رونوشت کامل Ep. 362: Alcohol Advice Keeps Changing. What Are We Supposed to Believe?

hear the government saying sunlight is a carcinogen or even, you know, that bacon is a carcinogen. 00:04:12.319 --> 00:04:15.840 And so I do think that's a little bit of a hard thing to interpret. 00:04:15.919 --> 00:04:16.639 What does that really mean? 00:04:16.800 --> 00:04:22.399 Because I agree when I hear something described as a class of carcinogen, I would think, oh God, I should never ever be exposed to that. 00:04:22.480 --> 00:04:26.720 But the reality is the science is a little bit more mixed than that when it comes to alcohol. 00:04:27.040 --> 00:04:28.160 Oh, interesting. 00:04:28.319 --> 00:04:28.639 Okay. 00:04:28.959 --> 00:04:38.879 So that's where the whole nuance and difficulty of studying something like this in that sort of lifestyle bucket becomes a little messy, right? 00:04:39.120 --> 00:04:40.000 It's so messy. 00:04:40.079 --> 00:04:47.360 Cause if you think about how we do scientific research studies for other things, the gold standard is something called a randomized controlled trial. 00:04:47.519 --> 00:04:56.480 And so what happens there is that researchers would randomly assign people to two different groups, and one group would get the thing that you want to study the effect of and the other group wouldn't. 00:04:56.639 --> 00:04:58.240 But you really can't do that with alcohol. 00:04:58.399 --> 00:05:05.920 You can't like randomly assign people to drink for the next 20 years and the other group to not drink for the next 20 years and then actually understand what happens. 00:05:06.160 --> 00:05:12.240 And the outcomes that we care about, things like death and cancer and heart disease, really do take 20, 30 years to accumulate. 00:05:12.319 --> 00:05:18.319 So you can't do sort of a short study where someone maybe would agree to not drink and be in a control group for that time period. 00:05:18.560 --> 00:05:33.040 And so scientists are left with really big observational studies, which is how a lot of public health data is done, that generally leverage other studies that have followed people for decades, where people were asked about their drinking habits as a part of that study. 00:05:33.199 --> 00:05:40.399 And then based on that, they try to control for different factors and understand is there an association between alcohol and certain outcomes. 00:05:40.639 --> 00:05:49.120 But that's a much more imperfect science than knowing I just administered, you know, 10 ounces of alcohol to this person every day for 20 years and this was the outcome. 00:05:49.360 --> 00:05:50.959 We really don't have that kind of data. 00:05:51.120 --> 00:05:55.360 And so I think it's a combination of the science that exists is somewhat messy. 00:05:55.439 --> 00:05:57.360 But then two, the findings differ. 00:05:57.439 --> 00:06:04.160 So if you're looking at cancer, the outcomes are actually different than if you're looking at overall mortality or risk of death or heart disease. 00:06:04.319 --> 00:06:09.279 So it is not a simple thing

to understand or to try to explain in public health messaging. 00:06:09.519 --> 00:06:16.639 No, it totally isn't, which makes your job super challenging because that educational piece is part of what you do. 00:06:16.800 --> 00:06:18.079 Obviously, we're here today. 00:06:18.240 --> 00:06:19.360 You wrote a book about it. 00:06:19.519 --> 00:06:27.279 And I want to come back to that unpacking the study details of the health outcomes of alcohol in a minute. 00:06:27.360 --> 00:06:36.079 But I I want to go back to the topic of moderation, because when asked, most people will say, Oh yeah, I drink in moderation. 00:06:36.480 --> 00:06:40.800 And I'm wondering how that is different than gray area drinking. 00:06:40.959 --> 00:06:43.360 Can you help differentiate the two? 00:06:43.759 --> 00:06:48.160 So it's confusing, and different organizations have changed their stance on this over time. 00:06:48.319 --> 00:06:53.439 But for a long time, we went by in the US, by the NIAA drinking risk limits. 00:06:53.519 --> 00:07:03.519 And their recommendation or sort of definitions were that lower risk drinking was seven or fewer drinks per week for a woman or anyone over 65 and no more than three drinks on a drinking occasion. 00:07:03.600 --> 00:07:07.759 So you couldn't sort of save up all seven for Saturday and still be in that lower risk category. 00:07:07.920 --> 00:07:13.120 And then for men under 65, it was 14 drinks a week and no more than four per drinking occasion. 00:07:13.360 --> 00:07:18.240 So if you have, you know, six drinks on one occasion, that is considered sort of a binge drinking episode. 00:07:18.319 --> 00:07:23.680 But it doesn't necessarily mean that you have alcohol use disorder, which we'll talk about, which is what we think of as addiction. 00:07:23.839 --> 00:07:30.240 It just means that above those lower risk limits, in the studies that we have, we've seen evidence that health risks start to accumulate. 00:07:30.399 --> 00:07:38.079 And so that can be things like um cancer, high blood pressure and heart problems and acid reflux, sort of more mundane medical problems. 00:07:38.160 --> 00:07:44.879 And so they with the best evidence we have from these large survey studies, they sort of set these thresholds of what they think are lower risk strengthening limits. 00:07:44.959 --> 00:07:47.199 And so when I think that's kind of the best we have. 00:07:47.360 --> 00:07:49.120 So I'm giving guidance to patients. 00:07:49.199 --> 00:07:56.639 That's sort of the general rule of thumb I try to keep in mind is, you know, as a woman, seven or fewer a week and no more than three on a drinking occasion. 00:07:56.720 --> 00:08:01.439 And as a man under 65, 14 or fewer a week and no more than four on a drinking occasion. 00:08:01.600 --> 00:08:03.920 That does unbeg the question of like what is a drink? 00:08:04.079 --> 00:08:05.839 Because that's the other piece of that equation. 00:08:05.920 --> 00:08:11.920 So if you have, you know, a drink

is a bottle of wine, that would that would not count and would be over the recommended amount. 00:08:12.079 --> 00:08:19.680 So the definitions in the US are that one standard drink is five ounces of wine, 12 ounces of beer, or one and a half ounces of liquor. 00:08:20.000 --> 00:08:24.240 Five ounces of wine is like, I mean, that is a tiny glass. 00:08:24.480 --> 00:08:25.439 It's a small four. 00:08:25.600 --> 00:08:26.000 Yes. 00:08:26.240 --> 00:08:26.560 Yeah. 00:08:26.800 --> 00:08:27.680 A small four. 00:08:27.759 --> 00:08:28.000 Yeah. 00:08:28.399 --> 00:08:29.920 Yeah, that's a small four. 00:08:30.160 --> 00:08:39.360 That's what we call like, you know, when you get a flight of beer, I don't know if, or like it's it's basically like a wine tasting, you know, is is five ounces. 00:08:39.519 --> 00:08:39.840 Okay. 00:08:40.080 --> 00:08:43.039 So let me repeat that just so that it's in my brain. 00:08:43.279 --> 00:08:51.120 One drink is considered five ounces of wine, 12 ounces of beer, or one and a half ounces of liquor. 00:08:51.200 --> 00:08:52.720 So like a one and a half ounce shot. 00:08:52.879 --> 00:08:53.120 Okay. 00:08:53.200 --> 00:08:55.360 So like the little glass shot is one and a half. 00:08:55.600 --> 00:08:58.559 The metal one at the bar, that's two. 00:08:59.120 --> 00:08:59.600 There you go. 00:08:59.840 --> 00:09:00.080 Exactly. 00:09:00.399 --> 00:09:05.519 So you can see how tricky it is already to measure your drinking, because you know, depending on where you are, these things will look different. 00:09:05.679 --> 00:09:05.840 Yeah. 00:09:06.080 --> 00:09:08.720 I guess the thing I would add, because the goal here is not perfection. 00:09:08.879 --> 00:09:12.320 The goal is thinking about overall health improvement in my mind. 00:09:12.480 --> 00:09:17.519 And so, you know, these recommendations are based on these large studies that ask people, how much do you drink? 00:09:17.679 --> 00:09:20.559 And so that also is very much open to interpretation. 00:09:20.720 --> 00:09:22.799 And so it is not a perfect science. 00:09:23.039 --> 00:09:30.639 So back to the term gray area drinking, is that more of a behavioral distinction or it does it have to do with quantity? 00:09:30.879 --> 00:09:37.279 So if you think of it as a pyramid, you know, then with sort of health risks increasing the further you get to the top of the pyramid. 00:09:37.440 --> 00:09:39.279 At the bottom of the pyramid are people who don't drink at all. 00:09:39.440 --> 00:09:43.519 You're obviously not going to have any health-related problems if you don't drink alcohol due to alcohol. 00:09:43.840 --> 00:09:50.559 Next is kind of the biggest group, which are people who drink in a way that actually doesn't cause obvious risk to their health or their life. 00:09:50.639 --> 00:09:53.360 And so that's that kind of lower risk or moderation bucket. 00:09:53.600 --> 00:09:54.879 Okay, let's unpack that really quick. 00:09:54.960 --> 00:09:55.360 Hold on.

00:09:55.440 --> 00:09:55.919 Oh, yeah. 00:09:56.159 --> 00:09:58.240 It doesn't cause, say it again. 00:09:58.399 --> 00:10:02.080 It doesn't cause negative impact on their life or obviously on their health. 00:10:02.320 --> 00:10:03.679 Okay, let's hang out there for a minute. 00:10:04.240 --> 00:10:07.039 Since this episode is about that department. 00:10:07.200 --> 00:10:23.919 And uh, so if somebody goes to the doctor and the doctor says, Hey, your drinking is negatively impacting your health and they choose to drink anyway, would that be more on alcohol use disorder side of things? 00:10:24.159 --> 00:10:25.120 Yeah, great question. 00:10:25.279 --> 00:10:32.879 One of the diagnostic criteria of alcohol use disorder, there's 11 and you have to meet at least two to be diagnosed with a mild alcohol use disorder. 00:10:33.039 --> 00:10:38.240 One is if you have known medical problems related or worsened by alcohol and you continue to drink despite that. 00:10:38.480 --> 00:10:39.279 But that's different. 00:10:39.440 --> 00:10:41.279 There's sort of two things embedded in what you said. 00:10:41.440 --> 00:10:44.879 One was a doctor just generally saying you shouldn't drink for health reasons. 00:10:45.039 --> 00:10:48.240 That's very different than a doctor saying you have liver inflammation. 00:10:48.320 --> 00:10:54.240 And if you keep drinking alcohol, alcohol is going to cause your liver to get even more injured and for you to develop cirrhosis. 00:10:54.480 --> 00:11:04.639 If you continue to drink despite getting that very personalized medical feedback that alcohol is making a health condition worse for you, that would be sort of one of the criteria towards alcohol use disorder. 00:11:05.279 --> 00:11:05.840 Interesting. 00:11:06.000 --> 00:11:06.320 Okay. 00:11:06.799 --> 00:11:09.840 And does it matter why a person drinks? 00:11:10.000 --> 00:11:13.120 So, like, say we're hanging out in the moderate zone, right? 00:11:13.360 --> 00:11:13.759 Yeah, yeah. 00:11:14.000 --> 00:11:17.679 But the reason that we drink is specific. 00:11:17.919 --> 00:11:25.440 You know, it could be you feel sad or you feel anxious or you feel angry or I don't know, you feel bored, or you want to socialize? 00:11:25.600 --> 00:11:32.159 Like there's so many reasons that we drink in our culture to celebrate, to mourn, to unwind, to wind up. 00:11:32.720 --> 00:11:33.919 It's a long list. 00:11:34.240 --> 00:11:38.240 Does answering that question matter when it comes to moderate drinking? 00:11:38.480 --> 00:11:57.600 It's not something that is on any of our sort of screening tools, but there are studies that have looked at that that people who drink to relieve bad emotions, so like who drink because of sadness or trauma or grief, are at increased risk of ultimately developing an alcohol use disorder compared to people who drink for sort of positive reasons, like drink to socialize, drink to celebrate. 00:11:57.759 --> 00:12:02.480 You know, it's hard to know is that speak to the fact that one of the biggest risk factors for addiction is trauma. 00:12:02.559 --> 00:12:10.159 And so if you're drinking to relieve sadness, you may have sort of pre-existing trauma versus is there something different about that type of behavioral pattern? 00:12:10.320 --> 00:12:21.360 But certainly that is something that would make me as a clinician more worried or sort of would my ears would perk up if someone said that they really drink to relieve depression or sadness or guilt or loneliness. 00:12:21.519 --> 00:12:26.799 That is a riskier situation than someone who's drinking, you know, at a social event with their friends or their family. 00:12:27.120 --> 00:12:35.279 I did a very casual Facebook survey of just personal contact to see, you know, what people do in terms of moderation. 00:12:35.440 --> 00:12:38.240 Do they have specific strategies that work for them? 00:12:38.480 --> 00:12:40.240 Do they have rules that they follow? 00:12:40.399 --> 00:12:45.200 Or is it just kind of a, you know, take it or leave it feeling towards alcohol? 00:12:45.440 --> 00:12:50.799 And the the responses that I got were all over the place, but very passionate. 00:12:51.120 --> 00:12:54.879 A lot of people who had decided to just not drink at all. 00:12:55.039 --> 00:13:02.960 And I'm starting to see, based on your answers here, how just not drinking would be like the drinking version of a capsule wardrobe. 00:13:03.759 --> 00:13:07.519 You know, like how Steve Jobs had all black t-shirts and jeans. 00:13:07.600 --> 00:13:13.200 And so he never had to make a wardrobe decision a day in his life because he just wore black t-shirts and jeans. 00:13:13.360 --> 00:13:20.960 I'm starting to see why people kind of exit the mental spinning that involves like, okay, now this is a drink. 00:13:21.039 --> 00:13:23.440 Now that counts as two drinks, and how many have I had? 00:13:23.519 --> 00:13:25.519 And oh, wait, I only do this on the weekend. 00:13:25.679 --> 00:13:26.879 Am I drinking because I'm sad? 00:13:26.960 --> 00:13:28.879 I could see where people would just go, you know what? 00:13:28.960 --> 00:13:30.000 I'm just not gonna do it. 00:13:30.240 --> 00:13:30.639 Totally. 00:13:30.720 --> 00:13:34.000 And I think it also depends on what someone's relationship is with alcohol. 00:13:34.080 --> 00:13:42.399 So for, I mean, it's sort of like if you think about food or eating dessert, there's similarities there where for some people it's sort of take it or leave, and it's not that big of a deal. 00:13:42.559 --> 00:13:52.720 They eat dessert when they're at an event, but it's not something that they are constantly thinking about or having to resist the urge to eat, or that it sort of consumes their mental energy or decision-making capacity. 00:13:52.879 --> 00:14:04.000 But there's other people who share this concept of like food noise that if you put a bag of cookies on the table, they're gonna be spending most of their mental energy

thinking about whether they should or could or how many cookies they're gonna eat the whole time. 00:14:04.159 --> 00:14:05.039 And that's exhausting. 00:14:05.120 --> 00:14:10.799 And so, in that circumstance, some people just say, you know, I'd rather just like not make that decision or not have to deal with it. 00:14:11.200 --> 00:14:13.360 So I think there's a lot of individual nuance here. 00:14:13.679 --> 00:14:20.799 And that again is really tough to sort of talk about or educate about, you know, when we think about these kind of gray zone topics like alcohol use. 00:14:21.120 --> 00:14:34.960 So for those who are moderate drinkers based on CDC guidelines, one drink a day for a woman and two drinks a day for a man, what are the health risks for those folks? 00:14:35.279 --> 00:14:35.840 Great question. 00:14:36.000 --> 00:14:42.559 So I think and and the CDC is sort of an extrapolation of that seven drinks a week for a woman and 14 drinks a week for a man. 00:14:42.639 --> 00:14:44.080 So just averaging it out of birth. 00:14:44.240 --> 00:14:46.559 I have a hard time with the total week count up. 00:14:46.639 --> 00:14:50.480 And so the days are like every day is easier for me. 00:14:50.639 --> 00:14:51.120 I don't know. 00:14:51.440 --> 00:14:53.440 So sorry if that's messing things up. 00:14:53.679 --> 00:14:54.399 No, that's really fun. 00:14:54.559 --> 00:15:05.600 I guess the the thing I would poke into that is that, you know, as people are thinking about how alcohol fits in their life, sometimes it can be helpful to think about having alcohol-free days so that it's not that, you know, alcohol is a part of your everyday life. 00:15:05.679 --> 00:15:09.120 And so in that case, the sort of how many drinks a day can get in the way of that. 00:15:09.200 --> 00:15:12.639 So thinking I could add like seven drinks a week a week-ish. 00:15:12.960 --> 00:15:22.080 And so as a woman, you know, two drinks a night for three days or having those kind of benchmarks can be helpful if people are thinking about sort of their own personal practices with alcohol. 00:15:22.240 --> 00:15:31.759 In terms of pelvis, I think the biggest one where there are concerns even with light drinking and there being an association with negative health outcomes, are for certain types of cancer. 00:15:32.080 --> 00:15:42.559 So for most health conditions that alcohol is associated with, thinking of things like fibro disease, heart disease, mortality, the risk really starts to increase as people are drinking more and more. 00:15:42.639 --> 00:15:46.720 And then flexion point of where that is varies depending on what condition you're looking at. 00:15:46.879 --> 00:15:54.000 But for mortality, that sort of light drinking, which would be less than those limits we just talked about, there does not seem to be a negative impact on mortality. 00:15:54.159 --> 00:16:06.399 But once you get above those thresholds that the sort of 14 drinks a week for men, seven drinks a week for

women, depending on what study and what definitions they're using, you stop seeing any sort of reduction in mortality and you actually begin to see an increase. 00:16:06.639 --> 00:16:08.000 For cancer, it's a little different. 00:16:08.080 --> 00:16:14.960 There are some types of cancer, including breast cancer, where even light drinking has been associated with an increased risk of getting breast cancer. 00:16:15.279 --> 00:16:22.879 So if you think of women, that one drink a day, actually, breast cancer, is associated with a very small increased risk of developing breast cancer. 00:16:23.039 --> 00:16:32.799 And so from a cancer perspective, there really is, you know, no amount of drinking that is safe or not associated with an increased risk of these types of cancer like breast. 00:16:32.879 --> 00:16:35.840 And that's probably most relevant, especially for women who are listening. 00:16:36.000 --> 00:16:37.919 That then varies again with your personal history. 00:16:38.000 --> 00:16:48.080 So if you're someone who has a strong family history of breast cancer or a personal history of breast cancer, if I were your doctor, I would counsel you very differently around thinking about alcohol use than someone without that risk factor. 00:16:48.159 --> 00:16:56.720 And then people have different preferences around their life and what they value in making health decisions and different risk tolerance as they think about different behaviors in their life. 00:16:56.799 --> 00:17:09.200 And so it really is this situation that is a little exhausting to your point about factoring in all the data, but deciding sort of what matters to you, what's your own health history, and then how do you think about this health-related behavior in the context of that? 00:17:09.519 --> 00:17:16.319 Is it common for a cancer doctor to tell their patient who has cancer to stop drinking alcohol? 00:17:16.559 --> 00:17:22.079 I think cancer doctors are counseling very differently about alcohol than they were 10 years ago before all of this data came out. 00:17:22.240 --> 00:17:27.680 You know, both alcohol and obesity are known risk factors for multiple different types of cancer, including breast cancer. 00:17:27.759 --> 00:17:42.000 And so, you know, I'm not a cancer doctor, but from my colleagues, my sense is that people are talking about alcohol in a different way, especially breast cancer specialists, of thinking about sort of really the less or or no alcohol is the safest option if you're if you're trying to reduce your risk of cancer. 00:17:43.200 --> 00:17:50.559 In other developed countries, the toxic load for people would be less than the US. 00:17:51.200 --> 00:17:59.119 And so they might have some of these what we call bad habits, smoking and drinking, and they could have different rates of cancer. 00:17:59.359 --> 00:18:14.480 How do we know that our breast cancer rates, to use this specific example, are specifically due to even moderate alcohol use and not the total toxic load of the country we live in? 00:18:14.799 --> 00:18:15.920 Yeah, great question. 00:18:16.000 --> 00:18:27.599 And this is one of the real limitations of the type of data that exists around alcohol use is that again, we don't have these controlled research environments where we can isolate the specific factor of alcohol. 00:18:27.759 --> 00:18:39.279 So, what researchers try to do in studies is, you know, with breast cancer, for example, they would take a big massive study that followed women for many decades that asked about lots of different health-related behaviors, including alcohol. 00:18:39.359 --> 00:18:47.279 And then they would compare the association between the amount that someone drinks and their risk of ultimately getting breast cancer across those groups. 00:18:47.440 --> 00:18:53.839 And they do this sort of statistical analysis where they try to control for other things that might be contributing to the risk factor. 00:18:54.079 --> 00:18:56.000 The issue is we can't control for all those things. 00:18:56.079 --> 00:19:03.279 Like we actually don't measure on these surveys, like, you know, do you live in an area that's more exposed to pesticides or other chemicals? 00:19:03.359 --> 00:19:10.480 Or, you know, they often ask about diet, but they don't ask in that great of a detail about sort of diet or preparation or, you know, many other elements. 00:19:10.640 --> 00:19:13.119 And so the science is imperfect at best. 00:19:13.200 --> 00:19:28.799 I think what they can say is that with the limitations of those types of studies, when you control for things like body weight and exercise and, you know, other health habits like tobacco, you do see this association with increase in alcohol use being associated with increasing rates of cancer. 00:19:29.279 --> 00:19:34.640 There's also the always the possibility of what we call confounders, which means that things travel together. 00:19:34.799 --> 00:19:41.440 So for example, if you didn't control for smoking, you might find that alcohol is associated with this really high risk of lung cancer. 00:19:41.519 --> 00:19:45.039 But then actually you look and you see that people who smoke are also more likely to drink heavily. 00:19:45.119 --> 00:19:49.599 And so you're not actually isolating the effect of alcohol, you're actually measuring the effect of tobacco. 00:19:49.759 --> 00:19:56.960 So that's one of the challenges is the studies are only as good as what inputs of data they have from these surveys and then what things they control for. 00:19:57.359 --> 00:19:59.119 So it really is this imperfect science. 00:19:59.200 --> 00:20:03.839 And I think, like many things, should be just sort of factored in as you're making health-related decisions. 00:20:04.240 --> 00:20:12.640 Does all of this make it particularly difficult for you in your job to help patients stop drinking? 00:20:12.880 --> 00:20:26.480 Because, you know, you it's it's not completely accurate to say, oh, this

100% causes X and Y, but we see a strong correlation and you're so good at it unpacking all these nuanced details. 00:20:26.640 --> 00:20:35.200 However, someone who is maybe negatively affected by their drinking habits, so we'll call that like diminished capacity, right? 00:20:35.279 --> 00:20:45.599 They're not feeling well, you know, and maybe there's some, as you said, trauma happening and they're dealing with that, and they're just trying to be like, lady, do I drink or do I not drink? 00:20:45.680 --> 00:20:54.559 And, you know, and you have to explain with accuracy and integrity, medical integrity, oh, well, it could cause this and it could cause that, but we don't exactly know. 00:20:54.799 --> 00:20:58.160 Doesn't that make it a bit difficult for you to really sell it? 00:20:58.400 --> 00:21:04.079 It's actually much simpler when, you know, when you think about addiction, which is what I spend, I do general medicine and also addiction. 00:21:04.160 --> 00:21:07.119 So I take care of patients, you know, come in for their annual visit. 00:21:07.200 --> 00:21:10.559 And that's where I'm really talking about sort of the moderation side of things. 00:21:10.799 --> 00:21:17.920 Once someone develops addiction, you know, by definition, at that point, they're drinking in a way that alcohol is causing negative consequences in their life. 00:21:18.000 --> 00:21:24.640 And so in that context, it's not that hard because sort of the horse is out of the barn at that point that however you measure it, alcohol is causing problems to them. 00:21:24.799 --> 00:21:25.119 Yeah. 00:21:25.279 --> 00:21:28.400 I think the nuance or challenge can be that people have different goals. 00:21:28.559 --> 00:21:30.960 So some people's goal is to never drink again. 00:21:31.039 --> 00:21:34.240 And for other people, their goal is to try to drink in a lower risk way. 00:21:34.319 --> 00:21:38.640 And so that is a more nuanced conversation and does vary person to person. 00:21:38.720 --> 00:21:45.359 But I actually think the much messier thing to understand is this moderation bucket where, you know, the science is not perfect. 00:21:45.599 --> 00:21:51.039 We do have really good data suggesting some things, and it is this very nuanced conversation. 00:21:51.119 --> 00:21:59.759 And, you know, I asked a dear colleague of mine who's an addiction specialist who's since passed away, but he was an alcohol researcher, you know, someone that I would turn to in the field to ask questions. 00:22:00.240 --> 00:22:03.359 And, you know, I would see him drinking a cocktail at dinner or at events. 00:22:03.440 --> 00:22:05.920 And so I sort of asked him, like, how how do you think about this? 00:22:06.079 --> 00:22:09.200 Because that, you know, alcohol has been known to be a carcinogen for a long time. 00:22:09.599 --> 00:22:16.960 And he said, you know, I think our problem is that we've been promoting alcohol as sort of a healthy positive behavior as something that improves your health. 00:22:17.200 --> 00:22:21.519 But it's actually a different conversation if you think, can alcohol be a part of a healthy lifestyle? 00:22:21.680 --> 00:22:28.799 So the shift there is a little bit like, I don't think anyone eats a bag of, you know, Skittles thinking they're going to make their health better. 00:22:29.119 --> 00:22:35.759 But many people have a healthy lifestyle and like eat dessert now and again and, you know, eat candy and it's not the end of the world. 00:22:36.000 --> 00:22:38.480 Same thing, you know, with bacon or with sunbathing. 00:22:38.559 --> 00:22:41.519 Like I think everyone knows melanoma can kill you and skin cancer is bad. 00:22:41.599 --> 00:22:44.880 And being out in the sun, you know, increases your risk of skin cancer. 00:22:44.960 --> 00:22:51.519 And yet we still go to the beach and, you know, we wear sunscreen, we kick precautions, but we're able to have a sort of nuanced framework for that. 00:22:51.680 --> 00:22:56.480 And I think alcohol's kind of in that bucket where it, you know, for some people is absolutely deadly. 00:22:56.720 --> 00:23:00.079 The more you do of it, probably the more health harms you're going to have related to it. 00:23:00.240 --> 00:23:04.640 And it is possible to incorporate low-risk drinking into an otherwise healthy lifestyle. 00:23:04.880 --> 00:23:05.599 Well, hey there. 00:23:05.759 --> 00:23:13.680 Since you seem to be enjoying this episode so far, double check that you've hit the follow button on your podcast listening app and subscribe on YouTube. 00:23:14.079 --> 00:23:21.119 And to join my free private Facebook group, search MFR Curious Insiders on Facebook or click the link in the show notes. 00:23:21.359 --> 00:23:23.119 Okay, back to the show. 00:23:23.440 --> 00:23:25.519 That's such a great way to explain that. 00:23:25.680 --> 00:23:26.480 And you're right. 00:23:26.720 --> 00:23:30.960 I remember when everyone was singing the praises of resveratrol. 00:23:31.359 --> 00:23:42.640 And in my research for our episode, I learned that in the 1700s there was this hospital in France that used to give two liters of wine per day to its patients. 00:23:42.799 --> 00:23:52.720 And so I thought, okay, well, this is not, you know, a particularly modern phenomenon, but it is a longstanding one, which makes it harder to undo. 00:23:52.880 --> 00:24:05.519 You know, especially when we see these robust centurions drinking their, you know, whatever, brandy at night, or, you know, grandma is drinking her wine at night, and we think, okay, well, it must be fine because it's fine for them. 00:24:05.759 --> 00:24:14.319 But the personalized approach does simplify it because you don't you can't outsource all of your thoughts, you know, to a study. 00:24:14.559 --> 00:24:18.960 As scientific and reliable as the study is, you have to make that decision for yourself. 00:24:19.039 --> 00:24:25.599 And if I'm hearing you right, what you're saying is that's what you help patients walk

through is that individual decision. 00:24:25.920 --> 00:24:26.400 Exactly. 00:24:26.559 --> 00:24:35.920 And I think, you know, for better or worse, that's true of so many health decisions, that there are very few things where we have sort of a black and white answer of, you know, you should absolutely only do it this one way. 00:24:36.079 --> 00:24:37.119 Often it depends. 00:24:37.200 --> 00:24:40.799 And it depends on your own personal history and and other factors. 00:24:40.960 --> 00:24:46.960 And so I think it is simpler to your point of the capsule wardrobe, it's simpler to just be like, tell me what to do and I'm gonna do it. 00:24:47.119 --> 00:24:50.720 But yeah, you know, in this space, it really is sort of an individualized perspective. 00:24:51.039 --> 00:24:51.279 Okay. 00:24:51.440 --> 00:24:58.480 So talk to me about other health risks that are potentialities in with moderate drinking. 00:24:58.640 --> 00:25:00.880 So, how about like, let's talk about the brain? 00:25:01.039 --> 00:25:03.279 What are the impacts of alcohol on the brain? 00:25:03.599 --> 00:25:08.559 Yeah, so the impact of alcohol on the brain depends on the sort of moderate level versus higher risk level. 00:25:08.640 --> 00:25:10.640 I'll start with the easier side, which is a higher level. 00:25:10.799 --> 00:25:16.319 So when people are drinking in a heavy category, we know that when their risk of stroke increases. 00:25:16.400 --> 00:25:19.759 So that obviously has negative, terrible impacts on the brain. 00:25:19.920 --> 00:25:22.799 But also we see an alcohol-related dementia can develop. 00:25:22.880 --> 00:25:33.680 So people can get cognitive impairment over many years of heavy drinking that looks almost like Alzheimer's or another type of dementia where they have just profound cognitive impact from heavy alcohol use. 00:25:34.000 --> 00:25:38.319 How would you know regular dementia from alcohol-induced dementia? 00:25:38.640 --> 00:25:41.599 There's not a clear diagnostic way of determining that. 00:25:41.680 --> 00:25:45.920 So dementia is actually a big bucket term, and then there's lots of causes of dementia. 00:25:46.000 --> 00:25:55.440 So people can get dementia from Alzheimer's, they can get dementia from having multiple strokes, they can get dementia from rare causes like frontotemporal dementia. 00:25:55.599 --> 00:26:04.000 So dementia is really sort of the end state that we understand and how we see people who've lost their, you know, are losing their memory and all of the symptoms of dementia. 00:26:04.079 --> 00:26:07.119 But the reason for why someone develops dementia can be varied. 00:26:07.200 --> 00:26:10.640 And with alcohol, it's really based on history and sort of excluding other causes. 00:26:10.880 --> 00:26:24.640 So if you see on, you know, on MRI or CAT scan that someone's never had a stroke, you know, they don't have classic findings consistent with Alzheimer's and they have a heavy alcohol use history, it would be sort of attributed to alcohol or alcohol-related dementia. 00:26:25.519 --> 00:26:31.440 I I know someone who has dementia right now and his symptoms get worse when he has a beer. 00:26:31.599 --> 00:26:33.920 Is that pretty normal, pretty common? 00:26:34.240 --> 00:26:43.839 Yeah, if you think alcohol impacts, you know, so many different parts of the brain, it crosses the blood-brain barrier very quickly and can make people more impulsive or, you know, more dysregulated. 00:26:43.920 --> 00:26:50.559 And so if someone already has a neurocognitive disorder or dementia, you know, that can really cause significant symptoms for them. 00:26:51.039 --> 00:26:54.000 Is it true that it reduces the neuroplasticity of your brain? 00:26:54.319 --> 00:26:59.759 You know, that area of research, I think, is more ongoing and evolving and a little bit tougher to determine. 00:26:59.920 --> 00:27:12.880 There have been earlier studies, much like the confusing cardiovascular literature, that sort of light drinking was associated with a reduced amount of dementia or a reduced risk of dementia, but then more recent studies have suggested perhaps there is an association. 00:27:13.039 --> 00:27:17.039 So I think it's it's not as clear as sort of the data around heart disease or cancer. 00:27:17.279 --> 00:27:18.799 And what about mental health? 00:27:18.960 --> 00:27:23.039 Because a lot of people drink to improve their mental health. 00:27:23.200 --> 00:27:29.680 I mean, it, you know, can make you feel relaxed and it can help you go to sleep. 00:27:29.839 --> 00:27:33.279 Sometimes not always stay asleep, but at least you're getting to sleep. 00:27:33.359 --> 00:27:36.319 It can help you socialize, which is good for your mental health. 00:27:36.480 --> 00:27:38.160 Is there, is it a two-sided coin? 00:27:38.400 --> 00:27:43.119 Yes, alcohol and mental health is a really interesting conversation because it can be bi-directional. 00:27:43.279 --> 00:27:58.799 So people with other mental health diagnoses, so people with depression, certainly trauma, we talked about adverse childhood experiences or PTSD, people with anxiety are more likely and at greater risk of developing alcohol use disorder or problems related to alcohol use. 00:27:58.960 --> 00:28:06.319 And part of that is, you know, again, that idea of seeking relief through alcohol and then the spiraling effect of the negative consequences of alcohol setting in. 00:28:06.480 --> 00:28:12.319 There's a saying that, you know, there's no problem that you can't make worse by drinking, that I haven't heard that. 00:28:12.559 --> 00:28:19.359 People think that drinking may relieve sort of a worry or stress or anxiety, but often it it ends up being the exact opposite. 00:28:19.599 --> 00:28:23.359 The other thing is that you can actually get what's called a substance-induced mood disorder. 00:28:23.440 --> 00:28:27.920 So someone who's drinking really heavily, that can actually cause rebound anxiety and depression.

00:28:28.000 --> 00:28:42.720 And so it's sometimes really hard to differentiate, you know, clinically, if I'm seeing someone who is meeting criteria for depression, feeling hopeless and has depressed mood, is having difficulty sleeping, low appetite, if they having heavy chaotic alcohol use, it's actually hard to know. 00:28:42.799 --> 00:28:48.559 Is this major depressive disorder that has led someone to drink heavily, or is this actually the alcohol causing the depression? 00:28:48.720 --> 00:28:55.279 And the only way to really clarify that is a period of sobriety where you can see do the mood symptoms get better or not. 00:28:55.440 --> 00:29:00.799 Sometimes if someone's had, you know, they've had depression their whole life and alcohol came later, then it's very obvious. 00:29:00.960 --> 00:29:10.160 But I think it's important to note that alcohol actually can cause anxiety and depression symptoms and make worse, you know, symptoms that people already have, even if in the moment it feels like it's giving reliefs. 00:29:10.400 --> 00:29:13.839 It's interesting that you mentioned having a break because I was gonna ask you about this. 00:29:14.000 --> 00:29:18.400 A lot of people love, you know, sober October or dry January. 00:29:18.640 --> 00:29:29.759 And I often wonder about the benefit of that, but you're saying sometimes it can provide a like a good set point, like, you know, before and after for that person. 00:29:29.920 --> 00:29:36.880 But I found, I found it interesting uh because I was thinking, well, I wonder what alcohol sales do in February. 00:29:37.759 --> 00:29:52.000 And there was a numerator report that dry January participants spend$4,000 a year on alcohol compared to everyone else spends about$1,300, which I'm like, oh my gosh, that is a big difference. 00:29:52.240 --> 00:30:01.519 So ironically, it means that the people who participate in these sober challenges are the core customer for alcohol companies. 00:30:01.680 --> 00:30:10.400 So it kind of makes me wonder for the general public, maybe not your patients who are actively striving towards that sobriety finish line. 00:30:10.559 --> 00:30:16.000 I wonder for the rest of us, for those moderate drinkers, what does that say about those sobriety challenges? 00:30:16.240 --> 00:30:17.759 Yeah, I think it's really interesting. 00:30:17.920 --> 00:30:30.480 And, you know, you always worry about sort of setting up for like heavy drinking or a binge in response to this period of deprivation that people go for a month without drinking and then they're sort of off to the races and drinking even more heavily in February. 00:30:30.559 --> 00:30:31.759 And the data's a little mixed. 00:30:31.839 --> 00:30:37.359 There have been different studies country to country, but I think the the benefit of someone wants to participate is twofold. 00:30:37.440 --> 00:30:39.200 One, it's just an opportunity to be curious. 00:30:39.279 --> 00:30:50.319 So even if you don't go the whole month

without drinking, maybe you try, you know, only drinking a couple days out of the week or trying to just better understand the role alcohol plays in your life, or taking a break for a month and seeing how you feel. 00:30:50.480 --> 00:30:51.920 It's sort of like keeping a food journal. 00:30:52.000 --> 00:30:59.200 Like it forces you to be more mindful of something that maybe you hadn't been sort of aware of, what were the associations between your mood and drinking? 00:30:59.359 --> 00:31:02.960 Are you drinking because you're sad, or are you drinking because you're in a social situation? 00:31:03.039 --> 00:31:06.079 It's actually pleasurable and you're building relationships with people. 00:31:06.240 --> 00:31:10.640 So I think that that opportunity for awareness actually is an intervention in and of itself. 00:31:10.799 --> 00:31:14.079 And then certainly it's kind of a litmus test to see do you feel better? 00:31:14.160 --> 00:31:24.079 So if you're wondering, like, is alcohol making me feel tired or giving me brain fog or is it interrupting my sleep, or is it causing my skin to look terrible, or am I gaining weight because of how much I drink? 00:31:24.240 --> 00:31:26.480 Or, you know, is my mood worse because I'm drinking? 00:31:26.640 --> 00:31:32.480 You know, month isn't for some of those things, you'd need to see longer than a month, but in a month, you actually can see a fair amount of change. 00:31:32.559 --> 00:31:43.359 And so sometimes that can be both helpful, kind of clarifying for someone whether alcohol is causing negative responses in their body, but also, you know, it just gives this moment of pause and reflection. 00:31:43.519 --> 00:31:55.119 And then I think the last thing is if you're worried that you may have problems related to alcohol, you know, in terms of like actually meeting criteria for alcohol use disorder, one of the criteria is trying to stop and not being able to. 00:31:55.359 --> 00:32:10.160 And so there is a little bit of a test there that if you kind of say that you want to stop and you find actually you're thinking about drinking all the time and you're not able to cut back or stop, that may be cause to be a little bit more concerned about your drinking and actually talk to a professional about it. 00:32:10.400 --> 00:32:13.599 So I think there are layers where these kind of sobriety challenges can be helpful. 00:32:13.680 --> 00:32:20.319 But I mean, for someone who is clear that alcohol, they're drinking in those lower risk drinking limits, alcohol is not causing a problem in their health. 00:32:20.400 --> 00:32:23.440 There's certainly no imperative to do a sober month challenge. 00:32:23.519 --> 00:32:37.680 And I think importantly, if you do it, just like if you sort of go through a period of healthy eating, you don't want to undo all the benefits by then, you know, doing the exact opposite, sort of eating everything in sight for a month, you're gonna erase any benefits you saw from that time of sobriety. 00:32:38.160 --> 00:32:38.400 Yes. 00:32:38.559 --> 00:32:40.319 Well, that would be very logical, Dr. 00:32:40.400 --> 00:32:41.039 Wakeman. 00:32:42.000 --> 00:32:43.839 And if only we all worked that way. 00:32:44.079 --> 00:32:46.319 Yeah, sometimes it doesn't work that way. 00:32:46.720 --> 00:33:07.039 I was doing some research on um sex addiction a while back for an episode, and I learned something really interesting that for many people, the reason that they categorize their sexual desires and their drive in the category of addiction is due to moral incongruence. 00:33:07.440 --> 00:33:17.279 A lot of these folks are from strict religious communities, and so the, you know, desire to masturbate would be a sin. 00:33:17.359 --> 00:33:25.119 And so then they they still do it despite their understanding that it's a sin, and therefore, ah, it must be an addiction. 00:33:25.359 --> 00:33:32.960 And I'm wondering how much that moral incongruence dynamic plays a part in your world in in drinking. 00:33:33.279 --> 00:33:36.480 Well, I think I mean morality is is very subjective to that point. 00:33:36.559 --> 00:33:41.599 It depends on the the norms and customs of your culture, of your community. 00:33:41.759 --> 00:33:44.400 And so that that's true with alcohol too. 00:33:44.480 --> 00:33:45.759 You know, there actually can be the opposite. 00:33:45.839 --> 00:33:53.839 There can be an incongruence if your entire social setting and relationships are based around heavy alcohol use and you decide to stop drinking, that's really hard. 00:33:53.920 --> 00:33:58.160 There's an incongruence there between sort of the accepted norms in your community and what you're doing for your health. 00:33:58.319 --> 00:34:01.359 So I think anytime there are deltas there, it's challenging. 00:34:01.519 --> 00:34:13.280 I think with alcohol, unlike other stigmatized drugs, like alcohol is a drug, it is every bit as harmful, if not more, more harmful than other drugs, but it is socially accepted or more socially accepted, generally speaking, than other drugs. 00:34:13.440 --> 00:34:20.639 And so because of that, people often are not wrestling with the same moral incongruence that they would with, you know, more stigmatized type of drug. 00:34:20.880 --> 00:34:27.440 And so I think, you know, often the social norm still is that alcohol is, you know, widely available and acceptable. 00:34:27.599 --> 00:34:37.760 And so I don't think people have that same sense outside of certain religious groups or cultural groups where any alcohol uses them as a sinner is incongruent with the beliefs of their culture. 00:34:38.079 --> 00:34:58.800 How much of what we experience as a pull towards alcohol is just what I've heard people call an alcohol puppy in the brain, meaning that uh strong and repeated reinforced association between pleasure and alcohol or relief from pain and alcohol. 00:34:59.119 --> 00:35:04.159 Yeah, there are powerful neurotransmitters and pathways in

your brain that are happening when you drink. 00:35:04.320 --> 00:35:10.639 And different people have differing amounts of activation in those systems, which is part of why some people are more at risk of developing addiction than others. 00:35:10.880 --> 00:35:23.280 But generally speaking, you know, the reason we feel pleasure when we drink is sort of the end stop of pleasure for any substances, dopamine release is the brain releasing dopamine, which is a feel-good hormone that also teaches you to pay attention to something. 00:35:23.360 --> 00:35:28.320 So it's sort of signaling to the brain this concept of salience, which is the idea that you associate things. 00:35:28.400 --> 00:35:36.400 So this idea of like, oh, I drank that glass of wine and I feel relaxed and more connected to my friends, or I, you know, felt more comfortable in that first date. 00:35:36.480 --> 00:35:38.480 And so you're creating an association there. 00:35:38.639 --> 00:35:40.320 And so that can, that's normal. 00:35:40.480 --> 00:35:42.800 That happens with many, many things in your life all the time. 00:35:42.880 --> 00:35:46.400 There's your sort of brain is constantly making associations between things. 00:35:46.559 --> 00:36:08.400 But that is particularly powerful in the con in the construct of addiction, where over time the brain, that sort of salience, that idea of pay attention to alcohol, this is the thing that's going to make me feel better, becomes kind of outsized and outpaces everything else and actually outpaces sort of normal, healthy, reward-seeking behavior like relationships or food or sex or other things where there's a reason behind that salience. 00:36:08.559 --> 00:36:13.039 I think the other thing that they're showing with alcohol is it actually activates your endogenous painkiller system. 00:36:13.199 --> 00:36:19.920 So in the brain, people have probably heard of the concept of endorphins, which are endogenous opioids in your brain. 00:36:20.000 --> 00:36:23.840 So endorphin is an amalgamation of the words endogenous and morphine. 00:36:23.920 --> 00:36:25.760 So it's like your brain's morphine system. 00:36:26.000 --> 00:36:32.239 And people hear of that with like runners high or other things, this idea that your brain releases these, these pain-relieving and feel-good hormones. 00:36:32.400 --> 00:36:37.920 And for many people, alcohol actually triggers release of their endogenous opioids that estimates that system too. 00:36:38.079 --> 00:36:43.280 And so not only you're getting a dopamine release, but you're actually getting sort of a painkiller relief when you're drinking. 00:36:43.360 --> 00:36:48.480 And so that also then, of course, causes pleasure and relaxation and positive feelings. 00:36:48.559 --> 00:37:05.519 And that's the way one of the medications we use to help people either stop drinking or reduce the amount of drinking that they're doing actually blocks that opioid system so that it tries to block that reinforcement of this

sort of pleasure and reward of alcohol use has a medicine called Naltrexone that people are hearing a little bit more about than I think they used to. 00:37:05.679 --> 00:37:10.159 But it's interesting when you first hear about it, it's sort of like, well, why would an opioid blocker work for alcohol use? 00:37:10.239 --> 00:37:17.199 But it's really the blunting of that sort of reinforcing cycle of, oh, I drink and I see all these amazing feelings from drinking. 00:37:17.519 --> 00:37:23.280 So if someone is trying to just moderate their drinking, would that be a viable option for them? 00:37:23.519 --> 00:37:23.760 Yeah. 00:37:23.840 --> 00:37:26.559 And we're there's, I think, more attention to that than there used to be. 00:37:26.639 --> 00:37:29.360 So niltrexin is a medication that's been around for a long time. 00:37:29.519 --> 00:37:40.960 And in part, I think due to a lot of separation of addiction from the rest of medicine, the fact that many people, even if we talk about addiction as an illness, really think that this is an issue, sort of bad behavior. 00:37:41.039 --> 00:37:45.519 And we have lots of, I think, thoughts that people should just have willpower and sort of knock it off. 00:37:45.679 --> 00:37:54.800 And so very few people with alcohol use disorder ever get treated with medications, even though we have really effective medications that can help people either stop drinking or cut back on their drinking. 00:37:54.960 --> 00:37:59.199 But this medication, altruxone, is interesting because it can also be used just to moderate your drinking. 00:37:59.360 --> 00:38:09.760 And so there's a thing called the Sinclair method, which is named after a scientist by the name of Sinclair who studied it, which is the idea of actually pre-medicating before an event where you're tempted to drink more. 00:38:09.920 --> 00:38:20.400 So if you know that whenever you go to happy hour, you walk in intending to drink one or two and you leave having drunk five or six, and you just like once you start drinking, it's really hard to stop. 00:38:20.559 --> 00:38:24.880 What Sinclair studied is actually taking this medicine before you're in a situation like that. 00:38:25.039 --> 00:38:28.159 And what happens is you drink, but you just don't get the same pleasurable effect. 00:38:28.320 --> 00:38:33.280 And so it's not like you get sick, but people, you know, patients will describe to me this sense of like, oh, I had a glass of wine. 00:38:33.440 --> 00:38:35.760 I just like didn't have that urge to want another. 00:38:35.840 --> 00:38:36.719 It didn't feel that good. 00:38:36.800 --> 00:38:42.400 And so that can help reinforce people's if they have an intention of trying to cut back or not drink in a heavy manner. 00:38:42.719 --> 00:38:50.559 So is that something that the average person could just talk to their regular doctor about without fear? 00:38:50.719 --> 00:38:57.440 Because, you know, there is a lot of stigma around drinking and as you said,

like willpower and all of that. 00:38:57.599 --> 00:39:11.760 So if someone is just trying to stay in the moderate zone and they're finding that it's difficult, but they're just not ready to do the cold turkey thing, do you realistically do you think that they could just say, hey, doc, I heard that there is a medicine that helps me do that? 00:39:11.920 --> 00:39:22.480 Or would that like, you know, trigger some sort of cascade of responses from that person's medical team that would be, you know, undesired? 00:39:22.719 --> 00:39:26.559 So in a perfect world, absolutely you can and should say that to your primary care doctor. 00:39:26.719 --> 00:39:29.039 You know, any doctor can prescribe that medicine. 00:39:29.119 --> 00:39:32.159 You don't need like special training or a special license or anything like that. 00:39:32.320 --> 00:39:37.039 And primary care doctors are often sort of the trusted healthcare professional that people know over time. 00:39:37.199 --> 00:39:46.000 And there have been lots of studies that patients actually feel most comfortable talking to their PCPs as opposed to some random other person or specialist about their alcohol use. 00:39:46.159 --> 00:39:51.280 And so I think absolutely you could say to your primary care doctor, you know, I'm realizing I'm drinking more than my goal. 00:39:51.440 --> 00:39:53.360 You know, I've heard about these lower drinking limits. 00:39:53.440 --> 00:39:56.159 I want to try to keep it to one drink a day or two drinks a day. 00:39:56.239 --> 00:40:00.320 And I find in certain settings, you know, I'm I I tend to drink more than that. 00:40:00.400 --> 00:40:04.079 And I've heard there's this medicine that can help people cut back and I want to try it. 00:40:04.159 --> 00:40:05.760 And they should be able to prescribe that. 00:40:05.920 --> 00:40:14.639 There actually are now these companies, online companies that are doing sort of direct-to-consumer consultations, kind of similar to the whole industry with GLP ones around weight loss. 00:40:14.800 --> 00:40:21.360 And I think that so that can be an option too for people if they either don't have a primary care doctor or feel like they're not able to talk to that person. 00:40:21.519 --> 00:40:30.960 To me, it's sort of a sad testament of medicine that we've so failed to address substance use as a part of health, that there have to be these like pop-off valves that are separate for people to find care. 00:40:31.119 --> 00:40:50.079 And I actually think that talking to your doctor is an important part of changing the system and normalizing this, that that's part of how doctors change their practice, actually, especially when we've been in practice a long time, is they realize they have to get with their times that their patients need help with different things and there are treatments that they can learn how to prescribe them and how to offer them and make them a part of their practice. 00:40:50.320 --> 00:41:05.280 Well, I find it interesting that you were talking about the intersection of behavior and medicine and what we consider disease, because in my non-medical brain, those things are always connected and always linked arms with one another. 00:41:05.519 --> 00:41:15.679 And so if a medicine could help a behavior which equals a better health outcome, then that feels like an obvious choice. 00:41:15.840 --> 00:41:33.199 I I think where I have trouble is the all or nothings of alcohol in our society, where people are saying it's 100% a disease, I inherited it, and it is always if someone has the same problem I do, it is 100% a disease. 00:41:33.440 --> 00:41:40.239 And or it's a hundred percent behavior, and you just need to buck up and you know make that change. 00:41:40.400 --> 00:41:44.079 And I don't know, that black or white part is is tough for me. 00:41:44.159 --> 00:41:47.599 I I found this study actually, I think that you would find interesting. 00:41:47.760 --> 00:41:49.280 It's it was an experiment, actually. 00:41:49.360 --> 00:41:52.400 It was South Dakota's 24-7 sobriety program. 00:41:52.639 --> 00:41:54.320 You probably already have you heard of this. 00:41:54.559 --> 00:41:54.880 Interesting. 00:41:54.960 --> 00:41:55.760 I haven't heard of it now. 00:41:55.840 --> 00:41:56.320 Oh my gosh. 00:41:56.400 --> 00:41:57.599 Okay, this is kind of cool. 00:41:57.760 --> 00:42:03.039 I I would love to see our town experiment with this, but I don't know how all that stuff works. 00:42:03.199 --> 00:42:07.119 But the participants were required to take twice daily breathalyzer tests. 00:42:07.519 --> 00:42:09.679 The participants were people who got DUIs. 00:42:09.920 --> 00:42:10.079 Okay. 00:42:10.400 --> 00:42:12.719 So they had to take a breathalyzer test twice a day. 00:42:12.880 --> 00:42:19.760 And if they failed or skipped even just one test, they went straight to jail, like and stayed there overnight. 00:42:19.920 --> 00:42:21.920 And it was very swift. 00:42:22.159 --> 00:42:27.599 So they did this from 2005 to early 2017 with over 30,000 people. 00:42:28.159 --> 00:42:52.320 And they accumulated over 5 million days without a detected alcohol violation, over almost a million breathalyzer tests recorded, 99.4% passed, which is really cool because like there was a strong and swift incentive because earlier you were talking about how strong that association becomes. 00:42:52.400 --> 00:42:57.519 Like it starts out as an alcohol puppy and it grows into a mastiff. 00:42:58.400 --> 00:43:04.480 You know, those little paws, they grow into a big old animal and you can't, it's like you've lost control. 00:43:04.639 --> 00:43:07.519 You didn't realize this is what it was going to snowball into. 00:43:07.760 --> 00:43:14.800 And so it was interesting to me that this experiment had a had a big consequence to kind of counter that. 00:43:14.960 --> 00:43:21.360 And it led to a 12% reduction in DUI arrests and 9% reduction in domestic violence arrests. 00:43:21.599 -->

00:43:25.519 So overall, it reduced the risk of death by 50%. 00:43:26.239 --> 00:43:34.480 And I thought that was so cool, but it it definitely pushes back a little bit on the alcoholism is 100% a disease narrative. 00:43:34.559 --> 00:43:49.840 And I'm wondering if it might be better for everyone if we could find some sort of compassionate middle ground where we don't need to be overly attached to labels and instead, as you were doing, taking a more personalized approach and like, okay, well, what what can I do? 00:43:50.000 --> 00:43:50.639 What can be done? 00:43:50.719 --> 00:43:54.320 But but from a systemic point of view, I thought that was fascinating. 00:43:54.639 --> 00:44:05.599 Yeah, well, I think, I mean, there's so many layers then to what you just shared, but I I think first the idea that Like most chronic health conditions, addiction is a mix of sort of behavior and biology. 00:44:05.679 --> 00:44:07.360 And that's true for diabetes. 00:44:07.440 --> 00:44:08.480 That's true for heart disease. 00:44:08.559 --> 00:44:09.599 That's true for cancer. 00:44:09.760 --> 00:44:15.199 That's true for addiction, where there's some element of your individual risk that you're, you know, inherit. 00:44:15.280 --> 00:44:19.039 And that can be like roughly half or or so of the picture. 00:44:19.280 --> 00:44:26.880 And then there's like what you're exposed to, the circumstances that you're in, your health-related behaviors, what age you start drinking, how often you're drinking. 00:44:27.039 --> 00:44:31.280 And so there's always this intercepting interplay between behavior and biology. 00:44:31.360 --> 00:44:34.800 And, you know, same thing with diabetes, where someone, you know, is born. 00:44:34.960 --> 00:44:38.719 If everyone in your family has diabetes, you're going to be at greater risk, but that's not a done deal. 00:44:38.800 --> 00:44:41.599 There's many things you can do to prevent diabetes from occurring. 00:44:41.679 --> 00:44:42.400 And same thing. 00:44:42.480 --> 00:44:45.199 Some people have no family history and, you know, develop diabetes. 00:44:45.280 --> 00:44:48.480 And so I think there are very few things that are totally binary. 00:44:48.559 --> 00:44:55.039 And certainly in the realm of substance use, most things are an overlapping mix of behavior and biology. 00:44:55.199 --> 00:44:57.840 And again, that aligns with other chronic illnesses. 00:44:58.079 --> 00:45:08.000 You know, the DUI literature is interesting because mixed in that group is probably a whole hodgepodge of people who actually have addiction and people who are just drinking at a heavy level. 00:45:08.239 --> 00:45:18.239 And so again, if we think of that as a spectrum, it's not sort of this all or nothing of either you are, you know, have alcohol use disorder or alcoholism, or you have no problems with alcohol. 00:45:18.320 --> 00:45:24.719 It's there's a whole spectrum in there that we've been exploring and beyond that of drinking in ways that are really beginning to cause problems in your life. 00:45:24.880 --> 00:45:33.199 And many people with their first DUI, they may not yet actually have the kind of compulsive loss of control characteristics that we see with alcohol use disorder. 00:45:33.280 --> 00:45:38.800 And so that's a time when there is more choice involved in terms of sort of decision change. 00:45:38.960 --> 00:45:41.599 So you're you've got like a mixed population there. 00:45:41.760 --> 00:45:53.920 But I think the other two things that I'm struck by what you say, one is, you know, I always say to our fellows who I'm I'm teaching or our teams that it really doesn't matter why we as professionals think someone should make changes to their alcohol use. 00:45:54.000 --> 00:45:58.400 Like the only thing that matters is that they think their life is going to change in a positive way if they do. 00:45:58.639 --> 00:46:16.159 And so in that context, if you don't want to lose your license or you don't want to go to jail or whatever it is that you're facing in your unique circumstances, like that is a very salient motivator of making change, especially if you're drinking in a way that's unhealthy and don't necessarily have this sort of compulsive loss of control that we see with addiction. 00:46:16.320 --> 00:46:28.320 You know, the flip side of that coin is the very severe end of the spectrum of people with severe addiction, you know, sometimes even facing terrible negative consequences like jail or losing their kids or losing their job, people just are not able to make changes. 00:46:28.480 --> 00:46:31.440 So there is, you know, shades of severity in there. 00:46:31.679 --> 00:46:44.000 And then the last thing is that one of the most sort of effective interventions from a behavioral standpoint for all types of addiction is something called contingency management, which is actually positive incentives for behavior change. 00:46:44.159 --> 00:46:54.400 So this would be things like if someone has a negative drug test or if they engage in treatment or show up to see their therapist or their doctor, they actually get positive incentives or rewards. 00:46:54.480 --> 00:47:00.559 So sometimes these are like vouchers that support a healthy lifestyle or other entering a raffle to win something. 00:47:00.800 --> 00:47:04.159 And it can sound kind of weird at first of like, well, why would that work? 00:47:04.239 --> 00:47:06.800 But actually, we do this across lots of different areas of health. 00:47:06.880 --> 00:47:22.239 So if you have a health insurance plan where you get money back if you join the gym or go to the gym a certain number of days of the year, or you get sort of a rebate for any pro-healthy behavior, that in essence is positive contingency management, trying to change people's behavior with positive rewards. 00:47:22.400 --> 00:47:31.840 And some of the concept of why that works with addiction is that when someone gets to the degree of having addiction, often they have a

lot of things that have fallen apart in their life. 00:47:32.000 --> 00:47:36.159 They may have lost relationships with family, they may have lost their work or their housing. 00:47:36.320 --> 00:47:38.719 And that stuff takes years to rebuild sometimes. 00:47:38.880 --> 00:47:43.280 And alcohol is a very powerful source of relief as we've covered. 00:47:43.360 --> 00:47:49.920 It's something that gives you immediate escape from the challenges of daily life or your pain or your suffering or withdrawal. 00:47:50.079 --> 00:48:00.400 And so you're essentially asking someone to discount the sort of immediate reward of drinking for these very abstract long-term rewards of like, well, if you just stay sober for two years, maybe you'll get your housing back. 00:48:00.639 --> 00:48:01.679 And that's really hard. 00:48:01.760 --> 00:48:08.079 You know, you're sort of saying no to this thing that can immediately make you feel better for this concept that maybe things will get better down the road. 00:48:08.239 --> 00:48:18.079 And so part of contingency management is actually giving people a positive, immediate good thing for doing the sort of healthy behavior that that is a part of supporting their recovery, like not drinking. 00:48:18.159 --> 00:48:23.039 And so, so there certainly are ways in which sort of behavioral interventions like that can be helpful. 00:48:24.079 --> 00:48:27.199 You said something interesting in another interview. 00:48:27.440 --> 00:48:33.360 You said the opposite of alcoholism isn't sobriety, it's connection. 00:48:33.599 --> 00:48:36.079 As we close, can you unpack that? 00:48:36.480 --> 00:48:40.719 Yeah, you know, I think we we focus so much on sort of is someone sober or not? 00:48:40.880 --> 00:48:43.360 What is their drug test show or their alcohol test show? 00:48:43.519 --> 00:48:45.679 Really, addiction is a disease of isolation. 00:48:45.920 --> 00:48:54.000 People often are isolated from relationships, from connection with people that bring hope and meaning and purpose to their lives. 00:48:54.239 --> 00:49:04.239 And as powerful as an incentive as negative things happening to you can be, you know, the idea that you want to escape the pain of ongoing alcohol use disorder. 00:49:04.719 --> 00:49:10.480 Actually, one of the biggest incentives is a sense of hope that your life could look better, that people care about you and believe in you. 00:49:10.719 --> 00:49:17.760 And those connections are a powerful vehicle for getting there, but are also sort of the reward that comes along with that journey of recovery. 00:49:17.840 --> 00:49:31.760 And so whether you find that through support groups or through engaging with a doctor or a nurse or a therapist, you know, that connection is often the thread that is so powerful in helping people get to a place where they they think their life could be better if they were to make changes to alcohol. 00:49:32.000 --> 00:49:32.159 Yeah. 00:49:32.320 --> 00:49:38.639 And I think that it's neat what you're doing to help kind of facilitate that that connection. 00:49:38.800 --> 00:49:46.800 You know, the very you seem very hands-on, personable with your patients and with your approach at educating the public. 00:49:46.960 --> 00:49:49.760 So I appreciate you taking time to do that with us. 00:49:50.000 --> 00:49:58.480 Can you can you tell people where they can find your book and any sources of ongoing research or educational material that you have? 00:49:58.800 --> 00:49:59.039 Yeah. 00:49:59.119 --> 00:50:01.679 Well, first, thank you so much for saying that and for having me. 00:50:01.840 --> 00:50:05.440 So my book is called Treatable, and it is coming out January 5th. 00:50:05.519 --> 00:50:09.039 And you can pre-order it now on my website, drsarahwakeman.com. 00:50:09.199 --> 00:50:13.039 You can contact me through my website or follow me on Instagram, also Dr. 00:50:13.119 --> 00:50:20.880 Sarah Wakeman or on LinkedIn, and I would be excited to connect and really hope people enjoy the book and can hear more about these topics there. 00:50:21.199 --> 00:50:22.239 Well, thank you again. 00:50:22.400 --> 00:50:23.199 This was great. 00:50:23.519 --> 00:50:25.039 Thank you so much, Meredith. 00:50:25.840 --> 00:50:26.719 Thanks for listening. 00:50:26.880 --> 00:50:30.960 Since you've made it this far, I'd like to invite you to be part of my private Facebook group. 00:50:31.119 --> 00:50:33.840 And there I post content that I don't share anywhere else. 00:50:33.920 --> 00:50:37.119 You can talk to me directly, and I even do occasional giveaways. 00:50:37.280 --> 00:50:41.360 Search MFR Curious Insiders on Facebook or click the link in the show notes. 00:50:41.519 --> 00:50:49.199 If you liked this episode, you'll also like the one with the sober scientist who answers the question how do you know if you're an alcoholic? 00:50:49.360 --> 00:50:51.440 That's episode 265. 00:50:51.599 --> 00:50:57.519 And stay tuned next week for a remastered favorite asking if political parties are just cults. 00:50:57.679 --> 00:50:59.599 Until then, keep it curious.