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

I have had various patients in my practice that have raised the dreaded question of “Am I an alcoholic? Can I stop on my own?” this question is quickly followed by “No! My problem is not that serious!” I decided to write this blog after attending an Addictions training by Mc Lean hospital, division of alcohol and drug abuse. In this training, there was an interesting talk about “cutting back vs abstaining,” this concept raised several questions and I began wondering about the possibility of cutting back. I must mention that the presenter emphasized that cutting back did not work, but this conclusion was mainly aimed at daily drinkers. This lead me to wonder if the same would apply for weekend drinkers? And is cutting back really possible? What barriers can I foresee in the implementation of moderation? All these questions sparked my curiosity and lead to me to write a blog that might help answer 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 fulfill 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.

10. Tolerance as defined by either of the following:

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

b. A markedly diminished effect when continued use of the same amount of alcohol.

11. Withdrawal as manifested by either of the following:

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

b. 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 and 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 that was intended.

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

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

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.

10. Tolerance as defined by either of the following:

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

b. A markedly diminished effect when continued use of the same amount of alcohol.

Do any of these sounds familiar?

If they do, it’s time to get help! Many times the people around you might be the first ones that raise the concern about you drinking, this is a result of them witnessing some of the behaviors that might be “out of character.” Drinking affects that part of your brain called the prefrontal cortex, this is 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 actions or not” said John J. Woodward, a professor in the department of nescience and the Center of Drug and Alcohol Programs at medical university of South Carolina. “It weights 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 weight the consequences of their actions.”

It is sometimes the risky behaviors that lead to concern and worry from those who love you, realizing or even considering that this can be a problem is extremely difficult. Seek support and resources that can help you in understanding what this all means, trying to do it 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 lead of a clinician that can track how you are doing during the time of abstinence. It is important to process how it feels, the challenges and difficulties that you have encountered and any cravings or urges. Also, notice the positives, 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’ 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. This symptoms vary according to the individual and the quantity of alcohol consumed. 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 are at with this issue and how serious it really is.

2. Cutting down – moderation moderation moderation!!!

Let’s discuss some facts first, what is considered over the limit?

Women 4 drinks max and men 5 drinks max, 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. It is important to be aware that 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 weight the same. Secondly, women have less dehydrogenase, a liver 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. Another fact to be taken into account when moderating, is how alcohol moves through your body. Alcohol is metabolized by the liver, where enzymens 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 in one hour, if you drink more than that, 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’s actually extremely difficult, and there are facts that always need to be considered . You are always welcome to try on your own and again asses where you are at. 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 again are very challenging to do on your own. Some of the ones I found emphasize 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 my 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 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 a 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, I am going to stop.

If the ability to stop is not there, you might have to consider professional help, don’t wait until you want to stop drinking, knowing that you need to do is enough.

The price of doing the same old thing is far higher than the price of change. Bill Clinton

Growth demands a temporary surrender of security – gail Sheehy

Ever tried. Ever failed. No matter. Try again. Fail again. Fail better. Samuel Beckett

Don’t be afraid to fail. Be afraid not to try. Michael Jordan

Start by doing what’s necessary; then do what’s possible; and suddenly you are doing the impossible. St. Francis of assisi

What can get in the way? Biggest barriers?

Understanding the lack of control