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The Dose Transcript for December 21, 2023

Host: Brian Goldman

BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. For some time now, the rules regarding safe drinking have been undergoing a seismic shift, in large part because of what alcohol can do to your health. New Canadian guidelines released in January say more than two drinks per week can raise your risk of some very common types of cancer, and there are other health effects as well. So this week, we are asking, what should I know about how alcohol affects my health? Hi, Evan. Welcome to The Dose.

EVAN WOOD: Hi. Thank you so much.

BRIAN GOLDMAN: I have never been a big drinker. And I'm wondering, have those new guidelines affected your own personal alcohol consumption?

EVAN WOOD: You know, I've never been a huge drinker either, but I actually I've elected to not drink just because of those guidelines, which, you know, show that even a small amount of alcohol probably harms our health. So, you know, a special occasion or something comes up like that, I'm not, you know, it's not a firm line in the sand, but in terms of certainly through medical school and as a physician early in my career, you know, if there was a bottle of wine open on the counter and it was a Tuesday night and I felt like having a glass of wine, I would. Whereas I just am no longer in that routine.

BRIAN GOLDMAN: Interesting. And, you know, that's probably one of the reasons why I have never given up jogging, because as we learnt more about the health benefits of jogging, I thought, well, you know, since I'm in the habit, I might as well continue it. So since you're not in the habit of drinking and I'm not in the habit of drinking, it's probably a good thing that we don't. And what we're going to find out in this edition of The Dose is why that is. So I can't wait to get into that conversation. But before we do, can you give us a Hi, my name is? Tell us what you do and where you do it. Just adlib.

EVAN WOOD: Sure. Yeah. Hi, my name's Dr. Evan Wood. I'm an addiction medicine physician in Vancouver, where at the University of British Columbia, I'm a professor of medicine and tier 1 Canada research chair in addiction medicine.

BRIAN GOLDMAN: Which is why we have come to you. And, you know, people think of alcohol as a substance that is associated with dependence or addiction. And that is true, but we're going to be hitting hard the health angle here. So let's start with low risk drinking. What are Canada's current new guidelines on alcohol and health?

EVAN WOOD: Yeah. Well, this is probably where people are feeling a little bit of whiplash because for a long time now, since 2011, we've had low risk drinking guidelines which have been, compared to the current recently released standards, fairly permissive, allowing men up to 15 drinks per week to still be low risk, women, 10 drinks per week. Whereas now, the new guidance essentially says if you drink more than two drinks a week, you're probably elevating the risk of health and social harms in your life.

BRIAN GOLDMAN: And by drinks, we mean standard drinks. Can you just talk a little bit about that?

EVAN WOOD: Yeah. If you think of a traditional glass of wine or a traditional 5% beer or one and a half ounces of spirits, that's a standard drink in Canada, and it varies a little bit internationally. But yeah, there's no cheating with what's a standard drink. It's relatively modest in itself.

BRIAN GOLDMAN: So let's get to the meat of this. What are the specific risks of drinking more than two standard drinks per week?

EVAN WOOD: Yeah. The risks sort of are dose dependent. And so for your average Canadian, if it's two or less, they're probably, you know, in that range of more inconsequential risks. And if you start drinking more than two, that's when you start to see some common oral cancers emerge. It's where in women, you start to see increased risk of liver problems, and it's where you start seeing intentional injuries increase by about sort of 10%. And so the numbers can sort of get played with a little bit. And how I take this, it's interesting, I have a fairly conservative family member who's like, oh, you know, government is trying to, you know, tell me how I can live my life. And I look at these recommendations totally differently in so far as it's really just information, but it should be individualized. You know, for somebody who has a family history of cancer, that might be, that 10% increase might be very meaningful. Whereas for somebody who's, you know, hasn't got any cancer risk in their family, you know, that may be less, less meaningful than a 10% elevated risk if the baseline risk is actually quite low.

BRIAN GOLDMAN: And it's really important for people listening to you and I talk about this to mention that, you know, this risk of, you know, increased risk, for instance, of cancer after drinking more than two standard drinks a week, that doesn't mean that if you have that third standard drink, you will get cancer. It increases your risk on a population level. Can you talk a little bit about that?

EVAN WOOD: Yeah. And that's really where it's important to have an understanding of the baseline risk. Like if the baseline risk of these oral cancers is, you know, one in 100,000, a 10% increase in that risk is modest. You know, it's sure you're putting yourself out there for increased risk in comparison to those that don't drink, but the risk is still, you know, really, really low. And I think what these guidelines show is there's really an exponential risk as you go from two to three to four to five. Once you get to sort of five drinks a week, for a liver disease like cirrhosis, that starts to go up really dramatically. So even in the sort of moderate risk, moderate drinking levels that we would consider low risk according to the prior guidelines, you actually start to see, you know, considerable risk elevation. And another important point about these guidelines, and I think something that's really well recognized from the literature and important given this time of year is those are weekly averages, but there's special risks associated with what we would call periodic excessive alcohol use or what sometimes gets referred to as binge alcohol use. So if you have three drinks on any one occasion, like at a Christmas party, you're at obvious risks of other kind of harms like getting behind the wheel or things, making bad decisions that you might not otherwise make under those circumstances.

BRIAN GOLDMAN: But certainly, you know, when we get back to the guidelines that we're talking about, many people were surprised by how low that threshold is for risk, just two standard drinks a week. How do you interpret that threshold?

EVAN WOOD: You know, I think, again, it really needs to be individualized. So, you know, there's some evidence of increased risk of self-harm. So individuals that have low mood or a family history of suicide, you know, alcohol could be, you know, particularly risky. Whereas if you're, you know, Mr. positive and you always have a really very positive outlook and you have three drinks a week and you're really controlled with it, then, you know, as a physician, if a patient was to ask me, I’d say, look, just continue doing what you're doing in being mindful and self-monitoring and I don't see a problem there. I think it's really recognizing that this is along a continuum. And as you say, if you have more than two drinks, no one’s saying you're going to get cancer, but you're going to be at elevated risk of harms in comparison to others, and two to three to four to five, that that risk is really going to go up considerably.

BRIAN GOLDMAN: So the key message I'm getting from you here that's really important is that people interpret the new guidelines, the two standard drinks per week according to their own personal history. So if they've got a strong family history of cancer, then that should really push them to obey those, those two standard drinks per week in the same way that if somebody has a history, you know, a strong family history of heart disease and they've already got type 2 diabetes and they've got hypertension, then drinking is another risk factor that could push them over the edge and get them into cardiovascular complications.

EVAN WOOD: Yeah, exactly. I mean, I'm sure there's hundreds of thousands of people in Canada that are getting treated for high blood pressure secondary to their alcohol use. So you're treating, you know, a consequence of alcohol use already. And if you already have high blood pressure, then certainly, drinking on top of that is going to be a risk of heart disease and stroke and the things that are identified in that guideline.

BRIAN GOLDMAN: One of the things we like to do on The Dose is provide what we call. Smart advice. And sometimes, that's being counterintuitive. So I want to go… I want to play the devil's advocate for a moment. You know, alcohol use is a topic that certainly generates shame and stigma. I think we know. I think we know a lot about that. What's the likelihood here that the new guidelines would simply reinforce the stigma?

EVAN WOOD: Yeah, I think that's a good question. You know, Canada's alcohol consumption, you know, we're…

BRIAN GOLDMAN: We’re not the U.K. Or are we?

EVAN WOOD: Well, we're not, but, you know, we drink more than the United States

BRIAN GOLDMAN: Really?

EVAN WOOD: We do. Yeah. And like the U.S., you know, life expectancy in Canada is going down because of substance use. And a lot of the policies that we're seeing in Canada, Ontario being kind of the latest in the news recently, is really favouring the consumer. And I think, you know, one of the roles of government is to keep prices down and to make things accessible and affordable. And so from a sort of libertarian perspective, in a number of Canadian jurisdictions, you know, governments are doing that. They're making alcohol more available. And we know that that will have increased public health consequences in terms of, you know, motor vehicle accidents and domestic violence and the health consequences and emergency room visits. So, you know, from a public health perspective, some of these changes are problematic. In other, you know, circumstances, people should be aware that the ecosystem that they're living in is evolving to make alcohol more freely and easily available. And from the perspective of stigma, I mean, it's such a huge issue when it comes to substance use. So I don't want to say, oh, that's not going to increase stigma because it is a huge issue. But I think these guidelines are really just intended to make people aware of the risks. I don't think we've arrived at a place in Canada where, you know, if you crack a beer at a softball game, people are going to be looking down their noses at you. But it's something to be aware of because stigma is such a huge issue. But from my vantage point, I don't see these guidelines particularly contributing to stigma.

BRIAN GOLDMAN: So that people who don't live in Ontario and haven't been paying attention are up to speed, the government has, as stated, that beer and wine will be available in Ontario corner stores by 2026, which will of course increase availability and could run counter to this whole new Canadian guideline of no more than two standard drinks per week.

EVAN WOOD: Yeah, it's a curiosity to me because I think when it comes to substance use in general, we can look at tobacco and be like, man, we've really done a great job with that. And when it comes to other substances, I think, you know, sometime in the future, we'll be looking back and thinking, you know, what were we thinking?

BRIAN GOLDMAN: Again, to be the contrarian, What do we know about the benefits of alcohol consumption? Because not that long ago, people were saying, you know, the French paradox that drinking red wine was good for your health. And, you know, I certainly remember being told that, you know, a glass of alcohol a day is okay. And that certainly would be way above two standard drinks a week.

EVAN WOOD: Yeah. Yeah. I mean, I can certainly say that, you know, the lobby groups and the alcohol industry find that, you know, research very compelling. Whereas, you know, from an evidence based medicine world where people have really looked at that research and passed it out, it looks like there's no amount of alcohol that provides a health benefit, even, you know, the sort of one drink a week argument. The data just don't support that viewpoint. Though, You know, certainly, I've noticed when there's, you know, a news story about, you know, the risks and dangers of drinking, oftentimes, the media will go to, you know, one of the alcohol industry lobby groups for comment and they'll sort of say, well, we are, you know, familiar with the decades of research suggesting moderate alcohol consumption provides cardiovascular benefits. If anything, the latest data reflected in the lower risk drinking guideline, or the Canada's guidance on alcohol and health is what it's called, essentially says that there's a host of heart disease secondary to alcohol use and there's no safe level of use. So it's a little bit you know, again, it's kind of whiplash for the public who's seeing these sort of, oh, you know, first they're saying this, now they're saying the opposite thing. And I appreciate that that's frustrating, but that's how epidemiology and science work and how these data are parceled out. And I would be surprised if we go back to thinking that alcohol provides health benefits because I think just the jury has kind of come back with the decision, and I'd be surprised if it gets flipped again.

BRIAN GOLDMAN: Okay. Let's assume that you've convinced at least some of the people listening to us to cut back on alcohol use. Say they've had, you know, a glass of wine every day with dinner and they want to cut back, how do they go about doing that?

EVAN WOOD: You know, I think there's a host of ways. I certainly have seen and personally have been happy to see the huge number of non-alcoholic drinks that have emerged, which my wife and I enjoy. I like some of the non-alcoholic beers. And now there's, you know, non-alcoholic gin and tonics and all sorts of other things that I think just, you know, water as a substitute for people who are used to having a nice drink is a step backward. So I think that that's useful. I think it's really important for people to check in with their emotions when they have a drink. And we know just from lab animal studies and human studies, when people get stressed out, their dopamine goes down. That's our feel good neurotransmitter in our brain. And through learning, we know that alcohol can help with that. So if people find themselves, you know, going to the liquor cabinet when they've got bad news or they're stressed, then, you know, that's something to really keep in check. And then in those circumstances, I think, hey, like what is it? Do you need to go for a walk? Do you need to phone a friend? Do you need to go to a yoga class? You know, what are the things that you can do when you're using alcohol to kind of supplement your mood?

BRIAN GOLDMAN: Some of the people who are listening to us drink more heavily. So let's talk about high risk drinking and let's also talk about alcohol use disorder. How are they defined?

EVAN WOOD: Yeah. So the high risk drinking definitions, as we're hearing, have evolved. Alcohol use disorder similarly has had an evolving definition, but essentially is ongoing use of alcohol in the face of health and social harms and having a desire to cut down or quit alcohol. And having difficulty or inability to do that is what we would call alcohol use disorder. And for people in those circumstances, the guideline that I co-chaired really highlights that there's things that we should be doing in the health care system and in society, and there's things that we should really avoid doing that we do routinely. So for those circumstances, there is a guideline now, that Canada's first national guideline for alcohol use disorder. There's a website that's accessible to the public called helpwithdrinking.ca. So there's things that certainly can be employed in that circumstance to help people.

BRIAN GOLDMAN: Evan, what would you say are the key points, some of the key points in those guidelines for which you were the co-chair of the committee?

EVAN WOOD: Well, there's psychosocial treatment interventions or non-medication interventions that can be really helpful. Unfortunately, in Canada, we've really kind of gone, I think, the wrong way with our mental health system in terms of total near reliance on pills and fleeting visits with physicians to try and enhance mental health. And I think that that's a mistake. But there are psychosocial treatment interventions if you can find a psychologist or a mental health practitioner skilled in those interventions. There are some inexpensive medications, one being naltrexone, another being acamprosate, that can really help with cutting down or quitting alcohol use. And the side effect profile is really acceptable in comparison to lots of other medications that people take. And then a big recommendation of the guideline is commonly prescribed medications to help when people are struggling with alcohol, because drinking alcohol does a hatchet job on our sleep. So people often suffer from insomnia. They can get low mood and anxiety secondary to using too much alcohol. And there's a very, very low threshold to prescribing antidepressants in that context. And a fascinating story from the evidence based medicine world is how many of the double blind placebo controlled trials that tested antidepressants in the context of trying to help people reduce drinking actually showed that people drank more alcohol on antidepressants in comparison to placebo, particularly the serotonin selective reuptake inhibitor class of antidepressants. There's a like multitude of studies, including studies looking at serotonin transporter genes that may be implicated in this adverse effect. And actually, if you go to your average physician in Canada, they have no idea that they may actually be giving a medication that'll make people's drinking habits worse.

BRIAN GOLDMAN: And, you know, on that note, I was astonished to learn that very, very few physicians actually discuss alcohol use with their patients, or at least patients who recognize eventually that they have a problem drinking pattern say that their doctors were unlikely to speak to them about it. Have I got that right?

EVAN WOOD: Yeah, yeah. Lots of this comes from the National Institutes of Health in the States, which is, you know, a multi-billion dollar health research funding body. So so much information comes out of U.S. studies. But among the high risk drinkers, so people who were drinking at an elevated rate and had seen a physician, and something like only 14% of the physician visits involved a physician asking them about their alcohol use. So there's a big problem with screening and there's a big problem with the effective treatments. I didn't say that, but there's studies to show there's more people on antidepressants in Canada than there are depressed people. So there's very, very low threshold to prescribe these serotonergic medications, which is just a fascinating evidence based medicine story in terms of, you know, people questioning their effectiveness. But when we look at the alcohol use disorder medications, they actually have very good metrics in terms of things like the number needed to treat, which are, as you know, ways of calculating how many people you need to treat to see a benefit. So very effective medications according to those metrics. And, you know, studies from Manitoba suggesting that only about 1% of people who might benefit from the medication actually are prescribed it. And in the absence of that, people are struggling. They bounce around oftentimes in primary care. And there's a lot of polypharmacy with anti-depressants and antipsychotics being used off label. And the evidence suggests at best, that's highly ineffective and probably costly, and at worst, it probably worsens outcomes for people.

BRIAN GOLDMAN: I want to make sure that I understand this, because what you've just said is really astonishing. Is it that there is a correlation between antidepressant use and alcohol consumption or is it cause and effect? Is it possible that putting people on SSRIs might actually increase their drinking?

EVAN WOOD: Well, again, it's a fascinating story from an evidence based medicine perspective. You know, we talk about preclinical studies. These are the controlled studies with lab animals where you control absolutely everything. And you give them an antidepressant, an SSRI antidepressant or placebo, and you can routinely show that you can make animals lever pressed to drink more in these experiments. That's causal for sure. There's case reports and there's huge numbers of them. There's a study of like 94 cases of antidepressant induced alcohol addiction, and then there's double blind placebo controlled trials, the same kind of trials that were used to get COVID vaccines approved. And there are double blind placebo controlled trials that show in comparison to, you know, the sugar pill, the antidepressant had people drink more. And it's so refined that they've actually looked at sort of alcohol use disorder phenotypes, where it's the sort of the heavy drinking, early onset severe alcohol use disorder that appears to drink more on antidepressants. And there's all sorts of biases in this literature. The biggest NIH funded study that was meant to ask and answer the question of whether SSRIs were helpful or not in alcohol use disorder was never published. I always tell people if someone was having chest pain and saw a cardiologist, they'd look at all of their medications and they'd know exactly, you know, what's the number needed to treat, what's the number needed to harm. It's just very unfortunate that we don't sort of hold ourselves to the same kind of standard in mental health and substance use as other disciplines of medicine.

BRIAN GOLDMAN: Final question I want to ask you, what are the warning signs that someone may have a problem with alcohol?

EVAN WOOD: You know, there's a host of things. And oftentimes, individuals won't have insight. It may be that they're not sleeping well or it may be that they're anxious or it may be that their blood pressure has become elevated. And so there's lots of subtle signs. Certainly, low mood can be an issue. But I think that the thing that's really been shown, which I'll repeat, is just how people respond to stress. And if people respond to stress by seeking out alcohol, that often implies that that sort of dopamine system of reward and educating us to do things and increasing the likelihood that behaviours will be repeated has maybe been hijacked by alcohol and you're leaning on that as a crutch to try and address stress and low mood, which unfortunately doesn't work. That tends to just lead to more stress and low mood as alcohol tolerance goes up. But yeah, I'll just repeat that website, helpwithdrinking.ca. There's tons of resources for the public on there that if people have questions, you know, am I drinking in a high risk way or maybe do I have an alcohol use disorder or what are the psychosocial things or other treatments that are available, lots of information is available there for the public.

BRIAN GOLDMAN: And that's a good destination to point our listeners to. Dr. Evan Wood, thank you so much for enlightening us on this fascinating subject, and I hope a lot of people who are listening to this learn from it.

EVAN WOOD: My pleasure. Thanks so much for the conversation.

BRIAN GOLDMAN: Dr. Evan Wood is an addiction medicine specialist physician and a professor of medicine at UBC, where he holds a tier 1 Canada research chair in addiction medicine. Here's your dose of smart advice. The short term risks of alcohol consumption are well known, things like injuries from falls and motor vehicle crashes. Over time, excessive alcohol use can also lead to the development of a long list of chronic health conditions. They include high blood pressure, heart disease, stroke, liver disease and digestive problems, cancer of the breast, mouth, throat, oesophagus, voice box, liver, colon and rectum, depression, anxiety and dementia. All of those are in addition to alcohol use disorder plus all of the social problems that arise from alcohol dependence, things like unemployment and family problems. We used to think that one or two drinks a day were okay and maybe even helpful for your cardiovascular health. But new and more conclusive research has shown that anything more than two standard drinks per week raises the risk of both the health and social harms I mentioned. For these new guidelines to pan out across the population, we need to talk more openly about safe alcohol consumption. That includes health care providers. Studies have found that fewer than one in five people with high risk drinking patterns say their doctor talked with them about their drinking habits. At some point, you need to assess your own personal risk from alcohol. For instance, if you have a strong family history of cancer or any of the other diseases I mentioned, then you should try and stick to the new guideline of a maximum of two drinks per week. The best time to try and curb your personal alcohol use is before your consumption becomes heavier. The biggest warning sign that you may have a problem with alcohol is if you try to cut back but struggle to do so. Other indicators include anxiety, poor sleep, low mood, increased blood pressure and using alcohol to cope with stress. We now have effective treatments for people with severe alcohol use disorder. These include cognitive behavioural therapy or CBT and medications such as Acamprosate and naltrexone. One final tip. This is not widely known, but being on an antidepressant may increase your consumption of alcohol. Given the wide use of antidepressants, it's a factor that may hamper the ability of some people to reduce their alcohol consumption. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you liked this episode, please give us a rating and review wherever you listen. This episode of The Dose was produced by Isabelle Gallant. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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What should I know about how drinking can affect my health? - Transcript

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