Sunday, January 28, 2018

The Most Important Decision In Your Life......

See Complete Reference Below

I thought a while about how to write this.   There are a lot of opinions out there about how a decision like this one should be philosophical or religious.  After practicing psychiatry for over 30 years I have to come down on the side of practical.  The most practical decision I think that anybody can make is to stop using intoxicants, at least to the point of intoxication.  I don't really care what your current intoxicant is.  It could be alcohol or cannabis or heroin.  Deciding to stop it will only improve your life and the lives of your family and friends for any number of reasons.  At this point I am a witness to the thousands of people who have stopped and seen those improvements.  I am also a witness to the unfortunate thousands of people who did not stop and ended up dead, incarcerated, homeless, chronically mentally ill, in nursing homes, or leading miserable lives.  I am not naive enough to think that my little argument here is going to make that much of a difference and will elaborate on that in the paragraphs that follow.

One counter issue that I want to address as early as possible because it is often used to short circuit arguments against intoxicants is what I consider an American pro-intoxicants argument.  It certainly can exist in other cultures, but I am restricting my comments to Americans because of the pervasive attitudes about intoxicants.  The most obvious attitude is alcohol and drug use as a rite of passage to adulthood.  This is a well documented phenomenon rationalized at several levels.  Common examples include: "If one is old enough to vote or go to war they are old enough to drink."  There is abundant current evidence that 18-21 year olds if anything are exposing brains that are neurodevelopmentally immature to the effects of alcohol and street drugs - often at toxic levels.  Rational arguments against exposure are not likely to have much of an impact on a population segment in the throes of the invulnerability of youth.  Even apart from the brain based argument, the driving and risk taking behavior of this group is well documented.  Adding intoxicants to the mix is not likely to alter those decisions in a positive way.

An extension of the rite of passage argument is the rights argument as in "Alcohol and tobacco are legal substances and therefore I have a right to use them."  There is no doubt that is true, but the right is limited.  Only people of a certain age can use these compounds and in the case of intoxicants that can affect public safety - their use is even more limited.  People who I have seen invoke the rights argument are generally not talking about limited rights.  The modern version of the rights argument is that "no one should have the right to tell me what I can put in my body.  On that basis all drugs should be legal and easily accessible".  A complementary argument is: "Alcohol and tobacco kill more people every year than (fill in favorite intoxicant here) and therefore I should be able to use it."  Another complementary argument that often gets more support is: "The War on Drugs is a complete failure.  All drugs should be legal and that way we can tax it and make a profit from it.  We can put the cartels out of business."  The rights argument frames an idyllic drug consuming society immune to the medical problems of acute intoxication and addiction as well as all of the associated social and legal problems.  Extreme arguments like this suggest to me that they are driven in part by desperation.  Of course intoxicants need to be regulated - we already have ample evidence of what happens when they are not.  The basic problem that they reinforce their own use at increasing levels cannot be ignored.  Tax on intoxicants is generally an unreliable revenue source when the total cost to the taxpayers for that intoxicant and the fact that revenue is diverted away from covering those costs.
A second cultural phenomenon is the use of intoxicants for celebrations.  Weddings, funerals, and various parties often result in the excessive consumption of alcohol. I attended a funeral where the clergyman addressed half of the audience and suggested that an AA meeting might be in order afterwards.  The deceased was probably a victim of excessive alcohol use.  Although alcohol remains predominant in many of these settings, since the 1970s second and third intoxicants are also common.  The relevant consideration is whether these celebrations can occur without the intoxicants.  Interestingly, that decision may come down to the cost of having an "open bar" versus less expensive alcohol on tap. 

A third consideration is the subculture of extreme use.  Many states are notorious for per capita alcohol consumption, binge drinking, and driving after drinking too much.  I don't think that the problem has been well studied, but growing up in a heavy drinking or using culture exposes anyone to early use and reinforcement that are both precursors to problematic use. 

There are several arguments in the popular media that seek to minimize the potential impact of drugs on your life.  Think about the counterarguments:

1.  If I don't have a diagnosis of alcoholism or drug addiction my pattern of using intoxicants is not a problem:

The most absurd presentation of this argument was the idea that a significant number of binge drinkers do not meet diagnostic criteria for alcohol use disorder.  I can't count the number of people who I know that have had their lives ruined or ended by a single drinking binge.  Many high schools in the US started a senior party strategy because so many students were killed around the time of graduation parties due to acute alcohol intoxication.  The drivers in these cases were not alcoholics.  They were high school seniors many of whom had limited exposure to alcohol before the fatal accident.  Binge drinking and acute intoxication is associated with a long line of accidental deaths, alcohol poisoning deaths, suicides, homicides, intimate partner violence, rapes, and other crimes.  All preventable by not binge drinking or more importantly getting intoxicated in the first place.  The same pattern follows every other intoxicant.  If you put yourself in a mentally compromised state in practically any setting - bad things will happen whether you have been diagnosed with a substance use disorder or not.

2.  Alcohol is a heart healthy beverage:

The CDC and the American Heart Association both recommend moderate intakes of alcohol and they define that as one standard drink of alcohol per day for women and one or two standard drinks for men.  This is based on data that shows that these amounts of alcohol may confer reduced risk for heart disease but that higher amounts increase risk.

3.  Intoxicants can be good for your health - some are natural medicines:

The great natural argument leaves a lot to be desired. It's like listening to that guy in a bar tell you that his doctor told him he could drink as much wine as he wanted because it was a natural beverage and then realizing that he is standing in a puddle of his own urine. Peak alcohol consumption in the US occurred at time when it was considered a medication in the early part of the 19th century.  The current best example is cannabis, a substance that has been around for at least 10 centuries and suddenly it is a miracle cure for everything.  The obvious question is what that wasn't noticed in that last 1,000 years. 

4.  Alcohol and drug use disorders are not diseases - it is a question of choice and therefore I have nothing to worry about:

Despite what you may read on some online blog, in opinion polls most people consider alcoholism and addictions to be diseases.  Almost everyone has had some contact with people who have these problems and they see that the usual negative consequences that cause most people to correct their behavior - have no effect on the addicted.  There is no or at least limited capacity for self correction.

5.  I am a libertarian and I believe that all intoxicants and drugs should be legal - I should be the only person deciding what goes into my body:

A familiar argument that ignores human history. The reason that there are controls on addictive drugs is because a significant part of the population will use them in an uncontrolled manner and that generally leads to a chaotic society with all of the costs of that chaos. The more free access there is - the more addiction and chaos.

This argument implies that everyone is the best judge of "what I put in my body" based on political beliefs. There is no evidence that is true.

6.  I am an adult and if I want to have a drink - I will have a drink:

That is a minor variation of the libertarian argument for non-libertarians.  It is basically a truism - yes of course unless you are prohibited by law (and some people are) you can have a drink.  Doing something basically because you can strikes me as a shallow argument. Looking at what happened during Prohibition, I think it is safe to say that the right to drink was preserved by a relatively vocal minority of people who want to drink.  They want to drink for the previously cited cultural reasons and in fact there were some famous exceptions to Prohibition that were based on purported religious ceremony and requirements for alcohol. 

A similar argument is that if a person wants to feel high "there is nothing wrong with that."  At a superficial level and strictly speaking that is true as long as the level of intoxication doesn't lead to medical, safety, or interpersonal problems. The larger question is whether there is something better to do. Let's define better as another recreation that leaves you better off than using intoxicants.  In that case walking around the block is better than getting stoned.

7.  It is part of my creative process:  

There are reviews and books written about how creative people have used drugs and alcohol to enhance their creative process.  These works are by their nature anecdotal.  I am unaware of any controlled sober group and their creative process but it is likely that they exist in large numbers.

8. I am self -medicating and need it to treat insomnia, anxiety, depression, and/or pain:

Self medication implies that intoxicants are actual treatments for these problems. If you talk to any person who uses this strategy - the amount of relief lasts for a few hours.  People tell me: "Look doc - if you can't get rid of this anxiety - I know how to get rid of it for a few hours."  Using alcohol, street drugs, or diverted prescription medications is usually a recipe for worsening symptoms and tolerance.  In that setting people often have the idea that more drugs will bring back the few hours of relief and there are always examples of associated catastrophes in the news. 

9.  The political argument that by allowing universal access to drugs - the cartels will be out out of business - 

Very common to hear that all drugs should be legalized and hear this argument in the next breath.  Most of the people making this argument seem naive to fact that black markets still exist with legal intoxicants.  In the WHO Global status report on alcohol and health 2014, 24.8% of the alcohol consumed was outside of government control.  In the US, it was 0.5 liters of a total of 9.2 liters per capita.  For tobacco the black market is somewhere between 8.5 and 21% of sales. In Colorado there is currently mixed concern about the possibility that drug traffickers are in plain sight, continuing to grow cannabis in remote areas and transport to other states, but reliable information is not available. In the case of heroin, the current impetus for its use is that it is 25% the cost of diverted pharmaceutical opioids.  In the worst case scenario of legalized opioids with no control is it realistic to consider governments regulating heroin at that low cost to consumers?  If not it is a recipe for continued uncontrolled black markets. 

10.  The "You are an prohibitionist" counterargument:

Whenever I present any of my arguments for avoiding intoxicants in the list above, there is the inevitably that some very angry guy accuses me of being a prohibitionist.  I don't know how much weight that ad hominem carries but I always find it amusing. If prohibition worked, I would not need to make these arguments.  My blog is one of the few places where you can see a graphic of how things went during prohibition and it obviously wasn't good.
Believe me - you can go through life without ever taking a drink, smoking a joint, snorting cocaine, or injecting heroin and not miss it.  The best case scenario is that it adds nothing to your quality of life.  It is also tempting to think that you have plenty of time to quit later.  With that plan many people either never quit or realize when they are 40 years old that they have been in a fog for 20 years.  Addictions sneak up on you and steal what should be your most productive years.

In fact none of the people with addictions who I talk to ever started out believing that one day they would end up with an alcohol or drug use problem.  Recognizing all of the defective arguments listed above is a good first step.  The most important ability to prevent addictions is self correcting abstinence.  If you wake up one day and realize you dodged a bullet when you were intoxicated, think long and hard about avoiding that situation again.

If you can't - you may have a serious problem.

George Dawson, MD, DFAPA


Graphic at the top is from:

Lavallee RA, Yi H.  Surveillance Report #92: Apparent per capita alcohol consumption: national, state, and regional trends, 1977-2009.  US Department of Health and Human Services. Public Health Service.  August 2011.  Link.


  1. Nice post, what prompted you to write this?

    What frustrates me most days is the level of addiction that comes into the office masquerading as mental health issues. I still believe that 50% of addiction has no comorbid psychiatric issues, patients staying clean invariably become less symptomatic psychiatrically.

    The Pot Lobby, who in my opinion are just cannabis dependent dopers, are behind this legalization press. People who use pot recreationally are not interested in legalization, they just want to be left alone to get high at their own pace which is more often fair and reasonable.

    Once again we see the polarization of behaviors, go from making it illegal to legal, and not going to a next step of decriminalization to see how people handle easier access to a mind-altering substance.

    Oh well, as I write it my site, the personality disordered society is just creeping into every aspect of America. And again in my opinion, there's a lot of anti-social crap that goes along with addiction, whether it precedes the substance abuse or is a result of it.

    Again, nice post.

    1. Many thanks - I was tired of the political approach to the problem.

      Dichotomous unrealistic arguments about disease versus no disease, teetotalers versus drinkers, and legalizers versus prohibitionists.

      None of that helps people avoid these problems. Like all political arguments - they are just excuses to keep doing things the way you want them to be. If you have an addiction or make money off of it - you will say and do anything possible to keep it going.

      Agree entirely about the addiction misdiagnosed as mental illness. In my line of work it is huge.

      If we could teach every kid this simple rule and all of the politics around this issue - they might have a chance.

    2. On the heart-healthy booze argument...the resveratrol theory is pretty much debunked at this point. Any positive effect is not due to wine specifically and you'd have to drink enough to get cirrhosis anyway to get enough resveratrol to help your heart. So that's out the window.

      Some studies show the effect of alcohol beneficial to heart health is by raising HDL but there are many ways to skin that cat. Including, most importantly, exercise and sugar reduction, so drinking appletinis (I remember when drinking sweet mixed drinks or putting vodka in a martini would get you beat up in most of my old neighborhood bars) is probably going to be a wash or worse.

      Beer is full of carbs and not a lot of alcohol so I'm pretty sure that's not helping hearts or metabolism at all, hence the freshman 15 effect. Many wines are also loaded with sugar, which is indirectly bad for the heart. Then factor that booze is consumed with junk food in sedentary settings etc.

      So it's pretty much down to straight liquor (most dieticians say if you want the most buzz per calorie, this is the way to go) without sugar, well-controlled and used responsibly. How many people do that? I can't really argue against a oleic acid rich 150-180 calorie dirty martini a few days a week but anything more is doing more harm than good at least from a cardio perspective.

  2. I am little stunned that bourbon and moonshine country Kentucky, West Virginia and Tennessee are on the low end and that Delaware and Rhode Island are on the high end.

    Something about that Atlantic maritime lifestyle...Florida doesn't surprise me at all, that's where the baby boom parrotheads go to retire.

  3. By the way I lived in Marina del Rey CA on a boat for a year...if Chesapeake Bay is anything at all like the booze scene at that marina, this fully explains the map. Marina del Rey is where Beach Boys drummer Dennis Wilson took his final plunge in an inebriated state.

  4. One more thing about that map and this:

    Clearly Mormonism and to some extent Baptist Protestantism has a regional effect on sobriety, which may explain the low rate in the mid South.

    There may be drunk hilltoppers but they are countered by teetotalers in Appalachia.

    Yes one can be a libertarian and think that intoxication is a bad idea. I was for mj legalization even though I knew there would be problems. Freedom includes the freedom to be stupid. My Dad never touched anything and lived a long happy life.

  5. I barely get intoxicated at all, but the occasional beers with friends and stoned art/music sessions are very happy memories of mine – not to speak of the careful use of psychedelics every few years, which have been positively life-changing. I understand that you see mostly the nasty end of the spectrum in your practice, and agree that unfettered access is a naive idea, and that our cultural attitudes around intoxicants are totally out of whack.

    It always seems to me that a licensing scheme might work, hoops not unlike those you have to jump through to acquire firearms (outside of the US, obviously). Want to use substance X? Take a week-long course on its risks, interactions, pharmacokinetics, social effects, tolerance/addiction potential, effects on brain and heart, contamination of its street derivatives, best safe use practices: you know, the things a responsible user would research on their own time anyway – and if you pass the exams and maybe a psychological evaluation, you get a license to buy pharma-grade personal amounts for the next two years (at which point you re-write the exam). Or something like that. Do you think that would be a viable plan?

    1. Doubt that any licensing scheme that you suggest would work for many reasons - not the least of which is that it is a variation of prohibition and therefore a lightening rod for those who think that everyone should have access to the intoxicants that they themselves are using. I also would not want to be teaching the course. Many of the self proclaimed geniuses in street drugs that I talk with don't really know anything. They seem to think that experience using a drug confers some sort of expertise in pharmacology and toxicology. It doesn't and I am not sure that attitude responds to education.

      If prohibition doesn't work, "just say no" doesn't work, scare tactics don't work, the only reasonable target is the cultural attitudes and individual philosophy of living. That's where the only hope is and that was the focus of my post.

      Since this post, there was a genius headline in a paper that said a recent seizure contained enough fentanyl to kill everyone in New York City and New Jersey. Our "opioid problem" suddenly became a national security problem. There are still people out there advocating for the open availability of all controlled substances.

  6. Group activities centered on planned and homogeneous alteration of participants' mental state have been a major component of socialization from back as long as can be seen. While this does not "prove" net societal benefit from this, it certainly suggests some, probably common, feature that drives the phenomenon. Yes, there are effective techniques, even group techniques, for entering an ecstatic state without resorting to exogenous chemical intoxicants, but substance use has always been a prominent alternative. Even without frank intoxication and measurable impairment of performance capacity, people have socialized around caffeine and nicotine. There is some kind of powerful attraction here. Abstinence in the great majority of a population seem achievable only by dint of religious prohibition. Avoidance of "intoxication" seems more reasonable... but that calls for determining why intoxication is so popular and prevalent and whether offering some substitute is necessary and/or promising for a substantial proportion of "recreational" psychoactive substance-users.

  7. Agree that avoidance of intoxication is reasonable. I would consider that to be a variant of self correcting abstinence. The common pathway to addiction seems to be a lack of self correction, increasingly severe outcomes, and in the end a loss of the social function you describe. In the end most people with addiction and alcoholism are socially isolated and using/drinking alone largely because of the amount of time it takes to consume the substance when tolerance develops and other complications like needing to acquire the compounds being used.

    Using intoxicants in social settings can be a stable pattern if addiction, social, and health consequences can be avoided.

    There is also probably a developmental consideration. Drinking socially in college varies considerably from drinking as an adult. Both are associated with certain patterns of drinking. The college pattern is high risk or binge drinking. Older social drinkers can drink and avoid intoxication and DWI arrests. Adults with problematic drinking patterns can often go to a social event and drink amounts similar to their associates knowing that when they get home they can consume their usual amounts. There is a range of uncontrolled drinking and drug use.

  8. That map cannot be right. Look at Oklahoma. The state was one of the worst for painkiller abuse as early as 2012 - but they don't consume much alcohol, even after there's a crackdown on painkillers? Statistics show 9.2% of their population is American-Indian, a group that has consumed so much alcohol that steps were taken recently to limit sales near reservations. Oklahoma is right next to Texas, and its rural areas share many of the characteristics of Texas' rural areas - and Texas is shown having dramatically higher alcohol intake? An obvious misrepresentation like that makes me doubt the whole map.

    1. The map overrepresents differences by methodology. For example, if you follow the link and look at the tables (also in the key on the drawing) - you will find that the actual difference between a high consumption state like Wisconsin and Oklahoma is only 1 gallon per capita. The per capita rate of alcohol in Oklahoma is still 1.95 gallons or 7 liters per year. The figures are also based on total sales and therefore illicit alcohol sales are not included.