Alcohol and HDL levels

Should Middle-aged Men Stop Drinking ?

Heavy drinking and age don't always mix very well, despite the alleged beneficial health effects of taking just a single drink per day. Now comes news that, for men in their 50s, even high levels of the protective HDL type of cholesterol will not shield them from the ravages of high blood pressure if they are heavy drinkers.

A recent Japanese study of more than 21,000 men suggests that even HDL cholesterol, the so-called “good” cholesterol, does not protect drinkers from high blood pressure once they reach their 50s.

High blood pressure is a known side effect of excessive drinking, but in 20-something drinkers, healthy levels of HDL, or high-density lipoprotein, help protect young men from developing high blood pressure due to excessive intake of alcohol. According to the paper, published in the September issue of Alcoholism: Clinical and Experimental Research, “The blood pressure of middle-aged men is elevated by alcohol drinking independently of blood HDL level and is more sensitive to drinking than is the blood pressure of young men.”

In other words, a man’s blood pressure become more sensitive to alcohol as he ages, regardless of his HDL levels. The research, undertaken at the Hyogo College of Medicine, demonstrated that men of any age cannot escape the likelihood of higher blood pressure if they are moderate to heavy drinkers. But for aging men, the problems are much greater. Even keeping their good cholesterol number high will not protect them from soaring blood pressure, if they continue to drink heavily in their 50s.

While men with the lowest HDL levels consistently showed the lowest blood pressure overall, the finding “fits well with the observation that the risk of stroke—which is more sensitive to blood pressure than heart attack—is not really substantially lower in moderate drinkers,” according to Dr. Kenneth Mukamal of the Harvard Medical School. 

Add to that the likelihood that moderate to heavy drinkers in their 50s are also likely to be cigarette smokers, and more likely to be overweight, and high blood pressure in 50-something men becomes all too easy to understand. The lifestyle changes required to do something about it are as obvious as they are profoundly challenging.

Graphics from: http://www.upei.ca/~stuserv/alcohol/effectsonbody.htm

The Morphine Scandal

Patients in Pain Due to "Opium Phobia"

“Opium has been recently made from white poppies, cultivated for the purpose, in Vermont, New Hampshire, and Connecticut.... comparatively large quantities are regularly sent East from California and Arizona, where its cultivation is becoming an important branch of industry, ten acres of poppies being said to yield, in Arizona, twelve hundred pounds of opium.”

--Massachusetts Government Health Report, 1871

By the mid-1800s, as many people know, opium could be legally purchased in the United States as laudanum, patent medicines, and various elixirs. Less well known is the fact that opium was a godsend during the bloody years of the Civil War. Maimed and disabled soldiers found relief in morphine, the potent alkaloid of opium named after Morpheus, the Greek god of dreams. Used against constant, intractable pain, opium and its derivatives were among the most humane medical drugs ever discovered. How could a physician withhold them?

Today, after countless drug wars have merged into a single, inflexible federal stance on “drugs,” morphine and its derivatives remain so stigmatized, so entangled in drug wars and global narco-politics, that the danger of losing sight of their humanitarian applications looms larger than ever.

At least half of all cancer patients seen in routine practice report inadequate pain relief, according to the American College of Physicians. For cancer patients in pain, adequate relief is quite literally a flip of the coin.

A September 10 New York Times report by Donald G. McNeil Jr. highlights studies by the World Health Organization which amply document the ongoing scandal in pain management. At least 6 million cancer and AIDS patients currently receive no appropriate pain treatment of any kind. In addition, WHO estimates that four out of five patients dying of cancer are also suffering severe pain. The numbers of untreated patients suffering intractable, unrelieved pain from nerve damage, burns, gunshots, sickle cell anemia, and a host of other medical conditions can only be guessed at.

Figures gathered by a different U.N. agency, the International Narcotics Control Board, make clear that “citizens of rich nations suffer less.” To put it starkly, the use of morphine per person in the United States is 17,000 times higher than per person usage in Sierra Leone. Doctors in Africa paint a grim picture of patients hanging themselves or throwing themselves in front of trucks as an alternative to life without pain relief. The U.S., Canada, Britain, France, Germany, and Australia together account for roughly 80 per cent of the world’s medicinal morphine use. Other countries, particularly the poor and undeveloped nations, scramble for what’s left.

The ironies fly thick and fast: In many cases, pain relief is the one thing doctors can offer their patients, and the one thing they withhold. Studies show that 70 per cent of patients present with painful conditions. Typically, non-addicted patients take morphine therapeutically for pain at doses in the 5 to 10 mg. range. But experienced morphine addicts regularly take several hundred milligrams a day—a huge difference.

As for concerns about addiction, recent evidence for the heritability of opiate addiction looks strong. “Harvard did some really superb studies using a huge cohort of military recruits in the U.S. Army,” according to Mary Jeanne Kreek, a specialist in opiate addiction at Rockefeller University in New York. “Heroin addiction has even a larger heritable component than any of the other addictions, so that up to 54% of heroin addictions seem to be on a genetic basis or a heritable basis.”

Opium, the main ingredient, is in abundant supply worldwide, and is relatively cheap to grow. The problem, as David E. Joranson of the University of Wisconsin’s Pain and Policy Studies Group told the Times, is the “intense fear of addiction, which is often misunderstood. Pain relief hasn’t been given as much attention as the war on drugs has.”

Moreover, generations of doctors have been taught in medical school that morphine must be used sparingly, with great caution, even if this “opium phobia” results in agony for patients, including infants. (Morphine is safe and effective for use in premature babies.)

The problem is not a new one. Ten years ago, a report by the American Academy of Pain Medicine laid the blame squarely on doctors, who were routinely underutilizing opiate derivatives for pain relief. Not much has changed. It is no secret that the move to HMOs has compounded the problem, as effective pain relief often gives way to the need to move patients out of beds as quickly as possible.

In 2001, the American College of Physicians called for more extensive pain-management education in the nation’s medical schools, noting that doctors are not learning enough about how to treat pain, or about how to talk to patients ABOUT pain, despite what Scott Fishman of the Division of Pain Medicine at the University of California, Davis, calls a “revolution” in the development of new pain medications.

We also need to recognize the problem of under prescribing morphine and other
addictive painkillers for children in hospital settings. If we continue to stringently prohibit the use and sale of opiates, then we had better remember to make one important exception: Pain abatement in medical applications “There’s a certain amount of hysteria about narcotics among doctors,” maintains one researcher. Patients suffering from serious pain cannot get adequate and sustained relief in many cases, because doctors and nurses remain reluctant to provide it.

This, rather than flashy cocaine seizures at the border, represents the lasting outcome of drug wars.

Email this •

Smoking in New York City

A Borough-By-Borough Survey

New York City has 240,000 fewer smokers than it did in 2002, according to a recent report released by the city’s Department of Health and Mental Hygiene. City health official Jennifer Ellis told the New York Times that the data represent the sharpest fall-off in cigarette smoking since the department began the surveys in 1993.

The report cited bans on smoking in public places, higher taxes on tobacco products, and a multi-million dollar local advertising campaign as the ingredients that helped lead to the overall reduction in the number of smokers. Based on a citywide survey of adults, Who’s Still Smoking states that as many as 800,000 smokers attempted to quit in the past year, but less than one-fifth of them succeeded.

However, quit rates over the 5-year period varied markedly from borough to borough. Staten Island proved to be the home of the city’s most stubborn and recalcitrant smokers: While the citywide smoking rate dropped by almost 20 per cent, Staten Island’s smoking rate—27 per cent, according to the survey--has remained steady since 2002. Manhattan and the Bronx ended in a virtual tie for first place, with smoking reductions of about 24 per cent, while Queens trailed slightly. Brooklyn came in second to last, with a quit rate of only 13 per cent.

On August 21, the Health Department began a nicotine-replacement giveaway program aimed specifically at Staten Islanders. The 5-week giveaway and associated media campaign will run Tuesdays through Thursdays at the Staten Island Ferry’s Whitehall Terminal.

Men still lead women in smoking, 20 per cent to 15 per cent overall, but the report claims that quit rates are similar for both sexes. Low-income adults and adults without a high school education are more likely to attempt quitting by a slight margin, but less likely to be successful per attempt. One important side note: A separate analysis of survey data showed that only 11 per cent of heavy drinkers who smoke were able to quit in the past year.

The average pack-a-day smoker now spends $2,500 a year to support his or her habit. Health officials stressed that the use of nicotine replacement, either as patches or gum, along with anti-craving medications like Zyban and Chantix, can at least double a smoker’s chances of successfully getting free.

Information in the report was gathered through a random telephone survey of 10,000 adult New Yorkers.

Image courtesy of the National Library of Medicine.

smoking

Book Review (Part Three): Women Under the Influence

Rehab and the Working Mother

According to Columbia University’s National Center on Addiction and Substance Abuse, more than 2.5 million women abuse or are dependent on illegal drugs. Women are almost 50 per cent more likely to be prescribed a narcotic or sedative, and teenage girls are more likely than teenage boys to abuse prescription drugs, with dramatic increases among 12 to 17 year old girls.

Statistics cited in Women Under the Influence, produced by the Center, show that while women convicted of drug-related offenses represent the fastest growing subset of America’s prison population, their representation in the drug rehab community has not kept pace. Fully three-fourths of these incarcerated women are mothers, and that fact is at the heart of the difficulties women face when they seek treatment.

Put simply, millions of women who need treatment for addiction to alcohol and illegal drugs do not receive it. This has been true throughout American history. Women were not admitted to meetings during the formative years of Alcoholics Anonymous (AA), and there is evidence that the 19th Century practice of performing hysterectomies on alcoholic women as a last resort quietly persisted until the 1950s.

AA soon opened its doors to women, who now comprise roughly one third of its membership. But when it comes to rehab centers, the treatment gap has not closed: “For women with small children, lack of childcare is a serious obstacle to seeking treatment…. For some women, fear of losing their children to the child custody system upon admission that they have a problem makes them apprehensive about entering treatment.”

Moreover, there are no universal standards of training, practice or accountability among the nation’s treatment providers, and women face differing approaches to their needs for child care, pediatric services, transportation, and the like. While older women have treatment needs that differ from girls and pregnant women, very few treatment centers offer programs designed specifically for older females.

If treatment is to become noticeably more effective for addicted women, “it must be readily available, tailored to fit the needs of the individual patient, and part of a comprehensive program that addresses associated medical, psychological, social, and economic needs…. Appropriate, research-based, and effective prevention efforts tailored specifically to the unique needs of girls and women are in desperately short supply.”

Women Under the Influence--purchase info

The Myth of Controlled Drinking

Forward into the Past: White-Knuckle Alcoholics

For the past two decades, social psychologist Stanton Peele has questioned the necessity of abstinence for alcoholics, claiming, in The Meaning of Addiction and in Diseasing Of America: Addiction Treatment Out Of Control, that the “myth” of instant relapse is not well supported by statistical research.

Bulling his way past hundreds of published scientific studies about the neurobiology of addiction, Peele continues to insist that the disease concept of alcoholism has no basis in current science. Believing that people’s personal values determine whether or not they become addicts, Peele has also written that “no data of any sort support the idea that addiction is a characteristic of some mood-altering substances and not of others.”

“Those with better things to do,” Peele writes, “are protected from addiction.”

Andrew Weil, a well-known drug authority and author of The Natural Mind, has also objected to the “grossly materialistic conceptions of addiction” offered up by proponents of the biochemical view.

A biological view of addiction can be a way of giving intractable addicts hope, researchers say. Peele, however, draws exactly the opposite conclusion, arguing that the disease model is telling addicts that there is no hope, that they cannot do anything about their incurable “disease.”

Considering all the basic qualifiers about biochemical theories that the researchers themselves felt obliged to use in the first place, it was galling in the extreme to have critics like Peele deriding the effort in its entirety--and most amazingly of all, bringing back the old bugaboo about controlled drinking. Adherents of the controlled drinking theory hold that alcoholics can frequently return to social, responsible drinking, without having to maintain total abstinence.

If an alcoholic limits himself to two or three drinks a day, and does it successfully for a period of time, this behavior looks from the outside like controlled drinking. Many alcoholics and other drug addicts are able to accomplish this feat for varying lengths of time. Indeed, AA members are familiar with this counterfeit form of controlled drinking, and even have a name for it: White-knuckle sobriety. Controlled drinking-- also known as sobriety without abstinence--is certainly not unheard of among alcoholics

But is it a practical response to alcoholism?

Dr. Arnold Ludwig, professor of psychiatry at Kentucky University’s College of Medicine, disagrees. In his book, Understanding the Alcoholic’s Mind, Ludwig writes: “Those authors who argue that many can return to normal drinking fail to grasp an essential point: it is less frustrating for the preponderance of alcoholics to avoid drinking altogether than to settle for one normal-sized drink, such as a single martini, a glass of wine, or a beer.”

For most serious alcoholics, it is easier to abstain altogether, rather than to engage in controlled, responsible, non-intoxicated drinking.

The idea of controlled drinking (or controlled drug use) is the one hope almost every addict brings to his or her initial encounter with treatment. As one AA veteran put it: “If it were possible for a majority of alcoholics to revert to controlled drinking, every alcoholic in AA would have found out about it a long time ago.”

It sometimes seems as if critics like Stanton Peele are attempting to resurrect the moral view of the past, offering no new approaches while legitimizing the criminal penalties and social stigma that has been America’s response to addiction all along.

Sources:

Peele, Stanton. Diseasing of America. Jossey-Bass, 1999

Peele, Stanton. "A Moral Vision of Addiction: How People’s Values Determine Whether They Become and Remain Addicts,” Journal of Drug Issues, Vol. 17, Spring, 1987.

Ludwig, Arnold M., Understanding the Alcoholic's Mind. Oxford University Press, New York, 1988.




alcoholics anonymous

Book Review (Part Two): "Women Under the Influence"

The Rise of the Binge Grrls

“Women get drunk faster, become addicted more quickly, and develop alcohol-related diseases—such as hypertension and liver, brain and heart damage—more rapidly than men.” --The National Center on Addiction and Substance Abuse at Columbia University


Today, about one out of every four American girls has had one or more alcoholic drinks by the age of 13, according to “Women Under the Influence,” a book by Columbia’s National Center on Addiction and Substance Abuse. In the 1960s, only 7 percent of girls reported having consumed alcohol by that age.

80 per cent of college women living in sororities engage in regular bouts of binge drinking, compared to 35 per cent of non-sorority college women. While most women are moderate drinkers, the Center estimates that at least six million girls and women meet the DSM-IV criteria for alcohol abuse and dependence.

When it comes to alcohol, the study turned a few common assumptions upside down. For example, the more education a woman has had, the more likely she is to be a drinker. Surveys indicate that 36 per cent of women with less than a high school education drink alcohol, compared to 60 percent of women who attended college. White adult women are more likely to be drinkers than African-American, Hispanic, or Asian-American women. And while men traditionally drink more than women, women are fast closing that gender gap. Among high school seniors, the percentage gap between heavy-drinking boys and heavy-drinking girls was 23 percent in 1975. By 2003, the difference was only 12 percent, and among very young teenagers, girls have closed the gender gap completely. In addition, older women have higher rates of late-onset (over age 60) alcohol abuse than men.

Teenage girls whose mothers drank regularly during pregnancy are six times more likely to report alcohol use than girls whose mothers did not drink. Whatever the cause, or most likely causes, no such maternal relationship has been demonstrated for teenage boys of drinking mothers. And—bearing in mind that such estimates are fraught with peril—the Center concludes that genetic factors account for as much as 66 percent of the risk for alcohol dependence in women. As evidence, women who are alcoholics are somewhat more likely that male alcoholics to come from a family with a history of alcohol abuse.

Women metabolize alcohol differently than men do. With less water and more fatty tissue in their bodies, blood alcohol levels are higher for women than for men, given the same number of drinks. After two beers, women are more likely than men to exceed legal levels of alcohol in the bloodstream. Women get drunk faster and have heavier hangovers, and the reason may stem from differences in ADH enzyme activity in breaking down alcohol into its byproducts. (More research is needed.) Female alcoholics also develop liver diseases like cirrhosis more frequently than alcohol-abusing men, and at lower levels of alcohol intake.

From the sociocultural point of view, women are targeted heavily in alcohol advertising, primarily through promotion of the idea that alcohol will relax sexual inhibitions and improve communication with men. Alcohol advertising has increasingly zeroed in on selling beer to women—“beer’s lost drinkers,” as one brewery spokesman put it. Only about 20 per cent of women currently drink beer regularly. Ironically, the alcohol industry’s official code of ethics forbade the use of women in alcohol ads until 1958. And as recently as 2003, the Code of Responsible Practices of the Distilled Spirits Council of the United States specifically prohibited any ads or marketing materials that “degrade the image, form or status of women…”

All of the foregoing pales in comparison to the potential for damage among pregnant women who drink. The fact that alcohol is dangerous to fetal development is not a recent discovery. Aristotle pointed out that “Foolish drunken or harebrain women for the most part bring forth children like unto themselves.” While warning signs on alcohol containers and tavern doors have become a common sight, the study group estimates that about 10 percent of pregnant women still drink. (That number is quite likely higher, given the reluctance of patients to accurately report their alcohol intake). “Drinking during pregnancy,” according to the Center, “is the single greatest preventable cause of mental retardation” in America today. Indeed, the number of birth defects caused by alcohol in one year exceeds the total number of recorded thalidomide births.

Tragically, “As many as 60 percent of pregnant women who drink do not discover their condition until after the first trimester.” In addition to the well-known Fetal Alcohol Syndrome (FAS), there is also a range of other neurobehavioral deficits to the fetus associated with drinking during early pregnancy. Pregnant women who drink heavily suffer three times the normal risk of miscarriages and stillbirths. In fact, to this day, no safe level of alcohol intake during pregnancy has been established. The American Academy of Pediatrics continues to advise women who are pregnant or thinking of becoming pregnant to abstain for alcohol completely.

Part Two of Three

Women Under the Influence--purchase info

Book Review (Part 1): "Women Under the Influence"

Women and Cigarettes: “The Virginia Slims Woman is Catching up to the Marlboro Man.”

“Compared to boys and men, girls and women become addicted to alcohol, nicotine, and illegal and prescription drugs at lower levels of use and in shorter periods of time, develop substance-related diseases like lung cancer more quickly, suffer more severe brain damage from alcohol and drugs like Ecstasy, and often pay the ultimate price sooner. Yet 92 per cent of women in need of treatment for alcohol and drug problems do not receive it. Stigma, shame, and ignorance hide the scope of the problem and the severity of the consequences.”

--Joseph A. Califano, Jr.

“Women Under the Influence,” with a Foreword by former Health, Education and Welfare Secretary Joseph Califano, appeared in print last year, but is well worth a second look. The result of studies undertaken at Columbia University’s National Center on Addiction and Substance Abuse, and collectively written by that group, “Women Under the Influence” gathers together a decade’s worth of research on the gender differences researchers have thus far been able to identify in the addict population.

The same genetic and biological mechanisms that predispose certain men toward alcoholism and other forms of drug addiction do the same in women. Young women with family histories of alcoholism will, like Pavlov’s dogs, salivate more intensely at the sight of alcohol than women from families without addiction histories. Studies of female twins also confirm the behavioral link between major depressive disorder and substance abuse. Women who have suffered from major depression are three to six times more likely to suffer from alcoholism than those who have not. Despite these and other commonalities, however, women and men often follow different arcs of addiction on a drug-by-drug basis.

We begin with cigarettes, since it is with nicotine that women have lately shown the ability to achieve a grisly parity, or in some cases even outdo men in the damage done by nicotine. About one American woman out of five smokes. While rates of lung cancer in men have been slowly declining since 1980, the number of women with lung cancer has increased 600 percent over the past 70 years. More women now die of lung cancer than the combined fatalities from breast cancer, ovarian cancer, and uterine cancer. As Antonia C. Novella, former U.S. Surgeon General, put it: “The Virginia Slims Woman is Catching up to the Marlboro Man.”

80 per cent of female smokers began smoking before the age of 18, and women did not begin smoking in large numbers until the late 1940s, thus producing a delayed epidemic of lung cancer in women. To make matters worse, the Columbia group concluded that “At the same level of exposure to tobacco smoke, women have a greater risk of developing lung cancer than men.” Up to three times more likely, according to some studies. Moreover, women who smoke more than 20 cigarettes a day face an 80 per cent greater risk of developing breast cancer, compared to non-smoking women.

Women who smoke heavily have four times as many heart attacks as non-smoking women. Add in oral contraceptives, and the risk of heart attack increases by 1,000 percent.

Women who smoke have more respiratory disorders. Wheezing rates are consistently higher for women than for men, at all age levels. Women smokers develop more crow’s feet around the eyes than men who smoke. Female pack-a-day smokers suffer a steady accretion of bone density and a concomitant increase in rates of osteoporosis. And the fact that nicotine is an effective appetite suppressant is an open secret, as a couple of generations of chain-smoking supermodels have demonstrated.

Cigarette companies are increasingly placing their bets abroad, among a new generation of young women in countries like China, where authorities estimate that as many as 20 million Chinese women have taken up smoking over the past ten years. In “Lung cancer in U.S. women: A contemporary epidemic,” published in the Journal of the American Medical Association (JAMA 291(14):1767), J.D. Patel et. al. suggest that “Curtailing the increase in tobacco use among women in developing countries represents one of the greatest opportunities for disease prevention in the world today.”

The silver lining, if there is one, is that a majority of women still choose not to smoke.

Women Under the Influence--purchase info

End of Part One.