity of alcohol you have consumed over the years?” Why not? Well, maybe because you can’t HANDLE the truth: Test results give an estimate of the total number of drinks you have consumed, an estimate of how much money you’ve spent—and an estimate of the number of Ferraris you could have bought instead.

And finally, we have the amazing and ever-popular CAGE Test, so called for the system of naming and memorizing the questions. The CAGE test takes less than a minute, requires only paper and pencil, and can be graded by test takers themselves. It goes like this:

1. Have you ever felt the need to (C)ut down on your drinking?

2. Have you ever felt (A)nnoyed by someone criticizing your drinking?

3. Have you ever felt (G)uilty about your drinking?

4. Have you ever felt the need for a drink at the beginning of the day—an “(E)ye opener?

People who answer “yes” to two or more of these questions should seriously consider whether they are drinking in an alcoholic or abusive manner. Unfortunately, the CAGE test is considered to be an accurate diagnostic tool primarily in the case of adult white males.

Photo Credit: http://tokyotek.com

Bill Manville’s Booze Book

A “professional bar fly” who flirted with death and Helen Gurley Brown.

"From the drinking man's classic, Saloon Society, back in the Sixties, to his sadder but wiser Cool, Hip and Sober, Bill Manville has consistently provided an honest, insightful first-person account of where alcoholism begins--and where it ends.”  So said the respected Keith Humphreys of Stanford University’s School of Medicine, when Manville’s account of beating booze was published some years ago. What makes his book unique in the annals of addiction books, so far as I know, is the additional blurb on Cool, Hip and Sober from none other than Cosmopolitan Magazine founder and Sex and the Single Girl author Helen Gurley Brown, who wrote: “I never read anything like this and am thrilled to recommend the book to anybody with the problem himself or with a suffering family member.”

That represents a pretty wide spectrum of opinion makers, so I took a look—and had fun with it. Written in a breezy, question-and-answer style based on his call-in radio show in Sonora, California, Manville represents an older generation of addicts whose distilled experience is as timely now as ever. Novelist, newspaper journalist, radio host, and a self-confessed “professional bar fly” on the New York City circuit who has been sober now for more than twenty years, Manville has been in the game long enough as a professional writer and practicing alcoholic to have seen a thing or two. “Those were the days when I was living on the Five-Martini Diet—writing for Helen Gurley Brown at Cosmopolitan Magazine by day, and passing out before dinner more nights than I like to remember,” Manville wrote in a recent piece for TheFix.com.

“Addictions and Answers,” the widely-read column he currently co-authors for the New York Daily News, takes personal questions and gives out useful, straightforward, evidence-based advice. So does his book. Some excerpts follow:
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--“Take an alcoholic or drug addict without a penny in his pocket. Deposit him, friendless and alone, in a bluenose town. Dump him there at 6AM Sunday morning, broke and hungover, the bars and liquor stores closed.  He’ll find a way to get high before noon. That’s will power.”

--"In vino veritas?  No. ‘In vino bullshit,’ says John A. Mac Dougall, D. Min., a United Methodist Minister who is also Manager of Spiritual Guidance for Hazelden in Center City, Minnesota.”

-- “‘Each time your addiction brings you smack up against trouble or grief,’ says Brian Halstead, a Program Director at the Caron Foundation, ‘you are being presented with a choice. Do you want this to be your bottom, or do you want to be hit harder?’”

--“Sobriety makes you a more competent player; it does not guarantee you will be a winner. You’re still a dress size too large, and your husband is going bald. Your wife doesn’t understand you, and you’re in a dead end job. You’ll be able to address these problems with a cool, sober brain, yes… with a bit of detachment, yes… but they are still there. You’ve discovered that even glorious sobriety has realistic limits. The pink cloud begins to float down, closer to earth. Very dangerous time.”

--“The essence of addiction is: it SPEEDS up. That’s why it’s called progressive.

--"The phrase I like is that the genetic type of alcoholic was born two drinks behind."

--“Says Scott Munson, Executive Director, Sundown M Ranch, one of the top rehabs in the country, ‘I think it is important for psychologists and psychiatrists to understand the mistrust of those professions by many people in AA. Chemical dependency is a primary illness, not the result of another disorder.’" 

 --“There are pharmaceuticals, like insulin, that correct a deficiency in the body's mechanism. When the patient takes them, he does not get high… any diabetes sufferer will tell you that is a small price. And if taking a daily pill will end your enthrallment to addiction, that's not a high price either."

--Let me end with this, a kind of self-test I heard during a lecture when I was a facilitator at Scripps McDonald: Do you remember your first drink?  How did it make you feel? If you reply, ‘For the first time in my life it made me feel normal, like other people’--take it as a warning bell. In the UC Berkeley "Alcohol & Drug Abuse Studies" catalog, it estimates "that more than one half of clients in alcohol and drug treatment have coexisting psychiatric disorders."

Photo Credit: http://www.sabredesign.net 

Diurnal Drinking

Casting a light on circadian disruptions.

Scientists and laypeople alike have known for years that the consumption of alcohol interferes with the body’s biological ability to synchronize its daily activities with light. Disruptions of the body clock due to alcohol increase the risk of cancer, depression, and other health problems. Furthermore, a recent animal study showed that the effect of alcohol on sleeping patterns could be detected several days after the last drinking event.

Alcohol’s chronobiological effects grow more profound as steady consumption continues. Previous research has demonstrated the disruptive function of alcohol on melatonin rhythms, body temperature and glucocorticoid release.  Disturbingly, recent research suggests that such disruptions along the hypothalamic-pituitary-adrenal axis may predispose alcoholics to relapse—a vicious hormonal feedback cycle. In a study on hamsters published in the American Journal of Physiology, researchers at Kent State University and the University of Tennessee describe “a feedback cycle of circadian rhythm deterioration and reinforcing alcohol self administration” mediated by glutamate and NMDA-driven “phase resetting of the circadian clock.”

The study separated drinking from non-drinking hamsters, and subjected both groups to light exposure in order to break up the regular diurnal wake/sleep cycle of the animals.  Hamsters that drank only water during the test woke up 72 minutes earlier than normal, while hamsters drinking 20% alcohol did not reset their internal clocks as acutely, waking up only 18 minutes earlier.

However, as Christine Guilfoy wrote for Medical News Today, “When the hamsters were withdrawn from alcohol for 2-3 days and then exposed to the same light treatment again, they woke up much earlier than the animals that had drunk only water. The hamsters that were withdrawn from alcohol woke up 126 minutes sooner compared to the water drinking control group, which advanced 66 minutes. This exaggerated response persisted even up to three days later, when the experiment ended.”

Bearing in mind that drawing conclusions about human brain behavior from animal studies is unavoidably speculative, what possibilities emerge from this study? From the short-term perspective, the researchers note that people who drink alcohol late at night are probably less likely to respond appropriately to light cues, and therefore less likely to keep their biological clocks synchronized over the next 24 hours. Moreover, this circadian disruption from drinking may continue for several days, like jet lag, even after a complete abstention from alcohol.

The researchers also discovered that the drinking animals had fewer bouts of activity during normally active hours, leading to the suggestions that heavy drinkers may be less active during normally active daytime hours, and more active late at night, when chronobiological systems are signaling for sleep. The result: chronic daytime sleepiness.

The major point of the study may be that “brain systems involved with circadian regulation are closely and reciprocally tied to those underlying alcohol abuse,” and that this connection has been underscored “by recent studies showing a link between circadian clock genes and an increased drive for alcohol consumption.”

Gimme a Drink--But Hold the Acetaldehyde

Another look at alcohol and cancer.

If beverage alcohol were a new drug, it would face an uphill battle to make it through the Food and Drug Administration (FDA) pipeline. Why? Because the amount of acetaldehyde in alcoholic drinks—combined with acetaldehyde from other sources—might be too carcinogenic to pass muster under existing regulations.

When drinkers drink, the first thing that happens is that enzymes convert the alcohol into acetaldehyde. Previous research has shown that this common organic chemical is implicated in certain cancers, particularly cancers of the digestive tract. Studies at the National Institutes of Health (NIH) showed that the concentration of acetaldehyde measured in human saliva during drinking episodes was sufficient to produce the kind of damage to DNA that can result in cancer.

In a study published recently in the journal Addiction, researchers from Canada and Germany showed that heavy drinkers ingest enough acetaldehyde to raise their lifetime cancer risk to as high as 1 in 1,000. The study concludes: “The life-time cancer risks from acetaldehyde from alcoholic beverages greatly exceed the usual limits for cancer risks from the environment.”

The real problem comes when alcohol is used in combination with acetaldehyde from other sources, such as tobacco, food flavorings, pesticides, and perfume. Heavy drinkers “face a magnitude of risk requiring intervention.” According to Dr. Jurgen Rehm at Canada’s Centre for Addiction and Mental Health (CAMH), quoted in Science Daily: “Most risk assessments to date were based on one source of exposure only. This has led to a negligence of the overall risk.”

According to the Science Daily article, “Alone, the risks associated with surpassing limits of acetaldehyde from the air may not yet be alarming, but for heavy drinkers and smokers, it adds to the acetaldehyde levels already received from these sources. This overall risk then surpasses established safety limits.” To make matters worse, acetaldehyde is a common substance in tobacco smoke—and alcoholics are often heavy cigarette smokers.

A Finnish drug company is currently conducting clinical trials of a time-release capsule of the amino acid cysteine, which can bind with acetaldehyde and render it inactive.

In a related development, a study in PLoS Medicine appeared to demonstrate that people who suffer from the so-called alcohol flush reaction—primarily Japanese, Chinese, and Koreans—are at increased risk for throat cancer. The culprit? An excess of acetaldehyde.

Photo Credit: National Institute of Standards and Technology

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Government Kicks Off New Alcohol Web Site

Will NIAAA site help identify problem drinkers?

Alcohol use exists on a spectrum, from occasional sippers to full-blown alcoholics. If you have ever asked yourself where, exactly, on the drinking spectrum your own alcohol use falls, a new government web site aims to help you answer that question.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) is making an effort to become more relevant and up-to-date by establishing a flashy new web site based on a revamped institutional philosophy. The idea, writes Melinda Beck of the Wall Street Journal , is to “help people recognize problems patterns earlier and catch themselves before they fall.”

Beck notes that the NIAAA web effort is a result of “a new understanding that there is a spectrum of alcohol-use disorders, which some experts hope will replace the current criteria for ‘abuse’ and ‘dependence.’”

The new site, called “Rethinking Drinking,” is a bit confusing to navigate at first. However, there is actually a wealth of information tucked away on the site. For example, people can compare their alcohol intake with the general population and with problem drinkers. There are “low-risk” drinking recommendations, an explanation of why women become intoxicated on less alcohol than men, and a list of medications that react negatively when combined with alcohol. Web surfers are also given a primer on “standard” drinks—some cocktails are equivalent to three standard drinks, and a bottle of wine counts as five glasses.

In the Wall Street Journal article, Mark Willenbring, NIAAA’s director of treatment and recovery research said that most people “don’t know what ‘drink responsibly’ means—they think it means not getting tanked. But there are levels of drinking that raise your risk for alcohol problems just like high cholesterol raises your risk for heart disease.” Low-risk drinking—no more than four drinks for men and 3 for women at a sitting, and no more than 14 drinkers a week for men and 7 drinks a week for women—can increase the risk of adverse events for people suffering from liver disease, heart arrhythmia, and bipolar disorder.

One little-known fact, according to the web site: Some 35 per cent of Americans don’t drink at all.

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