Mind the Brain: Mind the DrinkMay 12, 2020
The COVID-19 pandemic has brought new stressors into everyone’s lives. It can be tempting to pour a glass of wine or grab a beer to help cope. However, during this public health crisis, what are the ramifications in regards to alcohol use and alcoholism?
From my experience as an addiction psychiatrist for the CU School of Medicine and the Center of Dependency, Addiction and Rehabilitation (CeDAR) , I believe three styles of people with alcohol use issues will present throughout this period of social distancing. Our job as medical professionals is to determine a compassionate and effective means by which to address the needs of the active recovery patient, the sub-threshold drinker who is progressing toward alcoholism during social isolation, and the non-alcoholic heavy drinker who is at risk for health consequences as a result of elevated drinking levels.
THE RECOVERY PATIENT
Through my work at CeDAR, I have continued to admit patients seeking longer-term treatment for alcohol use disorders. Even in the facility, individuals must maintain social distancing, by participating in groups virtually or sitting at least 6 feet from other residents and group leaders. Some of these admissions have included relapses to alcohol use during the pandemic, triggered often by acute stressors such as isolation, unemployment or insomnia.
Some individuals in stable recovery have fallen back into a relapse, as they have felt disconnected from their recovery community. The inability to attend peer-support meetings, work collaboratively with a therapist, or volunteer at local service positions removes the key ingredient in someone’s health and wellness: connection. An often-recited phrase in the addiction treatment world is “The opposite of addiction is connection,” and we are witnessing this play out today. Accordingly, the staff and clinicians at our treatment facility have embraced the pathways of virtual connection, providing both virtual clinical encounters and peer-support meetings to our patients and alumni.
THE PERSON DEVELOPING NEW ALCOHOLISM
It is unclear how many individuals will progress to the full disease of alcohol use disorder over the coming months. The most important variables seem to be the lack of structure, the limited accountability for health that comes with physical isolation, and the impact of chronic stress on the brain, including biological mechanisms of craving and agitation.
We often see spikes in alcoholism connected to these factors. It is very common for someone to develop alcoholism secondary to marked life changes such as unemployment, retirement, or withdrawal from college. Each of these scenarios opens up a life in which responsibilities are lessened and the cost of binge drinking appears to be insignificant. If a functional life is quite far away, does it even matter if someone is drunk, day-in and day-out?
As clinicians, our role includes active screening for alcohol use disorder, provision of low-friction avenues for entering treatment, and encouragement of family supports to destigmatize the new development of alcoholism. We also need to provide education around risk factors for alcoholism, including genetic risk; a history of physical, sexual or emotional trauma; and prior history of a different substance-use disorder.
THE HEAVY DRINKER AND HEALTH CONSEQUENCES
How do we differentiate the heavy drinker from the alcoholic? It is important to acknowledge that alcoholism involves symptoms beyond the volume of alcohol intake, including the loss of control around alcohol use, cravings to drink, functional decline and impairment in one’s life, and the compulsive quality of drinking. There are many individuals who exhibit a marked tolerance for alcohol but don’t seem to show the other signs of the disease. What are the potential health hazards for these individuals?
According to the epidemiologic data published in the journal Lancet in 2018, alcohol use seems to affect health issues and mortality. The findings challenged popular medical beliefs of the 90s, namely that social drinking was good for your heart, and hence health-advantageous, if in moderation.
While noting some cardiac benefit from red wine consumption, this may be offset by the increased incidence of cancer connected to alcohol use, predominantly breast cancer for women, and oral and throat cancers for men, not to mention liver disease. Overall, the study reported that consuming around 14 alcoholic drinks per week was associated with a shortened life by about 6 months, consumption of around 21 drinks was associated with a loss of 2 years, and volume above 24 drinks, a loss of 4 years.
It can be difficult to help our patients anticipate the health risk factors associated with alcohol use during this stressful time. With chronic stress can come a sense of a foreshortened future, a common symptom of post-traumatic stress disorder. In other words, why should I worry about living to 75 versus 77 years old? I’m just hoping to get through 2020!
As clinicians, helping to promote mindfulness around drinking patterns is a good place to start. We can help people have a greater sense of satisfaction with alcohol as they are slowing down and appreciating a drink more as a savored product and less as a rapid method to drunkenness. These efforts can lead to long-term positive changes for someone’s relationship with alcohol.
THE POSITIVE EXPERIENCES
It is also important to comment on the positive experiences some of my patients have had in treatment during these weeks of the pandemic. Some patients were already on the road to recovery, and the pandemic has galvanized their path. They have gained a greater appreciation for their family and their own life during this time of stress. Others have taken a closer look at peer support programs such as Alcoholics Anonymous or Recovery Dharma, requiring only some simple clicks on a computer to show up. Stress can put pressure on someone toward relapse, but also reinforce commitments to health and recovery.
WHAT YOU CAN DO
As providers, having honest and validating conversations around alcohol use is a wonderful service to our patients, and I hope each of you will be unafraid to broach these topics. Will you be called upon to help support a recovering patient during a relapse? Will a family reach out to you as they are witnessing the development of new alcoholism during this time? How will you guide someone around safe drinking limits and the importance of our long-term health and wellness? I’ll be having all of these discussions and offering the most helpful clinical service I have at my disposal: connection.
As individuals with our own questions about alcohol use, we should try to emphasize mindfulness while drinking. It’s important to enjoy a savored beverage, rather than mindlessly downing multiple drinks. Pay attention to the numbers. It can be useful for anyone who consumes alcohol to reflect on the actual volume of alcohol consumed. For instance, one bottle of wine contains five drinks, a 750 mL bottle of whiskey contains 17 drinks, and a standard drink of beer is at 5% alcohol. Finally, it is important for family members and patients to understand that we have very good avenues for outpatient interventions. Outpatient appointments and meetings with your doctor have been shown to make a sizable impact on recovery, thus proving the value of connection.
Patrick Fehling, MD
Associate Clinical Professor, Department of Psychiatry
Center for Dependency, Addiction, and Rehabilitation (CeDAR)
University of Colorado Anschutz Medical Campus
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