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Episode 11 – Breaking Down Alcohol
by Dr. Ashish Bhatt | ❘
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Hayley: Hello. My name is Hayley, and you’re listening to Straight Talk with the Doc, a podcast that takes a real look at addiction, mental health and treatment. I’m here with our content director, Jeff and our medical director. Dr. Bhatt. How are you guys doing today?
Jeff: I’m doing just fine today. How are you doing Dr. Bhatt?
Dr. Bhatt: Good. Jeff, Hayley, how are you guys?
Hayley: I’m doing great. What we’re going to be talking about today is something that pretty much everyone has some experience with, and that is alcohol. The National Institute of Health says that over 85% of American adults have had alcohol at some point in their lives. So, you know, obviously it’s something that most of us have tried. And for many people, it’s no problem to have a drink at dinner or an event once in a while. It’s kind of just a social practice that we do. But for a lot of people, alcohol can completely destroy someone’s life. And it really is extremely addicting, but it’s legal. You can’t drive that far without passing a bar or a store that sells alcohol. So today I wanted to break down why alcohol is so addictive? What its effects on the mind and the body are? And why it’s such a problem for so many people? Dr. Bhatt, how much of a problem is alcoholism? How prevalent is alcohol abuse in the United States?
Dr. Bhatt: Yeah, Hayley. Comparatively to all of our substance use disorders, alcoholism or alcohol use disorder is the majority, and it is quite prevalent in the country. If we look at, at any given moment, the actual number of substance use disorders, at any given time alcohol use disorders will be by far probably up to 75% of them. It is the most prevalent substance use disorder that is out there.
Hayley: Does the age of someone’s first drink, like when they start drinking, does that impact someone’s chances of developing an alcohol use disorder?
Dr. Bhatt: Yeah, I think the age that somebody uses any substance that is potentially addictive and habit forming like that, the earlier you use the increase likelihood or chance you have of potentially developing a substance use disorder. So with alcohol, being that it’s often something that people try and adolescents and in teenage years. When you use it earlier and more often if you have additional risk factors, the increased likelihood is there,
Hayley: Can you kind of talk about the signs that someone has a problem with alcohol? You know, a lot of people drink and they might, you know, think like, “Oh, I don’t have an issue,” but what are those signs? What are some things to look out for?
Dr. Bhatt: I think this kind of speaks to a lot of other substances too. When we have behavioral, I think that’s often one of the biggest signs that we see, is that somebody is going to start acting erratically. Now with alcohol, there is a big sign that’s there. There’s a smell that people have. Or you’re around them and they often act quite bizarre, and disinhibited, and angry, or aggressive. When they’re intoxicated often is easier to see. But with other things that are often hidden and subtle, I think one of the biggest things that we see is these behavioral changes. Often we can see absences at work. We can see increased mood swings, mood changes. We can see, you know, problems at home or school with responsibilities, increased legal consequences, somebody who gets a DUI or other types of arrests, public intoxication. Often those overt signs are there, and those are the most common that are perceived by others. The subtle ones often take a little longer to pick up on them.
Hayley: I want to talk about, you know, some of the subtle ones as well, for people that haven’t had necessarily any legal issues or like big things like that. How much is too much when you’re drinking?
Dr. Bhatt: From a quantity point of view. We’ve established certain guidelines. The CDC and other organizations have a numerical value that talk about what’s considered a binge. For example, four drinks or more in a setting for women or five or more for men, is considered heavy drinking or binge in a certain amount of time or two hours. But, again, those are more overt.
I think you talked about the subtle signs that are there. And often it is when we see people’s hygiene or taking care of their personal needs, they start to get neglected. You know, those things might not happen overnight. Those are things that might take time and are a little bit more insidious in terms of their onset. But those things might not be picked up quickly.
And similarly, like missing work, it might be transient at the beginning, or, being late to pick up your children or making dinner. I’m not trying to pigeonhole or identify any specific gender or class or position in society, but these are things that we might not see overtly as we would somebody who’s intoxicated.
So how much is too much? It really depends on the individual. And it depends on what kind of effects are happening to them, both in their life and their relationships but also physically to their bodies. Sometimes those things that are happening to us physically beyond just a hangover, are happening within us. And we can’t see them.
Hayley: Can you kind of explain to me what’s going on in the brain of someone who has an alcohol use disorder? When they take their first drink of the night or the day? It seems like once they start, they can’t stop. What’s going on in the brain?
Dr. Bhatt: It depends on the individual and depends when they’re using that first drink. It might be something that we get some level of euphoria or relaxation. And I don’t want to get too particular in distinguishing somebody who’s drinking for the first time in their life or somebody who’s been drinking for years. But in general, most people drink because it serves a purpose for them. It’s giving them some sort of pleasure, relaxation. With other substances that are addictive, there’s an increase in a certain chemical in the brain, dopamine that provides pleasure to us and it’s, it’s rewarding. It kind of reinforces us doing it again. In general, when somebody takes that first drink or two drinks, they have that tendency to feel calmer, and feel more relaxed. That’s often pleasurable to an individual and once it triggers that dopamine rise within the brain and the body that’s often feels good and it’s rewarding to us. So we do it again and often that cycle repeats itself,
Hayley: So is that dopamine rise, why alcohol is so addictive?
Dr. Bhatt: Yes. The dopamine is implicated in there, but it’s not as simple because the development of addiction is a multifactorial process for human beings. Addiction is a complicated construct. But, in general, I can paint that picture.
When somebody starts drinking alcohol, if they start drinking with increased frequency, it starts to affect other chemicals in their brain and two major ones, the GABA and glutamate chemicals. Now, what are those things? GABA is a real significant calming agent, what we call an inhibitory chemical. When we drink it, it goes up and helps us have this kind of dulling, chill effect. Then on the other hand, there’s this excitatory chemical that keeps us alert and sharp and it keeps certain processes active in the brain. Alcohol dulls that.
Repeated exposure to alcohol creates, that GABA going up, that calming effect and that glutamate going down, which also dulls the brain. That net effect is people’s brain’s start to turn off. But after time, the brain recognizes there’s excessive GABA going on from that alcohol exposure. So the brain kind of tries to reset itself and turns that GABA down and actually does the opposite with the glutamate cranks it’s receptivity. When alcohol is no longer there, instead of having a lot of GABA and not enough glutamate, we actually have the opposite. We don’t have enough GABA activity, and we have too much glutamate activity. So the brain without alcohol is rendered more hyperactive, less calm. Often someone wants to drink again as a result to rebalance themselves.
I’m sorry if I threw out some technical terms or terms that people aren’t familiar with, but in essence, you keep giving something, your brain gets accommodated to it and gets used to it, tolerant to it. And then when you remove it, the brain needs it again. And that often is a driver for us to continue to use. Now, multiply this with having a pain condition or an anxiety or depressive disorder that can be either mitigated by adding alcohol. That further reinforces someone to use again. Or if they have a genetic predisposition for alcohol use. I don’t want to get into too much science there, but the point is the other risk factors that are there can increase the probability of using and developing that vicious cycle of continued use.
Hayley: Yeah. You mentioned, you know, anxiety and how that makes it worse. Can you explain that a little bit to me. How does alcohol worsen an anxiety disorder?
Dr. Bhatt: A lot of it is just like what I mentioned about that common chemical GABA and glutamate excitatory chemical. Without making it too simplified or complicated when we drink again, that common chemical goes up, but constant flooding and exposure of that GABA, when we’re constantly drinking or drinking in high amounts in high frequencies, our brain kind of turns it off or turns it down or becomes desensitized to it, whichever way you want to look at it. There’s less GABA activity. When you stop drinking, there’s this lack of calm chemical in your brain.
So for people who suffer from an anxiety disorder, who are already dealing with, worrying and dealing with problems. Your brains being reset to have less chill or calming chemical, and it’s it going on? So it almost feels exacerbated. And it actually is because our body now not only mentally is lacking those calming chemicals, but then physically it starts to rebound. Because our body is calmed by the alcohol. So our heart rates sometimes slow down, and our blood pressure is lowered. But then when the alcohol is removed, the body responds by compensating to overcome the alcohol. When the alcohol is not there, your blood pressure’s up, you start sweating, you start feeling tachycardia your heart starts racing really quickly. So on top of being anxious, mentally, physically our bodies acting like we’re running a marathon. That combined effect is very uncomfortable for humans.
Hayley: Could you tell me about some of the long-term physical effects that alcohol has on the body?
Dr. Bhatt: Alcohol basically is toxic to the entire body. There’s basically nothing that it doesn’t touch within the body. It really, depends on the individual. It can create, damage quickly, or it may take years and years. Our genetic makeup is different. The construction of each individual is different. So it’s hard to quantify and qualify how long it will take.
But studies have shown, the science has demonstrated that, long-term heavy use of alcohol, is destructive to the brain. It can cause dementia. It can cause problems with our GI system. It can cause bleeding and gastritis. It can cause problems, of course, with our liver, everybody hears that all the time. It can cause our liver to get cirrhosis of the liver. It can cause problems with our vision. It can cause problems with our blood pressure and our heart and our cholesterol.
I mean, there’s just, just every possible organ problem that can happen in every system that can be affected by alcohol. I would just be making a laundry list of everything bad that can happen to you. Cancers increase in cancer can happen. So everything from neurological to cardiological to psychiatric. Every system is affected from long-term alcohol use.
Hayley: Okay. Can you expand a little bit more on the long-term mental effects?
Dr. Bhatt: Again, this depends on everybody, individually. The relationship that alcohol has with somebody is not known beforehand. We can say, “Okay, somebody who might have a genetic predisposition or family history might have increased risk factors.” Yes. But you know, somebody also may be aversive to it because they’ve seen what alcohol has done.
But in terms of what can happen with alcohol, down the road, it really depends, on each person individually. The chemical imbalances that occur in the brain, with that GABA and that glutaminergic system and the dopaminergic system affect us mentally very quickly. Cause when we drink, that GABA depletion after long term and that glutamate going up, it becomes toxic. So right there, that glutamate goes on overdrive, that excitatory system is actually excited, toxic. So right there, people are in this constant state of hyperarousal and, anxious and feeling uncomfortable.
Mixed with the fact that when we often are drinking to that degree of alcohol use disorder, we act out, we become disinhibited, we make mistakes, we do things that we can’t remember. And so when we wake up in that present moment, we’re conditioning that sober situation to be uncomfortable because we’re always thinking, what did I do while I was intoxicated? What do I have to face now in the future? So we end up psychologically conditioning, ourselves to be depressed and anxious based on that conditioning. But also physiologically we condition ourselves to be feeling bad and depressed and sad and anxious. So the mental health consequences are robust. But then again, as this goes on over time, due to nutritional deficiencies or just the toxicity, dementing processes, memory process, neurological processes happen that further create negative issues for our mental health or mental health.
Hayley: Can these issues kind of be made worse if you also abuse drugs while you drink?
Dr. Bhatt: Any substances together elicit or in the case of alcohol non elicit. But yeah, definitely. It’s a compounding effect. The detriments of … I always say for every action that a drug has, your body’s going to want to produce the equal and opposite reaction. So if something is, and especially using drugs that have the similar effect, like using alcohol, which is a sedative, like I said before, it, it calms our brain and slows our body down, mentally. If we add a benzodiazepine like Xanax or Valium, not to, speak anything about these trade name drugs, but the bottom line is it can cause devastation. Because the more we use combined effects that can cause respiratory depression, decrease heart rate, these can lead to coma. They can lead to death. The outcomes are devastating.
Hayley: For somebody that has a severe alcohol use disorder, what would the withdrawal symptoms be like? If they’ve been drinking every single day and then they kind of go cold turkey, what happens to the body?
Dr. Bhatt: When withdrawal symptoms do start, for those individuals that have become physically dependent, they can start out slowly. They could just be waking up early. Once alcohol wears off, they can feel that heart racing. They can sweat, sweat, easily start to feel tremors and shakes. As this goes on after the first few hours, this could start leading to some sort of confusion, nausea, vomiting. As they go on, they can start having seizures. They can have altered mental status, they can even start hallucinating. They can start seeing things that aren’t there or hearing things that aren’t there. People can alter. Unfortunately alcohol withdrawal is life-threatening. People can die. Cardiac arrhythmias is something that happens and there’s this kind of informal thing called “holiday heart” when people tend to drink often around the holidays and they binge drink and drink for a few days in a row. Then when they stop often or while using, they can have a cardiac arrhythmia that can cause sudden death. So, yeah, alcohol intoxication at that point, but even alcohol withdrawal in general, it’s a life-threatening situation and should only be done with proper treatment.
Hayley: Yeah, absolutely. That’s scary. So, if someone is going to detox from alcohol, what is that process like? Are there things that can make it easier? Are there medications or something?
Dr. Bhatt: There are medications that exist for somebody who is coming off of alcohol. Somebody who has been identified as having alcohol use disorder and as physically dependent. We don’t want to take chances. Individuals shouldn’t take chances of stopping cold turkey. Medications that are sedatives, benzodiazepines and anti-epileptic drugs are often given to help that person slowly come off of that. So basically there’s a little bit of a substitution that occurs, where medications that act like alcohol or bind to the same receptors are given. They are given at dosages that can hopefully mitigate the withdrawal symptoms. Then they are slowly, tapered off, anywhere from five to 10 days, depending on the severity and the presentation of the individual. Usually alcohol withdrawal detoxification is, should be done, depending again, on the case, while supervised by a medical team or a physician and nurses, and often is done in a inpatient or residential treatment entity.
Hayley: So for someone who may be listening to this at home and, they may think “Maybe I do have a problem with alcohol?” When is that line? When should they seek professional treatment?
Dr. Bhatt: That’s a hard one for people to gauge themselves because often when you’re suffering with addiction, you’re in denial, unfortunately. So for someone to seek it on their own often, unfortunately happens after negative consequences. So if somebody’s seeing this happening in their life or have been told by others and are having problems at work or with their health or with their relationships as a result of alcohol, that’s the time to seek help.
But there’s often even brief screening questionnaires. We have a simple one that’s used in clinical space called the CAGE screening. If somebody feels that they need to cut down, which is C it’s an acronym, the C for wanting to cut down or feel the need to cut down. A for if they feel annoyed because of somebody talking to them about their alcohol usage. G if they feel guilty, due to their alcohol use, And E is, if they need an eye-opener. They wake up in the morning or after their usage or whatever time it may be, they need alcohol to subside their symptoms of withdrawal. If they meet any couple of those they really should seek help. That’s a quick, easy screening for somebody to know if they have an alcohol use problem. Often it’s played out in their life and if they see any of these things happening in any one of these domains, they really should seek help.
Hayley: If somebody wakes up and they feel hungover from drinking, is that technically withdrawal symptoms?
Dr. Bhatt: Not necessarily withdrawal. It can happen in the scope of withdrawal, but we’ve had people that are not physically dependent. Where coming off of alcohol is withdrawing the first time. I have seen people who drink and getting intoxicated at two or three events and they are going to be having a massive hangover. But we don’t look at just having a hangover as the clinical definition of withdrawal, as in what we use in the scientific community for somebody who needs treatment pharmacologically for that.
Hayley: Can you kind of explain to me briefly what the treatment process is like for somebody with an alcohol use disorder?
Dr. Bhatt: If you’re at the point when most people, if they have an alcohol use disorder, if they’re in a situation where they’re using, and they know that they’ve exhibited withdrawal symptoms, I think the first step for somebody is to seek out detoxification treatment. So detoxification, as I mentioned, it’s the medically supervised and medically managed treatment where people are monitored and safely prescribed medications under the oversight of a medical treatment team to get through those withdrawal symptoms. Then you need to engage in the rehabilitative process. Because one thing is addressing the physical symptoms of coming off of alcohol, but then the underlying addiction that you have to alcohol, in the first place, and that takes time. That is where you engage in rehab and in therapies in groups, support groups to help address any of the underlying issues that are existing in someone’s life that is causing someone to drink.
Hayley: So how do relapse rates for alcoholism compare to other drugs? Is there a difference?
Dr. Bhatt: Relapse rates are quite high. There may be a little bit of differences between like opioids, for example, and sedatives and alcohol, but it really depends on the demographic of the individual. Often we see different relapse rates in those that are mandated, or those which have certain stipulations involved in them seeking treatment. We often see pilots or physicians that are mandated through their employer or through the state or through the FAA or whatever governing body they have. We see better recovery rates amongst those individuals. So it really depends on the individual and you know, often the circumstances of why they’re seeking treatment. A lot of our younger folks sometimes are in and out of treatment multiple times before they end up attaining some significant sobriety. I don’t want to give a certain number to that. In general, it really depends on the individual and a lot of the circumstances around them.
Hayley: Dr. Bhatt, is there anything that we didn’t bring up today that you think people should know?
Dr. Bhatt: Alcohol use disorder, binge drinking, we didn’t get into a lot of this statistical stuff, but, we’ve seen certain rates in certain times when certain surveys are done and studies are done that we’ve seen certain decreases in usages. But right now, with the pandemic, and, what’s been going on in society, we’ve seen an increase. In general, alcohol use disorder is such a significant problem in terms of morbidity and mortality in terms of society and around the world. It’s a big problem and I think it needs to be addressed in terms of also prevention, post to reaction and treatment. I think we need as a society to get involved more in primary prevention of alcohol use disorders. And it’s tough because it’s a legal thing. We see it kind of glamorized on television and certain reality TV shows or anywhere. People often think, “Hey, let’s go out to, you know, socialize.” We really have glamorized it in society in many different ways. I think, when it’s such a financial, physical, societal loss that we have as a result of it, I think we need to be less reactive to it and more pre-AP proactive. I think we need to have a community-based and primary prevention type of approach to it. I think it needs to be addressed, earlier on. I know many schools in many public programs are trying to address drug abuse in general, but it’s going to take everybody on a systemic level to help address what’s going on with alcohol too.
Hayley: I also want to reiterate how important it is for someone with alcoholism to get help and not let things get worse than they are. Because you can turn things around. You don’t have to let alcohol have that power over you. If you want to learn more about treatment options and the treatment process, or just get a better understanding of alcoholism, Addictioncenter.com has a lot of resources for that. You can also check out more podcast episodes online, and we hope to have you next time for another episode of Straight Talk with the Doc.
Dr. Ashish Bhatt
Addiction Center’s Medical Content Director, Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.
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