It starts with us: Physicians and alcohol culture

Just a thought: The new Canadian guidance is simple: less alcohol is better, and no amount is risk-free. As physicians, we should not simply be aware of these guidelines; we should help lead the cultural shift they represent.If you believe in being part of something larger than yourself, or that you are part of a community, then those of us who have the strength and ability to say no to alcohol culture should try to say no to support those who do not have the strength. The issue is not simply that some people frequently say yes to alcohol; it is that many struggle to say no to a dominant alcohol culture that normalizes the use of this drug at nearly every social occasion.I often compare this to environmentalists who suggest that every time we choose a disposable plastic water bottle, we contribute, in a small way, to a larger environmental problem. Likewise, every time we say yes to alcohol culture, we contribute to a larger public health problem. Conversely, every time we normalize choosing healthy alternatives to alcohol, we make it a little easier for someone else to do the same and therefore reduce the burden on the healthcare and public health systems. One of the most rewarding conversations I have with patients is simply encouraging them to reconsider routine alcohol use. Many people developed habits in their twenties that they have never stopped to question. The mindless use of the drug with dinner, at every gathering, or while watching sports often becomes automatic rather than intentional. The science now clearly demonstrates that past beliefs about moderate alcohol use contributing to cardiovascular health have been proven wrong. Helping patients become more mindful of the actual harms of these habits is often an easy win, and they are frequently grateful when they experience the health benefits from alcohol reduction. Obviously, there is an motivational art to this conversation, as you want the patient to reflect on their use of this drug, not get defensive. Working in emergency medicine, it is impossible to ignore alcohol’s impact. We regularly see assaults, domestic violence, motor vehicle crashes, falls, suicide attempts, self-harm, and injuries where impaired judgment due to this drug has played a major role. Many traumatic events occur while under the influence of alcohol, which can lead to struggles with coping and problematic use. The disinhibition and reduced judgment can also lead to exposure and use of other drugs. How many patients only smoke, use cocaine or other drugs when under the influence of alcohol? While most of us will appreciate how alcohol contributes to low mood, anxiety and poor sleep, but alcohol also contributes substantially to chronic disease, including hypertension, atrial fibrillation, liver disease, and cancers such as pancreatic, breast, and colorectal cancer. Most of us have seen a friend or family member whose life has been profoundly harmed by alcohol. Almost everyone can recall a time they regretted something that occurred while under the influence of alcohol. Alcohol stimulates the brain’s dopamine reward pathway and feels good, which is why people use it. But we all recognize that drugs that initially feel good can make us feel irritable or down, and are not necessarily overall good for us. Like many substances that stimulate the brain’s dopamine pathways without requiring effort or meaningful activity, alcohol has the potential to contribute to dependence and a host of other adverse outcomes. Alcohol also plays an important role in the broader addiction crisis. Most of the people who develop opioid use disorder start with a history of alcohol use. Alcohol is often one of the earliest psychoactive substances people are exposed to, and it can normalize substance use as a way of coping. Patients often describe that it takes away the pain and worry related to self-imposed expectations that you will let others down or be a disappointment. I also wonder how often healthcare workers use alcohol simply to switch off the constant pressure of needing to be strong and care for others. If we are using alcohol to cope after a hard day, why do we accept that for ourselves but advise others that they should not?The effects of alcohol continue to disproportionately affect many First Nations communities, where historical trauma, colonization, and systemic inequities have compounded its harms. I recently treated a young First Nations patient for detox, and I question our expectation that he leaves the hospital stable, sober and never uses alcohol again, knowing that few of the hospital staff are even contemplating doing that. We are consistently disappointed when they relapse, when they return to a life of extreme triggers, exposure and alcohol culture. We, as physicians, would make more meaningful steps towards reconciliation if we did not support the alcohol culture in our own profession.Many people believe they need alcohol to relax or to enjoy social occasions. In reality, the event itself is often what provides the enjoyment, while we attribute much of the experience to alcohol. Reward comes from community and social interaction. Our closest friends and family generally value our presence, not our intoxication.Alcohol alters mood, judgment, behaviour, and self-awareness. It lowers inhibitions and can impair empathy. Many people have done or said things while drinking that they later regret and would never have done sober. It does not reveal someone’s “true self.” Rather, it changes how the brain functions and puts people in an altered states often predisposing them to anger and impulsivity. Our primary job as physicians is to help people become the best version of themselves, and alcohol does not help anyone become the best version of themselves.Our own profession often normalizes drinking through conference receptions, wine tours at CME events, celebrations, and even cancer fundraisers where alcohol is served. We should ask ourselves whether these traditions still align with the evidence. If addiction is continued substance use despite harmful consequences, and we better understand the harms of alcohol, including increased cancer risk, what do we now consider addiction to this drug? This is not an argument for prohibition or for insisting that everyone stop drinking. Rather, it is an invitation to be honest about alcohol’s risks and about the culture we help create. Look at the discordance between how we treat tobacco versus alcohol. Let's give alcohol the credit it deserves in the current healthcare crisis instead of turning a blind eye. If the wait times and problematic drug use genuinely concern us, instead of waiting and hoping for others to change, control what you can, change yourself and see how it can influence others. There was an era where physicians were once ambassadors for the tobacco industry but ultimately became change makers influencing others by explaining to their patients why they no longer smoke. If you feel your use of alcohol is not an issue, and the problem lies with others, I might suggest that the drug itself influences this mental state. The dopamine-agonist effect seems to lead to increased self-focus, entitlement and reduced sympathy, and entitlement is a significant contributing factor in the current healthcare issues. Every time we choose not to drink alcohol, or simply normalize that choice to make healthier choices, like a non-alcoholic drink, we help make it easier for someone else and reduce the burden on the healthcare system. Small steps towards reducing ER lines, specialist waitlist, and paperwork, as well as likely improving our own health and ability to deal with stress and burnout. As physicians, we are role models whether we intend to be or not. Our influence extends beyond the clinic. By being mindful of our own use of this addictive dopamine drug and the messages we send, we can help shift social norms in a healthier direction.It starts with us.I am more than interested in comments and thoughts. Dr. Luke Williston is a rural physician practising in Tofino, B.C.

It starts with us: Physicians and alcohol culture

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