Ask the Author: Questions for Charles Knowles

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.

The difference comes down to a combination of biology and psychology. 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 those 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 you're in with a chance; if it's your solution you've already lost."

Both play a significant role, but in different ways. 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 can be modelled experimentally in mice. It is almost certainly also 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 and 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 faces cultural pressure to drink — for example, to conform socially. This is reflected in the much larger proportion of people who describe themselves as social drinkers compared to those who develop problems of reliance or dependence.

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.