Every January one of the frequent pledges is to not use alcohol for the month. In my capacity as a psychiatrist – I have had patients tell me that if they could do it was a sign that they were not an alcoholic because it shows that they can control their drinking. Never mind the excessive drinking and adverse consequences the rest of the year. I saw an exchange between a sober bartender and a stress drinker portrayed in a new TV series just today. It went something like this:
Patron: “I stopped drinking whisky because I am an alcoholic
– so I just stick with beer.”
Bartender: “Well you know there is alcohol in beer.”
Patron: (motioning to his light beer) “There is more alcohol
in orange juice than there is in this”
Bartender: “I’m just saying…”
Patron: “I’ll tell you what – let me drink 6 of these beers
and 6 whiskeys and you tell me which one has more alcohol.”
And so, it goes. If you have a problem with alcohol or any
other substance (or behavior) that reinforces its own use – there are endless
rationalizations to keep using it and never enough deterrents. Studies have shown that it often takes a
life-threatening problem or major life event to quit - but even that may not be
enough. I am witness to many people who
kept drinking despite end stage liver disease in some cases fully supported by
their family: “It’s his choice – if he wants to drink, he is free to drink.” It seems that the only advocates for sober
living are in Alcoholics Anonymous or other 12 step recovery groups. I did post on a the Curious
Sober movement in the younger generation but that has either not caught on
or it is not being adequately covered if it has.
The history of using intoxicants is long and detailed. The
two dominant evolutionary theories are that the substances are used because of
a mismatch of currently abundant intoxicants on a reward and endogenous opioid
system originally there for other reasons or as a form of self-medication that
can be observed in other primates. The latter idea is that primates learn that
there are certain plants that contain compounds that can treat ailments. Both of those theories leave out the cultural
elements that include social settings, celebrations, religious ceremonies,
traditions, and local customs that use intoxicants as part of the event. There
are cultural portrayals in movies and television showing alcohol and other intoxicants
are being necessary to alleviate daily stress.
In more modern times, some of these substances are imbued with magical
qualities like being vehicles for mind expansion or even cures for mental
illnesses.
The reality of substance use for practically all of the
people I have talked with who do not have a substance use problem comes down to
using alcohol of drugs to get an enjoyable “buzz”, to get a heightened sense of
social competence from the initial relaxation, or just going along with the
crowd. In many crowds there is intense
peer pressure to not be the one who is not drinking or smoking cannabis. That
is a major source of binge use in the late teens and early 20s. Even in those
social situations it is common for people to experience excessive use,
intoxication with impaired judgment, and bad outcomes. I have talked with too many people who
sustained severe legal consequences from a single night of excessive drinking. I
have also talked with too many people to remember who were admitted to my acute
care psychiatric unit based on something that happened when they were acutely
intoxicated.
I have covered
this issue in the past and will link that post here without having to
repeat it. The basic issue for me is why
use intoxicants at all? Considering just
alcohol it is a neurotoxin, a carcinogen, and a direct toxin to the pancreas,
the heart, and the liver. For years it was promoted as a “heart healthy” drink
despite methodological problems with studies that put subjects with significant
alcohol exposure in the control group.
There are both informal and professional advocates for
getting high. One of the most well-known
advocates estimates that 70-90% of people can use intoxicants and they do
not become problematic. He describes his
own use of heroin as useful because it results in a “happy and stress-free
feeling”, helps him “maintain work-life balance”, and should be legal for everybody. He also describes the pain of heroin
withdrawal but apparently does not see that as a deterrent. A key question is whether it is possible to
get to that “happy and stress-free feeling” without using heroin? How many people are operating under this
premise today as they use various intoxicants some of which are excessively
hyped as being good for your mental health? American culture is promoting the
idea that you can fine tune your brain by using intoxicants even though there
is no evidence this works. To promote
that idea, we have been exposed to 20 years of intoxicants advertised as medical
treatments beginning with cannabis. As the dust settles this idea has little to substantiate
it, adverse effects have been minimized, and commercial conflict of interest
have not been disclosed.
The basic consideration comes down to the values you have
established for yourself and whether those values can be affected by
intoxicants. There are many approaches
to values that apply to intoxicant use. There are several religions,
philosophical approaches, and recovery movements that value not using alcohol
or other intoxicants as well. You may
value your short term and long-term health and consider not using intoxicants
on that basis. You may have had a close
call while intoxicated and decided that you did not want to take that chance
again. You might even survey the damage done to your family by intoxicants and
decide they are too risky to sample. On
the other hand, you can walk into any small-town bar in the Midwest and people
will be joking about the effects or alcohol and in some cases about who has
developed cirrhosis or died as a result. They may also be joking about the
associated behaviors of excessive intoxication.
Gallows humor is an easily observed adaptation. There are subcultures that value alcohol use
– no matter what. I would argue that
extreme position is a direct result of the reinforcing effects of alcohol
rather than any de novo philosophical position.
In the final analysis this is not about whether intoxicant
use is a disease or whether you can control the use or even gain something from
it. Most of the popular discussion comes
down to political arguments. In other words – I have a particular belief system
about intoxicants and I will marshal every possible bit of evidence to support
my position. I will be the first to acknowledge that as an acute care and an
addiction psychiatrist – selection bias was certainly in effect. I would see
the worst possible scenarios. But I have
also seen people in real life who were clearly not doing well at all varying from
an intoxicated man I tried to help at 7AM in northern Wisconsin to a young
woman my wife and I tried
to help in Boston. You can argue
that those folks still had a substance use disorder and most people using intoxicants
do not.
In that case – I would offer the evidence. If you are having a Sober January and things are unchanged, going well or even better than usual – why change that?
Keep it going.
George Dawson, MD, DFAPA
Graphics Credit - click photo for all details:
1:
2:
