Ask the Author: Questions for Charles Knowles
-
My own personal history – the book started life as a form of memoir – answering what I call the ‘why me?’ question was the main impetus. I quickly realised that looking at why some humans drink too much required looking at why we drink alcohol at all.My own personal history – the book started life as a form of memoir – answering what I call the ‘why me?’ question was the main impetus. I quickly realised that looking at why some humans drink too much required looking at why we drink alcohol at all.
-
I wouldn’t say it has ‘changed’, more that it has enhanced my own views on my own drinking.
I have known for a very long time that I was dependent on alcohol – and I didn’t need a psychiatrist to tell me I could never drink safely again. I have not found any compelling evidence that refutes this view and have found much that supports it.
As for other people, I have no opinion, this is for them to decide – I do believe that we should all be provided with the necessary information to make a reasoned choice e.g. in terms of health risks etc.
-
I was actually amazed by the number of effects that alcohol has in the brain. It has effects on neurotransmitters that mimic just about every major recreational drug and several anaesthetics. It is no surprise that so many people like it. On the flip side, I was astonished at the societal cost of alcohol, especially in terms of criminal activity. In the US, this is estimated at almost $250 billion annually more than the total annual government spend on health and social care in the UK!
-
I admit that I came at this subject first from my own experience of drinking and recovery. The latter has been very much AA focussed and I am a big supporter of AA for many reasons. As I wrote and re-wrote the book, I realised it was necessary to get to grips with the less ‘medicalised’ end of alcohol problems – including sober curiosity and grey area drinking. This was greatly helped by my wife Annie. The book is therefore now relevant to anyone who wants to re-evaluate their relationship with alcohol. In both instances, the science is only part of the story - lived experience is critical.
Other than that, as a doctor and a scientist (and someone with a penchant for organised thought and logic), I had to write something that made scientific sense whilst still being widely readable – some books, perhaps in the process of dumbing down the detail, lose factual accuracy; others present a narrative that is convenient to the overall message, but is not supported by actual evidence. I was determined to avoid this – there are some bits of the book which are difficult because which ever way you tell it, the truth is complicated.
-
Probably the idea that alcohol can be written off as being ‘a depressant and a poison’. This is a misrepresentation – while both descriptions are true in the sense that alcohol can cause depression and be acutely toxic at high doses, the majority of people are not depressed by alcohol – they are stimulated. The effects of alcohol on the brain (especially in the reward system) leads to dopamine mediated psychostimulatory effects. This is why pubs and bars are loud and people look energised and happy. This effect is fundamental - it is also why we and many other animal species consume alcohol The implication of the ‘depression-poison’ argument is that everyone who drinks must enjoy being depressed and poisoned – this is clearly not true.
-
This is the ‘why me?’ (perhaps better ‘why I?’) question. It considers our ability to control consumption and has little to do with how much we consume. Overall, the answer derives from a combination of biological (nature) and environmental (nurture) factors, both often mediated through observations on our psyche. Broadly, psyche has a role in our motivation to drink and biology determines whether alcohol will provide a solution to the psychological needs. If you have both (like me) then there may be trouble ahead. As a friend of mine once said “if drinking’s a problem your in with a chance; if its your solution you’ve already lost”.
-
Biology determines the effects that alcohol has on us – the range of responses we see in the real world from people who really love alcohol and are very stimulated by it to those who just feel unwell and miserable – this is partly genetic and it can be modelled experimentally in mice. It is almost also certainly true that biology (including genetic variance) determines how the brain re-wires in response to chronic alcohol ingestion – our ‘internal electrician’ and how stress responses (physical withdrawal develop from this).
Western culture makes alcohol available, affordable, attractive and acceptable (what I call the 4 As). Only a minority of people have the ‘at risk’ biology whereas nearly everyone has the cultural pressure to drink (e.g. to conform socially). This is reflected in a much larger proportion of people who describe themselves as social drinkers compared to those who develop problems of reliance or dependence on alcohol.
-
Many. To name a few. First, there need to be some studies on grey area drinking. Such people are currently disenfranchised by medical definitions – while a few in the darker grey might be captured in the mild end of alcohol use disorder (AUD), we need to study what drives ‘reliance’ on alcohol as well as dependence (these might be completely different or grades of the same risks – we just don’t know). Secondly, we need to understand epigenetic changes in our DNA as pertain to changes in our drive to consume alcohol. This is starting to be unravelled for obesity but even so, we are miles off understanding how this plays into heritability (inherited risk) and changes during life (especially earlier life). Finally, we need to understand how the reward system links to memory, because it certainly isn’t just dopamine (don’t hold your breath on this one).
-
I actually don’t think that research is going to be the main driver of meaningful change in how we chose to use alcohol. This will be societal – and it is already happening based on stuff we already know, and in some instances have known for 50 years (like the strong link between alcohol and breast cancer). I do however think that the more we understand the genetics (strictly genomics and epigenetics) of risk, the more support people with problems like me will get because it will further dispel the idea that alcohol dependence is a problem of the weak willed or morally bereft.
-
What advice would you give to someone who is curious about reducing their drinking but isn’t sure where to start?
Obviously, I am going to suggest buying my book. But after that, I would take a month break and make a conscious effort of noticing the differences. Here, it is key not to focus on the exercise as a punishment but rather an opportunity to see how great we feel without alcohol – during this time, my 3C exercise could be completed.
We should look at our consumption in units (weekly and binge), the consequences (health, wealth and happiness) and control (how easy was it to stop). Consumption can be aided by filling in the free WHO AUDIT-C questionnaire. For consequences, it is important to look not just at what has happened (harms) but also at what might happen (the hazards). Armed with this information, a more rational decision can be taken on the pros and cons of stopping for longer, moderating or continuing as we were.
-
What do you hope readers take away from Why We Drink Too Much?
For readers who have purchased the book to look at their own relationship with alcohol, I hope that it has helped rationalise their thinking. For those like me with more serious issues, I hope it benefits them in the same way it did me in writing it—the opportunity to find an answer to the “why me?” question. For everyone else, I hope it serves to improve understanding of a very difficult and widespread societal issue.
-
I would apply my 3 Cs approach – ideally during a defined period of abstinence – e.g. dry January. We should look at our consumption in units (weekly and binge), the consequences (health, wealth and happiness) and control (how easy was it to stop). Consumption can be aided by filling in the free WHO AUDIT-C questionnaire. For consequences, it is important to look not just at what has happened (harms) but also at what might happen (the hazards). Whether we then consider this a ‘problem’ is for only us to personally arbitrate. As Ozzy Osbourne once said in response to being asked if he has a drinking problem “I only have one mouth”
-
I think that this is possible although many would disagree. The medical position is that there “is no level of alcohol consumption that is safe”. I think that if the occasional drink brings joy in people’s lives then this is OK. It is simply a question of balancing the pros and cons (what I call the drinking scales). The problem is that for many of us, the scales are not very accurate.
-
It shouldn’t but it does. This is borne out by the controversy of using the term ‘alcoholic’. I have no issue with describing myself as a ‘recovering alcoholic’ but many find this shaming. The issue is not so much with the term (which is actually quite useful and has no easy alternative in common parlance) but rather societal prejudice and misunderstanding. Alcoholism (AKA alcohol dependence) is not the preserve of the homeless on a park bench – it affects the whole of society. In fact, I am a quite typical alcoholic in terms of upbringing and career.
-
I think society is definitely changing its views, especially in the younger generation where about one quarter of 16–25-year-olds now abstain from drinking. I am not big on fashionable anti-corporate or anti-government narratives regarding motivations to drink (we have been manufacturing alcohol for 15,000 years and animals also chose to consume it) but I think we can rightly question why so little has been done to curb the harms and societal cost of alcohol – especially in the UK. This is not party political – it is economics. At the time of writing this, the UK Prime minister has just returned from selling Whiskey to China.
-
Only really one important one. That is that despite several lunatic views, someone diagnosed with alcohol dependence can never safely moderate. I think everyone else can give it a go and see how they get on – I would however recommend a period of stop and review first to give stopping a fair chance.
