Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Alcoholism a Disease or a Moral Failing

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In the old days, people used to debate whether alcoholism was a disease or a moral failing. Now it is abundantly clear that not only is it a disease, but one with a strong genetic component.

At least 50 percent of the vulnerability to alcoholism is now believed to be triggered by genetics, and the other 50 percent by environment, such as living in a culture where heavy drinking is endemic.

What’s also increasingly clear is that many genes play a role and that genes work both ways — with some protecting people against alcoholism and others greatly raising the risk, said Dr. Mary-Anne Enoch, a research physician at the National Institute of Alcohol Abuse and Alcoholism.

Certain groups of people, for instance, like many Japanese, Chinese and Jews, carry genes that protect against alcoholism by raising levels of particular liver enzymes so that it’s unpleasant to keep drinking because of nausea, flushing and rapid heart beat.

Others, including many Caucasians, carry genes that act in the brain rather than the liver and raise the risk of becoming an alcoholic, although if people with these genes never touch a drop, they will never become alcoholics. Overall, those with a parent or sibling who is alcoholic, are at three to four times the normal risk.

Even with no genetic predisposition, people can become alcoholic by constant exposure to alcohol, which turns on genes in brain cells “that set up a vicious cycle of wanting or needing more and more alcohol,” said Bill Carlezon Director of the Behavioral Genetics Laboratory at McLean Hospital in Belmont.

The goal of this genetics research is to better understand alcoholism in order to design better drugs to protect people from it.

The latest statistics, released in August by the government, show that alcohol problems are on the rise. An estimated 17.6 million American adults — 8.5 percent of the population — now fit the diagnostic criteria for having an alcohol use disorder. Definitions vary, but alcohol abuse is often defined as recurrent drinking that disrupts work, school or home life and/or occurs in hazardous situations; alcohol dependence, also known as alcoholism, is defined as impaired control over drinking, preoccupation with drinking, withdrawal symptoms and/or high tolerance to alcohol.

For several years now, researchers have suspected that heavy drinkers drink as a form of self-medication — to calm overactive circuits in the brain.

Several months ago, researchers at Indiana University School of  Medicine reported findings on a study of 1,547 families that support this theory.

The researchers, led by Howard J. Edenberg, a professor of biochemistry, molecular biology and molecular genetics, found that variations in one gene raise the risk of alcoholism. This gene acts on GABA, one of the brain’s chief inhibitory neurotransmitters whose job is to slow down — or calm — the firing of certain brain nerves. Tranquilizing drugs like Valium and alcohol increase the ability of GABA to calm neural circuits.

People with a “high risk” variant of the GABA gene are at 40 percent increased risk of becoming alcohol-dependent.

According to researchers at University of California, San Diego, another GABA gene also seems to raise the risk of alcoholism, in this case by programming people to have a weak response to alcohol.  These people need to drink large quantities of alcohol to get the same effect other people would get from less, said Dr. Marc Schuckit, a professor of psychiatry at the San Diego VA Hospital and UCSD medical school. This trait is common in some Native Americans and Koreans.         

On the flip side, the genetic protection against alcoholism only goes so far — it can be overridden if a person persistently drinks heavily, Dr. Deborah Hasin, a professor of clinical public health at Columbia University, has shown.

Hasin studied Jews with the protective gene who had grown up in Israel and those who had emigrated to Israel from Russia, where heavy drinking is common. The Russian Jews were more likely to be alcoholics, said Hasin, showing that both genetics and environment clearly play a role.

That finding was also supported by a study by Christina Barr, a research fellow at the National Institute on Alcohol Abuse. She found that female monkeys who were separated from their mothers in childhood AND had a high risk gene were more likely to become alcoholics than monkeys with just the gene or just the unpleasant history.

The bottom line? So far, there are no genetic tests to tell if you’re predisposed to alcohol problems. But if you’re worried, talk to your doctor or drop in on an Alcoholics Anonymous meeting.

Some drugs may also help if your drinking is serious. Naltrexone can help reduce the craving for alcohol. Ondansetron can help reduce relapse in some alcoholics. Antabuse (disulfiram) helps by making people feel sick if they drink. And acamprosate (Campral), widely used in Europe but not yet available here, helps reduce alcohol craving.

Is Moderate Drinking The Answer?

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Until four months ago, Paul Robert, a hard-working, 42-year-old Connecticut businessman, would get home from work and knock back six drinks a night – 45 drinks a week. Sometimes wine, sometimes beer, sometimes the hard stuff.

“It was the stress,” he says, and alcohol “absolutely” helped. He didn’t think he was a true alcoholic. His job was going great, he says, and his family life – he has a wife and two  children,  ages 7 and 10 – was, too. He’d never been arrested for driving drunk. Even his liver showed no damage from all the alcohol it processed night after night.

Deep in his heart, though, Robert knew he was drinking far too much, and he wanted to cut back. What he did not want, however, was to go the Alcoholics Anonymous route and quit completely.

Today, Robert gets counseling and a daily dose of a drug called naltrexone to reduce his craving for alcohol, allowing him to cut back to12 drinks a week. His goal is “to go back to leading a normal life, so I can go out and have a couple of drinks. I am already there.”

But Robert’s treatment at Charles River Hospital in Wellesley raises one of the most controversial questions in medicine. The idea that excessive drinkers can safely return to moderate drinking contradicts the most famous alcohol abuse program, AA, and researchers fear it gives false reassurance to alcoholics.

However, advocates of moderate drinking believe that many alcohol abusers don’t get help because they fear they’ll have to stop drinking altogether. They say moderation could significantly reduce the nation’s most pervasive substance abuse problems.

An estimated 14 million Americans either abuse alcohol – meaning they’re impaired, but not physically dependent – or they are outright alcoholics prone to uncontrolled drinking, tolerance for high doses, and withdrawal symptoms when drinking stops. All told, about 40 million Americans drink more than the recommended moderate levels – one drink a day for women, and two for men, with a drink defined as  5 ounces of wine, 1.5 ounces of spirits or 12 ounces of beer.

So, can a heavy drinker really cut back without quitting totally? Yes, but the odds of success depend on the severity of the drinking problem, and on whether you have a family history of alcohol problems. If you’re an alcohol abuser but not yet alcohol-dependent, your chances are better; if you’re truly alcohol-dependent, they’re almost zero. In fact, doctors at Charles River don’t offer the moderate drinking program to people who are physically dependent on alcohol.

The good news is that most people with alcohol problems are not dependent, according to a 1997 analysis published by the National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health.

The bad news is that the line between abuse and dependence “is in no way a clean distinction,” says University of New Mexico psychologist William R. Miller, a leading alcoholism researcher. In fact, he says, mental health experts are reconsidering whether it makes sense to maintain this distinction at all.

The problem is that people with drinking problems tend to self-diagnose, to think their problem is less severe than it really is, and to avoid seeking help. That’s one reason why the famous 12-step meetings of AA are filled with people who have tried for years and failed to control their drinking rather than quit.

The research studies on controlled drinking are both encouraging and sobering.

A series of studies by Miller’s team at the University of New Mexico shows that people without alcohol dependence can indeed return to more moderate drinking. In these studies, about two-thirds of heavy drinkers managed to reduce their drinking substantially and to maintain their success for two years. When followed for up to eight years, the success rates decline – just 15 percent had maintained moderate, problem-free drinking, 25 percent had abstained completely for at least a year, 23 percent had cut back but still had some drinking-related problems, and 37 percent were no better than when the study started. Other studies in 1980, 1984, 1988, and 1992 showed similar results.

In a pivotal study of true alcoholics – published 15 years ago in the New England Journal of Medicine but still considered noteworthy by other researchers – Dr. John Helzer, a psychiatrist at the University of Vermont Medical School, showed that only about 2 percent were able to have an occasional drink without becoming dependent again. Curiously, noted Helzer in a telephone interview, a successful return to more moderate drinking was four times more likely in women. Other studies in 1979, 1989, and 1996 also suggest that women may be more successful at cutting back than men.

Cognitive-behavioral techniques, in which people are taught to recognize and change the thinking patterns that underlie their drinking, clearly help people cut back on alcohol intake. In fact, they are among the most successful approaches for people with less severe drinking problems, according to a 1999 review of the data in Alcohol Research & Health, the journal of the Alcohol Abuse and Alcoholism Institute. Cognitive behavior also works for true alcoholics – not to help them cut down but to help them remain abstinent – according to project MATCH, a large federal study in1996.

Brief interventions, in which a doctor or nurse schedules several short appointments to teach a patient about ways to reduce intake, also reduce consumption in people who are not alcohol-dependent, according to the same1999 review. In fact, in Seattle, a 1999 study of people who wound up in the emergency room after alcohol-related accidents showed that 30 minutes of alcohol counseling from a psychologist before discharge reduced the likelihood of readmission for other alcohol-related trauma. But nationwide, many doctors and nurses have yet to incorporate this technique into their practices.

On the more discouraging side, research in 1996 by Dr. George Vaillant, director of research in psychiatry at Brigham and Women’s Hospital, tracked more than 700 college-educated and less-educated male heavy drinkers for more than 50 years. Vaillant found that men who tried to control their drinking usually relapsed while those who managed to stay sober for five years rarely did.

Yet, despite the evidence that moderate drinking leads to relapse for most alcoholics, the idea of controlled alcohol consumption is a powerful lure for alcoholics.

“Nothing is more appealing to a lot of alcoholics than the idea that if they could just figure out how to control their drinking, that would do it,” says Dr. Roger Weiss, clinical director of the alcohol and drug abuse treatment program at McLean Hospital in Belmont.

Dr. Richard K. Fuller, director of clinical and prevention research at the National Institute on Alcohol Abuse and Alcoholism, agrees. With true alcoholics, he says, its very unusual for them to return to moderate drinking. “The reason this is so sensitive, why some alcoholics become livid about this, is because they feel their own recovery was delayed for many years because they struggled, kept chasing this will of the wisp. “Most people can have a drink or two and stop. The alcohol-dependent person can’t,” Fuller added.

The limits of moderate drinking were illustrated dramatically not long ago with the tragic story of Audrey Kishline, who founded a program called Moderation Management in 1993 on the premise that heavy drinkers who are not yet alcoholics can cut back without abstaining altogether.

Last March, Kishline went on a drinking binge and killed two people in a car crash. Afterward, she reportedly called her program an example of “denial in action,” and  pleaded guilty to two counts of vehicular homicide.

Even so, Stanton Peele, a Morristown, N.J., psychologist, lawyer and former board member of Moderation Management, points out that it is ironic that Kishline’s accident happened after she joined AA and tried to abstain. It wasn’t just moderation that failed her, he says, “everything failed her.”

Advocates of  moderate drinking like Anthony Martignetti, an addiction specialist who runs the Alcarrest program at Charles River Hospital, insist that, for selected people, reduced drinking programs work.

In fact, says Martignetti (whose family, ironically enough, owns the Martignetti companies, the New England liquor distributor), it’s the fear of abstinence-only programs that keeps many people from seeking traditional treatment. So far, about 200 problem drinkers have completed Martignetti’s program, and by one year after treatment, 70 percent say they’ve reduced their drinking by 70 percent.

The bottom line? For Paul Robert, at least, things look good. He’s optimistic he can continue to drink moderately.

For others, well, let’s put it this way: If you find yourself saying”Bottoms up!” too often, see a doctor or alcohol counselor to evaluate your drinking. Trying to diagnose yourself is likely to be fraught with denial.

Then, if you and your counselor agree your problem is not severe, try a program aimed at cutting back. However, if your alcohol problem is severe, total abstinence remains the best answer.

SIDEBAR:

There are a number of medications that can help people control or cut down on their drinking, says Dr. Shelly Greenfield, medical director of the alcohol and drug abuse ambulatory treatment program at McLean Hospital in Belmont.

Antabuse (disulfiram) is a so-called “aversive” drug that causes nausea and other unpleasant symptoms if alcohol is also consumed. At high doses, the combination of  Antabuse and alcohol can be dangerous. The idea is to make the drinking experience so unpleasant that a person doesn’t drink, but this only works if people take the drug.

Naltrexone (ReVia) is an opiate-blocking drug long used to combat addiction to drugs such as heroin. In 1994, it was approved by the US Food and Drug Administration to curb craving and prevent relapse in people with alcohol problems.

Acamprosate is a drug that has shown promise in European studies to curb craving for alcohol and help maintain abstinence. It is not approved in the United States, but studies are underway.

Antidepressant drugs  that are SSRIs, or selective serotonin reuptake inhibitors, such as Prozac, have also been shown to help some people who drink too much, especially if they are also depressed.

Here’s to your health: the benefits of drinking outweigh the risks, but only within limits

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On Thursday, the French will go nuts.

We know this because they go nuts every year on the third Thursday of November, the day the latest crop of just-off-the-vine wines hit the market.

Wine-lovers will swarm to those cute little bistros, swell with Gallic pride, swill a glass of this fairly flimsy red stuff, and proclaim, “Le Beaujolais Nouveau est arrive!”

(This proves either that the French really do have a better grip on things than the rest of us, as I suspect, or that they, too, can be suckered into a clever marketing ploy. Or both.)

But it’s not just the French who love wine. In recent years, American wine sales have been booming, too. Nobody knows why, but it may be that Americans have come to believe that wine is actually good for them.

And so it is. In the last quarter century, more than 50 studies from around the world have shown that people who drink moderately have up to a 40 percent lower risk of heart disease than those who don’t drink. Because heart disease is such a huge factor in overall mortality in the US, this translates statistically into a lower death rate in any given year for moderate drinkers.

But the whole truth — in vino, veritas — is a bit more complicated, so before you pop that cork, some caveats.

By government estimates, 14 million Americans have an alcohol disorder, which is defined as abuse and dependence (or uncontrolled drinking), tolerance for high doses, and withdrawal symptoms when drinking stops.

In excessive amounts, alcohol raises the risk of heart disease, hypertension, stroke, some cancers, violence, and suicide. It’s also bad for pregnant women because it can cause defects in the developing fetus. It shouldn’t be mixed with certain medications (check the labels). And it clearly doesn’t mix with driving.

For the record, alcohol consumption can also be tough to study because people sometimes lie about how much they drink. It’s especially tough to sort out the relative merits of wine, beer, and liquor because people typically drink different types of alcohol on different occasions.

Beyond that, researchers don’t always agree on what counts as “moderate drinking,” though it’s usually one drink a day for women and two for men, with a drink being 5 ounces of wine, 1.5 ounces of spirits or 12 ounces of beer.

That said, compared to most medical research, the data on alcohol and health are remarkably clear, consistent, and compelling, though things get murky on the finer points, like whether wine, especially red wine, is better than other alcohol.

The first hints that alcohol might carry health benefits came 25 years ago — as a surprise.

With a colleague, Dr. Arthur Klatsky, now a senior consultant in cardiology at Kaiser Permanente Medical Center in Oakland, Calif., was studying factors that predicted heart attacks.

In a 1974 study, Klatsky says, there was no hypothesis about alcohol, but he asked about drinking anyway and found that abstainers were actually at higher risk of heart attack than those who drank moderately. No one knew why.

Now scientists think they do. Alcohol, whether from wine, beer or spirits, raises HDL, or “good” cholesterol, and lowers levels of a blood-clotting protein called fibrinogen and reduces the activity of platelets, which also help form clots. (A recent Stanford University study showed alcohol may also help reduce the damage done to tissue during a heart attack — at least in rats.)

The study that clinched the link between moderate drinking and overall survival came in 1997. Researchers led by Dr. Michael J. Thun, who heads epidemiological research for the American Cancer Society in Atlanta, studied 490,000 people and found that moderate drinkers had a 20 percent lower risk of death in any given year than abstainers.

This holds true for women as well as men, Thun says, though he’s quick to warn that the risk-benefit ratio is trickier for women. That’s because the risk of dying from (not just getting) breast cancer is 30 percent higher among women who have at least one drink a day.

“For breast cancer, not drinking at all would be optimal,” he says. Yet because heart disease kills six times as many women as breast cancer, the benefits of moderate drinking still outweigh the risks for many women.

Here’s another way of looking at it. A huge, 1998 Harvard study of pooled data on 322,000 women found that the risk of getting breast cancer goes up linearly with the amount (though not the type) of alcohol consumed; one drink a day raises risk about 10 percent. Put another way, a woman who lives to age 85 has a 12.5 percent chance of getting breast cancer; adding a drink a day raises this to 13.6 percent. (On the other hand, just to confuse matters, a smaller study published in January and based on data from the ongoing Framingham Heart Study showed that women who drink one alcoholic beverage a day have no increased risk of breast cancer.)

If there is an increased risk, it’s modest and probably due to the fact that alcohol raises blood levels of estrogen, at least transiently, and estrogen can drive some breast cancers.

But this increased breast cancer risk from drinking is less than that from estrogen supplements, which raise risk about 40 percent in menopausal women who take them for five years or more. Even adding together the increased risk from a drink a day to the increased risk from hormone therapy, that’s still only a 50 percent increase in the risk of breast cancer, fairly modest by statistical standards. This may be a crucial difference for women with a strong family history of breast cancer, but for others, the benefits of alcohol may still outweigh the risks.

And what of the notion that red wine has even more health benefits than lowlier forms of booze? That gets tricky.

The theory is that many phenolic compounds in the seeds of grapes and a particular one called resveratrol from grape skins act as potent anti-oxidants, or disease-fighting chemicals. Grape seeds and skins are used in making red wine (and purple grape juice), but not white wine, notes wine chemist Andrew L. Waterhouse of the University of California, Davis.

In a study published in September, Waterhouse showed that a phenolic compound called a catechin shows up in the blood after people drink red wine. Other research has shown that red wine, but not white, causes changes in the blood that make it harder for LDL, or “bad” cholesterol, to be oxidized and thereby perhaps to help form artery-clogging plaques.

Researchers from the University of Wisconsin also reported recently that in 15 people who drank purple grape juice every day, blood vessels were more elastic and LDL cholesterol was oxidized more slowly.

But does this translate into real differences in disease?

Some researchers think so. In 1995, Danish epidemiologist Morten Gronbaek reported in the Copenhagen City Heart Study of 13,000 men and women that the risk of dying was reduced by 50 percent in people who had three to five glasses of wine a day. He did not find the same benefit for beer or spirits.

But he also found in a 1999 study that people who drank wine were more likely than those who drank beer or spirits to eat a healthful diet, with lots of fruits, veggies, fish, and olive oil.

Klatsky, the Kaiser Permanente cardiologist, has also looked for any special effect of wine and has concluded that if there is a benefit to wine over other forms of alcohol, it’s probably not the wine but the health habits of the people who drink it.

Eric Rimm, a nutritional epidemiologist at the Harvard School of Public Health, puts it this way. About one third of the 50 worldwide studies on alcohol and health look at wine, beer, and spirits separately. Taken together, he says, there’s no compelling evidence that red wine has more health benefits than other types of alcohol.

To which the only decent answer is a raised glass, a Gallic shrug, and a hearty, “C’est la vie!”

SIDEBAR: LABELS CAN’T TELL THE STORY

In February, the government took a long-awaited step toward legitimizing wine consumption when, at the urging of wine manufacturers, the Bureau of Alcohol, Tobacco and Firearms approved a voluntary label for wine bottles that refers consumers who want “to learn the health effects of wine consumption” to the agriculture department’s Web site.

But last month, the agency bowed to political pressure from Sen. Strom Thurmond (R-S.C.), and announced it was re-opening the issue for public comment. Last week, John De Luca, president and CEO of the California-based Wine Institute, an industry-supported group, said, “Far from fearing this, we welcome it. It’s a terrific new forum to share the scientific findings on the subject.”

The new label approved in February did not replace the required label carrying the US Surgeon General’s warning that pregnant women should not drink alcohol because of the risk of birth defects and that drinking alcohol impairs the ability to drive a car or operate machinery and may cause health problems.

It didn’t make outright health claims, either, but did refer readers to the US Department of Agriculture’s statement, which says that in moderation, alcohol is associated with a lower risk of coronary heart disease. The USDA defines moderate drinking as no more than one drink a day for women and no more than two for men.

To read the full USDA statement on the Web, go to http://www.usda.gov/fcs/cnpp.htm

For more information on the health effects of wine and other forms of alcohol, check out the Web site of The Wine Institute at http://www.wineinstitute.org. It’s an industry site, but has done a decent job of pulling together some scientific studies.

Alcohol’s insidious grip

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Barbara Raymond, now in her mid-50’s, started drinking hard as a 15-year-old in Abington. At the time, she had no idea why, though she later linked it to depression.

She made her first suicide attempt at 16. At 18, in the throes of alcoholic amnesia, she married a man she’d known for two weeks. He turned out to be an alcoholic and a batterer who broke her arm and gave her “a bunch of bruises” over the years. She rarely sought care, she says: “I was too ashamed.”

By 24, she’d had six kids and several more suicide attempts. After the last, she ended up “dead on arrival” at a local hospital, where doctors revived her and someone suggested Al-Anon, a program for people affected by other people’s drinking.

Nobody asked whether she had a problem herself. But she knew she did. “I detoxed at AA [Alcoholics Anonymous]. I had the DTs (delerium tremens, severe withdrawal symptoms). No one treated me. I did it by myself, at home . . .At the time I got sober, there was not as much help as there is today.”

Today, there are new medications, better understanding of male-female differences in alcohol metabolism, and research into genes that may trigger alcoholism. Most important, there’s the recognition that, as Raymond says, “you don’t have to hit bottom like I did. If you’re worried about drinking, get help. Sooner rather than later.”

This Thursday, you can get free alcohol screening at any of 2,000 sites nationwide, including 450 colleges. You just show up, fill out an anonymous questionnaire, then meet confidentially with a clinician for 10 minutes. If he or she thinks you have a problem, you’ll get a referral for help.

Modelled on the 9-year-old depression screening day (held each October), the alcohol screening is run by Dr. Shelly Greenfield, medical director of the alcohol and drug abuse outpatient program at McLean Hospital. It is sponsored by the National Institute on Alcohol Abuse and Alcoholism, a government agency, and dozens of professional organizations.

Depression screening has proved that offering a chance to drop in and talk privately with a counsellor turns up a “big, undiagnosed, untreated population who can be helped,” Greenfield says. It is hoped the same will hold for people with alcohol problems, she says. And there are many of them.

By government estimates, nearly 14 million Americans have an alcohol use disorder, which includes abuse (impairment but not physical dependence) and dependence (alcoholism), which is characterized by uncontrolled drinking, tolerance for high doses and withdrawal symptoms when drinking stops, among other things.

Granted, moderate alcohol use — one drink a day for women, two for men (with a “drink” defined as 5 ounces of wine, 1.5 oz. of spirits or 12 oz. of beer) — lowers the risk of heart disease.

This is because alcohol raises HDL, or “good cholesterol,” and lowers LDL, or “bad cholesterol.” It also makes it harder for platelets to form clots that can block arteries. And some alcohol, notably red wine, contains anti-oxidants that keep LDL from oxidizing; in oxidized form, LDL leads to arterial plaques.

Heavy drinking, on the other hand, can adversely affect not just the drinker — raising the risk for hypertension, stroke, heart disease, some cancers, violence and suicide — but family and friends as well. And half of all US adults have or have had a close relative with a drinking problem, government data show.

But researchers are getting an increasingly good grip on how alcohol problems develop and how best to treat them.

The drug Antabuse, for instance, has long been known to help people quit by making them sick if they drink, says Dr. Enoch Gordis, director of the National Institute on Alcohol Abuse and Alcoholism. But the drinker has to be motivated to take it.

A newer approach, using naltrexone (marketed as Revia or Trexan) may help more. In 1992 studies at the University of Pennsylvania and Yale, researchers found it reduced craving and increased abstinence. The drug is now FDA-approved for this use.

Yet another drug, acamprosate, also helps, perhaps by reducing craving.

In addition, anti-depressant drugs such as Zoloft have been shown to reduce drinking in people who have both depression and alcohol problems, though not in those who aren’t depressed.

Non-drug treatments work, too. The most famous is the 12-step AA model. But an NIAAA study of 1,726 alcoholics in 1997 found that several types of group therapy are also effective ways to quit and stay abstinent.

For true alcoholics, abstinence is still the only longterm solution. For alcohol abusers, cutting back may work.

Ultimately, scientists hope to find a genetic trigger — or several — for alcoholism. The idea that genes play a role is supported by indications that alcoholism, often, though not always, runs in families. If either parent is an alcoholic, you have three to five times the normal risk of becoming one yourself.

More support for the genetic hypothesis comes from the fact that half of Asians who drink experience unpleasant side effects such as flushing, almost “as if they had Antabuse built in” to their genes, says Gordis. Just like the drug, this genetic factor seems to protect against alcohol abuse.

But so far, scientists haven’t found a single gene related to any alcohol-related behavior, even in animals.

What is clear is that alcohol affects men and women differently. In men and women of equal size who consume equal amounts of alcohol, blood levels of alcohol are higher in women, because women’s bodies have less water and more fat, which means alcohol is not diluted as much as it in men. Women also produce lower amounts of a stomach enzyme called alcohol dehydrogenase, which helps digest alcohol.

Women’s livers also are more vulnerable to alcohol. Some data suggest it takes five drinks a day to cause cirrhosis, or scarring, in men, but only a glass and a half or so in women.

Breast cancer is another worry for women who drink. A study published last year of pooled data on more than 322,000 women found that the risk of invasive breast cancer is 41 percent higher for women who have two to five drinks a day than for nondrinkers. This is considered a modest increase in risk.

Women are also less likely to seek treatment for alcohol problems and more likely to say their drinking is related to depression or family problems, which means the drinking itself may not get addressed.

Whether you’re male or female, if you’re worried about your drinking, get screened and get help. Take it from Barbara Raymond, who now counsels alcoholics at McLean.

She’s been happily remarried for 12 years. She’s earned her bachelor’s degree from Bridgewater State and is about to get a master’s in social work. And she’s been sober — for 27 years.

SIDEBAR 1:

Some questions you might be asked in alcohol screening

  • How often do you have a drink containing alcohol?
  • How many alcoholic drinks do you have on a typical day when you are drinking?
  • How often do you have four or more drinks on one occasion?
  • How often during the last year have you found that you were not able to stop drinking once you started?
  • How often during the last year have you failed to do what was normally expected from you because of drinking?
  • How often during the last year have you needed a first drink in the morning after a heavy drinking session?
  • How often during the last year have you had a feeling of guilt or remorse after drinking?
  • How often during the last year have you been unable to remember what happened the night before because you had been drinking?
  • Have you or someone else been injured as a result of your drinking?
  • Has a relative or friend or doctor or other health worker been concerned about your drinking or suggested you cut down?

    • SIDEBAR 2:

    Bottom line on bottoms up, who has an Alcohol Problem?

    • Nearly 14 million Americans meet diagnostic criteria for alcohol use disorders.
    • Half of US adults have or have had a close relative with a drinking problem.
    • About 74 percent of male drinkers and 71 percent of female drinkers exceed moderate drinking guidelines at least once a year.

    Harmful Effects of Alcohol

    • Heavy drinking raises the risk for high blood pressure, stroke, heart disease, certain cancers, accidents, violence, suicides, birth defects and overall mortality.
    • Economic costs to society are $167 billion annually.
    • Harmful drinking is involved in one-third of child abuse cases and many unintentional deaths from falls, burns, and drownings.

    Drinking Among Teens and College Students

    • Young persons who begin drinking before age 15 are four times more likely to develop alcohol dependence and twice as likely to develop alcohol abuse as those who begin drinking at age 21.
    • More than one-third of high school seniors perceive no great risk in consuming four to five drinks a day.
    • Alcohol is a factor in about one-half of fatal traffic crashes among persons 18-24 years of age. Among fraternity and sorority residents, 81% report binge-drinking.
    • Two to three times as many teenagers and young adults die in alcohol-related crashes as die from illegal drug use.

    SOURCE: National Institute on Alcohol Abuse and Alcoholism and Dr. Shelly Greenfield.

    Drink up – or not? Studies in women are at odds on alcohol’s risks and benefits

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    Last May, a huge Harvard study of more than 85,000 women showed that moderate drinking — about one drink a day — lowers the overall risk of death, without apparently raising the odds of dying from breast cancer.

    Six weeks later, another big study — of more than 16,000 women — came to a more sobering conclusion: Over a lifetime, even one drink a day may slightly raise breast cancer risk.

    Given that women are roughly six times more likely to die of heart disease than breast cancer, and that alcohol protects against heart disease in both men and women, perhaps women shouldn’t worry about a small increase in breast cancer risk from drinking.

    But many do.

    Which is precisely why the new data on women and drinking is so frustrating. Taken together, the data suggest that drinking decisions for women may be even more complex than for men because risks and benefits are more closely balanced.On top of that, evidence is piling up that women’s bodies are far more vulnerable than men’s to the toxic effects of booze.

    All of which suggests that before you pour the next drink, ladies, you might want to ponder the research — on both sides.

    Medically, the main argument for drinking is that it protects against heart disease, the leading killer of both men and women.

    Alcohol can change the balance of lipoproteins in the blood, boosting ”good” cholesterol (HDL) and lowering “bad” (LDL), notes Dr. Enoch Gordis, director of the National Institute on Alcohol Abuse and Alcoholism.

    It can also reduce, at least temporarily, the ability of platelets in the blood to form clots that can block coronary arteries.

    And at least some types of alcohol, notably red wine, contain anti-oxidants that may keep LDL from oxidizing. In oxidized form, LDL leads to fatty plaques that clog vessels.

    Primarily because of the cardiovascular effects, the Nurses’ Health Study of 85,709 women showed that moderate drinkers (women who had between one-half and one drink a day) had a 12 percent lower risk of death from all causes than women who drank nothing and a 26 percent lower risk those who drank heavily.

    A drink was defined as a 4-ounce glass of wine, a 12-ounce can or bottle of beer and a half-ounce of spirits.

    But not all women benefit from moderate drinking. In fact, the Nurses’ study showed that if a woman is at low risk of heart disease to begin with, either because she is under 50 or has no coronary risk factors, moderate drinking doesn’t carry any health benefit, though it won’t hurt either.

    The women who do benefit are those at higher-than-normal risk of heart disease, notes Dr. Walter Willett , one of the authors and a professor of epidemiology and nutrition at the Harvard School of Public Heath.

    Factors that raise heart disease risk include high blood pressure, high cholesterol, diabetes, obesity, a sedentary lifestyle and having a parent who had a heart attack before age 60.

    And there’s other evidence that a drink or two may do more than just keep the heart doctor away.

    One study of nearly 10,000 women over 65, published last year in the Journal of the American Medical Association, showed that women who drank moderately did better than nondrinkers on physical function tests, perhapsbecause alcohol was a sign that the drinkers had a more active lifestyle.

    Another study, published in 1994 in the American Journal of Public Health, showed that women — and men — who drank moderately got less depressed under stress than teetotallers or heavy drinkers, again perhaps because moderate drinking was a marker for other healthful habits that offset stress.

    But drinking clearly has a dark side for women, too, quite apart from the obvious — alcoholism and fetal alcohol syndrome.

    At one and a half to two drinks a day, the Nurses’ study showed, the risk of dying from breast cancer — a risk that was invisible at lower levels — increases, perhaps because alcohol raises levels of the hormone estrogen, which promotes some breast cancers. At more than two and a half drinks a day, overall mortality begins to rise, too.

    And the risk of breast cancer may increase with as little as one drink a day, says Matthew Longnecker, an epidemiologist at the National Institute of Environmental Health Sciences whose report on more than 16,000 women was published in June.

    In contrast to the Nurses’ study, which focused on death rates, Longnecker studied the risk of getting breast cancer and found a daily drink was linked to a 40 percent increase in risk, suggesting that 5 to 10 of the 184,300 cases of breast cancer expected this year might be attributed to alcohol consumption.

    “That is a stronger association than what had been found in previous studies,” he says, perhaps because he studied lifetime consumption, not recent drinking.

    On the other hand, Dimitrios Trichopoulos, an epidemiologist at the Harvard School of Public Health, found in a smaller study of 2,400 women last year that it takes three drinks a day to increase breast cancer risk at all.

    To some, like epidemiologist Lynn Rosenberg of Boston University, all this simply means that any causal link between alcohol and breast cancer is farfrom established. But she adds that since “we don’t know how to reduce the risk of breast cancer, even the hint of an increased risk may be enough to persuade some women, particularly younger women at low risk of heart disease, not to drink.”

    Others, notably the Wine Institute, a California-based industry association, put a cheerier spin on ambiguous findings, especially the hint — from Longnecker’s study — that the kind of alcohol a woman drinks may affect breast cancer risk.

    Longnecker acknowledges that he found wine “was not related to risk of breast cancer,” while beer and liquor were. Beer drinkers had a 25 percent increase in breast cancer risk and liquor drinkers, an 18 percent increase. If wine has an advantage, it might be because it contains so-called “phenolic compounds” that may be protective, he and his team wrote, while beer and liquor “may contain substances that have estrogenic activity.”

    But he and other epidemiologists stress that other studies, including somefrom Italy and France, found an increased breast cancer risk even among wine drinkers, which means the issue is far from settled.

    And there is growing evidence that women’s bodies are more vulnerable than men’s to alcohol, says Dr. Charles S. Lieber , director of the alcoholism research and treatment center at the Bronx Veterans Affairs Medical Center and professor of medicine at the Mt. Sinai School of Medicine in New York.

    In men and women of equal size who consume equal amounts of alcohol, he says, blood levels of alcohol are higher in women, partly because women’s bodies contain less water and more fat, which means alcohol is less diluted in their blood. But women also make less of a stomach enzyme called alcohol dehydrogenase, which helps digest alcohol.

    Lieber, whose team recently cloned the gene for this enzyme, says that unlike male alcoholics, who still make some alcohol dehydrogense, female alcoholics make virtually none. And for some women, the ulcer drug Tagamet also exacerbates the problem, making alcohol dehydrogenase even less active.

    Women’s livers are particularly vulnerable to alcohol, too, he adds. French studies show men must have about five drinks a day to cause cirrhosis, or heavy scarring, of the liver, while women can get cirrhosis drinking only a glass and a half to two and a half glasses of wine a day.

    The bottom line, he says, is that “one drink in a woman of average size is equivalent to two drinks for a man.”

    And that is precisely what the revised US government dietary guidelines, issued last week, recommend for those trying to get the health benefits but not the risks of alcohol:

    No more than one drink a day for women, two for men.

    At this level of consumption, says Willett, alcohol “won’t have overall harmful effects and might even help some women.”

    SIDEBAR

    EARLY ABUSE IS OFTEN A FACTOR IN ALCOHOLISM

    Though male alcoholics outnumber female alcoholics 3 to 1, women seem to suffer medical complications from drinking at far lower levels of alcohol consumption than men. And different factors seem to predispose women to problems with alcohol.

    As with men, a family history of alcoholism raises women’s risk of alcoholism, perhaps even more so than for men.

    But women, to a greater degree than men, tend to start abusing alcohol during periods of transition like divorce, or when they are in relationships with heavy drinkers, says Norma Finkelstein, director of the Coalition on Addiction, Pregnancy and Parenting in Cambridge.

    But perhaps the most telling factor is that many of the 4 million American women who abuse alcohol or are alcoholics were physically or sexually abused as children, says the National Council on Alcoholism and Drug Depencence, Inc., in New York.

    But socioeconomic factors also play a part. Alcohol use is most prevalent among white women, according to the Commonwealth Fund Commission on Women’s Health. Seventeen percent of white women report moderate to heavy drinking, compared with 11 percent of African American women, 9 percent of Latinas and 6 percent of Asian women.

    Alcohol use also increases with income and education, the Commonwealth Fund found. Roughly 8 percent of women without a high school education are moderate to heavy drinkers, versus 20 percent of those with at least some college. Heavy drinking was defined in this study as having more than two drinks a day.

    Some states, Massachusetts foremost among them, have made a special effort to create women-only alcohol treatment programs. Research suggests that when men and women are treated together, “the men do better and the women do worse” because women “pay attention to what men need, not what they need,” says Finkelstein.

    Co-ed treatment groups can make it more difficult for women to talk about sex abuse, incest, violence and feelings of guilt and shame about raising children while drinking or having drunk alcohol during pregnancy, which can lead to fetal alcohol syndrome, adds Alan Milner, director of the Massachusetts Drug and Alcohol Hotline.

    Women drinkers also face more scorn from society than men, adds Dr. Roger Weiss, clinical director of the alcohol and drug abuse program at McLean Hospital in Belmont.

    Once in treatment, though, women who are both depressed and alcoholic do better than women who are not depressed, he says, though this is not true for men. Perhaps, he says, depression makes women “more ready for treatment.”

    SIDEBAR:

    If you need information or help with an alcohol problem, you may call:

    The Coalition on Addiction, Pregnancy and Parenting, 617-661-3991.

    The Alcohol and Drug Abuse Hotline, 617-445-1500 or 1-800-327-5050. For the deaf, the TTY number is 617-354-0997.

    Alcoholics Anonymous, 617-426-9444.