“My problem is not that serious!” The reality of alcohol related disorders

I have had various patients come to my practice wondering about their alcohol intake, how far from “normal” it is, and how close to “alcoholism” has it become. They fear the idea of becoming an alcoholic, often recognizing the illness by having lived with a family member, and other times simply fearing the idea of losing control. This fear has led to avoidance, and more often than not, a minimization of the effects of alcohol on that person’s life. The questioning itself is evidence of concern, and though most times patients provide the many reasons why their “problem is not that serious!”, there is often a sense of vagueness left in the room, a feeling of unfinished business, allowing for further exploration of the motivation for remaining the same or eliciting change.

At some point, one decides that something is not right, and then the question of what to do arises. “Can I stop on my own?”  “Do I need treatment?” “What if I try to moderate my drinking?”

I decided to write this blog after attending an Addictions training by Mc Lean hospital, division of alcohol and drug abuse. While there, one of the attendees brought up the idea of two different approaches to treatment, namely moderation vs abstinence. Naturally, this led to an intriguing interaction amongst addiction specialists, with the final thought being that cutting back is not a treatment considered for individuals with alcohol use disorder. Still, I wondered about “binge weekend drinkers”. Is cutting back really possible? What barriers can I foresee in the implementation of moderation? Many other questions sparked my curiosity, and lead to me to write a blog that might help answers some of these questions.

Let’s start with the DSM 5 criteria for alcohol related disorders

Alcohol Use Disorder Diagnostic criteria:

A.    A problematic pattern of alcohol use leading to clinically impairment or distress, as manifested by at least two of the following, occurring within a 12 month period.

1.       Alcohol is often taken in larger amounts or over longer periods that was intended.

2.       There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

3.       A great deal of time is spent in activities necessary to obtain alcohol, use alcohol or recover from its effects. 

4.       Craving, or a strong desire or urge to use alcohol.

5.       Recurrent alcohol use resulting in failure to fulfil major role obligations at work, school or home.

6.       Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused by exacerbated by the effects of alcohol.

7.       Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 

8.       Recurrent alcohol use in situations that are physically hazardous.

9.       Alcohol use is continued despite the knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

Tolerance as defined by either of the following:

·         A need for markedly increased amounts of alcohol to achieve intoxication or desired effect

·         Markedly diminished effect when continued use of the same amount of alcohol.

Withdrawal as manifested by either of the following:

·         The characteristic withdrawal syndrome for alcohol (refer to criteria A or B of alcohol withdrawal)

·         Alcohol (or closely related substance, such as benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

**Specify current severity:
                Mild: Presence of 2-3 symptoms
                Moderate: Presence of 4-5 symptoms
                Severe: Presence of 6 or more symptoms

In my current practice I have found myself treating mild to moderate drinkers, the most common symptoms that lead them to seek treatment are the following:

1.       Alcohol is often taken in larger amounts or over longer periods than intended.

2.       There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

3.       Continued alcohol use, despite having persistent or recurrent social or interpersonal problems, caused by being exacerbated from the effects of alcohol.

4.       Recurrent alcohol use in situations that are physically hazardous.

5.       Alcohol use is continued despite the knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

Tolerance as defined by either of the following:

·         A need for markedly increased amounts of alcohol to achieve intoxication or desired effect

·         Markedly diminished effect when continued use of the same amount of alcohol.

Do you meet criteria for any of these symptoms?

If you do, it’s time to get help! Many times the people around you might be the first ones to raise the concern about your drinking; this may be as a result of them witnessing some of the behaviors that might be “out of [your] character.” Drinking affects a part of your brain called the prefrontal cortex, a region of the brain involved in decision making.  “The prefrontal cortex is a part of the brain that helps us decide whether we should take action or not” said John J. Woodward, a professor in the department of neuroscience and the Center of Drug and Alcohol Programs at medical university of South Carolina. “It weighs the relative risks and benefits of our behavior and normally protects us from risky or dangerous actions, or those that might be inappropriate during social situations. When the PFC is damaged or its activity is decreased, behavior can change dramatically and people can lose much of their inhibition and ability to weigh the consequences of their actions.”

It is sometimes the risky behaviors that lead to concern and worry from those who love you. Recognizing that this can be a problem is extremely difficult.  Seek support and resources that can help you in understanding what this means, as trying to figure it out on your own may be an overwhelming process.

What now?

There are a couple of options, which I will discuss below:

1.    A trial of abstinence:

During the trial of abstinence you abstain completely from alcohol for one month. This is to be done under the guidance of a clinician that can track how you are doing during the time of abstinence. Some important points to process are: how it feels to be completely abstinent, any challenges and difficulties that you may encounter, and any cravings or urges during this time.  Also, it is important to note the positive aspects of this period, are your friends happy that you are not drinking and more likely to want to be around you? Have some on-going arguments decreased in your relationship because you are no longer drinking? Are you engaging in new activities because you are no longer spending a day getting over your hangover?  Keep in mind that a hangover is your body’s reaction to poisoning and withdrawal from alcohol. Hangovers begin about 8-12 hours after that last drink and symptoms include fatigue, headache, sensitivity to light and noise, general muscle aches, nausea and vomiting, mild diarrhea, shaking and tremors, thirst, and red eyes. These symptoms vary according to the individual and the quantity of alcohol consumed. If you consume alcohol daily, withdrawal can lead to seizures, very serious confusion, and can be fatal. In this case, you will need an admission to a detoxification unit to allow for a safe withdrawal with the use of medications.

The point of this trial is for you to become increasingly aware of how alcohol was affecting your life, and notice the difference. It will give you an idea of where you stand with this issue and how serious it really is.

2.    Cutting down – moderation, moderation, moderation!!!

Let’s discuss some facts first.

What is the criterion for binge drinking?

For women 4 drinks and for men 5 drinks are considered over the limit. Please be aware that the amount of each drink is a crucial detail, if your drink of preference is hard liquor each drink must contain 1 and half ounces max, wine 5 ounces and beer 12 ounces. In addition, there are some factual differences between men and women that need to be considered. There are several physiological reasons that cause women to be more susceptible to alcohol’s damaging effects than are men. First, women have less body water (52% for the average woman versus 61% for the average man) so men are likely to dilute alcohol more than a woman, even if both weigh the same. Secondly, women have less alcohol dehydrogenase, an enzyme that breaks down the alcohol, therefore a woman’s body will break alcohol more slowly than a man’s. Lastly, premenstrual hormonal changes cause intoxication to set in quicker during the days before a woman’s menstrual time. Birth control pills or other estrogen concentrated medication will slow down the rate at which alcohol is eliminated.

Alcohol is metabolized by the liver, where enzymes break down the alcohol. Understanding the rate of metabolism is critical to understanding the effects of alcohol. In general, the liver can process one ounce of liquor per hour, if you drink more, your system becomes saturated and the additional alcohol will accumulate in the blood and body tissues. This can result in high blood alcohol concentrations that can last for several hours.

As you can see moderation may sound like an easy task, but it is actually extremely difficult, and there are facts that always need to be considered. You are always welcome to try on your own, and then assess where you stand. As I began to write this blog, I looked at some of the information provided on the internet, and I noticed that the suggestions given were truly unrealistic, and are very challenging to do on your own. Some of the suggestions I found were, learning to say no, count your drinks, don’t forget to eat, never drink alone, never drink for courage, meet for coffee, not for drinks!! But wouldn’t this be difficult to apply if you think that you don’t have a problem? The first step to change is acknowledgement, so let’s continue.

In my work with patients I often talk about mindfulness, and I am a true believer that it helps. If you are up to the challenge and you want to go out one night and attempt to count your drinks, notice how it feels, notice if your mind starts rationalizing and telling you all the good reasons why you should have that 5th beer. Notice how fast you want to go back to the bar, or how fast the second drink goes down. Notice your anxiety when being around people without being “tipsy” or drunk. Notice the pressure that you get from others to have that one last drink, and how that affects your choices. The goal of this challenge is to be fully aware of what goes on, and how much control you really have.

I think it’s extremely important to help you understand what barriers can get in the way of moderation. My job as a clinician is to help you understand that the lack of control can be a major barrier to being able to simply count your drinks. There are two ways in which people know that they are beginning to drink beyond their limit.

1.    Amount: “I’ve had two drinks, that’s enough. I am going to stop.
2.    Effect: I am feeling tipsy, I’ve had enough, and I am going to stop.

If your ability to stop is not there, you might have to consider professional help.  If you are ready for help, contact us at 617-834-4235 or info@insightbrookline.com.