By Peter Flax
There will be no broken coffee tables in this story. No blackouts, shots of Jager, thumping hangovers, or epic tales of tossing park benches into duck ponds. I’m not the guy who makes a scene or curls up asleep on a dog bed. This story is not about a booze blowout; it’s about a slow leak that could have left me empty and alone.
There’s a decent chance that you drink like I do. I enjoy a cold IPA when I get home from work; maybe a glass of pinot with a plate of pasta later. I drink liquor only a few times a year; I can’t think of more than 10 times, all big nights out, in the past few years when I might have thrown down five or more drinks in two hours, which is how the CDC defines binge drinking.
And yet I couldn’t remember the last time a day had gone by when I didn’t have a drink. It had been years, that much was certain.
And over those years, as my two boys grew up and my career advanced and the stresses of work and family and suburban ennui intensified, I found myself in the kitchen many evenings pouring a final glass of Barbera that I really didn’t want or need. I was reading The Cat in the Hat with a drink in hand. I was falling asleep early and waking up sluggish. Even though I exercised all the time, I put on a few pounds.
I felt an emotional weight too: regret.
This is the kind of trouble that up to 17 million Americans find themselves mired in. Statistics indicate that the incidence of mild drinking issues is on the rise. Scientists and doctors avoid the term “alcoholism,” feeling it’s inaccurate and stigmatizing.
Right now, people with serious drinking problems are pushed toward rehab rather than medical treatment, and most everyone else just falls through the cracks. But change is coming. Some researchers contend that alcohol treatment is at a transformational moment, with care based on science and tilted more toward moderation than abstinence.
And the people who stand to gain the most may be guys like me who aren’t close to a severe alcohol problem.
Of course, you can’t tackle a problem until you admit you have one. It’s not like I was stumbling around drunk, missing deadlines, or keeping a pint of Jack stashed in my desk drawer. My social circle was full of people who drank more than I did, who likewise seemed to be highly functioning human beings. It was easy to reassure myself that everything was fine.
So that’s what I did. But deep down, I knew I was in trouble.
Paying the Tab
The simple fact is that America has a drinking problem—and it’s getting worse. No one knows that more clearly than Philip J. Cook, Ph.D., an economist and sociologist at Duke who wrote Paying the Tab: The Costs and Benefits of Alcohol Control. Cook analyzed data from a study surveying 43,000 Americans on their drinking habits and constructed a portrait of U.S. drinkers. It’s not a pretty picture.
The top 10 percent of Americans who drink—some 24 million people—consume an average of 61 drinks a week. The next 10 percent have an average of 22 drinks a week. “According to my calculations, 15 percent of American drinkers consume 75 percent of the alcohol sold nationwide,” says Cook. “And men are heavily represented in that demographic group.”
Deaths from alcohol hit a 35-year high in 2014, at 30,700, according to the CDC, and that was not counting deaths from accidents and homicides. We are talking about more than the number of deaths from heroin and prescription opioid painkillers combined.
But some of the damage is far subtler than that. The research community now believes that many people who have two or three drinks a day have a medical problem—that is, if they occasionally drink more than they intended to, wish they could cut down, or spend too much time thinking about drinking.
“If you’re uncomfortable about your drinking, if it’s causing you stress, then you probably need treatment,” says Mark Willenbring, M.D., founder of the Alltyr Clinic in St. Paul and former director at the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
This field’s terminology is evolving: Alcohol use disorder, or AUD, is the phrase of choice to encompass the range of people in trouble. People like me, and maybe you. “What most of us think of as an alcohol problem or alcohol dependence is a stereotype that really only applies to the sickest 10 or 15 percent of people,” says Dr. Willenbring.
The most recent data show that roughly 14 percent of U.S. adults have suffered from alcohol use disorder in the past year and that three-quarters of those people look more like me than the stereotypical alcoholic. (Think Nicolas Cage in Leaving Las Vegas.)
Photo: Misha Gravenor
The biology of booze is also coming into sharper focus. Drugs like heroin and marijuana influence dedicated systems of the brain, but alcohol acts as both a stimulant and a depressant, with effects spread over several brain sectors. Like Valium and Xanax, it binds to the receptors of a neurotransmitter called GABA, which makes you relax in a major way.
But through a kind of biochemical magic, it also jacks up the release of dopamine in your brain’s pleasure center, giving you that feeling of euphoria. It turns out men are twice as likely as women to have AUD. In research from Yale and Columbia, the brain scans of male drinkers revealed significantly greater dopamine release than those of women.
Over time, a drinker’s brain adapts to the chemical onslaught by desensitizing itself. So to maintain the feel-good effects, you need to drink more.
Perhaps that was happening to me. I wasn’t hitting rock bottom in the cinematic sense. I was earning promotions at work, helping the kids with their homework, and riding my bicycle thousands of miles a year. Yet I was drinking three or occasionally four glasses of wine a night, not stopping until I felt buzzed in a certain way.
I’d wake at 2 a.m. with my mouth parched; sometimes my gums would bleed. My sense is that someone who drinks habitually, even moderately, starts to normalize situations that are not normal. That’s clearly what I was doing.
Drinking at this level—more than the NIAAA’s recommendation for low-risk drinking, a max of four drinks a day and 14 per week for men—increases the risk of developing AUD. A body of research shows that moderate alcohol consumption—one or two drinks a day—can help reduce your risk of heart disease, stroke, and diabetes.
When you exceed that, though, the benefits are washed away. Excessive drinking increases your blood pressure, overtaxes your liver, damages your immune system, increases your risk of various cancers, and most insidiously, tangles your brain. Researchers equate it to sunburn. The longer you’re exposed, the more serious and life-threatening the damage.
New imaging research reveals that long-term alcohol abuse shrinks gray matter in the areas of your brain that govern learning, memory, decision making, and social behavior, explains NIAAA director George Koob, Ph.D. This damage is often subtle: You can’t remember a name, you have more frequent mood swings, you blurt out inappropriate comments.
Some clinicians are bracing for a wave of alcohol-related cognitive problems as the big-drinking baby boomer generation grows old. However, if you cut your intake to more moderate levels before age 50, you may reverse some of the damage, Harvard scientists say. Some researchers also note that “moderate” is open to debate.
My moment of clarity came about a year and a half ago. I had moved to California and started a new job; I suddenly was facing new stresses and found myself untethered from a solid social network. I don’t think I was drinking more, but I was getting home from work later and compressing my drinking into less time. I would lie down with my then 7-year-old son at his bedtime, sipping a glass of red as I answered work emails on my laptop.
One night I woke up a few hours later, with wine spilled all over myself, my computer, my kid’s duvet cover. At that moment, the fact that I didn’t meet CDC binge-drinking standards or diagnostic criteria for moderate AUD didn’t really matter. I needed to get my shit together.
The next morning, I felt like I was standing in swim trunks at the edge of a quarry cliff: ready to take a leap but unsure how I would land. I knew I needed to cut back but had no idea how to do it. I’d never had a substantive talk about my problem with a trained professional.
During my annual physicals, the doctor would ask scripted questions: “You smoke or do drugs? You don’t have a drinking problem, do you?” These inquiries always felt more like a formality than the start of a conversation. (And here are 10 Questions You Must Ask Your Doctor.)
Only 17 percent of drinkers have ever discussed their consumption with a doctor, according to a report from the CDC. “Many primary-care physicians aren’t comfortable talking about drinking, in part because many drink themselves,” says Reid Hester, Ph.D., director of the research division of Checkup & Choices in Albuquerque. And if a doctor does take action, it’s likely a referral to a counselor who often is a former addict with no more than a high school diploma.
A landmark report by the National Center on Addiction and Substance Abuse (CASA) likened the treatment of addiction to the “state of medicine in the 1900s.” The report itemized the symptoms of the crisis: the poor training and lack of accountability of treatment providers on the front lines, the nonmedical approach to a medical problem, and the absence of funding.
“Everyone agrees that addiction, whether it’s to alcohol or drugs, is a disease or disorder and it should be treated within the health care system,” says Linda Richter, Ph.D., director of policy research and analysis at CASA.
A cadre of researchers have been arguing for years that the rehab industry and Alcoholics Anonymous are not serving the best interests of people with alcohol use disorder.
For people with mild or moderate AUD, rehab seems out of step with the problem they’re looking to solve. Even for people with severe AUD, there’s scant evidence that 12-step programs are effective, according to a comprehensive review.
“Rehab is stigmatizing, disruptive, expensive, and outdated. It’s not even treatment,” says Dr. Willenbring. “We used to treat breast cancer with prayer too. We don’t do that anymore; we shouldn’t be treating addiction that way either.”
The NIAAA increasingly recommends one-on-one sessions known as “brief interventions.” During these consultations, health care providers sit down with patients and discuss their habits and risk factors, help set limits and develop coping skills, establish support, and offer further care if appropriate. “Most cases of alcohol use disorder can be treated in primary care, just the way depression is now,” says Dr. Willenbring.
What’s more, the Affordable Care Act requires many insurance plans and state Medicaid programs to consider substance use disorder services an “essential health benefit” and thus cover them at the same level as other medical services.
In addition, specialists are taking a closer look at moderation, especially for people like me with a mild to moderate problem. After all, one or two drinks a day is healthier than going cold turkey. It’s also less likely to lead to relapse and more likely to fit into the realities of life.
For many severe abusers, abstinence remains the end point, because the control mechanisms in their brains are so damaged that they cannot limit their intake, explains Dr. Willenbring. But for those on the mild end of the scale, a carefully managed drinking habit is a viable option.
The trick is pulling it off. In my case, that began only after six months of well-meaning but unfocused efforts to cut back. The experts I spoke with recommend taking a detailed and honest inventory, defining and tracking specific limits, and recruiting social support. I stumbled on that methodology on my own. I made a handful of rules and typed them into a Notes page on my iPhone.
1. No more than two drinks a night at home.
2. No red wine in the house; beer only.
3. I will screw up. Just wake up tomorrow and follow the rules.
4. No drinking in the kids’ rooms, period.
5. The rules don’t apply at social occasions.
It seemed goofy to codify this, but also powerful. I told my wife about my self-imposed limit, which helped. No guy wants his wife to think he can’t follow through with a plan. Nine months later, the rules are still effective. I’ll admit that I miss having red wine daily, but portion control had been tough; it gave me a buzzier feeling than other kinds of alcohol.
The impact on my life was quick. My sleep improved within a week; I was waking up earlier and feeling more rested. And over time I noticed that I was losing weight, and eventually shed more than 10 pounds. There was an uptick with my fitness too. The tracking app I use when cycling showed new personal bests on climbs.
Most important, I felt better about myself—as a father, a husband, a guy in control of his problems. The management phase of my controlled drinking might last, well, forever, but I feel a kind of strength knowing that my drinking life will involve years of vigilance—and enjoyment.
I ran my game plan by experts after the fact, and they liked it. Hester commended the specific ceiling as well as the individualized and realistic decisions I made about portion control. He said it was wise to accept minor failures: “Nobody learns a new habit overnight.
The key is to learn from mistakes and still move forward.” He suggested a daily written log of what I drink (useful advice for people who enjoy mixed drinks that contain multiple portions of alcohol) and keeping cold seltzer around so I’d have a carbonated drink to sip on.
As for sharing your rules with others, it depends: If you have supportive friends or family to lean on, that’s great; if not, sharing your struggle and goals might not be constructive. He also said many people benefit from listing a binge rule. And if you can do it, take one night off from drinking every week, to help yourself feel more in control.
Living With Dependence
My detente with alcohol remains uneasy. I know I can stick to my plan without wavering, but I don’t feel like I could just stop drinking. I can go all day without considering drinking, but the moment I arrive home, I want to walk straight to the refrigerator and crack open a beer.
Heck, the kids can wait another 30 seconds to tell me about their day, right? I often resist that urge, but it’s there. Maybe after years of controlled drinking, the pull of dependence will fade. Maybe it won’t.
As I reported this story, I discovered another option: prescription drugs. Among some clinicians, the practice of giving far-from-severe drinkers meds to control their habit is taking root. The drug with the best track record is called naltrexone.
It was developed to combat the addictive qualities of narcotics like heroin and codeine. It blocks endorphins that normally would produce a euphoric feeling. It also blocks alcohol cravings, and it was approved by the FDA for alcohol dependence in 1994. “Naltrexone is a buzzkill,” says Dr. Willenbring. “You can enjoy the drink, but you just don’t get the buzz, so it makes the experience of drinking less compulsive.”
Ultimately I decided to pass on the naltrexone. The decision felt more philosophical than logistical. As much as I’d like to step away from dependence, I realized that I’d rather wrestle with the seduction of alcohol (and try to enjoy it) than take a pill to mute that conversation.
I might have made a different choice if my efforts at self-control had failed. But I’m starting to realize that I have my habit under control. Perhaps naltrexone can help millions of people drink less, but I’m not one of them. Not today at least.
On a recent winter night, I walked in the front door after a stressful day of work. The kids were bouncing off the walls and my wife looked beleaguered. You know, like any Tuesday. Within minutes, I had pulled a bottle of Sculpin IPA out of the fridge and poured it into a glass. The pale golden color, the anticipation of crisp grapefruit and slightly bitter notes, the feeling of tranquility that comes from the first sip—all of this sitting on the counter in a pint glass.
My older son, the one who was in the hospital a decade ago, was desperate to tell me about his first dress rehearsal in a school play, and the younger guy wanted to shoot baskets outside, right now. My urge was to ask for two minutes of peace with my beer. But I left the pint glass on the counter untouched and got on with my life.