How many beers is too many?

“I drank beer with my friends. Almost everyone did.”

Alcohol has become constitutional to American culture: “grabbing a drink” after work, happy hour, cheers before meals, on New Year’s, or just because. Our society’s normalization of drinking creates a slippery slope toward excessive alcohol use. Unhealthy alcohol use is rampant: one in six Americans drinks excessively four times a month, according to the Centers for Disease Control (CDC). Almost thirty percent of Americans meet criteria for risky alcohol use according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA). This high prevalence of risky drinking creates an environment of leniency. Having one beer too many at a party is excusable because “almost everyone” is drinking too.

“I was at the top of my class academically, busted my butt in school. Captain of the varsity basketball team. Got into Yale College.”

The “functional alcoholic,” the drinker who excuses his excessive alcohol use with evidence of his achievements, is the most exempt from censure. Though the drinker’s accomplishments speak to some capability, no résumé points shield them from the social and medical consequences of alcohol use, and only the most powerful “functional alcoholics” receive clemency for alcohol-related legal violations.

President Franklin Pierce died of liver failure from alcohol use. Senator Ted Kennedy evaded conviction of possible alcohol-related manslaughter in the 1970s, but his son stated the senator died from “disabling alcoholism.”

Alcohol wounds our most important relationships. How much lower is the threshold for disagreement when you and your spouse have too many glasses of wine? How much more likely are we to offend a friend when we have too much to drink?

Alcohol can also obstruct professional progress. In May 2018, Virginia Congressman Thomas Garrett recused himself from his reelection bid to prioritize recovery from alcoholism.  Though we hope our laws are drafted soberly, imagine the consequences of a truck driver swerving into oncoming traffic or a surgeon cutting into the wrong body part while inebriated. With lives in the balance, if I made medical decisions with alcohol on my breath, I would rightly face immediate removal from my position and mandated rehabilitation.

“I did not drink beer to the point of blacking out.”

Our society draws a line at loss of consciousness or memory due to inebriation. Consider what that actually means: alcohol impairs our mind’s ability to encode memories, or place them into long-term storage, to the point of causing amnesia. Our societal standard for appropriate alcohol use should be loftier than avoiding organ dysfunction due to our behavior.

“Whatever the chart says.”

The law relies on the blood-alcohol chart, or the percentage of alcohol in one’s blood at a given time, to dictate safe alcohol consumption while operating a motor vehicle.  More than 0.08 percent blood alcohol content while driving earns the driver a DUI (“driving under the influence”) in most states, though DUIs can also be imputed for erratic driving or failed field sobriety tests. In most states, public inebriation or consumption of alcohol is also outlawed, as is drinking under the age of 21 – a cut-off that has been tied to fewer motor vehicle collisions and to decreased alcohol and drug dependence, alcohol-related birth defects, suicide, and homicide, according to the CDC.

“Sometimes I had too many beers.”

While the law does not delineate what “too many beers” is for adults who are not driving or in public, health professionals practice based on established guidelines regarding alcohol use. For years, we have counseled patients using the NIAAA guidelines, which recommend no more than four drinks for men or three for women in a day. In a given week, “low-risk drinking” is defined as less than 14 drinks for men or seven for women.

However, a recent study published in the Lancet suggests there may be no safe amount of alcohol. Compiling data from almost 200 countries, this study found that the amount of alcohol consumption that minimizes risk of death or illness is zero, suggesting our current guidelines might not truly capture “low-risk drinking.” The study’s findings also debunk the formerly held belief that some alcohol could be good for our health.

The health risks of alcohol stem from crime and disease. Excessive drinking is associated with motor vehicle accidents, sexual misconduct, and violent encounters. In 2016, nearly 30 percent of all traffic fatalities in the U.S. were associated with alcohol use, according to the CDC. At least one-half of violent crimes involve alcohol, and one-half of all sexual assaults are committed by men who are drinking alcohol, according to the NIAAA.  Alcohol use can lead to disease of almost every organ system, with clear ties to liver dysfunction, cardiovascular disease, infections, cancer, depression, and many other illnesses.

Our evolving understanding of the interwoven social, legal and medical risks of alcohol use challenges our day-to-day practice. Although the recent Lancet study suggests that no level of drinking is risk-free, how many things do we do each day that assume a certain level of risk? My daily cheese consumption probably slightly increases my risk of high cholesterol, heart attack, and stroke. This risk is acceptable to me, whereas the risk of lung cancer from smoking or traumatic injury from skydiving are not. “Too many beers” is likely not an occasional beer after work. “Too many beers” is more accurately the number that interferes with our relationships, our profession, our legal standing, and our health. Like many things in life, our approach should be balanced: everything in moderation.

“I ask you to judge me by the standard that you would want applied to your father, your husband, your brother or your son.”

Justice is meant to be balanced, considered and based on the sober truth. Pleas denying blackouts are immoderate.  Cursory citations of legal definitions fail to capture true risk. And excessive alcohol use clouds the truth. Most of us would ask our fathers, husbands, sons – and ourselves – to be cognizant of alcohol’s risks and humble in their analysis of its consequences.

Mariam Alam is an internal medicine physician.

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