The poison and pleasure of alcohol, revisited on Inauguration Day

It's been quite a month.

It is Inauguration Day 2025 here in the USA. Before I begin this post about alcohol, of which I intend to have a glass tonight, I’d like to share a eulogy given by Reverend Andrew Young at the National Cathedral on the occasion of President Jimmy Carter’s funeral. It is a stunning, soulful testimony from a 92 year-old pastor, politician, and civil rights leader who was once a close confidant of Martin Luther King, Jr.

Coincidentally, it is also Martin Luther King, Jr. Day — a federal holiday.

Rev. Young speaks with only a few glances at a notecard. He shows the magnificent power of wisdom, moral righteousness, and human decency that lives well beyond the frailty of his own condition, or the mortality of the man he eulogizes — a peanut farmer, Navy Lieutenant, American president, and Nobel prize winning force for good in the wider world.

MLK Jr., Jimmy Carter, and President Obama are all Nobel Peace Prize winners.

At the end of the video it is notable that another incoming president, currently deemed by historians as not great, softens his otherwise stone-faced expression. He leans over to the man whose country of birth he lied about as a political weapon, a former president and one of those Nobel Peace Prize winners, and seems to mouth:

That was good.

The other man nods in reverent agreement.

If only we could stay in that briefest of moments for four years. Mr. Trump, please realize that it is later than we think.

Though you cashed in on the presidency of the United States to the tune of $58 billion over the weekend by creating a cryptocurrency called $TRUMP, establishing a mechanism for the crypto industry to funnel you even more cash, and allowing anyone in the world to financially speculate on your political fortunes, we are not impressed.

The presidency is your incredible chance to shout into eternity ideas and actions that make the entire world better, human life more dignified with less suffering, democracy fiercely defended, and the planet more sustainable. And though the evil that men do lives after them; the good is oft interred with their bones, as we can see with President Carter, the good is oft celebrated around the world, too. It echoes into eternity.

Nota bene. $TRUMP evokes the archaic Scottish word STRUMP: noun. A short fragment of straw, esp. one broken off by the flail and sifted out from the grain with the hands.

Outrageous, immoral amounts of money hoarded by billionaires are still like broken strumps in the final accounting of the worth of a human life.

I’m guessing that Reverend Young doesn’t have a memecoin.

And now for today’s post. It is long, like a 12 minute read. It’s about alcohol. Feel free to come back to it. It will start off with wonky details, then wax lyrical about drinking while examining nuance, and then end with a vignette about MLK Jr, Trump, and the mountaintop.

Alcohol

There has been a convergence of attention on alcohol and drinking this month. Three major inputs — a National Academies of Science, Engineering and Medicine report, a Surgeon General’s warning, and a new federal report by the Interagency Coordinating Committee for the Prevention of Underage Drinking.

If you were to read all three, it would take you hours. Hundreds of pages in total. Here’s one paragraph I cobbled together:

That new federal report from the ICCPUD found that even moderate drinking within current U.S. dietary guidelines carries health risks, including increased chances of injuries, liver disease, and cancer, with risks rising as consumption increases. This report, along with a contradictory review from the NASEM that linked moderate drinking to lower mortality rates, will inform the 2025 Dietary Guidelines for Americans, sparking debate about what constitutes "safe" drinking levels. The findings have drawn criticism from the alcohol industry while being praised by public health advocates, and come shortly after the Surgeon General's advisory on alcohol and cancer risks, reflecting a broader shift in understanding of alcohol's health impacts.

Focusing on the Surgeon General’s report first we can extract the following key points. Understanding both relative and absolute risks is crucial for comprehending the relationship between alcohol consumption and cancer. Here is what they come up with in a neat table for absolute, overall risks associated with drinking:

The Surgeon General’s report further explains that while relative risk shows proportional changes (like a 10% increased relative risk of breast cancer for women who consume up to one drink per day, and a 32% increase for those consuming more than two drinks daily), absolute risk provides the actual probability of developing cancer. For example as we can see above, the absolute risk of developing any alcohol-related cancer over a woman's lifespan increases from about 16.5% for those who consume less than one drink per week to 19% for one drink daily, and to approximately 21.8% for two drinks daily.

For oral cancer, the report shows that consuming about one drink per day increases relative odds by 40% and two drinks per day by 97%… but the lifetime absolute risk of developing mouth cancer is only about 0.8% at baseline, with two drinks per day doubling that.

The absolute risk of breast cancer shows a similar pattern, increasing from 11.3% in women who drink less than one drink per week to 13.1% for one drink daily and 15.3% for two drinks daily.

Want the actual source? Here is the ironically “21” page PDF:

Alcohol And Cancer Risk, Surgeon General's Advisory

3.18MB ∙ PDF file

Download

Download

Next. If I were to summarize the 80 page ICCPUD report in one sentence, it would be this one from STAT News:

Men and women have similar risks of health harms from drinking, the researchers note: Both have “a 1 in 1,000 risk of dying from alcohol use if they consume more than 7 drinks per week.” This risk increases to 1 in 100 if they consume more than 8.5 standard drinks per week.

How does this happen? When consumed, alcohol breaks down into acetaldehyde which can damage DNA, generates harmful reactive oxygen species leading to inflammation, alters hormone levels including estrogen, and increases the absorption of carcinogens from other sources. Research increasingly underscores that cancer risk increases with alcohol consumption, and for some cancers, risk may increase even at one or fewer drinks per day.

The poison and pleasure of alcohol

I did a post about this whole mess exactly three years ago here on Examined. My writing style was a bit more embellished then, but I hope you still like it. Maybe it will distract you from unpleasant realities today.

~

The sun was slowly dropping in the sky, turning down its yellow-white heat, allowing the atmosphere to slip into a more comfortable orange, mercifully signifying the end of the day’s outside toils. I was still a kid, but my muscles felt old. Shoveling dirt, helping in the big garden, chasing the rooster. My shirt was salted with sweat, and I sat down with my similarly spent parents for a cool drink. Water, maybe lemonade. I heard the mystifying crack of an aluminum beer can popping open, the bubbles fizzing to life as my parents poured themselves a rarely consumed, but well-deserved beer. Michelob. A cold beer enjoyed in such August circumstances was about as good as it got. Maybe I was allowed a sip.

Maybe I thought I would stick with the taste of lemonade.

As we stumble through the first month of 2022 and a raging pandemic that won’t die, some New Year’s resolutions have become less resolute, especially those that pertain to cutting down on alcohol. The last two years have been terribly stressful, and it is no secret that alcohol consumption is way up. Many drink to relieve stress. Alcohol can bring pleasure and a temporary sense of well being, both of which have been hard to find. But as I see the effects of excessive alcohol consumption in my practice, and as I personally get older and find alcohol somewhat less enjoyable, I thought I should do a deep dive on the subject of drinking.

Full disclosure: there are some spoilers that follow, which might take the shine off the full enjoyment of alcohol. I still like a good drink, but with eyes open to the risks, and I’ve never had an eye-opener. And finally, the risks and benefits of alcohol are complicated.

I listened recently to an interview with Dr. David J. Nutt, an English professor, doctor, and “neuropsychopharmacologist” who specializes in the research of drugs that affect the brain. He presented ideas from his book entitled Drink? The New Science of Alcohol and Your Health. His commentary is compelling, and I hope to finish reading his actual book soon. This post reviews some very important aspects about alcohol that might inform your drinking choices. I’ve also synthesized some of his main points with additional information taken from medical references.

Introduction

It is estimated that 10-15% of the adult population have alcohol-related problems. Over the last 60 years the consumption of alcohol has increased steadily in the West. People are drinking twice what they used to drink in the 1950’s. The cheap price of alcohol has not kept pace with inflation, and the ubiquity of alcohol for purchase in places like grocery stores has also driven higher use.

Alcohol unfortunately is a drug. It is a great social lubricant, affecting the nervous system and brain, and many of us have great memories associated with it. But the slogan of “drink responsibly” is inherently a contradiction in terms, as alcohol works to loosen inhibitions. The industry has lobbied governments heavily, and advertising in the U.S. alone has ballooned to over 2 billion dollars a year. Just think of all the memorable beer ads.

Alcohol by itself tastes bad. There is a reason that we often recoil from our first try, and that the need to “acquire a taste” for the stuff has been misconstrued as developing sophistication. Alcohol burns your mouth the same way it burns when applied to a skin wound. It keeps burning all the way down the hatch. It can damage cells and nerves, and this is really what we are starting to feel. No one enjoys drinking rubbing alcohol. Yet when sugar or other flavors are added, or hops lend a floral citrus aroma, or complex organic molecules with notes of dark fruit excite the brain, we begin to acquire a taste. The pleasurable effects of alcohol take hold, and over time, we associate the enjoyable effects with the taste. We can learn to appreciate it. And that uncomfortable burn, the one that was originally a sensation to recoil from? Now, amazingly, that burn itself (and the pleasure our brains anticipate that is soon to follow) becomes part of the enjoyment of drinking.

Reconsidering this burn has actually caused me to decrease my alcohol consumption more than anything else. I admit that my brain, like anyone else who has acquired a taste, really learned to enjoy that fire. Now when I feel it, it gives me pause, and helps me “drink responsibly.”

It was the afternoon of a wintry, snowy day in New York City, at McSorley’s Old Ale House. It’s the oldest bar in the city, with sawdust on the floors to catch the beer spills, a cozy fire crackling from the stove, and good company among friends and strangers. 100 year-old wishbones hang upon a gas lamp, placed there by soldiers who shared a last drink before they were off to serve in the hell of World War One. Hallowed stuff. Having a pint of light and dark ale, with a simple plate of cheese, raw onion, and saltines, surrounded by ghosts who also found comfort in the dim light, yeasty ale, and complimentary joys of fermentation and conversation - was pretty much heaven. And after an afternoon hearing stories, when the barkeep deemed me worthy of stepping behind the bar to see his view while he snapped a photo… I might as well have taken a snap as quarterback in the Super Bowl.

McSorley’s

Physiology

We drink alcohol, our intestines absorb it, and then it goes to the liver for processing. But some of that alcohol makes it past the liver on the first go around, and makes it to the brain, where it interacts with neurons to produce mixed sedative and stimulant effects.

One of the first effects of alcohol is an increase in GABA neurotransmission, thereby inducing calm feelings and reducing anxiety. Yet it also increases dopamine activity, which acts as a stimulant, and that coupled with the release of endorphins, triggers feelings of pleasure and reward. With mixed sedative and stimulant properties, no wonder alcohol is such a unique and ubiquitous substance. The author has likened it to a watered down, poor man’s barbiturate + amphetamine + morphine, based on its interactions with the overlapping neurotransmitter pathways. At higher doses alcohol starts to block glutamate, which is an activating neurotransmitter. Too much blocking can progress from slurred speech, to amnesia, to passing out, to even coma and death.

Hangovers occur in proportion to the amount we have consumed. They can be compounded by the fact that people often drink at night before bed, thereby disrupting normal sleep. Dehydration is part of the problem, as is the triggering of inflammation. The body responds to the blocking of glutamate by upregulating that system, so that when alcohol wears off, the glutamate pathways are turned up - lights are brighter, noises are louder, the heart pounds, and feelings of anxiety can be enhanced. Falling asleep might be easier, but at 2 or 3 in the morning as the sedating effects wane, glutamate starts ringing like an alarm bell.

The relaxation we feel when drinking alcohol, and the loosening of social inhibition, are the main reasons most people drink. Some historians claim that once beer was discovered, and its pleasant effects appreciated, the inspiration to make more through organized agriculture took off. Those historians note that alcohol facilitates easy comradery, stimulates creativity and cooperation, and might have been the nurse that cradled human civilization. It has helped people overcome problems with intimacy to forge closer bonds. Otherwise, the default human social stance over the millennia has been one of defensiveness - being on guard against potential enemies, rivals, and different tribes.

And so when the British journal The Lancet came out with a definitive study on alcohol in 2018, and concluded: "our results show that the safest level of drinking is none," many drinkers sighed. While this is medically true, it may not be holistically true. For many over the centuries, alcohol has turned down the noise, down-regulating the prefrontal cortex to allow the creative, collaborative and communicative processes to run. If they had just served whiskey to all the leaders at the recent Glasgow Climate Change Summit, for example, perhaps they could have saved the planet - a major health benefit.

Many studies have also shown a trade off between reducing cardiovascular risks and increasing cancer and injury risks. The best advice could be given if there were a crystal ball, showing us our future cause of demise. Heart attack? Might be better to have a drink a day. Cancer? Best to avoid alcohol.

Possible Benefits

The relationship between alcohol and dementia is difficult to pin down, but the data point towards light consumption not affecting risk that much, and in some studies actually providing a slightly protective effect in women drinking 1/2 glass of wine per day. But once again, studies are conflicting. Heavy drinking is of course bad for the brain.

One would think that alcohol would worsen the effects of diabetes, but studies have shown that light to moderate drinking may actually help control blood sugars to a small degree, and reduce the risk of developing diabetes. This is perhaps mediated through improved insulin sensitivity, and higher adiponectin levels. But alcohol can worsen diabetic neuropathy. And I found this quote from the medical reference UpToDate shocking:

Mild to moderate alcohol consumption also may decrease the risk of death due to coronary heart disease in older diabetics [131]. In one study of 983 diabetics with a mean age of 69 years, the relative risk of coronary heart disease mortality compared with never-drinkers was 0.54 for those who drank less than 2 grams per day (less than one drink per week), and 0.21 for those who drank 14 or more grams per day (about one drink or more per day).

Alcohol might reduce mortality from cardiovascular disease. The graph below comes from a U.S. study of 333,000 people reporting their drinking patterns over 8 years (National Health Interview Surveys). On the Y-axis is the hazard ratio, with zero indicating neutral risk. Above zero, higher risk of dying, below zero is lower risk of dying. The black line is the study result, and the dotted blue lines are ranges of statistical confidence (the truth lies somewhere in between the dotted lines, with the black line the best guess). Compared with lifetime abstainers, individuals who were light or moderate consumers were at a reduced risk of all-cause mortality, but that risk increased dramatically with heavy alcohol consumption:

And remember this is just one study, and a perfectly designed one is very difficult. To make things even more timely as I was writing this, the World Heart Federation (a Geneva-based health advocacy organization that represents hundreds of heart associations worldwide, including the American Heart Association), dropped this bombshell just on Thursday:

In brief, our position is that studies showing a significant cardioprotective effect of alcohol consumption have by-and-large been observational, inconsistent, funded by the alcohol industry, and/or not subject to randomized control. Furthermore, any potential cardioprotective effect is negated by the well-documented risks and harms, rendering our judgment that no amount of consumption can be considered good for heart health.

The effects of alcohol on the cardiovascular system have been debated for years. The supposed French paradox, in which the French consume a lot of wine but with lower observed rates of heart attacks, has not been proven.

And finally, simply stated: alcohol can be pleasurable.

Monk’s Cafe in Philadelphia. We hiked through sleet to get there. I took off my cold and wet coat, and the welcoming bartender pulled an amazing draft of Belgian beer, brewed in a tradition that stretches back to medieval monasteries. A bucket of steaming mussels in broth. Fresh-cut, salty, double-fried potato frites, served with bourbon mayonnaise, to be washed down with a Belgian Tripel. The pleasures of such a meal ricocheted around my weary brain. Transcendance.

Risks

So let’s review more of the risks of alcohol that make the cost to benefit ratio unacceptable for some. Alcohol, especially when consumed heavily, has been associated with increasing the risks of numerous cancers, including esophageal, liver, head and neck, and breast cancer. The risk of cancer increases directly with the amount of alcohol consumed, with heavy drinkers having up to 5 times the rates of head and neck cancers for example.

Pancreatitis is a not uncommon consequence of drinking, and likely contributes to an increased risk of pancreatic cancer.

Alcohol may decrease blood pressure somewhat in light drinkers, but with increasing amount consumed, it does the opposite by increasing risks of hypertension. In fact, for people with hypertension, one of the best and often neglected bits of advice is to reduce alcohol.

Heavy drinking can also damage heart muscle directly, a phenomenon called cardiomyopathy.

Alcohol has also been associated with hemorrhagic strokes.

The liver bears a heavy load from detoxifying alcohol. A primary metabolite of alcohol is acetaldehyde, which is toxic, and related to formaldehyde really. With enough alcohol, it is almost like pickling the liver, with scarring and irreversible damage that can lead to fibrosis and cirrhosis. Even a major drinking binge can cause an acute hepatitis episode, triggering a liver-wide inflammatory event, releasing so much inflammation that serious liver injury or even failure can happen over the course of days instead of decades. This is why I have seen a good number of young people with premature liver problems.

Alcohol negatively affects fertility. In men, alcohol decreases the ability to produce testosterone, and can have feminizing effects including gynecomastia, striae on the abdomen, and erectile dysfunction. In women, pituitary hormone disruptions occur, leading to dysregulation of menstruation, skin changes, osteoporosis, and endocrine hormone problems.

Alcohol contributes to violence, car accidents, and domestic violence.

~

So, how can we conceptualize the absolute risk of drinking? The relationship between alcohol and harm is exponential - the more you drink, the very much more harm you get. Dr. Nutt quotes these estimates:

• If you drink a half bottle of wine a day, or that equivalent, it will probably take on average 1 year off your life. Unfortunately that is an average. It might be 2 weeks for some, or decades for others… or maybe those drinks you enjoyed save you from a heart attack. On average though, 1/2 bottle a day is not great.

• If you drink double that, or a whole bottle’s worth of wine a day, that will take on average 4 years off your life. See the exponential math at work?

• Two bottles a day, 16 years less on average.

Dr. Nutt admits that he drinks alcohol for pleasure several times per week. He enjoys the social benefits, and the relaxation he feels. When having wine with his wife over dinner, he never opens a second bottle. He does not drink every night. I agree with him that no matter what risks we decide to take with alcohol, we should be reducing our intake at least.

So, after this deep dive, can we say whether alcohol is good or bad for health? Patient education material from the reference site UpToDate that many doctors use states:

For many reasons, this is a question without simple or clear-cut answers. Drinking too much alcohol contributes to accidents and injuries and can lead to liver disease, high blood pressure, various cancers, and congenital anomalies (in pregnancy), among other health problems. However, limited or moderate alcohol use may provide certain health benefits for adults, such as possible reduced risk of coronary heart disease, although this has not been definitively proven.

I am aware that anytime we talk about alcohol, there is a defensiveness that is reflexive. Just like when I screen for alcohol problems in the office, I hope this post does not come off as preachy or judgmental, or cause someone to feel resentment. After all, life is full of danger, and even too much oxygen is toxic.

Cheers, and I wish you luck and good health with your decisions. Recently I’ve found a tasty non-alcoholic spirit called The Pathfinder.

Gordon’s Wine Bar

In another lifetime, before fatherhood and career and the rest, I found myself in a subterranean bar in London. It was like a stonemason’s wine cellar, a drinking catacomb, buried deep beneath the city, just in case of a sudden Prohibition movement or German blitzkrieg. People were drinking wine by candlelight at small tables, and meeting and making quick friends over bottles of wine. We met people from America and across Europe that night, and accepted their generous fillings of our glasses. It became hard to keep count. By the time I got back to my hotel the euphoric social experience had changed to a vertiginous, nauseating state of poisoning. I closed my eyes and got no rest, then packed my things at 6 in the morning. I dragged a suitcase down the hall and out into the wintry London streets, hustling to make a transatlantic flight, and to keep up with my wife, whom I swear must have been running. The plane flew through turbulent winds across the Atlantic. It was one of the worst physical experiences I can recall. Was it worth it? It depends, really.

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In remembrance of Martin Luther King Jr., on his day in 2025

In 1961, Dr. Martin Luther King Jr. visited Jim Sanders' wine shop in the South to buy Sherry for his wedding anniversary pecan pie, where he unexpectedly encountered segregationist former governor Marvin Griffin and liberal publisher Ralph McGill.

During their civil though tense interaction, Sanders offered them a wine tasting, demonstrating the differences between various Sauternes, with Dr. King astutely comparing real Sauternes to "the best cantaloupe you've ever tasted compared to damp pasteboard."

The encounter culminated in a remarkable moment of shared appreciation when Sanders opened a prestigious 1957 La Tâche Burgundy for the unlikely trio, temporarily bridging their deep ideological differences through their common experience of one of the world's finest wines.

It should be noted that President Trump does not drink alcohol. I salute that personal health decision. Maybe he is giving a speech right now. I’ll watch it later tonight.

I can only dream of what might have been had Trump sat down with his proclaimed enemies within, drank a glass or two at a tiny health risk over the course of an entire life, softened the moment, and found common humanity with fellow humans.

I’ll end the day watching this speech from April 3rd, 1968:

How are you?

What’s your take on alcohol?

How are you doing today?