Dry January? Why Not the Rest of the Year?

 

Every January one of the frequent pledges is to not use alcohol for the month.  In my capacity as a psychiatrist – I have had patients tell me that if they could do it was a sign that they were not an alcoholic because it shows that they can control their drinking.  Never mind the excessive drinking and adverse consequences the rest of the year.  I saw an exchange between a sober bartender and a stress drinker portrayed in a new TV series just today.  It went something like this:

Patron: “I stopped drinking whisky because I am an alcoholic – so I just stick with beer.”

Bartender: “Well you know there is alcohol in beer.”

Patron: (motioning to his light beer) “There is more alcohol in orange juice than there is in this”

Bartender: “I’m just saying…”

Patron: “I’ll tell you what – let me drink 6 of these beers and 6 whiskeys and you tell me which one has more alcohol.”

And so, it goes. If you have a problem with alcohol or any other substance (or behavior) that reinforces its own use – there are endless rationalizations to keep using it and never enough deterrents.  Studies have shown that it often takes a life-threatening problem or major life event to quit - but even that may not be enough.  I am witness to many people who kept drinking despite end stage liver disease in some cases fully supported by their family: “It’s his choice – if he wants to drink, he is free to drink.”   It seems that the only advocates for sober living are in Alcoholics Anonymous or other 12 step recovery groups.  I did post on the Curious Sober movement in the younger generation but that has either not caught on or it is not being adequately covered if it has.

The history of using intoxicants is long and detailed. The two dominant evolutionary theories are that the substances are used because of a mismatch of currently abundant intoxicants on a reward and endogenous opioid system originally there for other reasons or as a form of self-medication that can be observed in other primates. The latter idea is that primates learn that there are certain plants that contain compounds that can treat ailments.  Both of those theories leave out the cultural elements that include social settings, celebrations, religious ceremonies, traditions, and local customs that use intoxicants as part of the event. There are cultural portrayals in movies and television showing alcohol and other intoxicants as necessary to alleviate daily stress.  In more modern times, some of these substances are imbued with magical qualities like being vehicles for mind expansion or even cures for mental illnesses.

The reality of substance use for practically all of the people I have talked with who do not have a substance use problem comes down to using alcohol of drugs to get an enjoyable “buzz”, to get a heightened sense of social competence from the initial relaxation, or just going along with the crowd.  In many crowds there is intense peer pressure to not be the one who is not drinking or smoking cannabis. That is a major source of binge use in the late teens and early 20s. Even in those social situations it is common for people to experience excessive use, intoxication with impaired judgment, and bad outcomes.  I have talked with too many people who sustained severe legal consequences from a single night of excessive drinking. I have also talked with too many people to remember who were admitted to my acute care psychiatric unit based on something that happened when they were acutely intoxicated.

I have covered this issue in the past and will link that post here without having to repeat it.  The basic issue for me is why use intoxicants at all?  Considering just alcohol - it is a neurotoxin, a carcinogen, and a direct toxin to the pancreas, the heart, and the liver. For years it was promoted as a “heart healthy” drink despite methodological problems with studies that put subjects with significant alcohol exposure in the control group.    

There are both informal and professional advocates for getting high. One of the most well-known advocates estimates that 70-90% of people can use intoxicants and they do not become problematic.  He describes his own use of heroin as useful because it results in a “happy and stress-free feeling”, helps him “maintain work-life balance”, and should be legal for everybody.  He also describes the pain of heroin withdrawal but apparently does not see that as a deterrent.  A key question is whether it is possible to get to that “happy and stress-free feeling” without using heroin?  How many people are operating under this premise today as they use various intoxicants some of which are excessively hyped as being good for your mental health? American culture is promoting the idea that you can fine tune your brain by using intoxicants even though there is no evidence this works.  To promote that idea, we have been exposed to 20 years of intoxicants advertised as medical treatments beginning with cannabis.  As the dust settles this idea has little to substantiate it, adverse effects have been minimized, and commercial conflicts of interest have not been disclosed.

The basic consideration comes down to the values you have established for yourself and whether those values can be affected by intoxicants.  There are many approaches to values that apply to intoxicant use. There are several religions, philosophical approaches, and recovery movements that value not using alcohol or other intoxicants as well.  You may value your short term and long-term health and consider not using intoxicants on that basis.  You may have had a close call while intoxicated and decided that you did not want to take that chance again. You might even survey the damage done to your family by intoxicants and decide they are too risky to sample.  On the other hand, you can walk into any small-town bar in the Midwest and people will be joking about the effects of alcohol and in some cases about who has developed cirrhosis or died as a result. They may also be joking about the associated behaviors of excessive intoxication.  Gallows humor is an easily observed adaptation.  There are subcultures that value alcohol use – no matter what.  I would argue that extreme position is a direct result of the reinforcing effects of alcohol rather than any de novo philosophical position. 

In the final analysis this is not about whether intoxicant use is a disease or whether you can control the use or even gain something from it.  Most of the popular discussion comes down to political arguments. In other words – I have a particular belief system about intoxicants and I will marshal every possible bit of evidence to support my position. I will be the first to acknowledge that as an acute care and addiction psychiatrist – selection bias was certainly in effect. I would see the worst possible scenarios.  But I have also seen people in real life who were clearly not doing well at all varying from an intoxicated man I tried to help at 7AM in northern Wisconsin to a young woman my wife and I tried to help in Boston.  You can argue that those folks still had a substance use disorder and most people using intoxicants do not.

In that case – I would offer the personalized evidence.  If you are having a Sober January and things are unchanged, going well or even better than usual – why change that?  

Keep it going.

 

George Dawson, MD, DFAPA

 

 

Graphics Credit - click photo for all details:

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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