The New Science Of Alcohol With Dr. David Nutt

According to neuropharmacology professor Dr. David Nutt, you must think before you drink. In this fascinating interview, Dr. Nutt takes a science-based look at drinking to unpack what happens in your brain and body when you drink and why you should reconsider your alcohol use. Learn the impact of alcohol on your neurotransmitters, microbiome, and hormones, the best way to drink if you choose to, and the future of alcohol research.

Transcript

How does alcohol impact our brain, Behavior, And mood? And what is the right amount of alcohol use for you? That's what we're going to explore today with Dr. David Nutt on Your Life in Process. So there's no denying it, Alcohol is our drug of choice here in the United States and also in the UK. And alcohol makes you feel good in the short term. Part of the reason why we drink is that it can numb out our negative emotions. It also makes us feel connected to others, But it has some consequences that impact our health as well as our relationships. And Dr. David Nutt is a leading global authority on alcohol use and abuse. He's currently a professor of neuropsychopharmacology and director of the neuropsychopharmacology unit at Imperial College London. Previously, He spent two years as chief of the section of clinical science at the NIH Institute of Alcoholism and Alcohol Abuse in Washington, DC. And he has a few things to say about alcohol. We explore everything from what happens in our brains when we drink to the neurotransmitters impacted by alcohol. We're going to look a little bit at the history of alcohol use. He's got a fascinating take on that and the health risks associated with alcohol. We explore tolerance, We explore hangovers, How you can prevent hangovers, What to do. This was a fun one. I hope you enjoyed it. And I hope it makes you think before you drink. That's the most important thing that I'm hoping you get out of this podcast. I'll see you on the other side. I'll talk to you a little bit about how to know if you have an alcohol use problem and give you some ideas from the podcast around what you can do to maybe improve your relationship with alcohol. Meditation is a great way to practice some of the processes of psychological flexibility. Through meditation, You can step back from your thoughts. You can practice acceptance of whatever shows up in the moment. And you learn how to bring your attention to the present moment, While also opening your heart to compassion for yourself and others. That is why I am so excited to be offering a weekly meditation, A meditation in process at Yoga Soup. It is live so you can attend with me in Santa Barbara at Yoga Soup, Or streaming online on Fridays at 8am Pacific time. Or you can also watch the meditation on demand on your time. If you are a member of the More Life in Process membership, I'm going to be uploading the meditations there. And we'll be also offering them on demand through Yoga Soup. You can sign up at yogasoup. Com or become a member of More Life in Process at your life in process. Com. Links are in the show notes. I have the book cannabis on my table. It was funny because I had drink and cannabis right next to each other. And I told my son you have to read both of these before you do either of them. I will be just done. He's 13. And I'm a big believer in having conversations about drugs and alcohol and all of that before someone else gets to him. I'm so clean. Yeah, Well, There's obviously, You know, There's a chapter in each book about what to tell your kids. But the best thing of all is to make them read the book and tell you. Absolutely. And there's a lot of, At least in drink, There's a lot of myth busting that goes on. And even things that I just have assumed for a long time that you set me straight on things like the assumption that alcohol is good for our heart health. We all believe that having that glass of red wine, We're doing something that makes us very healthy. But you cover a lot in this book. And I'm excited to talk with you about it. But I want to just start with a little fact also that I learned about you. You were fired as the UK government chief drug advisor in 2009. One of the reasons why they said was because you had said that the drug policy was not evidence based. But you really think it had more to do with you making the statement that alcohol is the most harmful drug in the UK. So that's on one hand. And then on the other hand, You also own a wine bar in London with your daughter with one of your daughters. So yeah, Help us help us understand that like that you're not all you're not saying alcohol is all bad, But you certainly take it pretty seriously. Well, Alcohol is my favorite drug. As it is for most people, The problem with alcohol is it it's a very, It can be harmful and people get addicted to it and then get dependent. And so the so I own the wine bar is my daughter's wine, But it was her vision. It was it was like a safe, A safe place for women to go and drink. Because I don't know what it's like in the States. I haven't lived there for a long time. But in Britain, Pubs are places where men go to watch football. And the worst thing in the world is to be in a pub where there's a load of football matches going on, And then a load of drunk men coming up, Fattening you up afterwards. So her wine bar is largely targeted at women who want to who want to drink have always have a bit of food with them. So she always serves small amounts of food, You know, Little plates of tapas or whatever. But it's a safe place for women to go out engage socially with wine. So and it's all organic, And it's not cheap. So people don't drink a lot, You know, So it's all it's the right way of drinking, Which is with friends, Quality wine, And a bit of food, And without being pestered by drunks. Let's talk about the pharmacology of drinking and what sort of happens in our brain. Let's start there, Our brain and our body. And because I'm a clinical psychologist, I'm also very much interested in the impact of alcohol on mental health, Not just our physical health. You open drink with many ways that alcohol impacts our brain, The many neurotransmitters, It's not so singularly focused like some other drugs. What happens in our brain when we drink? So alcohol gets into the brain takes about 10 and 20 minutes to get to the stomach, Depending on how much you get into the brain. And as the levels rise, It starts to engage with different neurotransmitters. And the first one it engages with is called GABA. Now GABA is the calming neurotransmitter in the brain. It's what relaxes you which it takes away tension, Helps people become more relaxed, More sociable. And that actually is mostly what most people want from alcohol, They want the GABA effect. So that little bit of anxiety, Certainly in a party, For instance, You know, That bit of anxiety, When you don't know people and not sure what to say, That anxiety can be dampened down by alcohol going through GABA. But if you keep on drinking, When you get, Let's say the first drink, And then once you push up, Then you begin to engage other neurotransmitter systems. One of them is called dopamine. A lot of people would have heard of dopamine. Dopamine is the sort of motive system, It's the moreish system. When the dopamine system gets turned on, People get louder and more active and more energized. But they also often get a little bit irritating and a bit overdriven and begin to ignore other people. And that probably is one of the transmitters which begins to drive the addictiveness of alcohol. It also releases endorphins, Which is another feel-good chemical, Probably contributes to the disinhibition of alcohol. And then when you push it up again, When you get to about four or five drinks, When you're actually getting drunk, You're getting to a level where it's, You know, You're perhaps twice the drink driving level in Britain, Say 150 milligrams per cent of alcohol in the blood, Then you start to block another transmitter, Which is called glutamate. And glutamate is the transmitter that keeps you awake, It's the on switch of the brain. And blocking that switches your brain off. And that's when people start to have blackouts, Amnesia. That's due to the fact that you need glutamate receptors to lay down memories. And if you block them, You can't lay down. And then you move towards anesthesia. And then eventually, If you block glutamate enough, Well, You die because you need glutamate to turn on the respiratory centres of the brain to make them work. So you can see this over the course of a night of someone's drinking and start, They start off just by feeling more relaxed with the gaba. And isn't there also something that people seem more attractive and they actually feel more attractive when they're drinking alcohol? And that has to do with some of these neurotransmitters as well, Which can lead us to getting into trouble. Well, No, That's absolutely, There's no question about it. You know, They call it beer goggles. I mean, There's no question. People appear more attractive to you when you're drunk. We don't entirely know why that is, But it's partly that you probably your standards fall. But it's probably more than that. It's probably that you genuinely feel more attractive and more interested in people. And that is one of that is really why alcohol is such a commonly used drug. Why it's certainly more people use alcohol than any other drug by far, Even in cannabis, Even in America, In California, Where it's legal, People use because it's much more social, It enables sociability. I mean, There are theories, I don't know if you've come across this theory that the embedding of human civilisation in terms of towns and villages, As opposed to being nomadic was driven by the desire to grow cereals, Wheat. Now, It used to be thought that that was because we wanted to eat bread. And that's what the speakers say. They say that they're responsible for the towns, For the bread, But it's alcohol, Potentially. That's one of the arguments. In fact, It was growing cereals so that you could keep them and you could brew beer throughout the year. Yeah, Obviously, People could get alcohol in the end of the autumn when they could, You know, They could ferment wine or they can have fermented fruit, But the ability to actually have a food stuff that you could turn into beer on a regular basis. And that's an idea. And some of the great temples, You know, These great stone monuments that, You know, There's a five, 10, 000 years old. And we even think in Britain now, Maybe Stonehenge was actually a place where people came on an annual basis to get drunk, But to get drunk as a group. And that's interesting, You know, Bringing together social, You know, Different tribes coming together. And there would almost certainly be an interchange of people, You know, Relationships would start off and you spread the gene pool. So, You know, There was a man called Edward Slingerland. He's an American anthropologist and philosopher, And he believes that alcohol actually is the underpinning drug of all human society because it brought early human needs together. And then from that, The human race developed. So there's these social benefits, Right? And certainly for someone that has a little social anxiety, Which is many of us feeling a little more attractive, Seeing people as more attractive, Having that relaxed feeling initially can really help people get together, Right? If you have social anxiety, You may not go if there weren't alcohol. A lot of health consequences and a lot of mental health consequences and physical consequences to alcohol. You're not actually that big of a fan. I think you said at one point that we have this recommendation of our health standards of two drinks a day if you're male or one drink a day if you're a woman. But actually, When you look at the physical impact of health and you were to apply the same standards as we use for food, It would be one drink a year that would be healthy for us. So let me. . . Yeah. So basically, There are different thresholds of safety for different harms. But the reality is if you treat alcohol as a carcinogen, Like you would treat any food additive, If you were going to put a different colorant into food or even put something else, You know, A new vitamin into food, If you treat it in alcohol like that, Then in terms of the risk of cancer, The maximum recommended allowance of alcohol per year is a big glass of wine. So that's one extreme. So if you say, Well, I don't really care about cancer so much because the risks are there, But they're not that great. But I care about liver disease. Then if you care about liver disease, Then it's about a small glass of wine a day. So those are the two extremes. So you can. . . If you want to be absolutely sure you're not going to run any health risk whatsoever from alcohol, You pretty much got to drink none. But on the other hand, If you think, Well, The benefits are quite good, I quite enjoy it and it's fun. I don't want to get serious harms. Then sticking to the recommended level of one or two drinks, That gets you into a range where the risks are not that high. I mean, They're measurable, But they're within what most people would accept as a sensible range. You know, They're within the range of crossing the road or certainly not as dangerous as driving a motorbike, Let's put it that way. One of the things that I'm going to have my 13-year-old read in your book is what do we mean by a drink? We have these big red wine, Beautiful big red wine glasses. And those red wine glasses are somewhere around 12 ounces, But we're talking about five ounces of wine. Just a little bit. Once you get a little sloppy, You're filling that whole thing up. One can of beer, One and a half ounce shot glass of hard alcohol. So a drink is actually a little bit less than what people think about when we think about a drink. As you drink more, The consequences get worse, But there's sort of an exponential effect is what I was reading from some of your work. It's not just linear. Absolutely. For most of the harms of alcohol, The relationship is exponential. The doubling of the dose gives you more than doubling of the harm. I mean, The simplest example really is if you're drinking a bottle of bourbon a day, The likelihood of you dying as a result of an alcohol-related illness is about 30 or 40 times that if you're drinking a drink of bourbon a day. And that's actually hugely important in terms of health education because reducing that much consumption by 50%, If you drink half a bottle a day, You actually reduce the risk by probably about eightfold. And if you drink to a quarter, Then it'll go down again significantly, And then you'll reduce the risk by about 16-fold or so. So less is always more with alcohol. You should always be drinking as little as it takes to get what you want from it. And that is what most of us do, Especially when we know what the risks are. But there are those 10% of people, 15% maybe, Who cannot control their drinking, And those are the ones that are most vulnerable. Some of the vulnerability has to do with your response and whether or not you get a hangover and also whether or not you feel like alcohol is energizing or helps you feel lively or social. That can help predict whether or not you're going to go on to have problems. You touched on one a bit earlier in the discussion about social anxiety. So let's just talk a bit about that. We know that the commonest reason for young men to become alcoholic is because they're socially anxious. So the commonest diagnosis, If you want to say, Look at the different reasons why young men become alcoholic, The most common reason is they're socially anxious. And alcohol is great at reducing that social anxiety. But then you get into this loop where the adaptation that the brain makes to the alcohol the next day when you're in the withdrawal and hangover phase, That is driving the anxiety. So you get this vicious circle which encourages people to keep on drinking. In my book, I give an example of one of the patients I treated who actually started having panic attacks before he even got to get the booze because he was still in withdrawal at the time and he was desperately getting to the pub. And then the compensatory system kicked in and he was panicking. That's a very vicious circle then because he's drinking to deal with his anxiety. But then there are other factors. So there are those people who are vulnerable because they like it too much and that they actually can, They get high, They get higher than the average person on alcohol. And then there are the others. And this is a paradox. There are the others. And these are the very vulnerable young men. Usually they're children, Male children of male alcoholics who are sub-sensitive to alcohol. And when they start drinking, They discover that they can drink more than their peers. And they then become stars. Wow, Look, They're all falling about and I'm still drinking. And everyone looks up to them and they're tougher. You know, And in the war, The people go over the front leading you on. They're always into the booze. But in the end, The booze kills them because their brain is sub-sensitive to it, But the rest of their body isn't. That's, It's a genetic, They're born genetically with some tolerance because their father had alcohol use disorder or had alcohol problems. So it can be passed on just like you're born with tolerance. What is happening in the brain when someone develops tolerance? Yeah, We think in those, And it's very interesting, We've done a bit of work on this. We think that they have a sub-sensitivity of the GABA system. So alcohol doesn't turn it on as much so that they don't actually end up getting much affected. It may be that they have some sensitivities in the other systems as well, But it's almost certainly a brain target or a brain resistance rather than a bodily resistance. Yes. So when somebody is maybe they're born with tolerance, But someone develops tolerance over time and tolerance, Meaning it happens with a lot of different drugs, Meaning that you need more of the substance to get the same effect. A lot of it has to do with these feedback loops in our brain. Our brains and our bodies want homeostasis and they do the best they can to try and maintain that. What is happening when you develop tolerance and why is that part of the problem? Again, Not much studied. I mean, One of the amazing things about alcohol, Of all the health harms, Alcohol is disproportionately under-researched. I mean, Just to throw you in this interesting statistics, 80% of all people presenting to liver doctors are presenting because of alcohol and about 5% of all research on liver disease institute is looking at alcohol. And that's because people don't want, You know, People want alcohol to be safe because they're all drinking it. It's a sort of collective denial. All the doctors are drinking it and all the researchers as well. Yeah. People like me who research it still drink it. So, But, You know, I'm not in denial, But a lot of people are. So it's not really much research, But what we can say is that tolerance comes in part from the GABA system, But for people who get into real problems, It comes from the glutamate system. So as I mentioned before, As you push the dose of alcohol up, You start to block glutamate and glutamate is that on switch of the brain. Now the brain really must protect its on switch. Otherwise you die. As you start to get those receptors blocked by alcohol, The brain starts to make more of them and attempt to compensate. Generally it does. Most people don't die when they get very drunk. But what happens then is as the alcohol levels fall, The receptors don't fall as fast. So you get to a state where there's more receptors than are needed to compensate for the alcohol. That's a state because they're excitatory receptors. The brain is hyperactive. And that is why when you wake up in the morning, Lights are too bright, Noises are too loud. You've got a thumping headache. You're shaking because the glutamate system is in overdrive and that's the key driver of withdrawal and also quite a driver. It's not the sole factor in terms of hangover as well. Glutamate and GABA are two hands. One is excitatory and the other calms you down and they balance each other out. The unique thing about alcohol is it works on both of them. So you're kind of in this position when the alcohol wears off, You're going to have more receptors of glutamate. And then also you're not going to have that relaxation effect of GABA. And so you're also going to feel anxious. It's terrible. That is exactly right. And that is why alcohol is such a challenging drug to work with because it is so promiscuous. There are 80 different neurotransmitters in the brain and it's almost certain that alcohol will affect about probably a third of them. So let's talk more about hangover because that's something people are always interested in. They want to know, Okay, How do I first don't get a hangover? And then second, If I have one, What do I do? And there was some interesting things that I read from you around hangover that I had not heard about before. Because many people know if you drink more alcohol, You're more likely to get a hangover, But there's other things at play. The primary determinants of a hangover is how much you drink and the peak level. So if you drink half a bottle of vodka in the space of five minutes, You're going to get more of a problem than if you drink it over a few hours. The reason the peak level predicts hangover is because it's the adaptive changes in the brain we've just discussed are driven by the amount of receptors occupied. So the more at the peak gives you more influence than the lower level. So that's the first thing. So it's just more push to the brain. So you're going to get a higher peak if you drink more alcohol in a shorter amount of time. If you drink five drinks over five hours versus five drinks in one hour, That peak is going to impact. Okay, Got it. And binging with high peaks, That's now been shown to produce more damage to the brain, Interestingly, And drinking over a more gradual period and as well as more hangovers. So that's the first thing. And the second thing are these conjugates. So different alcohols have different mixtures of what most people think of alcohol being a molecule called ethanol. But when you make any ethanol, You're always making other alcohols too. And even in beer, There's 20 or 30 small amounts of other alcohols, And they're often more powerful than ethanol. But then if you take really mature spirits, If you take cognac or whiskey or a very mature bourbon or something, You might have 100 and 200 different conjugates. So the alcohol molecules stick together and stick together, Make big sort of spiky molecules, All with alcohol-like effects. And they're really powerful. And that's one of the reasons we like these sophisticated drinks, Because they give you a different flavor, But they also give you a different effect. No one knows how safe these conjugates are. They don't really probably study, But they're almost certainly not as safe as ordinary alcohol. So the more of those you drink, The likelihood is you're going to get a bigger hangover because of their more powerful effects in the brain. And so one way you assess for that is the darkness of the drink. So something like a white wine will have less, But something like rum or brandy has a lot of these conjugates that will contribute to your hangover. Things that have been matured, It has an impact, But the longer it's been matured, Particularly if it's been matured and they would almost always be matured in some kind of oak cask, The longer it is more of these complex alcohols that are made. This is devastating for the wine drink connoisseurs that like these old mature wines. But the positive side is this, Is that the longer they're matured, The more expensive they are. And there aren't that many people that get drunk drinking their 1964 Pertruse, You know, When it's $500 a bottle, They tend to savour that rather than swill it. So the more expensive drink you can buy, In some ways, The less likely you are to abuse it. Yeah, So that's a tip. Buy expensive alcohol. I mean, I do the same thing with desserts. I'm going to savour a really rich, Beautiful chocolate cake much more than I would like a Hershey bar. Never buy donuts, By the way. Never buy donuts. Yeah, You could eat the whole box. Okay, Good. What about the microbiome? Yeah, Microbiome. That's the part that I get super excited about because that's newer. Yeah. The microbiome is this fascinating recent discovery. Well, We always knew there were bugs in your gut, But we didn't realise the bugs in the gut were useful. And it turns out that a lot of the bugs in the gut use GABA as a chemical modulator for them, And they chew up alcohol and they can turn it into acetaldehyde. So effect your gut bugs can have a huge influence on how you deal with anything you eat, And certainly alcohol, And also have an effect more globally on your health. So alcohol changes the microbiome in a way which isn't generally very good. One of the big problems we have with people who drink a lot is that they end up getting malnourished, In part because they damage their microbiome and they also damage the lining of their intestines. So they go through a thing called malabsorption syndrome, Which is a problem. So I don't know if you've heard about this. There are people who are making an anti-hangover cure, Which is taking bugs, Which eat up alcohol faster. And if you take those before you drink, Then you'll get less drunk. I mean, It seems an expensive, Well, You actually, It seems like a double whammy. You're buying something to reduce the amount of alcohol you drink, Even though you paid for a full amount. So to my mind, It's not a very sensible approach to controlling your drinking, But anyway, It's out there. Conceptually, It's interesting. Interesting. So one of the hangover tips that you give, If you do have a hangover, Is to take some probiotics that may help kind of with your microbiome. But what are some other tips for people that, You know, Maybe we don't want to encourage people drinking and then doing all these measures afterwards, But if in case it does happen, Would you recommend? One of the things that always intrigue me is what contribution hangovers make to the perpetuation of drinking. And for two years, I worked in NIH in Washington, D. C. And I ran the research ward there, The alcohol research wards. So I probably interviewed about 350 severe alcoholics in the course of the two years I worked there, And none of them had hangovers. And that made me very interested in, You know, The hangover is maybe a deterrent. It may actually be something that sort of stops people. I mean, Everyone who's had a hangover says never again, But they don't necessarily manage to achieve that goal anyway. So what is going on? Well, We've been looking to find alternative drinks to alcohol that might be less hangover free. So we set up a model of hangover. And what was fascinating is that you can see certain inflammatory, What we call cytokines, Some of those substances that are released when your body gets ill and, You know, Give you this feeling, You know, If you get flu, You know, You get this terrible feeling of exhaustion and headache. That's produced by particular cytokines. And some of those are elevated in the brains during alcohol withdrawal. So this looks like an inflammatory process. We don't know which part of the body these are driven by the alcohol, But it certainly makes sense as to why you get headaches and you feel lousy, Because it is like having a slow grade flu. And then, Of course, The implication of that is anti-inflammatory substances like ibuprofen, Which people have used for long time to hangover, Will work there. That's another useful tip. But of course, Other people, Just painkillers will also work. Other people, You know, Drink a lot of water. There is a degree to which you get dehydrated from drinking alcohol and drinking water before you go to bed. If you're very, Very drunk, Getting rid of it is one of the safest things you can do. Because, You know, In America, Probably 10, 20 young people a day probably die a week of alcohol poisoning, Often on their 21st birthday. So, You know, Getting rid of it is a good thing, Provided you get rid of it while you're awake. The worst thing, Of course, Is that it's haunting when you're asleep, And that's where the real danger comes. And that's another reason just to throw in a plug. Never, Ever, Ever, When you're drunk, Take other drugs, Because that combination of other drugs and alcohol can be lethal. Yeah, Sometimes people do the up or downer combo, You know, Just to kind of combat that, The later effects of alcohol, The sleepiness, And that, Yeah, Certainly dangerous. Another thing that you had mentioned for hangover was B vitamins. And that's certainly something that also people will sell you in that little probiotic cocktail. But there is some link between B vitamins and what happens if you have alcohol use disorder over a period of time. Can you talk a little bit about that? Yes. And of course, The big danger is that you end up becoming vitamin B1 deficient. And that's a serious problem. And it happens for two reasons. It happens because, It used to think it happened because people's diets were so rubbish. Everyone was spending all their money on booze, They weren't actually eating properly. And that is a factor. And there was quite an, Actually, As just a historical aside, There was quite an attempt to get these vitamins into drinks, Particularly beer, In the same way as it, You know, I think most breads are fortified with B1. But that was resisted by the drinks industry, Unfortunately. So people get, If all you do is drink, You're not going to get an adequate diet, You're going to be, Actually, Going to be vitamin C, You're going to have scurvy as well. So vitamin deficiency through poor diets, One factor. But the second factor, Which we've only discovered recently, Is that the alcohol, Either directly or through changing the microbiome, Leads to a failure of uptake of thiamine. If you, You know, Even if you take enough, You're actually not absorbing it, So you're thiamine deficient. What does that lead to? Well, That leads to several things. It leads to peripheral neuropathy. People often start saying that they're numb in their, Particularly their toes and their legs. And that's a very worrying sign. If you've got that, Then you've got a neuropathy. But the biggest threat are people who suddenly get what we call Wernicke's encephalopathy. So they have an acute brain syndrome where they're confused, They're unsteady, And their eyes, When they try to move their eyes, Their eyes don't move synchronously, So they get low vision. And that's a medical emergency, Because if you don't treat it, You can end up damaging a part of the brain called the mammillary bodies, Which is an essential part of the memory circuit. And if you damage those, You can't lay down new memories. So people end up just living in the past, They can't form any new memories. That's called Korsakoff syndrome. Korsakoff syndrome is one of the things that you learn about when you're a clinical psychologist in terms of diagnosing. They always put that on the EPPP licensing exam, But it's important to know about. And some things that with chronic alcohol use are irreversible, But some things are reversible. And you recommend reversing the effects of alcohol by taking breaks, By taking either week-long breaks or two days off. Why would you recommend that for folks that are drink that are regular drinkers? What's the benefit of that physiologically, Mental health wise? Well, Because it allows the body to heal. The best evidence relates to the liver. Alcohol, Even that small amount is a bit toxic. And if you're drinking more than small amounts, Then it is toxic. So try to give your brain and your heart and your liver a chance to recover by giving yourself a break. It kind of makes sense. And in fact, There is evidence to show that it does make sense. So some of the places that you could also see the benefit of taking a break from alcohol is something like your appearance. You write about the impact of, You may feel like you look better when you're drinking, But actually you look worse. How does alcohol impact our appearance? Well, I mean, That's one of the things that most people don't realize. It has a very deleterious effect on the skin. It accelerates aging. It alters the fat distribution, So people look older, Makes the hair grow less. Well, I mean, A lot of people with chronic skin conditions, Their skin conditions are caused by too much drinking. And that's not widely known by people. And it's not widely known by doctors. So it's a critical question. If you've got some chronic rash, I mean, Everyone knows about a red nose, But that's just one of the many ways in which alcohol alters the skin. So again, Less is better if you want to stay young. Yeah. And related to that is hormones and alcohol's impact on our fertility for men and for women. Most of what's been known as always is the way in medicine has been known about men, Because up till now, Most doctors have been men. So they continue to research things that are kind of relevant. Yeah, We absolutely know that chronic alcohol use changes the metabolism of hormones. Men become what we call estrogenized. They become more like women. They grow boobs and they become infertile. If you are trying to conceive in your 30s or 40s as a man, It's good to be reducing your alcohol consumption. That will help your fertility. But it's in recent years, We've begun to learn a lot more about alcohol in women. Up to that point, We tended to think, Well, It's the fetus we've got to be concerned about. And of course, We have to be concerned about the fetus. I suppose the big game changer for women is really the understanding that the risk of alcohol and breast cancer, Alcohol consumption is pretty much the only environmental controllable exposure that women have to reduce the risk of breast cancer. So, I mean, Again, The risks are not enormous, But they're real. And I think if you have a family vulnerability to breast cancer, It would be sensible to, Again, Not drink as much as perhaps, You know, You might be tempted to. And is that due to alcohol's impact on estrogen? Or is it other pathways? Do they know why it's increasing? I think it's more, To be honest, I think it's more just that alcohol and acetaldehyde, The main metabolite, Is their oxidative species. They tend to produce free radicals, Probably damage DNA through that. I don't know, And I'm not sure it is known, But it's a risk factor. That's all I can say. What about its effect on menopause? Because a lot of women report that as they go through menopause or as they age, Alcohol impacts them differently. They're like, I can't even drink anymore because I can't sleep. It impacts my menopause symptoms. What's happening there with menopause or perimenopause? Well, After research on the harms of alcohol, The second least researched problem in medicine is menopause. Right. Of course, Yeah. Half of the people are suffering from it, But yeah, Yeah, There's no research. It's just women complaining. Come on. That's the assumption. It's a really fascinating question. And the answer is, I don't think there really is any research. Obviously, There's loads of anecdotal evidence, But there's not been any systematic study to explain it. Although there is one interesting thing I've been learning recently is, Again, The microbiome does change. The microbiome is sensitive to hormonal levels, So the microbiome changes through menopause. And that is possible. That alters, Again, The impact of alcohol. It might be through that. We know that changes in estrogens have a very profound effect on certain receptors in the brain. So as they change, The mood effects in menopause are quite likely to be related in part to serotonin receptors, As they're very, Very sensitive to estrogens. Their levels are estrogen sensitive. But the alcohol sensitivity, That is pretty obscure, Frankly. But I am thinking about it. I think there is some evidence that the GABA system does begin to deplete after menopause. And actually, One of the targets developing, Amongst other things, We're looking at the possibility of having an alcohol substitute drink, Which might be particularly targeted at women after the menopause to make up for that sort of deficits of the good estrogens and also GABA. So watch this space. It might be a few years coming, But I'm working on it now. That'll be for your daughter's wine bar down the road. You'll have the 20s wine bar, And then you'll have the 50s and above wine bar. That's good. Okay, Well, Let's talk a little bit about mental health. It seems really important for us in terms of co-occurring problems that people have that come into my office. I'm not an alcoholic treatment specialist. I actually usually refer folks out when they come in with substance use disorder, Or I work on the psychological factors, And then I'll work with somebody that's a specialist. But what mental health concerns are exacerbated by alcohol, Which probably is most of them, And how does alcohol impact our mental health over time? Yeah, Well, Big, Big questions. We've talked about alcoholism being a problem. Okay, So that is a mental health problem in the sense it's a brain disorder. But we put that to one side, And if you want, We can come back to how to treat it in a minute. But the other huge relationship is this fact that so many people turn to alcohol to deal with mental health problems because they either can't or won't get help from other sources. So we know there's a massive overlap between alcoholism. PTSD, For instance, And almost all traumatized veterans end up becoming alcoholics because they get help enough with their PTSD. Alcohol numbs the pain, It numbs the misery, It can help people get off to sleep, Although it can often make the nightmares worse when they do wake up. It's very common for people to use alcohol to numb emotional states like PTSD, Like anxiety, Like depression. And that's really very risky because tolerance develops to the numbing pretty fast. And so you're escalating your dose, And then you're getting into withdrawal, And then that vicious circle starts. Because you end up feeling worse than how you started off, And then you're managing your alcohol withdrawal in addition to your mental health concern. You know, One message to everyone listening to this is never, Ever use alcohol to overcome the effects of drinking the night before. Even if you feel really terrible and very anxious or more depressed in the morning because you've been drunk the night before, Don't ever, Ever turn to alcohol to do that. Can you say why? It starts that vicious circle. That's the cycle of addiction. And I don't know if you're familiar with Anna Lemke. She wrote the book Dopamine Nation, But she's at Stanford studying dopamine. And that's her suggestion, Is like, If you get low and then you use something to get your dopamine back up, You're guaranteed to have that roller coaster. But unfortunately, It's a roller coaster where the dips get lower and lower. And the highs, You don't get as high either. So you just end up never actually feeling as good, But feeling a lot worse. And then it is very much part of the addictive cycle. How would people know if they have a substance use concern? We have the 11 symptoms in our DSM-5 that we could go down. But what are some of the questions that you pose to people to help them take a look at, Okay, Am I in the risk zone? Yeah, And that's a super question. And of course, The biggest problem is actually not that people don't know, It's that people deny and don't want to know. And most people, When they finally stop drinking, Will say, Yeah, It was there, I saw it all along, But I didn't want to believe. And often they're very aggressively defensive of their behavior. Very many marriages and their friendships have been destroyed because someone has tried to tell them that their drinking is out of control or dangerous, And they've just been abused. If you have a friend or a partner, It is important that you do at least try to tell them that this is a problem, Because there is always a chance they might listen. But even if they don't listen, Then they are likely to come back to you afterwards at some point and say, When they have stopped drinking, They might come back and say, Thank you. It is a challenging thing to do. And I think even it's often thankless, But it is worth doing it. The other point I really want to make is if you're in a relationship, If your spouse, Particularly if you're a woman and your male partner is drinking heavily, Never, Ever challenge them when they're drunk. Never, Ever do that. Because disinhibition and the anger that can come with being drunk could be very threatening. So if you're going to challenge them, You must do it when they're sober, Partly because to protect yourself, But partly because they're not going to listen anyway when they're drunk. So if you're a reflective person and you're wondering about whether you're drinking too much, Then what you should do is obviously read my book and ask yourself the questions. One of the key questions is, Have you ever got angry because someone has commented on your drinking? And if the answer is yes, Then you probably should look carefully at how much you drink. Have you ever done things that you don't remember that people have told you afterwards? When you were drunk, And it doesn't sound plausible, But you have no reason to disbelieve them, Then that's likely that you have a blackout and you were probably drinking too much. One of the things I try to get in the book is that I'm not against alcohol. I trick myself. I enjoy socializing with alcohol. It's just a wonderful social tool. But people need to think very carefully about why they're drinking. I like this term mindful drinking. And you should only drink a drink if you could say clearly sometime afterwards that drink was beneficial. And usually the first drink is very beneficial. The second drink is a bit beneficial. Usually, Generally the third or fourth drink, You actually can't even tell the difference. You're just perhaps just prolonging the experience. Most people should try and to have some kind of, At least in their mind, A notional diary of what I'm drinking and what the value is. And if you get rid of the drinks that don't add value, You save a lot of money and you have a lot of health benefits. Yeah, It's knowing the point of diminishing returns. And that requires awareness. It requires maybe some tracking, Which is one of your suggestions as well. You have a whole slew of pages and pages of suggestions that are fantastic in the back of your book around if you want to reduce your drinking, This is how you can start to do it. And what I love about them is that they're small steps. They're not big, Like you have to go cold turkey, Although it is a good idea to try dry January. There's some evidence behind that, You say. But they're little things, Things like start tracking your drinking. Don't drink alone. What are some of the other ones that you would recommend? I think, Yeah, I mean, Don't drink alone. If no one drank alone, That would really cut tremendously into the problems of alcohol. We really would. Another one, My favorite one, Which I kind of invented, Was when you're dining with your partner of an evening, Never open the second bottle. Because once it's open, You're going to drink it. So always limit after one bottle per pair. Absolutely. Yeah. And then I did the math on that, Like that if a glass of wine is five ounces, One of those bottles has 25 ounces in it. So it's really five glasses of wine, Not four, Although many of us think it's four glasses, Two each. Remember that if a bottle of wine is five glasses of wine. So you're at binge drinking if you're drinking that whole bottle yourself. But yeah, Don't open the- Never open the second bottle. That's one of my favorite tips. So the other point I'd like to make is that most people have some interest in their health. Most people know their weight. And if you don't, You should know your blood pressure and you should know your cholesterols. These are important variables. And with all those variables, What you should be doing generally is reducing them. And so alcohol should be one of those things. You should have some notion of how much you're drinking and you should be honest about it and you should be trying to reduce it. And that way, At least you're looking in the right direction. You might not be walking the walk yet, But at least you know which direction to walk when you need to. And then notice the exponential benefits when you do, Because we know that when we make a behavior change, Focusing on the rewards of the behavior change immediately, On how you feel leaving the party when you had less to drink versus and how you feel the next morning and reminding yourself of these benefits. Because often what happens is we forget about the negative stuff around drinking. We only remember the positive parts and that reinforces the drinking. So reminding yourself of the positives, The exponential positives. Yeah. And that's why it is important. Alcohol, Of course, Allows you to block out the negatives because once you get to that point where you've actually, You're not remembering, You are not remembering. There's no question. I mean, A lot of alcoholics actually have no idea what they're like. And there was actually a rather remarkable study done many years ago of actually filming people when they were drunk and showing it to them. And most of them were actually horrified because they had no recollection and no sort of insights whatsoever into what was going on. If you're not sure, Ask people what you were like. What's interesting is just how the languaging's changed. You're using the word alcoholic and it's changed over time. There was a period of time where we used the word alcoholic and then in my training, We did not use the word alcoholic. That was like, No, We don't use that word. That's not really clinical. We use the word alcohol dependence. But now it's changed to alcohol use disorder and people are using the word alcoholic again because that's what people often describe themselves as. And that is a, It's useful to use the languaging that people use themselves. So I just wanted to point that out. It's a shorthand. I mean, It's not, I'm not, I'm not in any sense stigmatizing any people. Most, When you have a commodity, Which is as widely available and as well advertised as alcoholics, You can't blame people for using it because that's vast amounts of the income to all countries like yours and mine comes from the alcohol taxes. So we're all complicit in the making of just making alcohol available and we're all benefiting from the tax pay. So we, What we have to do is be very sympathetic to people. That 12, 15% of people who can't use it sensibly, We mustn't blame them. We've got to help them and be ready to treat them, But also devise ways in which we can minimize that transition from sensible social drinking to harmful drinking. I'm wondering if there's anything that, Any messaging you want to share about the direction of research is going and if people want to learn more about you. Well, Yes, I mean, Maybe just share with you what we're trying to do is I've set up a company called Gabba Labs and we're looking to develop alternatives to alcohol. In fact, I've got one here. So that's a synthetic alternative to alcohol, Which is a small molecule which could be used instead of alcohol in all sorts of drinks. What I'm trying to do is to raise funding to take it through food safety testing, Which is quite a complicated thing to do and it's going to take quite a few years so that it could be then available so people could have their cocktails or their beers or their even their wines, Non-alcoholic. Yeah, What is it? We have non-alcoholic beer. What's different about this substance that you're studying? So this produces an effect like alcohol, But it isn't alcohol. So it's a very important distinction between non-alcoholic drinks and functional drinks. So that will produce an effect like a small glass of wine, Half a pint of beer for a period of about 35 to 40 minutes. So it is a functional drink as non-alcoholic drinks are not functional. They just, They have taste, They're like lemonades. Yeah. So this will actually change the way you feel. It gives you, It's a gab. It'll make you a bit more relaxed, A bit more chatty. I mean, So we've obviously tried it out on ourselves. We can't try it out on the population until we've been through the safety testing, But we know it works. But in the interim, I've developed this botanical alternative called centia, Which is a herbal drink, Which also has within it, It has herbs which make substances that work on the GABA system like ethanol, But not ethanol. I think we can use science to progress harm reduction in relation to alcohol, Giving people what they need, Sociability, But with less harm. And I'm excited by that. I think probably your son, When he gets to my age, Will have forgotten what alcohol is and he'll be using one of these alternatives. Yes. Well, That sounds great. That's wonderful. Many lives saved by that and many relationships saved by that as well. So that would be wonderful if we could have the benefits of alcohol without all of the costs to our health and our wellbeing. Wonderful. That's exciting. So we'll connect with folks to your lab if they want to contribute to that research. And I love that your research is not, You kind of have removed yourself from alcohol advertisements and marketing, And you've also removed yourself from the government to some degree. Well, That's what I've tried to do. I mean, Actually, I didn't remove myself. I was removed by the government. I was sacked. You were sacked. But the point is the message got out there either way. I don't know if you'll have time because it was hard to get this hour with you. But if you have another hour in your future, I definitely would love to talk with you about Cannabis, Your next book that's on my counter that I have to read and that I'm going to give my son to read as well, Because I'm so curious about that. You've done a similar amount of deep research into the substance of Cannabis, Which here in California is another one. It's just on the rise. Lots of people are using it. Teens are using it. People are using it for medicinal reasons and social reasons and all sorts of things. So I can't wait to crack that book open. Let's do that. I'd be delighted to talk to you again. Thank you. Oh, I would adore that. Good. Okay. Well, Thank you so much, Dr. Knight. You're just a delight. You're a pleasure. You're so fun to talk to. And hopefully we'll be meeting up in the new year to talk about weed, Cannabis. Lovely to talk to you. Thank you. Great interview. So I hope this conversation with Dr. David Knight helps you think before you drink. We learned that alcohol has widespread effects on your brain. It impacts multiple neurotransmitters and two of the most powerful neurotransmitters in your brain, GABA and glutamate, Which impact our sleeping, Your thinking, Your ability to lay down memories. And they work as a pair. They're often released together, But having opposite impacts. Alcohol also impacts your dopamine, Your endorphins, Serotonin. And unfortunately, As you use alcohol and impacts these areas of your brain, It can impact your decision-making. The recommended use of alcohol is one drink a day for women, Two for men. But if you apply food standards, The safe amount is one drink per year. So drinking needs to be a conscious act so that you can make it a positive experience and not just this uncontrolled reflex. Here are four things you can try to help you be more conscious in your alcohol use and think before you drink. Number one, Track your alcohol. You can use a phone app like Reframe or the Sunnyside app, Or you can just keep a little note sections in your phone where you indicate when you've had an alcoholic beverage and just put a mark of whether it was worth it or not worth it to you. You may find that one drink, Two drinks are worth it. Certain settings are worth it to you, But other settings or other experiences of drinking more are really not worth it later on. Find your sweet spot of how much alcohol is the right amount for you. And number two, Try and not drink alone, Stick with one to two drinks and don't open that second bottle of wine. If you open it, You're more likely to drink it. Number three, To help mitigate the physiological sort of hangover effect with alcohol, Stay hydrated, Drink with food, Pace yourself. It takes about an hour and a half for alcohol to be processed. You could try a probiotic alcohols and it has an impact on your microbiome and, And keeping a healthy microbiome may be important in terms of metabolizing your alcohol. I really liked the tip around conjugates, Which come from fermenting alcohol. And when you alcohol with higher conjugates in it, You're more likely to have a hangover. They're not the only cause, But they do contribute to hangovers. So choosing alcohol that has fewer conjugates that is not fermented as much things like white wine, Light rum, Light beer, And sake. Those are all low in conjugates as a rule of thumb, The lighter the drink, The lower the conjugate level, Because the drink is not as heavily distilled. So for example, Brandy has 4, 766 milligrams of conjugates were, But only has 102 and beer just 27. I'll put a link in the daily practice to where you can find more about conjugates, But in general, Choose alcoholic beverages that have fewer or buy really expensive alcohol and drink a lot less of it. Finally, Take a self-assessment. There is a screening assessment called the cage that Dr. Nutt kind of referenced. And it's one that practitioners use to screen for possible alcohol problems. The cage just has four questions and you give yourself a point. If you answer yes to any of these, If you have two or more points, You are at risk for an alcohol problem and should look into further assessment or treatment. So number one, Have you ever felt like you should cut down on your drinking? Number two, Have people annoyed you by criticizing your drinking? Number three, Have you ever felt bad or guilty about your drinking or number four, Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? If you answered yes to two or more of those questions, Please go find some resources. I have some in the show notes for evidence-based treatments for alcohol use, Get an assessment and get some help. All right. Thanks so much for listening to this episode of Your Life in Process. It's wonderful to share this episode with you all. And until then, Please stay safe and please think before you drink. Thank you so much for listening to this episode of Your Life in Process. When you enter your life in process, When you become psychologically flexible, You become free. If you like this episode or think it would be helpful to somebody, Please leave a review over at podchaser. Com. And if you have any questions, You can leave them for me by phone at 805-457-2776, Or send me a voicemail by email at podcast at your life in process. Com. I want to thank my team, Craig, Angela Stubbs, Ashley Hyatt, And thank you to Ben Gold at Bell and Branch for his original music. This podcast is for informational and entertainment purposes only, And it's not meant to be a substitute for mental health treatment.

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