Alcohol: the Good, the Bad and the Ugly
Acknowledgement is made to Michael Pollan’s informative essays. I also thank my daughter, Ali Klein, for her invaluable encouragement and criticism.
Before launching into the considerable hazards of alcohol, let me begin by saying that I sometimes enjoy the buzz that comes from drinking it, just as I enjoy taking automobile or airplane rides for pleasure. We do things for pleasure in spite of their risks. Pleasure is a reasonable goal in itself.
The use of alcohol and other mind-altering substances has a long history. Cultures have been using psychoactive substances (not only alcohol) for as long as there have been cultures. As Michael Pollan has observed, something about us is just not satisfied with ordinary consciousness and seeks to transcend it in various ways, some of them disruptive and others generally accepted as productive, like drinking coffee. He writes, “But context is everything: In many Native American communities, peyote, a psychedelic, is not at all disruptive; to the contrary, its ceremonial use promotes social cohesion and heals trauma.” Thus, alcohol is incorporated into many people’s lives in a nondestructive manner. They may have a drink at dinner or in social situations, without lasting harm. But, it can be destructive if done to excess or in circumstances like drunken driving. Any assessment of the harms of alcohol has to take into account individual variation and tolerance.
In Greek mythology Dionysus was the God of Wine (with the Roman counterpart Bacchus).
Shesmu was the ancient Egyptian god of wine. Odin, in addition to being the king of the gods in Norse mythology, was also the god of alcohol. That is how important drinking alcohol was to the ancients!
It also figures prominently in the Judeo-Christian religion. When Jesus attended a wedding at Cana and the wine ran out, he turned water into wine. In the Sacrament of the Holy Eucharist in Catholicism wine (not water!) symbolizes Jesus’ blood. In the Jewish celebration of Passover, which commemorates the Hebrew deliverance from slavery, for some reason the prophet Elijah gets a lot of sips of wine at millions of seders throughout the world, just as Santa comes down all those chimneys — two amazing feats in space and time. Soot is probably more benign than wine. Would you trust a drunken prophet? (The deliverance occurred hundreds of years before Elijah, suggesting that Moses might appropriately be the seder wine-sipper!)
Drinking alcohol is often taken for granted as the norm, and the question “Do you drink?” is intended to mean alcohol. The cocktail party is a fixture of modern life.
Most of us don’t drink before a certain hour in the day. We drink only in the company of others. We eat food with alcohol; after drinking, we don’t drive — a practice codified in law. The people who follow these rules and rituals are by and large not the people who get into trouble with alcohol. Even at such a serious venue as the United Nations, the Lounge figures importantly in mingling and negotiations. One might worry about serious matters being determined while “under the influence,” but then again, alcohol is the “social lubricant” and thus a facilitator.
Not every American drinks alcohol. Only 69.5 percent reported that they drank in the past year. Some prefer a “natural high.” Emily Dickinson celebrated it in verse: “Inebriate of air am I/And Debauchee of Dew…”
Addiction like alcoholism may be defined as compulsive substance use despite harmful consequence. Alcohol addiction appears to have been on the increase as the Covid pandemic has pushed many anxious, desperate and isolated people to drink to excess.
Alcohol abuse can be driven by a complex array of factors, including stress, depression and anxiety, as well as a person’s genetics, family history and socioeconomic circumstances
We shouldn’t forget that two of the most destructive drugs in use today — alcohol and tobacco — have long been perfectly legal.
Not all non-drinkers are “recovering alcoholics”, although this may sometimes be assumed to be the case. In any case, that is an odd term that suggests the dubious proposition “Once an alcoholic, always an alcoholic”, and that a reformed alcoholic can never drink again with impunity.
This brings us to the subject of Alcoholics Anonymous (AA — not to be confused with the American Automobile Association), an important entity in the struggle against alcoholism. Does AA work? It is hard to tell. One could conceivably do a prospective study in which participants were randomly assigned to join AA or not. The problem is that the success of AA depends on the motivation of the participant, not a directive to join it. Some alcoholics find the traditional 12 steps to be rigid and too much oriented toward religion. After all, atheists can be alcoholics. There are several references to God, such as “We came to believe that a Power greater than ourselves could restore us to sanity,” and “We made a decision to turn our will and our lives over to the care of God as we understood Him.” That said, one can redefine God or a Power greater than ourselves to mean any sort of abstract entity in which to put one’s confidence. It can be the universe, nature, energy or self-will. Even AA says “Members are free to choose for themselves what their higher power is.” Some alternative organizations like Rational Recovery eschew the religious connection and emphasize self-efficacy i.e. confidence in self-control.
One virtue of AA and its twelve steps is humility, as exemplified by the seventh step, “We humbly asked Him to remove our shortcomings.” This is a useful trait in general. That is not to say that a proud person cannot conquer alcoholism. More general, the adage, “Different strokes for different folks,” rings true.
Participation in AA has sometimes been mandated by courts, but this policy does not respect the importance of the motivation of the participant and has been struck down in courts on the grounds of being in violation of the Establishment Clause of the First Amendment of the Constitution, which prohibits the government from making any law “respecting an establishment of religion.”
Notwithstanding the lack and impracticality of prospective studies of AA, anecdotally many people have ascribed their success in overcoming alcoholism to it. That may be the best one can do, but, again it is important that such programs are entered into voluntarily, not coercively.
AA participants are sometimes discouraged from taking medications for addiction, whether to alcohol or to other addictive substances like opiates, because “You’re just substituting one drug for another.” Bill Wilson himself supported the use of niacin in combating alcoholism and there is nothing in the principles of AA that opposes the use of medications. However, the 2016 pamphlet of Narcotics Anonymous (NA) states “NA is a program of complete abstinence. By definition, medically assisted therapy indicates that medication is being given to people to treat addiction. In NA, addiction is treated by abstinence and through application of the spiritual principles contained in the Twelve Steps of Narcotics Anonymous.” According to one woman’s essay, her loved one died of an opioid overdose after a 12-step program persuaded him to stop his opioid agonist medication. Still, an addict can seek and find a 12-step group that accepts the medications. Because of the potential conflict between 12-step programs and MAT, a new kind of 12-step program has been developed, called Medically Assisted Recovery Anonymous (MARA), which combines the advantages of AA or NA with full acceptance of on-going MAT.
There are also medical treatments for alcoholism, like naltrexone (Vivitrol), an opioid antagonist more commonly associated with the treatment of opioid addiction. By antagonizing opioid receptors, it also takes away the buzz that comes from drinking alcohol. This happens despite the fact that, unlike heroin, alcohol does not attach to opioid receptors.
Withdrawal from alcohol has risks like delirium tremens (DT), which causes symptoms and signs like high blood pressure, and ketoacidosis, a buildup of harmful substances in the blood.
As a society, we have addressed alcoholism with Prohibition (the Eighteenth Amendment to the Constitution, called the Volstead Act) which was in effect from 1920 until its repeal in 1933. Making a substance illegal can logically be expected to decrease its use and its harms. Indeed, alcohol consumption declined dramatically, by 30 percent to 50 percent according to one estimate, but drinking was not eliminated and increased again after its repeal. Furthermore, cirrhosis death rates for men went from 29.5 per 100,000 in 1911 to 10.7 in 1929; admissions to state mental hospitals for alcoholic psychosis declined from 10.1 per 100,000 in 1919 to 4.7 in 1928, and arrests for public drunkenness and disorderly conduct declined 50 percent between 1916 and 1922. However, the black market was not squelched. In fact, Prohibition spawned criminal syndicates and random violence.
Prohibition evokes colorful terminology like speakeasy, rotgut, bootleg, and moonshine, and colorful imagery such as the joyous abandon of the roughly contemporaneous Roaring Twenties (preceding the Great Depression) immortalized by F. Scott Fitzgerald. (Alcohol could still be prescribed by physicians.) Moonshine means strong illicit liquor and rotgut means poor-quality and potentially toxic liquor. Prohibition gave rise to the use of methanol (sometimes called “wood alcohol”) the deadly cousin of drinking alcohol (ethanol, or grain alcohol). Overall, Prohibition is considered to have been a failure.
Schedule I of United States Drug Enforcement Agency (DEA) lists drugs, substances, or chemicals with no currently accepted medical use and a high potential for abuse. Examples are heroin, LSD, marijuana (cannabis) and ecstasy. Interestingly, alcohol and cigarettes are not on Schedule I, although they have no acceptable medical use and a higher potential for abuse than marijuana (which isn’t deadly). Each kills more people annually than opioids. (In the case of alcohol, that includes deaths for reasons other than overdose).
The strong liquor lobby has succeeded in keeping liquor taxes, which could be a major disincentive, low. For some reason, it appears to be stronger than the also powerful tobacco lobby. The industry does not appear to have done much if anything to counter underage drinking and drunken driving, and its endorsement of self-driving cars needs to be viewed with cynicism.
Is alcohol healthful? A huge study on the possible health benefits of drinking alcohol was proposed by the National Institutes of Health and was designed to follow over 7,000 people for years, at a cost of around $100 million. Half of the study’s participants would be instructed to abstain from alcohol, while the other half would be told to have a drink every day. The study was aborted because it was being funded in part by major players in the alcohol industry, through a nonprofit foundation linked to the NIH, thus compromising its credibility. Also, although the advisability of such a prospective controlled study seems indubitable, it seems doubtful in any case that one could be assured that the abstainers completely abstained and that the drinkers drank a specifically prescribed amount.
It is unquestionable true that drinking large amounts of alcohol is harmful to health. An estimated 95,000 people die in the United States from alcohol-related causes annually, making it the third-leading preventable cause of death in the United States after tobacco (a whopping 480,000 deaths), and poor diet accompanied by physical inactivity. The alcohol-related deaths include diseases like cirrhosis of the liver, cancer, and those resulting from alcohol-impaired driving. This also may be compared with 70,000 deaths from drug-involved overdoses, making it the 9th preventable cause of death. One would think then, that alcohol should get as much attention as drugs in the “drug war.” This speaks to the extent to which alcohol consumption is woven into the fabric of our society. Comparing the causes can be like apples and oranges. With opiates, death may be precipitated in young people who overdose, whereas the diseases of alcoholism tend to occur later in life. A better basis of comparison might be to tally the number of lost years (or useful years) of life.
The Seventh-Day Adventists of Loma Linda, California, a group from which a wealth of data can be obtained, oppose drinking alcohol (but do not always totally abstain), and they live as much as a decade longer than the rest of us. However, they also follow a generally healthful life style, including exercise and diet, eschewing meat and tobacco.
Underage drinking is a particular problem, partly because the brain is not fully developed. Binge drinking is especially risky.
French women are known for their longevity, and it has been ascribed to their drinking wine, in particular red wine. This is called the “French Paradox.” It is said that they can eat butter, eggs, and cheese and still have a low rate of heart disease because of the wine. The resveratrol (a possible antioxidant) in red wine is said reduce blood clots and “bad” cholesterol production, among other benefits. (They also justify excessive smoking with the motto “Better dead than fat,” but they pay for it in terms of mortality from tobacco-related disease.) Correlation, however, does not prove causation. (See below.)
Self-driving cars carry a special risk, in my opinion, i.e. drunken driving. Oddly, I haven’t seen this mentioned. Despite claims to the contrary, self-driving cars currently have a higher rate of accidents than human-driven cars, but the injuries are less severe, although some have been fatal. The driver is supposed to be in charge but may wrongly assume that her or his attention is not needed. The victim of a self-driving car accident can bring a law-suit, but it is an unusual circumstances. It seems an imposition to have to drive on roads where there are self-driving cars.
There are already too many stories of accidents involving inattentive (if not drunken) drivers. It would be better to design a system that gives assistance to a driver only when she or he needs it and which requires him or her to be continually attentive. There have been accidents involving vehicles that run on rails going past their termini. If we have that problem, how can we expect not to have problems with self-driving cars? Putting cars, self-driving or not, on rails ( at least for certain stretches, is a possible remedy.
Two alcohol industry groups have expressed their support of autonomous vehicles on the basis that they could reduce drunk driving. Without the need to drive home after a night at the bar, drinkers could also consume far more and that would boost alcohol sales.
Just as cigarette packages include a warning of health dangers, alcoholic beverages appropriately have a warning on them, like this from a bottle of wine: “(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.”
Another benefit that has been imputed to moderate red wine consumption is a reduced risk of dementia. Maybe exercise would work as well! Excessive alcohol consumption may increase the risk of dementia.
The question remains whether small amounts of alcohol are dangerous. Alcohol in moderation is linked to decreased cancer. On the other hand, it may be that any alcohol intake at all increases the risk of cancer, but it is difficult to determine such things because statistical significance is difficult to achieve when we are discussing small amounts and a small risk. In this respect, it is analogous to the data from Hiroshima about radiation causing cancer after the atomic bomb. The correlation is clear for those who were not too far from the explosion and unclear for those at a great distance. It has been speculated that the resveratrol in red wine also helps to prevent cancer, but this has not been proven. In any case, correlation does not prove causation. An old medical professor mine stated it nicely in Latin, “Post hoc ergo propter hoc” (“After this, therefore because of this”). In other words, “Since event Y followed event X, event Y must have been caused by event X,” a logical fallacy.
In the face of alcohol’s dangers, it can be considered just like many things that we do and justify because they make us happy and we accept the risk, like taking pleasurable drives. We have mitigated the risk by useful conventions like designated drivers. In former times, I believe that the risk of drunken driving was mitigated in former times by the fact that people walked to taverns whereas now they drive.
Accommodations are made to drinking as well as to consumption of drugs like heroin. In some countries, a user can get a shot of heroin, say, three times a day, and can lead a somewhat normal life, holding a job, etc. This is called Heroin-Assisted Therapy and it seems to be a reasonable alternative for those who do not do well with more conventional treatments like Suboxone. In a similar manner, alcohol could be prescribed to alcoholics, bearing in mind the risks of decreased mental function. It could be a kind of alcohol maintenance therapy. The Dutch have a program of rewarding alcoholic workers with beer! Such measures fall in the category of harm reduction. That is, in the presence of a harm that cannot be eliminated, we do our best to control the damage, as with the use of seatbelts or condoms.
Good quantitative research requires knowing the amount and alcohol content of the drinks involved.
Other drawbacks of drinking alcohol are the cost and the calories (typically 700 in one liter of wine). (Beer but not wine is linked to weight gain.)
In any case, determinations of the risks of alcohol generally involve retrospective studies, and they suffer from the pitfall of inaccurate representation of the truth. For example, if we examine the correlation of birth defects with drinking during pregnancy, we are likely to underestimate the risk because of denial by the subjects. Prospective studies are better, but suffer from the problems that I have cited with regard to the above-mentioned NIH study. Ideally studies have experimental and control groups and are double-blinded, i.e. no one knows to which group a given subject belongs. For example, one group might receive new medication and the other a placebo. This condition could not be achieved with alcohol studies. It is surely hard to imagine an alcohol placebo, although O’Doul’s nonalcoholic beer might stand a chance. A study showing that nondrinkers are less healthy than moderate drinkers suffers from the pitfall that an adverse health condition may have been the reason that they quit drinking! It can be very hard to establish risk or benefit at low levels, statistically. About individual drinking, one may be wise simply to do what feels right. One cannot fault a teetotaler.
Research has shown that alcohol tends to reduce people’s ability to focus on some things and ignore others, which also happens to benefit creative problem solving. It is assumed that drinking will interfere with success in school, but this isn’t always true. Among American Nobel laureates in literature, four — Sinclair Lewis, Eugene O’Neill, William Faulkner and Ernest Hemingway were ‘’clearly alcoholic,’’ and a fifth, John Steinbeck, was ‘’probably alcoholic.’’ two Nobel winners who were not (as far as is known) were Pearl Buck and Saul Bellow. It has been said that alcoholism is to writing what black lung disease is to coal miners.
Alcohol is a great source of humor. W.C. Fields is a notable example. He was a prodigious drinker if not an alcoholic. Some relevant quotes are “I cook with wine, sometimes I even add it to the food”, “I was in love with a beautiful blonde once, dear. She drove me to drink. That’s the one thing I am indebted to her for”, and “Once, on a trek through Afghanistan, we lost our corkscrew … and were compelled to live on food and water for several days.” He would have appreciated what Jesus did to the water at Cana. Dave Barry said, “Not all chemicals are bad. Without chemicals such as hydrogen and oxygen, for example, there would be no way to make water, a vital ingredient in beer.” Ernest Hemingway said, “I Drink To Make Other People More Interesting.” Coco Chanel said, “I only drink champagne on two occasions: when I’m in love and when I’m not.” David Lee Roth said, “I used to jog but the ice cubes kept falling out of my glass”. Will Ferrell said, “Alcohol is like Photoshop for real life.”
Foster Brooks, who had also had problems with alcohol, adopted a drunken persona as the basis for his comedy.
A. E. Housman celebrated the pleasures of alcohol in a light-hearted manner in the poem “Terence, This is Stupid Stuff”:
“…And malt does more than Milton can
To justify God’s ways to man.
Ale, man, ale’s the stuff to drink
For fellows whom it hurts to think:
Look into the pewter pot
To see the world as the world’s not.
And faith, ’tis pleasant till ’tis past:
The mischief is that ‘twill not last.
Oh I have been to Ludlow fair
And left my necktie God knows where,
And carried half way home, or near,
Pints and quarts of Ludlow beer:
Then the world seemed none so bad,
And I myself a sterling lad;
And down in lovely muck I’ve lain,
Happy till I woke again.
Then I saw the morning sky:
Heigho, the tale was all a lie;
The world, it was the old world yet,
I was I, my things were wet,
And nothing now remained to do
But begin the game anew.”
We say, “I’ll drink to that,” and toast with drinks, as though that was the only way to express support or agreement.
“Duffy’s Tavern” (radio) and “Cheers” (television) are shows that have glamorized drinking if not alcoholism.
There are many funny synonyms for drunk: blotto, sozzled, stoned, smashed, well-oiled, tanked-up, plastered, sloshed, bombed, legless, three sheets to the wind, stewed, tanked, soused, crocked, blitzed, pickled, tipsy, tight, etc. Perhaps we look for facetious terms to take the edge off of sensitive concepts.
Funny, for sure, but one has to be skeptical about humor regarding something that takes such a toll. There does not seem to be much comparable humor about heroin, oddly enough. A Saturday Night Live sketch with a fake add , “Heroin AM: For people who want to do heroin, but also want to be productive, there’s Heroin AM,” is an exception and engendered some outrage.
I can envision a museum based on the many facets of alcohol as presented in this essay, history, alcoholism, health harms and benefits, humor, alcoholics anonymous, other treatments, prohibition and other public policy, etc. It could be fixed or a traveling exhibit or a podcast.
