Science Club: Mark Willenbring
In which DCist interviews area scientists, researchers, and academics on topics pertaining to natural and scientific interests. As Thomas Dolby would say: science!
Mark Willenbring, M.D., is the Director of the Treatment and Recovery Research Division of the National Institutes of Health (NIH) National Institute on Alcohol Abuse and Alcoholism (NIAAA). He is a former professor of psychiatry at the University of Minnesota, and has worked to develop and test management strategies for people with complex addiction problems. In his work he has worked to develop evidence-based clinical practice guidelines for treating mental and addictive disorders. Dr. Willenbring co-led a national initiative to determine the feasibility of introducing guidelines for treating addictive disorders within the U.S. Department of Veterans Affairs. The NIAAA recently introduced Rethinking Drinking, a Web-based test that examines your drinking patterns and their effect on your health.
DCist: What was your role on the Rethinking Drinking project?
Mark Willenbring: This was a collaboration between me and one of of our other staff members, Maureen Gardner, who is a medical writer and who did most of the writing and the working with the contractors on the appearance and the construction of the Web site. I'm responsible for the content.
I have to tell you, I polled the staff of DCist, and of those who responded, 90% were in higher risk category while 70% are in the highest risk category. Are we all drunks? Is that what this site is telling us?
Not at all. The first thing to keep in mind about Rethinking Drinking is that this is a wellness product. This is not oriented toward treating a disease. One of the problems with thinking about drinking is that we tend to think of it in blight terms. Either you're a severe alcoholic or you're not. When we think of somebody with a drinking problem, we think of somebody who is falling down at weddings, embarrassing themselves, losing their jobs, getting DWIs—their life is falling apart.
And in fact, that of course does happen in the most severe stages of alcoholism, alcohol dependence. But this product really isn't directed toward people who have an alcohol use disorder. This is oriented toward people who are drinking more than is medically advisable but who don't have any problems yet. This is a wellness product. This is a product for people who want to drink, but want to do it in a way that they stay healthy. They don't want to put themselves at excessive risk for developing problems later.
Problems like dependence.
Like dependence Problems like driving while intoxicated. Or relationship trouble. Or liver disease. Those are the big ones that develop over time. There are others as well, but those are the big ones.
In many ways, alcoholism is a preventable disorder. This is really about risk reduction. And education—one of the problems is that people just don't have the information they need to even assess their drinking. I don't think we have been teaching people how to evaluate that. And that's one of the major goals here. So just the fact that the staff found out that they're going over the recommended limits—which is not at all surprising in what I would guess would be the demographic of your staff?
Journalists?
Younger people. Most heavy drinking occurs between 18 and 30. It peaks between 18 and 22. Then it goes down pretty rapidly to 30, and then it sort of levels off. By the time you get to 30, less than half of the heavy drinking is going on than was going on at 20. That's just the way it works. And that's something we all have observed. We call it growing up, typically. Right?
Right.
So in a group of young people you're going to see a lot of people who at least occassionally, and in some cases regularly, go over those limits. That's not saying their drunks. Well, let's take a look at that—are you at increased risk and if so, how much? You know the way risk works? It's not an all or nothing thing. It's not like, for a man and you drink four drinks most of the time and then one day you go over into five, all of a sudden your risk jumps—that's obviously absurd. As it says in Rethinking, the more you drink on occasion, and the more often you do, the higher the risk. So if you're drinking eight drinks on occasion and you're doing that twice a week, your risk is going to be much higher than if you're going over the limit and drinking five drinks twice a year.
There's such a moral component associated with alcoholism, how we view alcoholism. So when you see someone tell you, You're in a high-risk category, your instinct is to dismiss anything they're saying, because—
It's like Just Say No. It's like preaching sexual abstinence to teenagers. Yeah, and we took great pains to try to avoid that, and not have a moralistic tone. Everything is based on solid science. What we report—we're just giving people the facts.
Yes, well, it's the fact I think that has the impact on people. Alcoholism is one of those things that you really will not think about in relation to yourself. It's this other category: it's other people, who are anyway born that way. You don't think of it as something in you or your group.
Going over the limit is not a disease. You don't have a "drinking problem" if you're just going over the limit and not experiencing any difficulties or symptoms or distress. This is a lot like learning that your cholesterol level is high.
What about that? This doesn't take into account a person's physiology—height, weight, body-mass index. None of that applies when you're talking about alcohol dependency or risk?
Okay. Alcohol dependency is not just heavy drinking. It's heavy drinking that causes symptoms or problems. The difference between what we call at-risk drinkers and people who have an alcohol-use disorder is that at-risk drinkers don't have any symptoms or problems. They're like somebody who has high cholesterol but hasn't had a heart attack. They're like somebody who's engaging in unsafe sex but have not contracted any sexually transmitted diseases.
But you can calculate the likelihood that—
That's correct. There you go. Perfect analogy. There's not just unsafe sex and safe sex. There's degrees of unsafe sex. There's having a hundred partners a year. Then there's once forgetting to put a condom on with someone you know well. They're both unsafe sex and they theoretically at least raise your risk. But again, if you're engaging in unsafe sex on a regular basis, your risk of developing, of contracting a sexually transmitted disease, is obviously going to elevate. That doesn't even mean that most people will develop it—that just means your risk is increased. So what does that mean? Well, risk increase means that instead of 1 in 100 get it, 5 in 100 get it. That means that 95 still don't. But your risk is increased. Does that make sense? I think that people often have a hard time understanding what that means and tend to think of it as all or none.
Let me give you a concrete example. In a very large epidemiological study, 43,000 people, they were assessed at time one and then three years later. So at time one, low-risk drinkers versus at-risk drinkers, and you follow them out over time. In the low-risk drinking group over a three-year period—this includes all adults in the United States, it's a representative sample—over three years, a little over 2% developed problems related to their drinking. Between 2 and 3 in 100 developed problems related to their drinking in the low-risk group. In the at-risk group—so at time one, they're exceeding those guidelines but they don't have any symptoms or problems—three years later, about 15% had developed.
That's a way to present this that people can really understand and it puts it in perspective. We kind of think in terms of relative risk: How many times more likely? Well, that's seven times more likely. But seven times what?
Drinking is a self-selecting activity. If you're out drinking socially but you're in a high-risk category, then you're drinking with the other high-risk drinkers. It strains your your views of what these categories mean.
Absolutely. That's one of the reasons in there you get information about how many adults in the country actually do drink that way. You're absolutely right. People who like to drink and tend to drink more tend to socialize together. Again, we're not saying you shouldn't drink. Another way to think about this is encouraging people to eat well. In order to do that you have to have some idea about nutritional content. People who are successful at weight maintenance read labels, weigh themselves—they keep track. This is about keeping track.
So for example, if you're keeping track and you're finding that over time, your drinking is increasing in frequency and quantity, that's an early indicator that, well, maybe there could be a problem developing.
Is there a genetic component that determines for the population that moves from at-risk into problem territory?
There's genetic influence, first of all, on preference for alcohol. Even how much somebody's likely to drink or whether they are. And I'm not talking about dependence here, I'm just talking about drinking. So there are genetic components to that. Then there are additional genetic influences on progress to dependence and type of dependence. Most people who develop dependence develop mild dependence—they don't develop a severe, chronic dependence.
What's the difference between mild and chronic dependence?
The important thing here is that, currently for example, on [the list of symptoms in Rethinking] there are 11 symptoms. Seven of them are currently used for diagnosing alcohol dependence or alcoholism. In the current criteria for making a diagnosis, you have to meet 3 out of 7 of those in a year. It turns out that most people who develop dependence in this country average about three symptoms. They just barely meet criteria. Basically, the experience of not being in charge of your drinking. I'm going to have three drinks tonight, I'm not going to get tanked tonight.
I'm just going to go stop in, say hi—
Have a couple of beers, then after that I've got work to do, or I've got to get up early in the morning. There they are at midnight, and they've put away 12 beers. Then they start to develop a persistent desire. This time I'm going to try something else: I'm going to switch from vodka tonics to beer. But then it happens there again. There's this sense that I'm not fully controlling my use.
The next thing is getting relatively mild but still important physical or psychological symptoms from your drinking. Hangovers, basically. Not feeling well, not performing quite up to par, and yet continuing to use despite those consequences.
Those are the most common symptoms. These people are typically quite functional. They're going to work. You know some of them. I'm sure you do. I'm sure you know people who have the reputation as hitting the sauce too often and too frequently. But they're still working. They haven't wrecked their lives, they haven't gotten divorces. They probably haven't had a DWI, either. Those things tend to happen only in the really severe, regressive forms. And only about—among the people who develop dependence, only about 30% have that really severe dependence.
Hangovers: Is that something a person can develop a tolerance for?
You certainly can develop a tolerance for alcohol. That is another early symptom, is that you're increasing your amount of drinking to get the same effect. Here's what's interesting about that. People who can "hold their liquor," that is drink a lot without seeming real impaired and without puking your guts out and without getting a terrible hangover, are at increased risk of developing a problem.
Because you're consuming more of it?
That's right. A lot of people don't end up consuming more because they don't feel good. But for the people who the more they drink, the better they feel, they have a much higher risk of developing a problem. Being the one who's standing while everyone else is under the table is not a good thing.
Do you have an opinion on whether the United States should reduce the legal drinking age?
No, I don't have an opinion on that. We're not involved in making policy. We try to produce scientific findings that inform policymaking. That's a complex issue. So, no, I don't have an opinion on that.
Who does that research? Is that work done by sociologists?
We have certainly funded studies like that. I would say, the science is—the science isn't a slam dunk, let me put it that way. We went through a period of lowered drinking ages a few decades ago. When I was young, so 85 years ago. No, about 35. There was a period of years there where drinking ages were pretty widely dropped to 18 or 19. Then, there was an outcry about that, and it was raised again to 21 nationally. The research is pretty clear that when the drinking age was raised from 18 to 21, drinking went down and drinking-related problems went down: DWIs, traffic-related fatalities among young people, things like that. I think it is clear that you do see the drinking age is no panacea.
There is obviously a group that is making the argument that having the age at 21 means you can't talk to younger people about drinking. Again, that's a policy issue. I'd say in general that there are any number of other things that are involved here—such as enforcement. It's still routinely very easy for underaged people to walk into a liquor store and buy alcohol. In terms of reduction of fatalities, there are several things that were going on at the same time. There were things like the designated driver approach. And the sort of zero tolerance to drink-driving. There was a real sea change around that time. Over the last 20 years, there's been a huge change in terms of people's behavior in drinking and driving. It's routine now to have a designated driver—it never used to be routine. But the drinking hasn't decreased. Drinking-driving did, but the drinking hasn't decreased.
That's an interesting one because it's not an enforcement, but behavioral.
Actually it was enforcement. When you're not 21, you lose your license until you're 21.
I mean, the designated driver.
The designated driver was education too, but it was a result of people's understanding that the consequences were very severe.
It was a response to increased enforcement.
Absolutely. Traffic crashes is one of the major, I think it's a leading cause—trauma is the leading cause of death among young people, traffic crashes in particular. Everyone knows someone who has been hurt, or almost hurt, or killed. Nobody wants to do that, so people changed their driving behavior, and that's a good thing. But people didn't change their drinking so much. The issue about the legal drinking age is complicated because it has to do with enforcement of underage drinking laws and many other things. Whatever happens with that policy arena, what we know is that the peak of heavy drinking and of alcohol dependence occurs between the ages of 18 and 20.
If there's a person out there who wants to move from the highest-risk to the higher-risk category, should he drink fewer drinks when he goes out or go out less frequently?
That's a really good question. In terms of making a choice, it appears that there's more harm if you drink a lot at once. So reducing the drinking per episode is much more important.
Why is there more harm?
There's two reasons. In terms of things like acute things that happen like trauma, assault, suicide—that's much more likely to happen if you're really drunk. Or just falling over and breaking your arm. Or alcohol poisoning. So drinking a lot all at once really increases your risk for that kind of thing. Another thing is unsafe sex. You're really vulnerable. Those risk behaviors go up dramatically when you're intoxicated.
That's one main reason. The second one has to do with how high your blood-alcohol level gets per episode is probably on average more important than how often you drink, in general.
In terms of developing dependence?
Developing dependence, developing liver disease, harm to fetuses for a woman who's pregnant and doesn't know it. The amount per occasion, of the two, is more important. The first focus is reducing the amount per occasion—especially for younger people, who tend to drink more per occasion but less frequently than older people.