LUI: Living Under the Influence

by Shiban Ganju

We spent approximately $115.9 billion to buy alcohol in the USA in 2003 and spent billons more to treat its ravaging effects on our bodies. We are not alone. All people - Asian, European, American, and African – enjoy and suffer almost equally. No society is exempt; rich spend discretionary income while poor spend sustenance money; liberal societies buy it from the local liquor stores and conservative societies get surreptitious home delivery. And our world has about 140 million LUI - living under the influence.

One of them may be Mark, your high school buddy who staggers towards you and slurs at your class reunion. You notice: Mark has changed more than others; he looks different - the purplish hue of his face, red dots below his visible collar bone, lush thick hair, his tremulous hands with pink palms - he has aged more. You suspect alcohol. How do you verify? Simple: apply the CAGE test. Ask four questions. Are you concerned that you may be drinking too much and want to cut down? Are you annoyed when asked about your alcohol habit? Do you feel guilty about drinking? Do you need an ‘eye opener’ - a drink early in the morning just to get started? If Mark cares to entertain your curiosity and says yes to at least two questions, he has a problem.

Your classmate, like millions of others, was probably genetically predisposed – not by a single gene but a complex interaction of a number of genes acting in cohesion. His nurture was also permissive; his father relaxed with a six-pack of beer after work. And Mark’s enabling peers started drinking in high school. He fell into the trap of early start like many teenagers but unlike them he was unlucky and succumbed to his genes.

Mark started with beer. “ I don’t do hard liquor, just beer.” He had heard his dad announce in a moral tone many times. So beer was OK. And so was its euphoria and adventure. He drank mostly over the weekends and sometime sipped a beer or two during the week. His liver kept up with his pace; it slogged overtime and manufactured more enzymes to detoxify the poison. The metabolism would convert alcohol into acetaldehyde. Excess of acetaldehyde would flush his skin; give him headache, nausea and stomach pain – a hangover. Another enzyme - acetaldehyde dehydrogenase – would now rush to his rescue by neutralizing accumulated acetaldehyde and relieve him of misery.

Mark, propelled by his dad’s genes and convinced by his morality, did not seek any help. It was just beer, after all. But that did not last long.

On his prom night Mark , dressed up in a rented tux, bought a bottle of Champaign and twenty-four long stem red roses. He borrowed his dad’s car and went to pick up his sweet heart, only to find that she had gone with his best friend. He drove back home, parked his car in his driveway and found solace in a bottle of Champaign, which he had planned to share with her but had to gulp it all alone. A swirling head, high bass rap on the radio and vivid red color of the left over rose bouquet made the evening bearable. When he woke up, he found himself crumpled in the driver’s seat.

Next night and for many nights after, he craved for the same effect. But he had to drink more to get the buzz.

After high school Mark worked as a painter and made enough money to buy cheap hard liquor. He could not wait for his two off days every week, when he would binge with his friends. Sometimes it went non-stop for twenty-four hours, only to leave him deathly sick afterwards. Three years later, he decided to become a truck driver and he tried to stop drinking. But he suffered tremors, sweaty palms, racing heart and confused thoughts. He had to drink just to steady himself. He had developed four cardinal features of alcoholism: tolerance – drinking more to replicate pleasure; craving – compulsive need to drink; loss of control to stop after starting; and withdrawal symptoms if he stopped. Mark had graduated from high school into the fraternity of approximately 20 million alcoholics in the USA.

Alcohol abuse takes it toll. WHO estimates, alcohol causes 4.4 percent of the world morbidity and 3.7 percent of world mortality. In the USA, an estimated 100, 000 people die of alcohol-linked events, which include respiratory infections, heart failure, liver diseases, accidents, car crashes, suicides and homicides. Alcohol is a link in forty percent of auto accident deaths, thirty percent of suicides and sixty percent of homicides. And this all comes with a heavy financial burden. In 2002, the WHO estimated, between $210 billion and $665 billion was the cost of global alcohol abuse.

We have no cure for this disease. A preventive approach of legal prohibition by the government or abstinence by the individual has been the historical solution. After the US Civil War, the temperance movement morphed into a National Prohibition Party and became a loud cry for preserving the family and eradicating immorality of alcohol. In 1919, with prohibition law about to become national, a leader, Billy Sunday addressed ten thousand people. “The reign of tears is over. The slums will soon be a memory. We will turn our prisons into factories and our jails into storehouses and corncribs. Men will walk upright now, women will smile and the children will laugh.”

By 1933, it was obvious that prohibition had not delivered promised utopia to the American society and the law was repealed.

In 1935, two alcoholics - Robert Smith, a doctor and Bill Wilson, a stockbroker met and started Alcoholics Anonymous (AA) fraternity. The main premise was that an alcoholic is powerless over his drinking habit and a support group suffering from the same condition will help him in achieving abstinence. It recognizes that alcoholism is an inborn disease, hence a life long condition. An alcoholic is constantly on the brink – always recovering but never recovered. AA demands total abstinence and a need to surrender to a higher power to gain control of life. AA mixes biological etiology of alcoholism with a quasi-religious cure and has occupied the therapeutic space with considerable success. (Mention of God occurs six times in its twelve-step program, which also include elements of confession, repentance, prayer and spirituality.)

Recently the quest for a gene that predisposes to alcoholism has accelerated. Evidence points to chromosome 15 and multiple genes closely located on this chromosome seem to play a part. Alcoholism may also be closely related to nicotine addiction, anxiety state and possibly ‘over active’ brain seeking comfort in alcohol. But the mechanism is far from clear. Many Chinese and Japanese are fortunate to carry a mutant gene, which renders the detoxifying enzyme – acetaldehyde dehydrogenase - ineffective. After a drink they accumulate acetaldehyde, which takes all the fun out of alcohol and gives them all the horrible effects. The mutation protects them from alcoholism. Some drugs also imitate this effect. Doctors have used drugs like Antabuse to inactivate acetaldehyde dehydrogenase, which makes drinking a punishing habit. But alcoholics must swallow this pill before they drink and obliging alcoholics are rare.

Since we do not understand the biology of the disease, our approach to therapy - by abstinence or prohibition - has not changed in centuries. We have invoked political-social-moral-religious-economic-legal methods with limited success. While we have started drinking early in life, the consumption has stayed almost unchanged for the past 150 years in the USA. Annual per capita consumption was 2.27 gallon in 2006, 2.60 gallons in 1906 and 2.10 gallons in 1850. Based on the current data, the WHO has suggested some therapeutic strategies in March 2008. They include political commitment, raising awareness, community action, screening, and establishing public policy about marketing, availability, pricing, production and drunk driving.

We hope, that in near future, cure will come from understanding the genetics of this disease, yet till that time no society can wish away alcohol and its serious consequences. It may help if we change our perception about alcohol. As Abraham Lincoln observed about alcohol in his contemporary society, "None seemed to think the injury arose from the use of a bad thing but from the abuse of a very good thing." The attitude has not changed; we still find a desirable goodness in a cocktail.