Drinking Defined: The Sober Curious & Beyond

Are you sober curious?

After the isolation and stress of a multi-year pandemic, many people are examining their lifestyle choices to look and feel healthier than they did while locked away from friends, work and family.  One of these lifestyle choices under scrutiny is alcohol use — and rightly so. According to the National Institutes of Health, alcohol sales rose by about three percent during the first year of the pandemic — the largest increase in 50 years. Several small studies also suggest that 25 percent of people drank alcohol more than usual during that difficult time in our history.

Enter the sober curious movement. It was Ruby Warrington who popularized this idea with her book “Sober Curious: The Blissful Sleep, Greater Focus, Limitless Presence, and Deep Connection Awaiting Us All on the Other Side of Alcohol.” While the concept isn’t new — Warrington’s novel came out in 2018, and think ‘dry January’ and ‘sober October’ — the examination of our relationship with alcohol is trending.

WakeMed Voices had the opportunity to speak with Christopher Thompson, MD, HMDC, FAAHPM, FASAM, a WakeMed Addiction Medicine physician about all-things-alcohol — from experimenting with sobriety to recognizing you may be more than just a social drinker and what you can do about it.

What is the sober curious movement about?

Right now, there is a global focus on wellness and the impact stress can have on both physical and mental health. The sober curious concept has been around for a while, but it has become the latest buzz word with this global focus on wellness. The concept centers around being mindful of when and why you drink and looking at how your life would be better without alcohol use. It’s experimenting with sobriety. This may mean taking a break from alcohol for, say, a month or quitting forever.

Is there a type of drinker who would benefit from sober curious concepts?

Individuals who are right around the maximum recommended amount of alcohol consumption — seven drinks a week for women and all genders 65+ as well as 14 drinks per week for men — who do not physically or mentally “need” alcohol — may have success with the sober curious concept of being mindful about their drinking habits. However, there is benefit in recognizing that one is unable to abstain from alcohol and that an individual may need medical help.

What is “unhealthy drinking”?

The Centers for Disease Control & Prevention’s Drink Less, Be Your Best web page offers great information about how much is too much along with risky behaviors. Binge drinking — the most common type of unhealthy alcohol use — is defined for women as having four or more drinks on one occasion. For men, it’s five drinks on one occasion. Heavy drinkers consume more than this per week. Alcohol use disorder starts when patients meet certain criteria — as they would with any chronic disease.

Talk about alcohol use disorder (AUD). Is the term alcoholism passé? 

‘Alcoholism’ is still used, but I and many of my colleagues prefer ‘alcohol use disorder.’ I think the change in terminology represents that we are talking about a serious, chronic brain disease that impedes a person’s ability to stop drinking alcohol. There’s a social stigma about chronic alcohol consumption — that it is somehow a weakness. It has nothing to do with weakness and everything to do with what is happening in a person’s brain. And, just like heart disease and diabetes, genetic components may put people at greater risk for developing AUD and other substance use disorders. Research indicates that genetics can increase a person’s risk for unhealthy alcohol use by 50 percent.

So, how do you determine if a person has an AUD? Are there different severities of the disease?

In general, we look at how the person uses alcohol. If a person has a drink to celebrate a special occasion or to relax, that’s a social user or someone who has not experienced adverse consequences from using alcohol. Conversely, those experiencing AUD use alcohol throughout the day, have a drink as soon as they get up in the morning and/or use alcohol to avoid alcohol withdrawal symptoms.

Alcohol use disorder and diagnosis have evolved throughout the years as experts, specifically those with the American Psychiatric Association (APA) and the Substance Abuse and Mental Health Services Administration (SAMHSA), have learned and proven more and more about the disease. Simple questionnaires are available, including the CAGE that all users can complete to think about their relationship with alcohol. Many providers such as addiction medicine physicians (also known as addictionologists), psychiatrists, psychologists and counselors as well as primary care providers often use the APA’s fifth version of the “Diagnostic and Statistical Manual: Mental Disorders (DSM-V) to understand a person’s disease and how to treat it. The questions are similar to those in the AUDIT questionnaire — another popular and great tool to better understand alcohol use.

Criteria for Alcohol Use Disorder

Here is a checklist that providers and patients commonly discuss to help determine the presence and severity of their AUD.

In the past 12 months, have you:

• ⃝Consumed alcohol in larger amounts or over a longer period than intended?
• Had a persistent desire or unsuccessfully tried to cut down or control your drinking?
• Spent a lot of time in activities necessary to obtain alcohol, use alcohol or recovering from hangovers?
• Had cravings, strong desires or urges to drink?
• Failed to fulfill major role obligations at work, school or home because of your recurrent alcohol use?
• Continued to drink alcohol despite having persistent or recurrent social or interpersonal problems caused by or worsened by the effects of alcohol?
• Given up or reduced your involvement in social, work or recreational activities due to your drinking?
• Recurrently drank in situations that could potentially cause you bodily harm?
• Continued to drink even though you know you have a physical or psychological issue that was caused by or is aggravated by alcohol use?
• Found your tolerance/need for alcohol has changed in one of the following ways:
  • You need to drink more than you did in the past to achieve alcohol’s desired effects.
  • The effects of drinking your usual amount of alcohol diminished.
• Had issues with withdrawal:
  • Common symptoms of withdrawal syndrome — headache, anxiety/irritability, upset stomach, insomnia, excessive sweating, increased body temperature, confusion, racing heart, seizures, hallucinations, etc.
  • Using alcohol or another substance (ex. benzodiazepine) to avoid withdrawal symptoms.

The presence of two or more of the above criteria indicate possible alcohol use disorder. A provider can then get a general idea about severity using the following guidelines.

MILD — two to three symptoms
MODERATE — four to five symptoms
SEVERE — six or more symptoms

Let’s talk about treatment. Does it begin with a person’s primary care physician?

It certainly can. Alcohol use is among the leading causes of preventable death in the United States and primary care providers are on the forefront of preventative medicine. They can do a screening, do a brief intervention (through education) and even provide treatment for AUD. There are three medications that are approved by the Food & Drug Administration to help individuals overcome their AUD and safely recover. They can also refer to specialists and different care settings depending on the needs of the patient. WakeMed Primary Care patients have access to my services and those of my psychologist and psychiatrist colleagues here at WakeMed.

What is your approach to treatment as an addiction medicine physician?

Patients can receive outpatient treatment from WakeMed Primary Care providers. I work with hospitalized patients who come to WakeMed hospitals when they are experiencing a substance use emergency or other issue. We provide about 250 substance use consults at our hospitals each month.

What is the biggest factor for success? 

The patient must be motivated to cut down or quit and those reasons need to come from within. It’s a dramatic lifestyle change — one that is very difficult to make. We use motivational interviewing to help a patient determine why it’s important to pursue sobriety. Reasons can vary from living health to saving a relationship; addressing legal issues; navigating financial issues — you name it. Everyone is motivated by different things. We need to first find those motivators and develop a plan.

Those who have an alcohol use disorder cannot stop drinking on their own, and it is interfering with their life. Treatment typically involves a combination of medication and therapy. Medications used to treat AUD include naltrexone, acamprosate and disulfiram. It is extremely important to work with a physician, particularly in the case of severe addiction. Serious side effects of withdrawal — seizures, spikes in heart rate and blood pressure, hallucinations — can be life threatening.

A provider can also determine the best approach to therapy for a patient. Some patients may benefit from a stay in a mental health hospital for intensive inpatient treatment and then move to a residential facility — often called a “sober house”  — where they receive intensive outpatient therapy with and without others who are going through the same thing. Others can receive individual and group therapy without a stay in a mental health hospital or residential facility. It varies widely and a patient’s needs may change throughout their recovery. Afterall, there is no cure — only remission — but that remission can last a lifetime with the right care.

How can people access mental health experts like you?

As I mentioned, WakeMed Primary Care patients can access adult and pediatric outpatient mental health providers through their primary care physicians. WakeMed also has a great relationship with many outpatient community mental health providers through the Network for Advancing Community Health (NABH) and being a WakeMed Primary Care patient is not required to see these providers. Many of these providers also offer mental health urgent care, which is the right choice for people experiencing non-life-threatening mental health crises — more appropriate than a hospital emergency department.

A referral from a mental health or medical provider is typically needed for access to mental health hospital stays. Our area really needs additional mental health beds to support our growing community and we look forward to the opening of the new 150-bed WakeMed Mental Health & Well-Being Hospital in the coming years.

There are several routes to take to get the care you need. Do not give up. 

Additional resources include:

• Call or text 988.
• Visit the Alcohol/Drug Council of North Carolina website.

What about support programs like Alcoholics Anonymous (AA)?

AA is a decades-old, peer-run organization that provides lots of literature and support for people with any relationship to alcohol that they want and need to change. It’s outstanding, and, since the pandemic, there are great opportunities to participate in meetings either online or in-person. We recommend it to our patients as part of their recovery plan. There’s a meeting going on somewhere in the world 24 hours a day, seven days a week. Many of our patients develop a lifetime relationship with AA and the people in their community; others find the conversations that go on at meetings to be a trigger and do not benefit from them. As is true with recovery from any illness or injury, one size does not fit all. Everyone who is in recovery should at least try AA meetings for a while.

Why are people hesitant to seek treatment for issues with alcohol?

A lot of it is stigma and that stigma is costing people their lives. People wouldn’t hesitate to seek treatment for a serious medical issue, but they feel that admitting they have an addiction to alcohol or other substances shows their weakness. The fact of the matter is, once individuals become physically dependent on alcohol, they must seek medical help to safely quit. 

Don’t be embarrassed. Don’t be afraid. Talk to your doctor, pastor or someone you trust and connect with professional help.

Christopher Thompson, MD, is an addiction medicine physician with WakeMed Mental Health & Well-Being. He received his medical degree in family medicine and completed fellowships in both palliative care and addiction medicine.

WakeMed Mental Health & Well-Being services, programs and people bring together professionals from WakeMed and throughout the community to reduce the stigma surrounding mental health and serve the inpatient and outpatient mental health care needs of adults and children in our area. 

Sources

NIAAA. (2022). Surveillance report COVID-19: Alcohol sales during the COVID-19 pandemic. https://pubs.niaaa.nih.gov/publications/surveillance-covid-19/COVSALES.htm

Rodriguez, L. M., Litt, D. M., & Stewart, S. H. (2020). Drinking to cope with the pandemic: The unique associations of COVID-19-related perceived threat and psychological distress to drinking behaviors in American men and women. Addictive Behaviors, 110, 106532. https://doi.org/10.1016/j.addbeh.2020.106532

Schmidt, R. A., Genois, R., Jin, J., Vigo, D., Rehm, J., & Rush, B. (2021). The early impact of COVID-19 on the incidence, prevalence, and severity of alcohol use and other drugs: a systematic review. Drug and Alcohol Dependence, 228, 109065.