How can I cut back or even quit drinking alcohol?
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I'm Sam Mullins, and this is Sea of Lies from CBC's Uncover. Available now. This is a CBC Podcast. Hi, I'm Dr. Brian Goldman. Welcome to The Dose. Earlier this month, the U.S. Surgeon General called for cancer warnings on alcohol consumption. He pretty much said there's no safe limit. Health Canada suggests limiting alcohol to one or two drinks a week.

It puts some urgency to those calls that you consider having a dry January. So this week we're asking, how can I cut back or even quit drinking alcohol? Hi, Peter. Welcome to The Dose. How do you do, Brian? Thank you for the invitation. What do you make of the calls from health authorities to warn the public about alcohol? I think it's long overdue. We have known since the mid to late 1980s through the World Health Organization that

Beverage alcohol is a group one carcinogen known to be causative of seven different types of cancers. We know it's teratogenic in addition to carcinogenic. It causes birth defects.

We also know that it contributes significantly to accidents and injuries, liver disease, heart disease, and the list goes on. So this is really way overdue when you consider the fiduciary responsibility of most manufacturers to warn people with regards to the potential health harms that might arise from using their product.

So there's a serious underpinning to this conversation, and I'm looking forward to it. But before we begin, can you give us a hi, my name is, tell us what you do and where you do it. Hello, thanks so much for the welcome to the show. I'm Dr. Peter Butt, a clinical associate professor in the College of Medicine at the University of Saskatchewan, and I live outside of Saskatoon. From a purely health perspective, who should be thinking hard about cutting back on alcohol consumption?

Everyone who drinks, because we know that the health impacts of alcohol increases with the amount consumed. And arguably, those that are drinking at a much higher level are going to derive greater benefit from even decreasing somewhat the amount that they drink, as opposed to people that are already drinking lower, thinking that they should reduce further.

simply because of the exponential curve of these harms with the increase that people consume. Exponential curve of harms. Can you say a little bit more about that? We know that at relatively low levels of alcohol consumption, and this would be at one to two standard drinks per week, people rise up to a level of one in 1,000 risk of harm, which is what we generally accept for voluntary exposure.

If, however, you look at what traditionally has been defined as low-risk drinking historically, what we find at that 1 in 100 level of risk of harm is people drinking at about six standard drinks per week. So we use these international epidemiological definitions to define low-risk drinking, up to two standard drinks per week,

moderate risk drinking three to six standard drinks per week and then you get into an increasingly high risk zone and people are beginning to experience more and more negative consequences from their alcohol consumption practically speaking from what you're saying you could try to quit entirely but what you're saying is at least cut back to one or two standard drinks a week am i right

Absolutely. It really is dependent on the individual to decide what the goal is for themselves. If people are having significant health problems with regards to their liver, their heart, cancer that's causally associated with alcohol, or a concern with regards to a strong family history of, let's say, breast cancer, then they might be very well advised to reduce to zero and consider abstinence.

However, for other people that perhaps are on medication for hypertension, knowing that reducing their alcohol consumption might decrease the pill burden that they take may or may not sway them nearly as much. And they might say, well, thank you very much. I'll reduce the amount that I drink, but I'm not going to quit altogether. I think we need to help people to make informed decisions. They have the right to know with regards to these negative health consequences that

We need to help them to activate with regards to reduction, but at the same time, not just

make them feel that they're being imposed upon. People are smart and they can decide for themselves. Remind us what we mean by a standard drink. If people are pouring more than a standard drink, they got to know what a standard drink is. So go ahead. Absolutely. And this is part of alcohol literacy. And it seems arcane when you think about it. In terms of the volume, it's 13.45 grams of ethanol.

Now, on beverage alcohol, we have percent alcohol by volume, but you pretty much need a calculator to figure out what that actually means in terms of the number of standard drinks. And it's been really quite interesting to have industry reluctance in Canada and indeed in North America to have standard drink labeling.

I suspect this will shift, though, with increased popularity and lower alcohol content beverages so people can appreciate that if they're drinking a 0.5 standard drink, they could have two of those instead of one that's a full standard drink. So 13.45%

grams of alcohol is five ounces of beer, of wine. It's 1.5 ounces of 40% liquor. But measuring this is awkward. And this is why having standard drink labeling on beverage alcohol helps so much. Because sometimes there's more than one standard drink in that can or that bottle. Sometimes there's half a standard drink. There might be five or six in a bottle of wine, depending upon the percentage of alcohol.

So it does pose a challenge to consumers. And one of the first things we need to help people to do is to measure what they're consuming. How often do you suspect people may be drinking way more than a standard drink? If they say they drink one standard drink a day, in fact, they could be having the equivalent of two standard drinks a day, couldn't they?

Oh, absolutely. And we know self-reporting with regards to the amount that people drink is under-reporting. And we generally adjust it up by 25 to 50%. Wow. Certainly, if you're dealing with somebody who has an alcohol use disorder, we know clinically that it's grossly underestimated because of some of the shame issues and the fear of judgment that people have.

In working with people clinically, it's important to try to quantify how many bottles of what beverage do you actually drink? And is that all that you drink? Is there more that you drink on the side? What about other beverage types? And just go into a line of inquiry that's very nonjudgmental, just saying, look, I'm just trying to measure how much you're drinking so I know what services you might require. So let's get into talking about how you do it.

How do we take a person who's used to drinking what we might have called moderate in the past, you know, having a nightcap or having a glass of wine with dinner every day? How do we get them to taper back to, say, one or two standard drinks a week only? If that's indeed their goal, and they may want to go from seven plus standard drinks per week down to four rather than two.

They need to set a goal for themselves, something that they feel that they can reasonably achieve, that has good reason behind it, given their own circumstance, and then count their drinks. How much are they actually drinking? Is that a standard drink of wine with their meal, or is it actually two or three? How much of the bottle is left at the end of the meal? How many people are consuming?

So these are really practical things that are important with regards to alcohol literacy. Once they know how much they're drinking, then they can set a target. And there are different ways to reduce. It depends upon the pattern and the beverage that people use.

For example, you can alternate an alcohol beverage with a non-alcohol beverage. You could go to a lower alcohol content beverage. You could consider not drinking on particular days because we know that daily drinking leads to escalation because it's not only daily, the amount can escalate and then it can become problematic.

It's also important to keep in mind the motivators as to why they're drinking. Is it for enjoyment or are they deliberately trying to alter their mood? Are they avoiding boredom? Are they escaping problems? Are they just drinking to get drunk? Understanding the personal motivators is important. And then we also need to prompt people to look at the social impact of their drinking.

Very frequently in our culture, people drink in order to socialize, and reduction in drinking seems to be a war on that, a war on pleasure. And that's not the case at all. We can enjoy other people's company without so much chemical. So that leads me to the next question. If people are consuming more than they think they're consuming in terms of standard drinks...

when they do start to taper, they could well get symptoms of alcohol withdrawal. And what would some of those symptoms be? Well, we know certainly that when people are drinking at higher levels, particularly on a daily basis, they might end up with withdrawal symptoms where they have headache, where they're feeling sluggish and slow. It really depends on how heavily they're drinking, Brian, because this is a continuum, isn't it? And we know that people that are drinking

42 standard drinks per week or more, which would be six a day, or in need of managed alcohol withdrawal. So up to that level, people may have varying levels of withdrawal. They may feel a little shaky. They may feel the need to drink in the morning and have an eye opener, as they call it, in order to settle their nerves and make them feel better. They may have nausea, perhaps vomiting,

So the list of symptoms goes on depending upon the severity of the withdrawal and how much they've been drinking. An important side note here, we're talking about standard drinks, but really we're talking about drinking alcohol per kilogram of body weight. And for example, women tend to weigh less than men. If they consume the same standard drink as a male, somebody who's born male, they're

then they are consuming more alcohol per kilogram than somebody who weighs more. And that's an important point that needs to be raised. Have I got that right? Yeah, sex and gender plays into this as well. With regards to sex, people that are typically female have decreased lean body mass compared to males. They also have less alcohol dehydrogenase, which is the enzyme that metabolizes alcohol.

So drink for drink, a woman will have a higher blood alcohol concentration for longer than a man will. At that higher risk zone that we identified within the Canadian guidance on alcohol and health, women are actually experiencing more harms than men at the same level of consumption. When you get down below that,

six standard drinks per week, the difference between males and females is not that significant. But once you get above a drink a day, yes, women go down harder and faster. They tend to develop cirrhosis earlier. They're at increased risk of breast cancer. Not to mention from our work with regards to alcohol, violence, and aggression,

women are by far the more likely victims of intimate partner violence, generalized violence, and sexualized violence. Is there a level of alcohol consumption from which you can safely quit without fear of withdrawal symptoms? Sure. And again, it depends on how people are quitting. Even at a very high level, people can taper off.

And indeed, this is something that was done amongst people within Alcoholics Anonymous. They would help people by putting them in a room with permission, obviously, and helping them to taper off over a period of days by giving them a gradually reduced amount of alcohol. When people are preparing to go into long-term care facilities as older adults because of their health challenges who are heavy drinkers, sometimes this is an approach that's used in the community.

where they may decrease the amount of alcohol that's actually contained in their favorite beverage by cutting it, by putting in a lower alcohol content amount, and tapering it off over time. So a gradual taper can be done in the community quite safely because it's the abrupt cessation that requires medication and other support. So tapering is a good strategy. The problem is that when people have lost control of

or when they're beginning to feel the negative consequences of their withdrawal and they're getting symptomatic, it's hard to maintain the course. They need some sort of support. A random influencer, a friend who read something somewhere, your doctor. It can be hard to know where to get trusted health information.

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And in the emergency department, I have a lot of experience of a particular kind. We tend to see people who either binge alcohol or are very heavy daily users of alcohol. Heavy consumers can have severe anxiety, tremors, fast heart rate, and some get seizures, which can be lethal.

Often, when they quit drinking, it's entirely involuntary. It may be because they've developed what we call alcohol hepatitis or alcohol gastritis, and they start to vomit.

and they can no longer consume alcohol. And from that point, you can set the clock. They're at risk of getting into severe withdrawal within 24 to 48 hours. And for them, we have protocols. We have a protocol for monitoring withdrawal down to a safe level, monitoring the withdrawal period and using medications like lorazepam and diazepam to help manage the withdrawal symptoms. We're also using phenobarbital to greater extent compared to years ago. I just want to put that out there.

We're not really talking about heavy users who have alcohol use disorder. We're talking about more moderate consumers. You mentioned earlier that drinking has a social aspect to it. So how do you avoid the social pressures of drinking when you're trying to cut back for health reasons?

There are a number of ways of doing that. First of all, it depends upon the company that you're keeping and how closely are they monitoring how much one is consuming? Is it really any of their business? Frankly, I think not. But if other people in your social group perhaps are uncomfortable with the amount that they're drinking, even though they're drinking heavily, to see somebody reduce, they'll interpret as point of judgment that somehow you might be better than them because you're reducing.

These individuals frequently see the amount that they drink as a power play as well. If they can drink that much, consume it and hold their alcohol in a very masculine sort of way, it seems to give them a sense of power. But these are all problematic patterns of socializing, obviously. And it really isn't anyone else's business with regards to how much a person is drinking.

So if you want to, you might disclose to people that you've been thinking about alcohol and your health and you're going to reduce the amount. This might engender further support. It'll be interesting as a social task, quite frankly, as to what the response of your friends or drinking colleagues are. Are they threatened by this? Are they supportive?

Are they neutral? And that sometimes helps to understand what is the social milieu here that you're navigating. There are situations, again, such as power lunches, where there's an expectation that you're going to drink with the others. This is sometimes highly culturally defined, where everyone is supposed to take a shot repeatedly.

And it can make it very awkward for people in those circumstances. Nevertheless, by clearly understanding what the dynamics are and who you're drinking with, there are a number of things that you can do. Again, I think that it's important for people to get a measure of how safe they are.

Is this something that they can do in an open way? Or are they needing to mix their drinks and control the amount of alcohol in a way that's more surreptitious? It doesn't mean that they give up on socializing. It simply means that they navigate it in a different way. Perhaps a different type of beverage, holding the beverage longer, putting water in an alcohol beverage container if that's what they need to do.

There are ways of masking whether or not they're drinking and how much they're drinking. I imagine that for some people listening to this conversation, that drink at the end of the day or that glass of wine with dinner is actually important to them. It's one of their little rewards. And, you know, life is tough. People want to have small rewards. It strikes me that you kind of need to rewire your brain when it comes to rewards. How do you do that?

You're right, because we frequently use alcohol to mark special occasions. It could be a birth, a death, a marriage, the end of the work week, the end of the work day, whatever the case may be. But do we need three glasses of wine, or would one be sufficient? Do we need that full drink, or would a 0.5 standard drink be sufficient?

The other is to keep in mind that there are other things that we can do to celebrate this. It doesn't have to be a chemical. We can shift our focus and say, you know, I'm returning home from work and here I have this other person that I want to engage with, a partner, a child, whatever the case may be. And I'm going to use a loving embrace at the end of the workday to mark that transition rather than rushing to the fridge and popping a drink.

And I think the other thing that is really important here is to talk about the benefits of alcohol reduction. Because it's not just about taking away alcohol. It's about thinking about the things that we can replace it with. More time to exercise, for instance, or having a better quality relationship.

And when we start to consider the benefits of alcohol reduction, such as decreased calories, decreased alcohol will also improve immune function.

and decrease cancer risk. It will decrease the risk of accidents and injuries. It improves relationships. It creates a financial saving. So this is a long list of things that people can benefit from with a reduction in alcohol. And even choosing one of those to focus on as a reason to decrease might help with that transition.

Some people who are listening to this are going to resolve to taper their consumption of alcohol. And along the way, they may discover that they need professional help.

Can you describe those people? Essentially what we see when people are really struggling with an alcohol use disorder, and keep in mind that this is a spectrum disorder. It's on a continuum of mild, moderate, and severe. But generally speaking, what we see is loss of control. So people can do well in their relationship with alcohol when they're not drinking. They can go a month and there's no problem with alcohol because they're not drinking. It's when they start to drink.

that you begin to discern that there's a problematic relationship. So loss of control is a key feature. Continued use despite negative consequences is another one where people are losing control. They know they're running into problems. They're having negative consequences, but they're continuing to use.

Another one that comes into focus is craving. What happens when people aren't drinking? Are they thinking about it? Are they craving for it? Are there problems there? People who have a measure of control will try to reduce, and they may accomplish a great reduction, but not be able to taper off completely or achieve the goal that they've set for themselves. And this is where assistance is available. There's

underutilized pharmacological support. There's medications such as naltrexone and ecamprosate that are grossly underutilized with regards to helping people to taper off and quit. And certainly the Nordic approach is for people to continue drinking, initiate naltrexone, which decreases the reinforcing effect of the alcohol, and then with counseling support, they taper back or

over time. And during that period of time, they're getting help navigating the changes, the changes in relationships, the changes in how they socialize, the changes in their pattern of exercise and that sort of thing. So it's a reduction with counseling to support reintroduction of better ways of living.

What resources are available to make sure that people don't relapse? I guess one of them would be joining a group like a smart recovery group. Absolutely. Just as drinking is a social event for many people, so also reducing drinking or recovery if their goal is cessation is best done as a social event. So you have other people reinforcing the process and providing feedback, providing encouragement and so on.

So these are some of the self-help organizations that are available through the web. But it's also important to remember that the healthcare system is there for us as well. I mentioned pharmacotherapy has been helpful for some people at different times, depending upon the severity and the different types of pharmacotherapy. In BC, there was a study that showed that certainly less than 10% of the people that met criteria for an alcohol use disorder were offered

anti-craving medication. But those people had a 50% reduction in morbidity and mortality. A 50% reduction is significant, as you know, and this is medication that has absolutely no restrictions. Any primary health care provider can prescribe. It should be done in emergency departments. It should be done by family physicians and nurse practitioners. This is medication that can be very helpful to individuals that are really struggling with their cravings.

I think that one of the challenges we face in the healthcare system, however, on the other hand, is that it's been woefully inadequate. If we think of people struggling with an alcohol use disorder

as being in early remission after three months of non-use and then being in sustained remission after 12 months of non-use. And we do the math with regards to what's typically provided, let's say 10 days, 7 to 14 days of detox, if that, a 28-day or 30-day rehab program.

Those days don't add up to the three months to get people into early remission. They need counseling. They need support on an ongoing basis. Some people might need 90 days of residential treatment. Some people might just need 90 days of continued contact and a rational plan and program with support. So I think a lot of people that have struggled with this in the past have not been adequately served by our health care system.

Many times, drug and alcohol problems are an orphan child of the system and aren't given the funding and the support that's required, even though we know they play a significant role in so many other health care problems that people present with.

So we need to be thinking about revamping the system, providing more support over a longer period of time. Supportive housing, therapeutic housing could be part of this. This doesn't have to be provided by the healthcare system, but it does need to be thoughtfully designed. Dr. Peter, but I thought I knew a lot about this subject, and it's pretty clear listening to you that I was wrong. You know...

Dr. Peter Butt is a clinical associate professor at the University of Saskatchewan.

Here's your dose of smart advice. The health hazards of alcohol consumption are well known. The World Health Organization says alcohol contributes to 2.6 million deaths per year globally. And overall, the harmful use of alcohol is responsible for just under 5% of the global burden of disease. In a statement published in 2022, the WHO said this, when it comes to alcohol consumption, there is no safe amount that does not affect health.

Alcohol increases the risk of developing cardiovascular disease. It also increases the risk of several kinds of cancer, most notably breast, colorectal, liver, esophageal, and head and neck malignancies. The more you drink, the more harmful it is. But the less you drink, the lower your risk. Health Canada recommends lowering your alcohol intake to one or two standard drinks per week.

The power of that recommendation is that if you can reduce, for instance, your consumption from one standard drink per day to one or two per week, you'll actually reduce your risk of serious illness substantially. You need to know what they mean by standard drinks. These vary by country. In Canada, a standard drink is 13.45 grams of pure alcohol. This is equivalent to a 12-ounce bottle of beer or cider with 5% alcohol.

a five ounce glass of wine with 12% alcohol or a 1.5 ounce shot glass of spirits with 40% alcohol. It's easy to overshoot the Health Canada recommendation by not knowing what percentage of alcohol is in the drink and how many ounces you tend to consume. That's why some experts want manufacturers to put cancer warnings with consumption labels on bottles of alcohol. People may underestimate how much alcohol they consume by as much as 25%.

Another thing to keep in mind is that the health risks of alcohol consumption are generally greater in women than men because women tend to weigh less and because their bodies don't metabolize alcohol as men do. In general, it's easier and safer to reduce alcohol consumption gradually.

than it is to do so abruptly. There are lots of tips on tapering alcohol use. These include designating specific days of the week to drink non-alcoholic beverages and consuming products with lower percentages of alcohol than those found in standard drinks. For some consumers, it may be helpful to break the habit of a daily drink of alcohol with dinner. One way to do that is to switch to a more healthy reward such as exercise. It may also help to be deliberately mindful of specific health benefits such as reduced risk of breast cancer.

People who consume alcohol on a daily basis are more likely to have withdrawal symptoms such as headache, nausea and vomiting, anxiety, insomnia, hot and cold flushes, sweating, muscle cramps, diarrhea and tremors.

People who try to taper their use of alcohol may encounter resistance from family, friends, and coworkers, especially in settings where alcohol use is built into social rituals. It can sometimes be helpful to state explicitly your intention to reduce alcohol consumption or just surreptitiously cut back by diluting your alcohol beverages and by switching to lower alcohol products. People who binge on alcohol or who drink heavily on a daily basis should seek medical attention for controlled withdrawal.

medications such as naltrexone and acamprosate are most helpful for patients with alcohol use disorder. Groups such as AA or Smart Recovery can also help provide emotional support and reduce the risk of relapse. If you have topics you'd like discussed or questions answered, our email address is thedoseatcbc.ca. If you liked this episode, please give us a rating and review wherever you get your podcasts.

This edition of The Dose was produced by Samir Chhabra. 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. For more CBC Podcasts, go to cbc.ca slash podcasts.