The Problem of the Drinking Spouse

Any physician treating alcoholism knows this scenario very well.  You have finally convinced a person that they have a problem with alcohol.  They have been in treatment and either using or not using MAT (medication assisted treatment - naltrexone or acamprosate).  They are at the point where they are abstinent many more days than they are drinking.  This is a critical point for many people who are daily drinkers.  As you work with them in trying to define critical factors for continued use they identify: "My husband/wife refuses to stop drinking.  They say it is my problem.  They like drinking and they refuse to stop.  They have alcohol at the house."

There are many variations on that theme.  Some spouses will keep all of the alcohol locked up and imbibe only when the sober spouse is sleeping.  Some will not have any alcohol at all, but continue to drink in social situations accompanied or unaccompanied by the sober spouse.  Some will just resent the sober spouse and the sudden restriction in the couple's social life.  Many couples start drinking to increase their social activity and expand their social contacts.  In many businesses, this level of socialization and the associated drinking is expected.  The associated level of emotionality in the marriage can increase precipitously based on the new expectations of the sober spouse about how things should be to support their sobriety.  The combination of the environmental cues from alcohol and increased emotionality greatly increase the risk for continued alcohol use and make all of these patterns untenable.  Convincing the drinking spouse that their behavior does not facilitate sobriety in the marriage is a difficult task - if it is attempted at all.

Are there any large scale studies that back up those clinical observations?  A certain portion of drinking spouses may respond to clear scientific evidence if they cannot respond to the advice of a counselor or physician.  It turns out that there are and a lot of that work has been done by Kendler and co-authors. 

The most recent paper in JAMA Psychiatry (1) looks at the issue of spousal resemblance for alcohol use disorder.  In the study, subjects were obtained from a generational sample of all people born between 1960 and 1990 in Sweden who were married before December 31, 2013.  They were identified as having alcohol use disorders (AUD) through several databases that looked at medical diagnoses, medication assisted treatment prescriptions (disulfiram, naltrexone, acamprosate) and convictions or suspicions of at least two alcohol related crimes.  That resulted in marital pairs - 5883 where the husband first developed an AUD and 2679 where the wife first developed an AUD.  They note that in marital pairs, first onset AUD was much greater in pairs where a spouse had an AUD than when they did not.

They analyzed the data by two methods.  First, they looked at hazard ratios of developing an AUD relative to a control group matched by sex, birth year, year or marriage, family history of AUD, and parental educational level.  Second, they looked at intraindividual hazard ratios across subsequent marriages and divorces.

In the first analysis, the hazard ratio of AUD in the wife after the husband had an initial AUD was 13.82 dropping to 2.75 over the first two years.  In the case of  husbands after a wife's first registration of AUD the hazard ratio was 9.21 falling more slowly to 3.09 after 3 years.

In the intraindividual comparisons - for husbands moving from a spouse with no AUD to one with an AUD resulted in a HR of 7.02.  Moving from a spouse with an AUD to one without and AUD decreased the risk to a HR of 0.50 for AUD.  The protective effects persisted in the same direction in second and third marriages.  They produced a comprehensive tables of 20 possible combinations of spouses +/- AUDs and list the protective and predisposing combinations.  In each case, whether or not the prospective spouse has an AUD predicts the the probands status.

The authors conclude that this is tentative evidence that a spouses alcohol use status has a causal effect on their spouses drinking.  They suggest the likely processes and suggest that assortative mating is a factor in the large increase in drinking that can occur when a man or woman without an AUD marries a man or woman with an AUD.  Assortative mating has been previously studied by Kendler (4) and is defined as mate selection that depends on similarity across traits - in this case drinking patterns and risk factors for AUD.  It is an interesting concept because it suggests at least part of the mechanism of greatly increased risk in the spouses of drinkers.  A non-drinking spouse with those characteristics may have more credibility as a protective effect, but those specifics are not clear at this time. 

The limitations are discussed in the original paper and I won't belabor them here.  Clearly the study design is an issue.  It is likely that cases were missed.  I have not seen it studied, by my experience with diagnoses and the American insurance system suggests that many people will do what they can to stay off of a database.  I can't imagine that is not also true in Sweden.  They did a comparison of the AUD prevalence of their data to Norway and found the prevalence was lower.  This methdology also focuses on more severe AUD.  I based that on the fact that the DSM-5 committee eliminated legal problems as a diagnostic criteria for AUD based on it not adding much to the criteria because it was associated with most of the other criteria.              

An observation about the study.  It could not have occurred in the United States - at least not on the same scale.  In the US, treatment for alcohol or substance use problems comes under the the auspices of §CFR 42, limiting access to information for research purposes.  Advocates for these restrictions will of course say they are necessary and that people can still release information like they can for any other medical condition - but like most of these regulations there is general confusion and intimidation of clinicians to the point that the extra hurdles necessary to do research are seldom breached.  In the US, in the case of non-public programs like Medicare or Medicaid, all of the data is aggregated by health care system.  In Scandinavian countries all patients are on a single national database.  In the Swedish study, the researchers assigned unique serial numbers to all of the subjects and the ethics committee approval waived consent because of this procedure.

This study gets back to a philosophy of life and the issue of sobriety or at least self-correcting abstinence.  Couples do have conversations about drinking.  They do make conscious decisions about drinking and substance use.  They observe one another when they have become too intoxicated and had significant embarrassment or hangover effects.  If there are no baseline agreements about the use of intoxicants early in the marriage there should be a discussion about self correcting abstinence.  When do we agree to stop whatever we are doing as a couple and reassess our use of intoxicants.  Things do not have to get to the level of an actual alcohol or substance use disorder.

Finally, what about the approach to the couple when there is a clearly defined alcohol or substance use problem?  The couple's dynamic does need to be identified and addressed.  For any physician or counselor approaching the problem is fraught with difficulty.  Spouses tend to be defensive, resentful, and in some cases openly hostile to the idea that they need to stop drinking.  The drinking spouse may see the physician or counselor as affiliated with the nondrinking spouse and that can amplify the resentment and negative emotion.  There are programs with a more neutral response that treats the drinking spouse in an entirely different context and provides the necessary education.  Al-Anon is the prototypical self help program for spouses that attempts to address anger, resentment, and provide a focus on positive strategies.  I am still waiting to see an explicit manual, pamphlet, or book that is focused on why the drinking spouse needs to stop drinking.  If I missed that please send me a link to that resource.   

Before you send a comment on the couple where one person is sober and the other person drinks, I can assure you that I am aware that the situation exists.  I typically see it where the spouses are independent and often have separate social and recreational outlets.  In many cases, one of the spouses works excessively and alcohol use is incorporated into work activities or becomes a ritual on the way home.  The situation I hope to address here is one where both spouses are drinking - usually too much and one of them wants to quit.

I have not seen a lot written about the problem or the solution.


George Dawson, MD, DFAPA


References:

1: Kendler KS, Lönn SL, Salvatore J, Sundquist J, Sundquist K. The Origin of Spousal Resemblance for Alcohol Use Disorder. JAMA Psychiatry. 2018 Feb 7. doi: 10.1001/jamapsychiatry.2017.4457. [Epub ahead of print] PubMed PMID: 29417130

Full text available on line.  Please read it.

2: Kendler KS, Lönn SL, Salvatore J, Sundquist J, Sundquist K. Effect of Marriageon Risk for Onset of Alcohol Use Disorder: A Longitudinal and Co-Relative Analysis in a Swedish National Sample. Am J Psychiatry. 2016 Sep 1;173(9):911-8. doi: 10.1176/appi.ajp.2016.15111373. Epub 2016 May 16. PubMed PMID: 27180900.    

3: Kendler KS, Lönn SL, Salvatore J, Sundquist J, Sundquist K. Divorce and theOnset of Alcohol Use Disorder: A Swedish Population-Based Longitudinal Cohort and Co-Relative Study. Am J Psychiatry. 2017 May 1;174(5):451-458. doi: 10.1176/appi.ajp.2016.16050589. Epub 2017 Jan 20. PubMed PMID: 28103713; PubMed Central PMCID: PMC5411284.

4: Maes HH, Neale MC, Kendler KS, Hewitt JK, Silberg JL, Foley DL, Meyer JM,Rutter M, Simonoff E, Pickles A, Eaves LJ. Assortative mating for major psychiatric diagnoses in two population-based samples. Psychol Med. 1998 Nov;28(6):1389-401. PubMed PMID: 9854280.


Graphics Credit:

Photo at the top is from Shutterstock per their licensing agreement.

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 why 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



Supplementary:

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.

A Short (11 minute) Film About Alcoholism - Breakfast Wine

"In Ireland, they say it takes just 3 alcoholics to keep a small bar running in a country town....."



I ran into this film last week and was impressed enough to write this post about it.  It is an award winning short film about four people in a pub in rural Ireland and events that transpired on a certain day.  Given the availability and brevity of the film, I encourage anyone interested to view the video before reading this post.

You can go to any number of Saturday Night Live skits and see alcoholics ridiculed.  This film takes the problem more seriously. What you see will depend on your experience observing and interacting with people who have an alcohol problem.

To set the scene, the film begins with the quote posted at the top of this page.  We see two middle-aged men standing outside a pub waiting for it to open.  The owner shows up.  They all enter and the two men who were waiting commence drinking pints of Guinness.  Over the duration of the time lapse in the film they each drink 6 pints of Guinness - the first two in what seems fairly rapid succession.

After they put down about two pints a young woman enters, asks them about the availability of wine.  After getting their recommendations she proceeds to drink the first glass rapidly. Over the time lapsed in the film she drinks a total of 4-187.5 ml bottles. The pub owner and the two men in the bar seem impressed with her ability to drink, but they are also impressed with her ability as a ranconteur.  She tells a fable about getting rid of all motor transport and lining people up against the wall and shooting them.  She moves on to describe severe physical abuse by her husband and shows lacerations on her wrists where she was tied up on the garage floor.  She tells them what her husband was saying to her when he became abusive and does not miss a beat.  She sarcastically dismisses her rant by saying "I should have seen it coming."  At that point she says good bye and the pub owner tells her what the opening time for the pub is every day.  She thanks him for the information and walks out.  The men are clearly impressed with her and one of them longingly touches the stool where she was  sitting.

At the level of entertainment, I can see why this is an award winning short.  The writing and acting are good.  The woman in the scene, actress Ruth Bradley is a compelling screen presence.  She plays this  role perfectly. It is a plausible scene from any bar - Irish or American. From the standpoint of an addiction psychiatrist - what is wrong with this picture?

The alcohol consumed per unit time is a red flag.  The CDC defines binge drinking as probably occurring if a woman consumes 4 or more drinks or a man consumes 5 or more in 2 hours.  The time span of this film may be subject to debate but I counted 6 pints of Guinness per man or 9.6 standard drinks and 750 ml wine (4 - 187.5 ml bottles) or 5 standard drinks for the woman.  It is clear from the depiction by the actors that they are drinking these beverages at times like water.  In bars or pubs bad things tend to happen when the patrons are binge drinking. Binge drinking alone whether it is associated with a diagnosis of alcohol use problems has associated mortality and morbidity per the CDC site.

 There is a high tolerance for unusual behavior in the pub.  One of the men leaves and his behavior is discussed among the remaining people.  In another scene marking the sixth pint he becomes irate with his associate and that behavior is translated as an acknowledgement that he does want another pint.  The woman had two discrete rants about motor vehicles and the violence she has sustained by her husband and immediately resumes a normal even joking manner.  The men are intensely interested in this woman, she breaks up their routine, is attractive to them and is charismatic.  Their response to her description of the violence she has sustained and even the presentation of her wrist lacerations is definitely muted. No one is interested in the violence or her newly acquired wounds, everyone is interested in moving on as soon as possible.

The dynamic that jumps out at me whether I am listening to heavy drinkers talk about relationships or observing them first hand in bars is grandiosity.  Grandiosity can be a feature of mood disorders or narcissism.  One theory of grandiosity in narcissism is that there is an inadequate mental representation of affirming objects representing attributes or real relationships in the environment.  If people with those attributes are absent or the people present have an inadequate positive affiliation with the person in question they can form their own representations.  That leads to grandiosity and narcissism  as an amplification of a deficient process with more realistic balances.  In alcoholism this can occur as a reaction to the hopelessness of the addiction and its sequelae.  As an example, a bar full of middle-aged men with alcoholic liver disease betting on who is going to die first.  Sometimes it occurs on a larger scale - the family that supports their father's grandiose statements about drinking himself to death during a hospitalization for recurrent hepatic encephalopathy from alcoholic cirrhosis.  The person involved comes across as though they are indestructible - but at a deeper level they cannot reconcile the severity of their illness and their inability to stop drinking.

That is what I think the female character brings to this scene.  She is clearly in an abusive marriage that she fled earlier the same day that she comes into the pub.  She does not appear to be traumatized at all until she demonstrates the injuries and even then she is loudly mocking her husband and eventually herself: "I should have seen it coming!"  The men seem transfixed on this story - unable to challenge it or accept the reality of her status as an abused wife.

I saw one comment posted on the YouTube site from a person who watched this film on an airline flight.  He was left thinking about the lives of the people in the film and what happened to them.  That is natural enough and something I wondered when I encountered a heavily intoxicated young woman in Boston and tried to help her.  To me it is always a lesson in the dynamics of heavy alcohol use.  There is an element of intoxication involved, but there is more than that driving a lot of the interpersonal behaviors and what you see happening in a pub or bar.

Defensive behavior about the inability to stop can be part of that.                       

 

George Dawson, MD, DFAPA

Making Sense of Alcohol Consumption in the USA

I don't know how many people are aware of it but a crisis of alcohol use was declared about a week ago (1) by Marc Schuckit, MD.  Dr. Schuckit is one of the top psychiatric experts in alcohol use disorders and I have been reading his work for the past 35 years.  His commentary was based on an article (2) in that same issue of JAMA Psychiatry  on the epidemiology of alcohol use in the United states in the 21st century.

Most of the researchers listed as authors of this paper are affiliated with the Epidemiology and Biometry Branch of the National Institute on Alcohol Abuse and Alcoholism (NIAAA).  They are analyzing data collected in the National  Epidemiological Survey on Alcohol and Related Conditions (NESARC and NESARC-III)) during two different time points: 2001-2002 (N=43,093) and 2012-2013 (N=36,309).  Typical response rates were noted for both the initial selections and the individual response rates for the face-to-face interviews.  Both surveys were designed to be nationally representative samples adjusted to account for sampling error and non-response.  I interpret that to mean that the percentages listed in the following table to represent population wide numbers based on these samples. Respondents were paid $90 for participation.  The specific sampling strategies were listed in the paper.

The structured interview was the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV) in NESARC and AUDADIS-V in NESARC-III.  The definitions of high risk drinking are noted in the table.  DSM-IV diagnoses of alcohol abuse or dependence were given according to the suggested criteria match.  Various measures of reliability and validity of the structured interview are referenced as being fair to high.  All of the demographic variables noted in the test subjects are noted in the article as well as some discussion of how subgroups varied.  For example very  large increases were noted in practically all subgroups for 12-month DSM-IV AUD diagnoses with subjects in the 65 years and older increased by 106.7%  

Metric	NESARC (2001-2003)	NESARC III (2012-2013)	Percentage Increase
12-month alcohol use	65.4%	72.7%	11.2%
12-month high-risk drinking	9.7%	12.6%	29.9%
12-month DSM-IV AUD diagnosis	8.5%	12.7%	49.4%
12-month DSM-IV AUD among 12-month alcohol users	12.9%	17.5%	35.7%
12-month DSM-IV AUD among 12 month high-risk drinkers	46.5%	54.5%	17.2%

The trend according to this study is only in the upward direction.  The authors speculate about socioeconomic etiologies (unemployment, discrimination, income disparities, stigma of alcoholism) and increased permissiveness in what is acceptable drinking for women.  Subgroup analysis shows these groups had the highest increases in alcohol use.  The authors also point out that there are primary and secondary effects in these groups that can significantly increase the known morbidity and mortality associated with drinking such as more significant alcohol related illnesses in women for the same dose of alcohol due to decreased metabolic clearance and increased likelihood of adverse drug effects due to polypharmacy in both women and the elderly.  They also point out that alcohol related problems seem to have gone under the radar with higher visibility of less commonly used intoxicants like cannabis and hallucinogens.  I would add that permissiveness of intoxicant use in general is a cultural phenomenon and it probably not too surprising that the widespread legalization and hype about cannabis would be associated with increased alcohol consumption.  There are certainly many people with the belief that alcohol alleviates chronic pain, insomnia, anxiety, and depression as well as cannabis.  The popular notion that alcohol is a healthy beverage that provides protection against heart attacks and stroke is undoubtedly another factor.  Few people realize that the maximum number of drinks per day for men and women (2 and 1 respectively) was based on the fact that above that level the risks for cardiovascular disease and cancer increase significantly.

The new study also has some implications for other large scale estimates of alcohol use and the associated morbidity and mortality.  As an example, the World Health Organization came out with a large study in 2014 that reported on data from 2010 and 2012.  Comparison with the NESARC data shows that 12-month alcohol use (WHO v. NESARC III) is fairly close at 68.9 v. 72.7%.  Comparison of 12-month high risk drinking uses different measures.  For WHO, high-risk drinking is defined as at least 60 grams of alcohol in a single day in any 30 day period.  For NESARC III, the definition is 4 or more standard drinks on any day for women and 5 or more standard drinks on any day for men.  In the US, a standard drink is considered 14 g of pure alcohol.  That results in 16.2% of American drinkers being classified as heavy episodic drinkers and 12.6% classified as 12-month high risk drinkers.  From a diagnostic standpoint, WHO estimates that the prevalence of 12-month alcohol use disorders is 7.4% and NESARC III gives and estimate of 12.7%.  It is likely that different methodologies explain the marked difference in prevalence estimate for alcohol use disorders.  The WHO estimate was based on ICD alcohol use disorders as well as disorders representing harmful use of alcohol.  The NESARC III estimate was lay interviewers using a standard interview format to provide as DSM-IV diagnosis.  That means that the WHO estimate for alcohol use disorders based on the NESARC III data would be 20-30% higher than the 12.7% estimate.  A further note on the heavy episodic or high-risk drinking.  In treatment centers it is very common for people seeking admission to be drinking in excess of those rates on a daily basis.

A closely related phenomenon to high risk drinking is binge-drinking.  The CDC uses the same volume definition for high risk drinking but states that it occurs in an unspecified short period of time to elevate blood alcohol content above 0.08 g/dL.  According to their reviews the average binge drinker consumes 8 drinks per episode.  The main risk is alcohol poisoning.  Six people a day die of alcohol poisoning in the US, most of them are white men between the ages of 35 and 64.  Binge drinking carries with it all of the related risks of acute intoxication.

In his commentary, Dr. Schuckit reviews his concerns about the potential implications of alcohol use increases in both women and the elderly.  He points out that elderly patients almost always have co-morbid medical illnesses that will be exacerbated by drinking.  He discussed an intervention that his group did with 500 college freshmen as 4 - 50 minute internet-based videos.  The course was designed to help them recognize their vulnerability to heavy drinking.  The intervention was effective at both 6 and 12 months.  He concludes by focusing in on the threats to research funding in this area - specifically with the proposed cuts to the National Institutes of Health budget.  He suggests that supporting politicians who recognize the importance of research, identifying health crisis, and addressing them.

I think there is a lot of room to be a lot more proactive in our society.  Apart from the cultural myths that I already mentioned, a dangerous one is: "I am not an alcoholic and therefore I don't have any problems with alcohol."  The above research and others point out that it is possible to be a high risk drinker and not have a 12-month diagnosis of an alcohol use disorder.  Psychiatrists see variations of this pattern over the course of their careers.  They may be called on to assess the teenager in the ICU after they had an episode of acute alcohol poisoning after voluntarily drinking too much.  They may be called on to assess people who were violent or victimized when they drank too much.  They may have to do specialized assessments on professionals who engaged in high risk drinking for some reason and ended up placing their credentials and licensure at risk.

It is time to realize that there is much more to alcohol use than being an alcoholic or technically having a diagnosis of an alcohol use disorder.  Even one episode of high risk drinking may end or permanently alter a persons life.  Education on alcohol use is needed to dispel these popular myths and help people negotiate what is commonly a difficult decision in their life.  


George Dawson, MD, DFAPA






References:

1: Schuckit MA. Remarkable Increases in Alcohol Use Disorders. JAMA Psychiatry.2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.1981. [Epub ahead of print] PubMed PMID: 28793142.

2:  Grant BF, Chou SP, Saha TD, Pickering RP, Kerridge BT, Ruan WJ, Huang B, Jung J, Zhang H, Fan A, Hasin DS. Prevalence of 12-Month Alcohol Use, High-Risk Drinking, and DSM-IV Alcohol Use Disorder in the United States, 2001-2002 to 2012-2013: Results From the National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.2161. [Epub ahead of print] PubMed PMID: 28793133.

3:  World Health Organization.  Global Status Report On Alcohol and Health, 2014 edition. 

4:  CDC Press Release November 20, 2014.  Most people who drink excessively are not alcohol dependent. 

5: Quinn AE, Brolin M, Stewart MT, Evans B, Horgan C. Reducing Risky Alcohol Use: What Health Care Systems Can Do. Issue Brief (Mass Health Policy Forum). 2016 Apr 27;(46):1-50. PubMed PMID: 27911073.

6: Stahre M, Roeber J, Kanny D, Brewer RD, Zhang X. Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States. Prev Chronic Dis. 2014 Jun 26;11:E109. doi: 10.5888/pcd11.130293. PubMed PMID: 24967831; PubMed Central PMCID: PMC4075492. 

7: Landen M, Roeber J, Naimi T, Nielsen L, Sewell M. Alcohol-attributable mortality among American Indians and Alaska Natives in the United States, 1999-2009. Am J Public Health. 2014 Jun;104 Suppl 3:S343-9. doi: 10.2105/AJPH.2013.301648. Epub 2014 Apr 22. PubMed PMID: 24754661; PubMed Central PMCID: PMC4035890. 

8: Gonzales K, Roeber J, Kanny D, Tran A, Saiki C, Johnson H, Yeoman K, Safranek T, Creppage K, Lepp A, Miller T, Tarkhashvili N, Lynch KE, Watson JR, Henderson D, Christenson M, Geiger SD; Centers for Disease Control and Prevention (CDC). Alcohol-attributable deaths and years of potential life lost--11 States, 2006-2010. MMWR Morb Mortal Wkly Rep. 2014 Mar 14;63(10):213-6. PubMed PMID: 24622285. 

9: Sacks JJ, Roeber J, Bouchery EE, Gonzales K, Chaloupka FJ, Brewer RD. State costs of excessive alcohol consumption, 2006. Am J Prev Med. 2013 Oct;45(4):474-85. doi: 10.1016/j.amepre.2013.06.004. PubMed PMID: 24050424. 

10: Nelson DE, Naimi TS, Brewer RD, Roeber J. US state alcohol sales compared to survey data, 1993-2006. Addiction. 2010 Sep;105(9):1589-96. doi: 10.1111/j.1360-0443.2010.03007.x. Epub 2010 Jul 9. PubMed PMID: 20626370. 

11: Woerle S, Roeber J, Landen MG. Prevalence of alcohol dependence among excessive drinkers in New Mexico. Alcohol Clin Exp Res. 2007 Feb;31(2):293-8. PubMed PMID: 17250622.

12:  WHO Global Information System On Alcohol and Health: http://www.who.int/gho/alcohol/en/


Supplementary:

Click to enlarge and clarify the graphic at the top of this post.

Supplementary:

This article was published after the original post and is presumptive evidence that the trend in consumption is real:

Death Rates for Chronic Liver Disease and Cirrhosis, by Sex and Age Group — National Vital Statistics System, United States, 2000 and 2015. MMWR Morb Mortal Wkly Rep 2017;66:1031. DOI: http://dx.doi.org/10.15585/mmwr.mm6638a9

Alcohol Overuse After Gastric Bypass Surgery

Alcohol use disorders after gastric bypass procedures are a significant complication of this surgery.  I typically see people who have developed the disorder after the gastric bypass procedure.  The majority of those procedures these days are Roux-en-Y (RYGB).  The surgical mechanics of RYGB are widely available and I am not going to review them here.  This post is about how the procedure can change a person into a problem drinker endangering both their health and in some cases leading to substantial weight gain after initial losses from the bypass procedure.  Although there are other surgical techniques used for gastric bypass that also lead to this complication RYGB is the most common technique and is more likely to be studied.  In the figures above, blood alcohol levels are determined in individuals who had undergone RYGB surgery after ingestion of alcohol.

One of the well known principles in addiction medicine is that overuse of any potentially addictive substance generally follows pharmacological principles especially as tolerance to a drug develops.  Other factors such as economics, whether a drug can be used by a particular route, and biologically determined sensitivities to drugs can modify that basic concept.  To illustrate, most current opioid users with addiction problems started by using prescription painkillers.  They may have modified the original prescription pills by crushing them and either smoking or snorting them.  In some cases, they crush the pills, dissolve them, crudely filter them and inject them.  In this case they are trying to optimize the time to peak drug concentration Tmax and maximum drug concentration Cmax for maximum effect.  In the case of alcohol, it is generally too dangerous to use by the inhaled or intravenous route.  The effects are limited by absorption and elimination by zero order kinetics.

The graphics at the top of this page are from reference 1. It shows the results of blood alcohol concentration of 5 RYGB patients after drinking a solution of 40% vodka and orange juice calculated to contain 0.3 gram per kilogram body weight. The vodka and orange juice mixture was adjusted to contain a 50:50 mix of vodka:orange juice. Mean dose of ethanol given was 26.9 ± 2.3 grams or about 2 standard drinks consumed over a period of 5 minutes. On the graphs alcohol concentration is given as mg/dl. In the US, the current legal driving limit is 80 mg/dl or 0.08%. The researchers decided to look at the time from 0-10 minutes apart from 0-60 minutes because previous work started the measurements at 10 minutes.  The other point to notice in these graphs is that there is no control group.  That is unfortunate given the variable methods (alcohol dose and consumption time) that are used to determine the pharmacokinetics of alcohol in research papers that look at this question.

A comparison with control subjects in the literature can be done, but I could not find any studies that used a dose of 0.3 g/kg of ethanol.  Many studies used a dose of 0.6 g/kg.  The study used in the comparison below used a dose of 0.8 g/kg ingested over 30 minutes.   Comparing Tmax and Cmax for the study on RYGB patients to a study of 12 healthy male controls shows the following differences:

	Male controls (n=12)	RYGB patients (N=5)
Cmax (mg/dl)	106	138.4
Tmax (min)	60	5.4

Experimental differences aside. the Cmax and Tmax for alcohol in the RYGB patients are markedly different.  The time to peak alcohol levels was only 5.4 minutes in the RYGB group and at that time the average Cmax easily exceeded the legal driving limit on what amounts to 2 standard drinks.  Although the study did not correlate the rapid peak of alcohol with effects, they are readily observed by any clinician interested in how intoxicants affect the conscious state of the patient.  People typically tell me that they feel immediate intoxication or in some cases blackout.  The intoxication is a rapid sense of euphoria combined with an immediate cessation of negative mood states.  In the case of blacking out, this is a frequent end point with severe alcohol addiction.  Many people are self professed "black out drunks" and that is their preferred endpoint of acute intoxication and the goal of subsequent drinking sessions.  These states are highly reinforcing for susceptible people and probably explain the greater than expected occurrence of alcohol related disorders following RYGB surgery.  Looking at the prevalence of alcohol use disorder (AUD) before and after RYGB surgery, Mitchell, et al found that 8% had AUD within the 3 year post op period including 48% who had no prior history of AUD.  Including a more permissive screening tool the number increased to 18.4% and 40.6% respectively.  A previous study  showed that the prevalence of AUD symptoms was greater in year 2 post gastric bypass surgery (9.6%) and was associated with a number of preoperative variables including RYGB, male sex, smoking, and regular alcohol consumption before the procedure.

The studies that look at the prevalence of alcohol use are interesting.  From the perspective of an addiction psychiatrist who only sees patients selected for addiction, observing the effect of scale is significant.  As an example, the patients who I see with this problem are predominantly women and practically all of them did not have an alcohol use problem prior to surgery.  In many cases they did not drink alcohol.  Practically all had undergone RYGB but there were also people with other bypass procedures. 

An additional research question has been whether the anatomic changes in RYGB lead to changes in the brain and central nervous system that changes addictive behavior.  The model used for these investigations have been obese rats that have undergone RYGB and intravenous self administration of alcohol and drugs.  That model would eliminate pharmacokinetic considerations from oral administration with rapid increases in plasma concentration in a short while.   Rats with RYGB self administer intravenous alcohol and opioids at a higher rat than rats that have not had gastric bypass surgery suggesting a centrally mediated mechanism more independent of gut absorption (5,6).  One set of authors (5) proposed that in obesity there is blunted dopamine and ghrelin signalling.  They make the case that leptin and ghrelin both affect dopaminergic signalling in the reward system. (see diagram - click to enlarge).  

Despite being well known to eating disorder and addiction specialists, I don't think the phenomenon of alcohol overuse in gastric bypass patients is well known.  It has implications for informed consent for this surgical procedure, some risk factor modification, and follow up.  It also may have implications for the diagnosis and treatment of alcohol use disorders.  As an example, binge drinkers and blackout drinkers are a known subset the population of people with alcohol use disorders.  Does this group have any similarities with the population of RYGB patients who develop alcohol use disorders?  What would pharmacokinetic studies of alcohol in this group show?  If a profile of peptide hormone changes in the RYGB group is defined - should that be studied in binge and blackout drinkers as well?

These might lead to useful endophenotypes for alcohol use disorder that could lead to treatment interventions.


George Dawson, MD, DFAPA


References:

1:  Steffen KJ, Engel SG, Pollert GA, Li C, Mitchell JE. Blood alcohol concentrations rise rapidly and dramatically after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2013 May-Jun;9(3):470-3. doi: 10.1016/j.soard.2013.02.002. PubMed PMID: 23507629; PubMed Central PMCID: PMC4487806.

2:  Jones AW,  Jönsson KÅ.  Between subject and within subject variation in the pharmacokinetics of ethanol.  Br J Clin Pharmac 1994; 37: 427-431.

.
3:  Mitchell JE, Steffen K, Engel S, King WC, Chen JY, Winters K, Sogg S, Sondag C, Kalarchian M, Elder K. Addictive disorders after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2015 Jul-Aug;11(4):897-905. doi: 10.1016/j.soard.2014.10.026. PubMed PMID: 25862182; PubMed Central PMCID: PMC4430439.

4:  King WC, Chen JY, Mitchell JE, Kalarchian MA, Steffen KJ, Engel SG, Courcoulas AP, Pories WJ, Yanovski SZ. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA. 2012 Jun 20;307(23):2516-25. doi: 10.1001/jama.2012.6147. PubMed PMID: 22710289; PubMed Central PMCID: PMC3682834.

5:  Polston JE, Pritchett CE, Tomasko JM, Rogers AM, Leggio L, Thanos PK, Volkow ND, Hajnal A. Roux-en-Y gastric bypass increases intravenous ethanol self-administration in dietary obese rats. PLoS One. 2013 Dec 31;8(12):e83741. doi: 10.1371/journal.pone.0083741. PubMed PMID: 24391816; PubMed Central PMCID: PMC3877092.

6:  Biegler JM, Freet CS, Horvath N, Rogers AM, Hajnal A. Increased intravenous morphine self-administration following Roux-en-Y gastric bypass in dietary obese rats. Brain Res Bull. 2016 May;123:47-52. doi: 10.1016/j.brainresbull.2015.08.003. PubMed PMID: 26304761; PubMed Central PMCID: PMC4761525.

Attributions:

1.  Figure at the top of this post is used with permission from copyright holder Copyright © 2013 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved through license 4007221260909 via the Copyright Clearance Center.

2.  Figure at the bottom is from VisiScience and is used per their licensing agreement.

Why Is The Cirrhotogenic Dose Of Alcohol Important?

The Standard Drink http://rethinkingdrinking.niaaa.nih.gov/How-much-is-too-much/What-counts-as-a-drink/Whats-A-Standard-Drink.aspx

One of my main tasks during an interview is assessing the medical condition of the patient.  That is important in determining associated comorbidity, potential causes of psychiatric symptoms, factors that might affect how any medications I assess or prescribe are metabolized, medical tests that I need to order and follow, the insight and functional capacity of the patient - are they aware of the physical problem and doing something about it, and any referrals that I need to suggest and make to primary care physicians or specialists.  When I see people who are using significant amounts of alcohol - alcoholic liver disease and cirrhosis are high on that list.  In many cases they are seeing me and already have a diagnosis of cirrhosis, but nobody else in the current system of care seems to know that.  Continuity of care is really not an administrative priority in American health care.  We all practice in administrative silos defined by electronic health records (EHRs) that don't talk to one another and produce very low quality printouts.  Just recently I reviewed an EHR printout that was 30 pages long.  As usual the hospital and dates of service were not evident.  About 20 of those pages was a consultant's report that pulled in every lab the person across their lifetime - spread in uneven columns across the pages.

How to get to these important but obscured diagnoses?  It is always important to ask about hepatitis and cirrhosis.  I also ask about infectious and alcoholic types.  Some standard review of systems include questions about jaundice and that is a good one to ask.  Non-standard question include asking about seeing a gastroenterologist or liver specialist.  I will ask about specific imaging like hepatic ultrasounds, CTs, and MRIs.  I will ask if there has ever been upper GI endoscopy or colonoscopy, the indications, and what they were told about the findings.  I will ask about whether a doctor has ever told my patient to stop drinking and why?  In the population of moderate to heavy drinkers that I see, it is rare to find all of a person's care provided at one location.  There are typically emergency department visits and hospitalizations that the primary care MD is not aware of.  There may be attempts to treat the alcohol use problem and there is often not a very strong medical component associated with that treatment.  The patient may be actively avoiding contact with medical care out of fear of what might happen with the illness.  All of these factors make it extremely important not to miss the diagnosis and at the minimum recommend optimal care for that person.

From a strictly historical standpoint, the key question is whether there are some historical markers that allow for the stratification of risk.  Can you tell whether your patient might have cirrhosis just based on their drinking history?  Moderate to heavy drinkers vary considerably in their veracity on reporting alcohol use.  It may depend on the phase of treatment.  A reliable description of consumption may occur early in treatment after a conscious decision to "come clean" about it.  There will be a number of people who are not ready to stop drinking irrespective of the quantity they are drinking and the problems that it has caused.  They might be in the assessment because of external factors like family members who are upset by their drinking.  There are also the limits of memory.  If a person acknowledges 20-30 years of moderate to heavy drinking and multiple DWIs in their early 20s - they are unlikely to provide a detailed description of their progression of drinking and may only hit a few of the high points - like when they started experiencing blackouts on a daily basis.  In my experience, most moderate to heavy drinkers focus on the last 2 or 3 years of drinking.  That can create the impression that they have not been drinking long enough to cause significant damage.

Part of the problem in taking the clinical history of drinking is that there can be a bewildering array of drinks and measures - often to the point that the clinician is not sure about absolute quantities or alcohol concentrations.  The literature on cirrhosis and alcoholic liver disease often requires a conversion to standard drinks or grams.  Those drink sizes especially the ones that are culturally determined (there are definitely drinking subcultures in the US) or self-determined can lead to wide variation in the amount of alcohol actually consumed.  Collateral information is always very useful.  From the graphic at the top of this page 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.   That is 14 grams or 0.6 ounces of pure alcohol.  The amounts that I hear about being consumed include a mini bottles (50 ml), a pint (473.2 ml), a fifth (750 ml), a liter (1000 ml), and a handle (1500 ml).  Consuming the entire container of these beverages is the equivalent of taking 1,  10.7, 17, 22, and 33.8 - 1.5 ounce standard drinks respectively.  In the literature the standard drink size in Australia is 10 grams of alcohol or 30 ml of 40% alcohol rather than the 14 grams specified in the US.  That results in more drinks per beverage or container.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has several definitions that are based on consumption that are useful.  Binge drinking is defined as 5 or more drinks on a single occasion for men or 4 more more drinks on a single occasion for women - usually in less than 2 hours.  Heavy drinking is defined as 15 or more drinks per week for men and 8 or more drinks per week for women.  9% of the US population exceeds both the single day and weekly consumption limits of these definitions.   28% of the US population will exceed either the single day limit or the weekly limit.  37% always drink within low-risk limits and 35% never drink.  Those results are based on a sample of 44,000 Americans 18 years of age and older.                              

What are the estimates of alcohol use that cause cirrhosis?  The first time I encountered this concept was in a Medical Clinics of North America reference (1) that suggested 15 pint years of drinking a pint of whiskey per day for 15 years.  The American College of Gastroenterology makes a different estimate of 20-40 grams of alcohol daily -  will result in liver damage in most women.  They go on to specify that 80 grams of alcohol per day will lead to cirrhosis in men in 10 years and the same amount of daily alcohol consumption will lead to cirrhosis in women in 5 years.  They also specify that in their use, 4 drinks is 4 - 5 ounces of distilled spirits so the standard drink size is less than the usual definitions.  Converting all of those numbers into standard drinks -

20 grams = 1.4 standard drinks
40 grams = 2.9 standard drinks
80 grams = 5.7 standard drinks

In other words 5.7 standard drinks per day will result in cirrhosis in men in 10 years or cirrhosis in women in 5 years.  On a clinical basis, I have seen very young people with alcoholic cirrhosis and the youngest were women in their late 20s.  So the range for cirrhosis in the literature ranges from a low of about 1/2 pint of 80 proof alcohol per day for 5 or 10 years to 1 pint of 80 proof alcohol per day for 15 years.

The Australian National Health and Medical Research Council (NH&MRC) recommends that the maximum standard drinks per day for men is 4 and for women is 2.    The range between the high and low estimates of toxicity is considerable given the fact that a pint of distilled spirits contains 10.7 standard drinks.  The pint-a-day drinker exceeds both the NIAAA maximum recommended single day and weekly consumption.

There are a number of variables that affect the individual pharmacokinetics of alcohol and ultimate toxicity.  Patterns of consumption are also important.  Knowing the range of alcohol consumption that may have already impacted the patient is useful in terms of deciding if the history is accurate and how the treatment plan may need to be modified.  It is also useful to know from a public health perspective, especially in the current era of liberalizing policies and attitudes about intoxicants.  




George Dawson, MD, DFAPA


References:


1: Lefton HB, Rosa A, Cohen M. Diagnosis and epidemiology of cirrhosis. Med Clin North Am. 2009 Jul;93(4):787-99, vii. doi: 10.1016/j.mcna.2009.03.002. Review. PubMed PMID: 19577114.


Supplementary 1:

The dose of alcohol that is associated with pancreatitis is 4 or 5 drinks daily for a period of 5 or more years.

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


Supplementary 2:

British National Health Service guidelines based on a standard drink of 25 ml of 40% alcohol.



Attribution:

Graphic at the top of this post is from the NIAAA we site Rethinking Drinking and is in the public domain at the references URL.