The Curious Sober Movement

 

I saw an interesting story on the news yesterday and found it was linked to an even earlier report in the Tokyo Times. There is a cultural movement in Japan among the younger generation to abstain from alcoholic beverages or drink only on special occasions. I saw a young woman interviewed and she described her motivation as wanting to spend her money on other things.  The report also said that alcohol use in Japan was a ritual for bonding in the workplace.  They showed images of work parties with many people drinking as well as a man in a suit passed out on at the edge of a train platform.  Survey data was quoted as saying that 90% of Japanese drink alcohol rarely or not at all. The most sobering statistic was that tax revenue from decreased alcohol use was down 30%. That drop caused the government to ask for suggestions about how to get people drinking again. That approach did not get any positive reviews in the man-on-the street interviews including a bartender serving non-alcoholic drinks. 

This story was immediately interesting to me for several reasons. First, I have always been puzzled by the American approach to intoxicants. On a cultural basis, they are considered a rite of passage and the best evidence is the data on substance use in college aged students and how it generally decreases over time. Second, there is always a great deal of ambivalence advocating sobriety as a reasonable lifestyle, even though most Americans either don’t drink or drink very little.  The American population has a lower level of lifetime abstainers and (expectedly) a higher number of former drinkers per the world average.  There is ample rhetoric in popular media and culture to ridicule people who don’t drink and in many cases drug users are idealized.  Third, the attitude extends to other drugs. Contrary to pro-cannabis hype, there are very few countries in the world where cannabis is legal much less sold in highly concentrated forms.  That same hype promoted the medical use of cannabis even though there is little evidence that it does much.  Similar arguments are being made about hallucinogens and in some cases, all scheduled drugs that are currently considered illegal. Fourth, intoxicants are generally heavily marketed to the public.  Vodka is a clear example.  The New York Times did a famous taste test of vodka comparing various vodkas to the least expensive brand (3). The least expensive brand won the competition.  At the time, many much more expensive designer vodkas had emerged from several countries.  One of the authors main points is that vodka is sold based on marketing rather than taste.  Many essays about vodka describe is as tasteless. Since 2005 there have been endless taste tests, rankings, and other promotions - basically more marketing.  More recently several prominent celebrities have promoted their own expensive brands of vodka and tequila. In some cases, the businesses have grown to very large values.  All of that based on marketing what is essentially a tasteless, intoxicant that comes with a long list of problems to people who want to drink it for how they see it advertised.  Fifth, the issues of tax revenue. Let’s face it – the only good reason to promote intoxicants is to make money. 

Most common intoxicants also reinforce their own use – at least for a significant segment of the population. That leaves politicians needing to counter that common knowledge. There are two arguments commonly used to do that.  The first is that we will tax the new intoxicant and that will create all kinds of revenues for services that taxpayers want. Alcohol, tobacco, and gambling taxes have been around for a long time and generate billions of dollars per year at the federal level.   Since, everyone knows that drugs and alcohol carry a heavy burden in terms of mortality and morbidity the second argument goes something like this: “We will create a special fund to help all of the people adversely affects by these intoxicants (and gambling).”  During my career as an addiction psychiatrist, I saw treatment services basically disappear.  They were few functional detox units, few functional substance use treatment units, and few addiction specialists.  There was a small remote gambling addiction residential treatment program – but it did not match the degree of gambling problem in the state.  If adequate finding for substance use treatment from sin taxes exists – please let me know about it because I have not seen it.  Like many products and services in the US, alcohol, intoxicants, and gambling all end up being promoted by governments at all levels as a revenue generating activity.  The damage done is rarely discussed.  

In the case of alcohol, the damage is unmistakable if you know friends or family members with the problem. Damaged relationships and marriages, legal problems and incarceration, and a list of significant medical complications.  The current government warning (7) on alcohol is:

GOVERNMENT WARNING: (1) According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects.

(2) Consumption of alcoholic beverages impairs your ability to drive a car or operate machinery, and may cause health problems.

 May cause health problems is an understatement. A more appropriate statement would say can cause health problems up to and including birth defects and intellectual disability, mental illness, severe cognitive problems, liver disease, pancreatic disease, cancer, hypertension, and death. Rather than being explicit about the health risks for many years alcoholic drinks were promoted as heart healthy and increasing HDL or "good" cholesterol. Any slight advantage disappears when subjects recovering from alcohol use disorders are eliminated from the control group.

What about consumption figures?  The usual way that consumption is compared is by taking the alcohol content of all of the beverages consumed in a country and converting it to the equivalent amount of 80 proof ethanol. The per capita annual consumption can be compared in total volumes or standard drinks. A standard drink is 1.5 fluid ounces of 80 proof (40%) alcohol or the equivalent in any one of those drinks is considered a standard drink.   In the US 14 grams or 0.6 ounces of pure alcohol is considered a standard drink. Apart from consumption there are estimates of what the standard drink threshold might be to cause cirrhosis or pancreatitis. 

Comparing levels of alcohol consumption between the US, Japan, and Russia those numbers are 10.5, 10.09, and 9.97 liters per year. These are population averages and there is typically great variability between various populations and historically – even within the same population over time.  There is also a graphic that I made a few years ago (see header of this post) that takes a look at comparisons across several types of drinking relative to the average consumption of the world.

What is curious sober movement?  There seems to be very little written about it and essentially nothing in the scientific literature. That may be why the headlines all involve decreased tax revenues from decreased drinking.  Historically there have been sobriety movements in the past. The most well known one in the United States was the Temperance Movement.  It seems that a basic mistake of these movements is proselytizing and trying to influence politicians. The resulting Prohibition Era in the US is widely cited by drug legalization advocates as a failure, even though it was a law that could never be enforced and there were clear cut benefits for those who had no choice but to abstain.  The current pandemic highlights how limits on established behaviors including measures designed to limit infection and loss of life are immediately politicized and the resulting chaos results in a loss of any benefit. Some people would rather threaten public health officials rather than simply wear a mask. In the area of intoxicants, I am sure any measure to prohibit the sale of alcohol would result in similar reactions today. The legalization of cannabis has been sold to the public and politicians and once that is out of the gate – there is no turning back even though there is early evidence that it will be another blight on the land.

Whatever curious sober is – I hope it has traction in the United States. The travelling medicine show here never seems to stop. We have a massive drug and alcohol problem here and everybody should know it and more importantly act like it. The single best way to stop it – is not by providing treatment for addiction. The single best way to stop it is to not pick up a drink or a cigarette or any other intoxicant in the first place. In the public health field that is called primary prevention.  All of the intoxicant promoters joke about the "Just say no to drugs" public service messages.  Of course they would. Nobody ever talks about the fact that the best life you can live is a sober life. 

The young people in Japan are discovering that.

 

George Dawson, MD, DFAPA

Supplementary 1:  Vodka Pricing, Cost, and Profit 

I decided to make a graphic to show the raw material cost and various taxes on a 750 ml bottle of 80 proof vodka to illustrate how much profit can be made from marketing intoxicants in various ways. The raw material cost in this case is very low since beverage alcohol is distilled and sold by agribusinesses in large volumes.  There is apparently only one manufacturer in the US that does their own distilling. For most the manufacturing process consists primarily of filtering and adding various flavors.  The tax references are at the bottom of the page using Minnesota Department of Revenue guidelines.  There is conflicting information on sales tax but the Dept of Revenue said that it is charged so I included it in the graphic.  In Minnesota there is also an excise tax and a separate 2.5% tax on gross liquor sales.  Minnesota has taxes like the the MinnesotaCare Provider Tax on health care services that is currently at 1.6%.  In theory it can be passed through to the customer/patient but it is selective since reimbursement rates are set without it.  I would see this 2.5% tax as being similar and it would be included in the pricing. (click to enlarge graphic)

 

For tax comparisons, here is a table from reference 3 about the tax revenues generated from the last year available.

Note the differences in excise tax collected on each group of beverages based on the fact that alcohol content is the basis of taxes and also that the 2.5% tax on gross sales generates substantial revenue.

The most recent budget for the state of Minnesota was $53.7B compared with alcohol excise taxes of $187M or about 0.35%.   For comparison Japan generated $8.1 in alcohol tax in 2021 – 1.7% of overall tax revenue.

References:

1:  Why Japanese government is encouraging drinking.  CBS Morning News. December 31, 2022  https://www.cbsnews.com/video/why-japanese-government-is-encouraging-drinking/

2:  A 'sober-curious' generation leaves Japan with a hangover.  Should an arm of the government be encouraging people to drink, even in moderation?  Japan Times. August 24, 2022  https://www.japantimes.co.jp/opinion/2022/08/24/commentary/world-commentary/liquor-taxes/

3:  Asimov A.  A Humble Old Label Ices Its Rivals.  New York Times.  January 26, 2005.

4:  Lachenmeier DW, Kanteres F, Rehm J. Is it possible to distinguish vodka by taste? Comment on structurability: a collective measure of the structural differences in vodkas. Journal of agricultural and food chemistry. 2011 Jan 12;59(1):464-5.

5:  Hu N, Wu D, Cross K, Burikov S, Dolenko T, Patsaeva S, Schaefer DW. Structurability: A collective measure of the structural differences in vodkas. Journal of agricultural and food chemistry. 2010 Jun 23;58(12):7394-401.

6:  World Health Organization (WHO).  The Global Health Observatory. Global Information System on Alcohol and Health.  Levels of Consumption. https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/levels-of-consumption  Accessed on 01/04/2023

7:  PART 16 - ALCOHOLIC BEVERAGE HEALTH WARNING STATEMENT.  § 16.21 Mandatory label information.  Link

8:   AMERICA'S INSATIABLE DEMAND FOR DRUGS.  COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS.  UNITED STATES SENATE.  ONE HUNDRED FOURTEENTH CONGRESS.  April 13, 2016  Link

Incident Atrial Fibrillation and Intoxicants

I remain very interested in the cardiac and brain complications of medications and substances that are commonly used to get high or create altered states.  I am also very interested in the popular trend to characterize cannabis as some previously undiscovered medication that can cure everything ranging from anxiety to obstructive sleep apnea.  I was naturally interested when I saw this paper (1) looking at the issue of incident atrial fibrillation and common intoxicants.

The authors examine a very large database in California that included anyone who had been seen in an emergency department, ambulatory surgery center, or hospital over a period of 10 years (2005-2015).  After they eliminate minors, subjects with persistent atrial fibrillation, and subjects with missing data they had a total of 23,561,884 people. 998,747 of those people had incident atrial fibrillation (defined as the first encounter for atrial fibrillation).  Since their study design is a retrospective observational study they also recorded substance use was considered present if Substance use was considered present if there was coding for any indication of use of methamphetamine, cocaine, opiates, or cannabis.  Knowing the atrial fibrillation and substance use diagnoses – the authors calculate the hazard ratio for each of the substances of interest.

Hazard ratios are basically the ratio of the people exposed to intoxicants who developed atrial fibrillation over the unexposed who developed atrial fibrillation.  So any number greater than 1 means that the population exposed to intoxicants had greater risk.  The corrected hazard ratios were noted to be 1.86 (methamphetamine), 1.74 (opioids), 1.61 (cocaine), and 1.35 cannabis. The authors adjusted for common atrial fibrillation risk factors and ran an additional negative control analysis and looked at the scatter of data pints for these 4 substances and hazard ratios of developing appendicitis, connective and soft tissue sarcoma, and renal cell carcinoma and showed no consistent pattern for these illnesses.

There are a couple of interesting considerations relevant to this study.  The first is the mechanism of action in each case. With stimulants there is a direct hyperadrenergic effects and depending on the individual and dose of the drug varying degrees of tachycardia, palpitations, and hypertension.  Long term users frequently end up with cardiomyopathy from these effects and in some cases ventricular arrhythmias and congestive heart failure. There can also be acute vascular effects like ischemia either due to the increased cardiac demand or pre-existing arteriosclerosis. Atrial fibrillation has not typically been placed in that group of morbidities from stimulant use. Patient with atrial fibrillation often notice emotional precipitants for discrete episodes or atrial fibrillation although a recent study showed that the only reliable precipitant was alcohol use (2). There were significant limitations with that study with attrition and length of the study although I generally agree that alcohol is a clear participant.  Precipitants need to be carefully approached and I suspect that attentive physicians have noted variable phenomenology on an individual basis. 

The high hazard ratio for opioids is a little puzzling. Hyperadrenergic states can occur with the euphorigenic effects and withdrawal effects as well. Direct comparison with stimulants may be difficult due to rapid dose escalation and some degree of tachyphylaxis.  Cannabis is not surprising to me at all. Many initial cannabis smokers notice that their heart is pounding and don’t know why.  They find it unexpected given the conventional wisdom that cannabis is supposed to be a benign substance. Many initial users also get increased anxiety and, in some cases, have a panic attack that may be due to the cardiac sensations. The primary heart pounding sensation is because cannabis causes hypotension and they are experiencing reflex tachycardia. The effects may be less predictable because cannabis use can affect both sympathetic and parasympathetic pathways that can potentiate arrhythmias. A case report of cannabis induced atrial flutter (3) was described as occurring in a woman with a history of hypertension that eventually had to be terminated by an intravenous antiarrhythmic.   

Atrial fibrillation and other cardiac arrhythmias are another good reason for avoiding intoxicants including alcohol (in the supplementary analysis alcohol had a Hazard Ratio of 2.37).  It could be argued that it is basically a numbers game – since most people who use these intoxicants do not develop incident atrial fibrillation.  As of this moment, even if you have had your DNA analyzed for what are known about atrial fibrillation genes – you can’t be certain that you are not susceptible to the problem. And as outlined above there are many additional cardiac problems and that are possible from using these compounds.  The safest path is to avoid these intoxicants all together.

 

George Dawson, MD, DFAPA

 

 

References:

1:  Lin AL, Nah G, Tang JJ, Vittinghoff E, Dewland TA, Marcus GM. Cannabis, cocaine, methamphetamine, and opiates increase the risk of incident atrial fibrillation. Eur Heart J. 2022 Oct 18:ehac558. doi: 10.1093/eurheartj/ehac558. Epub ahead of print. PMID: 36257330.

2: Marcus GM, Modrow MF, Schmid CH, Sigona K, Nah G, Yang J, Chu TC, Joyce S, Gettabecha S, Ogomori K, Yang V, Butcher X, Hills MT, McCall D, Sciarappa K, Sim I, Pletcher MJ, Olgin JE. Individualized Studies of Triggers of Paroxysmal Atrial Fibrillation: The I-STOP-AFib Randomized Clinical Trial. JAMA Cardiol. 2022 Feb 1;7(2):167-174. doi: 10.1001/jamacardio.2021.5010. PMID: 34775507; PMCID: PMC8591553.

3: Fisher BA, Ghuran A, Vadamalai V, Antonios TF. Cardiovascular complications induced by cannabis smoking: a case report and review of the literature. Emerg Med J. 2005 Sep;22(9):679-80. doi: 10.1136/emj.2004.014969. PMID: 16113206; PMCID: PMC1726916. [full text] 

Drinking Your Way To Your 90s.

The headlines recently have been unmistakable:

Drinking alcohol key to living past 90, study says

Drinking Tied To Long Life In New Study

Drinking alcohol increases longevity more than exercise, according to study

Alcohol more important than exercise for living past 90, study claims


Could these headlines be true?  After all, wasn't there a recent headline that said drinking alcohol was the largest single modifiable risk factor for dementia (1)?  Buried in some of those headlines are also secondary stories about political decisions that did not go well for the producers of some alcoholic beverages.  France's Health Minister Agnès Buzyn - a physician stated recently that alcohol is alcohol.  She went on to say that contrary to what French citizens are taught to believe about the health effects of wine it is no  different than drinking beer or distilled spirits and it is bad for health.  I think that we have been in the midst of a tremendous  amount of hype about alcohol, the specific types of alcohol, secondary natural products, the purported metabolic effects and the effect of alcohol on longevity.  The current headlines were the only ones I can recall where the positive effects of drinking alcohol was estimated to be on par with exercise.

I come at the problem from the perspective of an acute care and addiction psychiatrist. For 22 years, I worked at a tertiary care center that was also a Level 1 Trauma Center and it contained a burn unit.  At one point our medical director surveyed our admissions and determined that at least 50% across the entire hospital were there because of drugs or alcohol.  We saw every type of injury and chronic illness due to intoxicants and the patients with those insults often had markedly shorter life spans than expected.  How could alcohol use extend life?  Why was it seen as a common finding? Most importantly - why were all of these headlines surfacing right now?

Some of the articles named Claudia Kawas, MD and her work in the 90+ Study and Leisure World Cohort Study as the source for the headlines (2-4).  The Leisure World Cohort Study (LWCS) followed a group of 8,371 women and 4,828 men from a media baseline age of 74 for a period of 28 years or until death.  The group was located in a retirement community and were described as predominately white, middle class and well educated.  They were sampled at intervals with questionnaires that asked about their dietary habit including beverage intake in terms of alcohol and caffeine containing beverages and other types,  a number of activity levels, and total amount of exercise.  A large number of papers resulted from this study and are still being written as the continuation study of the members that survived into their 90s.  Dr. Kawas gave a presentation at a recent American Association for the Advancement of Science (AAAS) meeting on some of her findings and that appears to be what the headlines based on.

 From the LWCS group, there were several notable findings.  In terms of activity level (2), any activity of 1/2 hour per day or more reduced mortality risk 15-30%.  A broad range of exercise of various levels of intensity and whether they were done inside or outside.  Level of activity at age 40 was a predictor of activity in old age.  Relative Risks (RR) for all cause mortality were calculated for the activities and their duration. as well as the time spent.  After 3/4 of an hour per day the RR effect tapered off.  Sedentary activities like watching television had no significant impact on the RR.  The greatest observed risk occurred when activity levels were reduced due to injury or illness.  They found no survival advantage for a high activity level (1+ hours per day) compared to a moderate level of 1/2 to 3/4 hours per day.

The same group looked at the issue of alcohol intake in the LWCS group.  In their introduction they note that 4% of the annual mortality in the world is caused by alcohol.  They review some of the previous literature and the purported J - or - U shaped mortality curves for alcohol consumption - meaning higher mortality rates for abstainers, lower mortality rates for moderate drinkers (1-2 standard drinks per day), and higher mortality rates for higher levels of drinking. The response choices on the survey were for 1, 2, 3, and 4 or more drinks per day.  They also broke the sample down based on their responses drinking surveys in 1992 and 1998 to to stable non-drinkers, stable drinkers, starters, and quitters based on comparing their survey answers.  Three quarter of the sample drank.  Two drinks a day conferred a 14-16%  in decreased mortality irrespective of the type of alcohol.  At follow up there were more non drinkers than at baseline (36% versus 26%).  The quitters and starters acquired the expected mortality risks in each group.  They conclude that there was a small beneficial risk of alcohol on mortality of about 15% but qualify the result based on the study limitations.

The final dimension in this sample of the LWCS paper was a look at non-alcoholic beverages and caffeine content.  They looked a coffee, decaffeinated coffee, black or green tea, cola drinks (sugar or artificially sweetened), other soft drinks and sweetener combinations, and the amount of chocolate eaten (daily versus a few times per month.)  They found that there was a U-shaped mortality curve for caffeine consumption with peak protection at about the 100-399 mg/day.  They also found that consuming as little as one can a week of artificially sweetened soft drinks had a small increased risk of death (11-24%).  They looked at specifics and determined that 1-3 cups of regular coffee/day reduced mortality risk by 5-10% and drinking decaffeinated coffee or tea reduced risk by 5-9%.   Drinking sugar sweetened cola - had an 8% lower risk of death.  Infrequent chocolate users also had a reduced risk of death (3-9%).

Taken all together these three papers suggest that moderate levels of alcohol, caffeine, and activity are all consistent with longevity.  In order to look at the alcohol findings in perspective, I searched the literature for a meta-analysis of all of the alcohol x longevity studies and came up with an outstanding paper by Stockwell, et al  (5).  In it the authors look at and extensive analysis of existing alcohol effect on mortality studies and initially duplicated a J-shaped mortality curve based on 87 studies they included in their analysis.  They went back into that sample and corrected for abstainer biases such as including including former and occasional drinkers in the abstainer category.  They model four types of abstainer bias in their in the paper.  When those corrections are made or when only very high quality studies are used - the purported mortality advantage of moderate (1-2 standard drinks per day) - disappears completely.  I could not find any data from the LWCS studies used in this meta-analysis.  According to the author's selection criteria the LWCS data probably would have been eliminated because it was a cross sectional study.

That alcohol is not a heath food should not come as a surprise.  Any cohort of drinkers in their 90s suggests to me that they are biologically selected to survive the alcohol and that is probably why they are drinking into their 90s and not because of it.  Since the activity, caffeine, and diet soda effects noted in this study were collected using similar methodologies, that can be a cause for concern. The authors were careful to cite supporting data  and discuss the limitations.  Observational studies like the LWCS and 90+ Study add to the literature but it is necessary to keep these findings in perspective and consider the potential biases of the design.

At this time I have not found a similar meta-analysis for each of the other cases (activity level, caffeine consumption).

 

 George Dawson, MD, DFAPA


References:

All linked papers below are to free full text articles.


1: Schwarzinger M, Pollock BG, Hasan OSM, Dufouil C, Rehm J; QalyDays Study Group. Contribution of alcohol use disorders to the burden of dementia in France 2008-13: a nationwide retrospective cohort study. Lancet Public Health. 2018 Feb 20. pii: S2468-2667(18)30022-7. doi: 10.1016/S2468-2667(18)30022-7. [Epub ahead of print] PubMed PMID: 29475810.

2:  Paganini-Hill A, Kawas CH, Corrada MM. Activities and mortality in the elderly: the Leisure World cohort study. J Gerontol A Biol Sci Med Sci. 2011 May;66(5):559-67. doi: 10.1093/gerona/glq237. Epub 2011 Feb 24. PubMed PMID:21350247.

3:  Paganini-Hill A, Kawas CH, Corrada MM. Type of alcohol consumed, changes in intake over time and mortality: the Leisure World Cohort Study. Age Ageing. 2007 Mar;36(2):203-9. PubMed PMID: 17350977.

4:  Paganini-Hill A, Kawas CH, Corrada MM. Non-alcoholic beverage and caffeine consumption and mortality: the Leisure World Cohort Study. Prev Med. 2007 Apr;44(4):305-10. Epub 2006 Dec 29. PubMed PMID: 17275898.

5:  Stockwell T, Zhao J, Panwar S, Roemer A, Naimi T, Chikritzhs T. Do "Moderate" Drinkers Have Reduced Mortality Risk? A Systematic Review and Meta-Analysis of Alcohol Consumption and All-Cause Mortality. J Stud Alcohol Drugs. 2016 Mar;77(2):185-98. Review. PubMed PMID: 26997174.

The Moral Dilemma Of Alcohol Exposure

Before anyone schools me about Prohibition - I give lectures on Prohibition. I know it doesn't work and I know the reasons why. I also know that talking about restricting intoxicants in any way is counter to the current zeitgeist of liberalizing their availability.

I also treat alcoholics and I know how that works. When I see Minnesota's largest and most famous retailer opening up large and attractive liquor stores where there used to be not so attractive foods courts and positioning it right across from the cash registers - I know that will be a problem for a lot of people trying to stay sober. I know that for many people in recovery - an attractive liquor store in their favorite retail store or grocery store creates a very high probability of relapse - even if they know that relapse may result in death or severe disability. In Minnesota liquor stores hours is another issue. In states where liquor sales are prohibited like Minnesota, it is incentive to drive across the border into bordering states in order to buy alcohol. A modification is the availability of low alcohol content beer from grocery stores and gas stations.

Another proxy measure for relapse risk would be the total number of bars in each state.  That data is harder to get.  I have information from a tavern owner that the business organization representing them sets the maximum number at 1 tavern or bar per 500 people, but the actual limits are subject to local jurisdiction.  In reality the maximum tavern/bar concentrations occur in North Dakota, Montana, Wisconsin, and South Dakota ranging from 1621 - 2268 people per tavern/bar.  At the lower end Virginia ranks 50th at 64,773 people per tavern/bar. (US Census Bureau Data per The Forum).

Are retailers that desperate that they all need to compete in this low margin business? Why are governments in this business at all? I know that there are vocal people everywhere who argue for their unalienable right to intoxicants. One of the main arguments has always been that the vast majority of people can drink and not incur any problems from it. What about the people who cannot? Binge drinking, alcohol poisoning, and excessive alcohol use are all major public health problems according to the CDC. The direct and indirect cost of excessive drinking in the US is about $249 billion in direct and indirect costs.

One of the main arguments of cannabis advocates is how dangerous alcohol is. Alcohol costs $1.90 per drink according to the CDC in complications from drinking. That cost is probably artificially low because treatment and detoxification from alcohol is rationed and most people don't get anywhere near the level of treatment they need. In Twin Cities metro hospitals - drug and alcohol use can account for up to 60% of admissions. Potential consumer advocates in this case belong to an organization that values anonymity and as far as I know has not been very politically active.

The CDC (Community Preventive Services Task Force) suggests that alcohol excise taxes need to be increased, alcohol outlet density needs to be decreased, hours of sales need to be decreased rather than increased, and retailers need to be held liable for damages caused by underage or intoxicated drinkers. The tax suggestion reminds me of the general theory of sin taxes and why they really don't work from a governing standpoint. It basically generates money for politicians to spend and is typically diverted away from any stated use that involves treating complications of the activity.

To me the alcohol issue is much bigger than who sells it, but governments have a big problem at the moral and public health levels. Just carrying forward the CDC recommendations invites rhetorical response about prohibition or temperance. I have found myself in illogical arguments with both individuals and families about the right to drink oneself to death. Make no mistake about it, the issue was not suicide - just continuing to drink with advanced liver disease and repeated hospitalizations for bleeding problems and encephalopathy due to advancing liver disease and the associated anatomical and physiological changes.

At its base, the alcohol problems and tolerating excessive alcohol use is a cultural problem. In the Midwest where binge drinking is most prominent, teenagers start drinking in middle school. In many areas it is a rite of passage. Even though the majority of people don't drink. It is very difficult to find social settings that are alcohol free. Alcohol use in most settings is promoted as the social norm with the exception of a few subcultures. Barring a widespread cultural movement that promotes moderation or abstinence, it appears that the usual educational measures about the dangers of alcohol use will be the primary intervention point. Secondary and tertiary prevention depends on a robust system of care for alcohol use and that currently does not exist. In some cases close monitoring by the correctional system for people with DWI infractions can be effective, but that does not address either the group of people who do not come to legal attention or those for which legal intervention is not a deterrent.  It also does not provide long term solutions to the problem of continued alcohol use.

Despite all of the current hype about how some intoxicants are wonder drugs and the ongoing arguments about legalization of all or most intoxicants - I can't help but see this as another moral dilemma. The will of the many basically writing off the serious problems of the few. This often plays out in families where one member clearly has a severe drinking problem and the others (usually a spouse) refuses to not drink in front of them or not have alcohol available in the home.  It all comes down to the rationalization that everyone can control their drinking or that drinking can be seen as bad behavior and that is obviously not true.

The moral dilemma of increasing alcohol availability or the government sanctioned availability of any intoxicant is the same.  It is based on the theory that people in general can use these intoxicants without damaging other members of society or themselves to the point that they do not become a cost to the rest of society.  That essentially writes off the group of people with uncontrolled use who cannot do that.  American society traditionally handles that problem by punishment and rationing availability of treatment and detox services.  Functional detox services staffed by physicians are practically unheard of.  Contrary to that guy in your freshman philosophy course who doubted the meaning of everything - moral philosophers can also add a perspective here.  Consider this quote from Blackburn about the nature of moral knowledge:

"There are countless small unpretentious things that we know with perfect certainty.  Happiness is preferable to misery, and dignity is better than humiliation.  It is bad that people suffer and worse if a culture turns a blind eye to their suffering.  Death is worse than life; the attempt to find a common point of view is better than a manipulative contempt for it." (1).

The availability and treatment of alcohol related problems in American society on one hand and the motivation to profit from it on the other hand seems to stand Blackburn's quote on its ear.  In the US there is a clear blind eye approach to alcoholism.

It may be time to come up with a better plan for living.


George Dawson, MD, DFAPA


References:

1:  Simon Blackburn.  Being Good - A Short Introduction To Ethics.  Oxford University Press. Oxford, UK. p. 134.


Graphic:

Liquor store density is from Health Indicators Warehouse at www.healthindicators.gov and is in the public domain.  This graphic was generated on that site. (click to enlarge)

Pancreatitis

There is an outstanding review of pancreatitis in this week's New England Journal of Medicine.  I thought I would add it here as a reference for any addiction or medical psychiatrists who come across this post and may not be regular readers of the NEJM.  I recommend getting the entire article because it has an excellent table and infographic.  The table is on the causes of acute pancreatitis.  The top two - gallstones (40%) and alcohol (30%) have not changed since I was in medical school.  Hypertriglyceridemia (defined as fasting triglycerides >1000 mg/dl) was the third most common cause at about 2-5% or the total.  Some of the causes occur only in a very specific context like endoscopic retrograde cholangiopancreatography (ERCP) and patients undergoing cardiopulmonary bypass.  In both cases, the authors estimated that 5 -10% of patients undergoing these procedures got pancreatitis.  Although the ERCP was expected I was surprised that many cardiopulmonary bypass patients got pancreatitis.  The remaining 5-8% are caused by medications, viral and parasitic infection, and blunt trauma.  Psychiatrists should be aware of valproic acid/valproate correlation with pancreatitis,  especially if they are treating patients with significant alcohol exposure.  Some facilities use a valproate detox protocol and those patients need to be carefully assessed for alcoholic liver diseases and undiagnosed pancreatitis.

The diagnostic features of acute pancreatitis are reviewed and these are important for any acute care psychiatrist who is seeing patient with associated risk factors.  At the clinical level abdominal pain and elevations of amylase and lipase 3 times the upper limit of normal are the initial features that require confirmation by MRI or CT imaging finding consistent with the disease.  From a diagnostic perspective the availability of testing and practicing in a medical facility are limiting factors.  Any abdominal pain with a suspicion of pancreatitis in a non-medical facility makes a trip to the emergency department for rapid assessment and diagnosis most reasonable.

The infographic was on the time course and management of acute pancreatitis.  The time frame used was 6 weeks.  80% of patients with acute pancreatitis have self limited disease and are discharged from the hospital in a few days.  The incidence of acute pancreatitis is rising with a 20% increase in admissions in the past decade.   On the mortality dimension half of the deaths occurred in the first two weeks due to multiple organ system failure.  The other other half of the death occur after two weeks and are due to pancreatic and extrapancreatic infections.  On the pathophysiology dimension, 80-85% of the disease was the interstitial form and 10-15% the necrotizing form.  There was also a therapy dimension outlining critical markers such as aggressive fluid resuscitation in the first 24 hours and enteral nutrition after day 5 if tolerated.   The therapy dimension was linked to the text that reviewed state of the art details on the medical and surgical management of the disorder.  These sections will not apply to psychiatrists, but the authors point out common mistakes in management including the unnecessary use of total parental nutrition and antibiotics for presumed pancreatic infection.   The main lessons for psychiatrists at that stage is that patient management has exceeded the capabilities of psychiatric settings and that the patient must be transferred as soon as possible to an appropriate medical setting.  Once that has occurred, the plan to take the patient back when stable also requires a clear plan with the attending who is discharging the patient.

The other highlights in this article from a psychiatrist's perspective was the estimated dose of alcohol necessary to cause pancreatitis.  The authors give that as 4 - 5 drinks per day for 5 or more years.  This is well below the dose of alcohol required for cirrhosis and probably explains why larger numbers of young patients are seen with pancreatitis.  Apparently, in the 2-5% of heavy drinkers that develop pancreatitis it occurs as a chronic form initially with episodic acute exacerbations superimposed on this chronic form.  That also explains why binge drinking does not precipitate acute pancreatitis.  Diabetes, smoking, and obesity are seen as correlates of acute pancreatitis but not direct causes and these are all significant comorbidities in patients with psychiatric disorders.  Once an episode of pancreatitis has occurred abstinence from alcohol is critical because it decreases the likelihood of recurrence.  The authors reference a structured consistent intervention that they cite as being successful (2).  I don't have access to the full text of this article, but it suggests that an infrequent intervention by a nurse in outpatient clinic is more effective than a single intervention during  hospitalization in preventing relapses.

This was a great overview of acute pancreatitis by some of the top experts in the field.  It is another problem that you never want to miss.  It is a reason to resist simplifying biochemical screening of patients on admission or clinic intake.  Since metabolic syndrome, obesity, and tobacco use is high and elevated triglycerides may be a factors in the pathophysiology of pancreatitis - it seems reasonable to do metabolic screening on patients without recent testing.  If you are seeing patient with risk factors particularly alcohol use, tobacco use, obesity, and diabetes - discussion of lifestyle management, smoking cessation, and abstinence from alcohol is useful in addition to the discussion about their primary psychiatric problem.  Addiction psychiatrists will probably see significant numbers of patients with chronic pancreatitis and a discussion with them on how to prevent recurrences and their understanding of the illness is important.

George Dawson, MD, DFAPA


References:

1. Forsmark CE, Vege SS, Wilcox CM. Acute Pancreatitis. N Engl J Med 2016; 375: 1972-1981.

2.  Nordback I, Pelli H, Lappalainen-Lehto R, Järvinen S, Räty S, Sand J. The recurrence of acute alcohol-associated pancreatitis can be reduced: a randomized controlled trial. Gastroenterology. 2009 Mar;136(3):848-55. doi:10.1053/j.gastro.2008.11.044. PubMed PMID: 19162029.