We Need to Talk About Your Drinking

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Is alcoholism less serious than other addictions? Is my husband’s drinking out of control or am I just being a nag? What should I expect when my fiance leaves a faith-based treatment program? This week, Nzinga answers listener questions on alcohol and offers tips on how to define an alcohol use disorder, how to talk about it with your partner and how to take care of yourself during a time when drinking feels like a necessary escape. 

Please note, In Recovery contains mature themes and may not be appropriate for all listeners.

Show Notes 

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Here are some of the resources from Nzinga:


[00:54] Dr. Nzinga Harrison: Good morning, afternoon or evening, depending on what time you’re listening. I’m Dr. Nzinga Harrison and this is In Recovery. For those of you who may not know who I am or are listening to this show for the first time, I am a physician, a psychiatrist and an addiction expert. I’ve dedicated my life to taking care of people with addiction, and so much so that I’m co-founder and chief medical officer of this objectively amazing company called Eleanor Health. This show In Recovery is a question and answer show. So you send in your questions and I will give you answers about all things recovery from my own personal experience as a support system, from my professional experience as a physician and a psychiatrist and an addiction expert, from a human experience as a mom and a wife and a sister and a friend. So we need your calls. Please send in your calls about all things addiction. So that’s alcohol. That’s opioids. That’s other substances. That’s also sex and gambling and exercise. Anything that you feel like is having a negative impact on your health or your mental health. Call us. The number is 833-453-6662.


[02:31] Dr. Nzinga Harrison: This week, we’re talking about alcoholism. So before we jump into alcoholism, Claire, I wanted to follow up because at the end of last episode on work, you and I made the commitment to be each other’s work accountability buddies. And we said, I’m going to leave work by this time on Friday. And this is the most work I’m going to do over the weekend. And we were supposed to check in with each other today to see how it went. So, how did it go? 


[02:56] Claire Jones: I would say it went pretty well. I didn’t take any breaks. All of last week was like, I’m working straight through, but I’m actually staying with some friends in Colorado. And everybody has been climbing every day. And so usually when I’m done with work, I will go and drive to wherever they’re climbing. And because the sun doesn’t set until like 9:00 now, I am able to go outside and get a couple of climbs in, which feels really good. That has been very relaxing. And so I think when the work is happening, it’s really intense. But because you and I have been talking about it, and I notice — I think we talked about this last week. There was one night where I was like, OK, it’s like 5:30. I could start this one really short project and just get it done so I don’t have to do it tomorrow. But then I was like, realistically, if I do that, I will be working until 6:30, so then I was like, no, it doesn’t have to happen today. I can do it tomorrow. It will be fine. How has it been going for you?


[03:59] Dr. Nzinga Harrison: I would say the same thing. So definitely Friday when you texted me and it was like we should be getting up from work now. I was like, yup, getting up and did not. Full disclosure. So I probably worked till like 8:30 on Friday and then I worked all day Saturday, like, forget it. But then Sunday was amazing because it was Father’s Day. And so I think our listeners can probably relate to this, that it’s easier to honor a commitment that you’ve made to somebody else than maybe it is to honor the commitment you made to yourself. So I did not work at all on Sunday, period. At all. Because it was Father’s Day. Mm hmm. We play Guitar Hero with our whole family band. We ate like tons of food and watched a movie. It was amazing. And it was so easy. I didn’t even think about work. But if we hadn’t kind of been in, quote, celebration, I probably would have been checking my phone and thinking about it. So I guess one thing I will encourage us to do is to know that we don’t have to have some external reason to control our workload. We can control it just for our own health and happiness. Awesome. All right. So keep me on the up and up, accountability buddy. And let’s jump into alcohol, shall we?


[05:21] Claire Jones: We shall. So I’m going to start off with the same question I always start off with. Tell me a little bit about the stigma around alcoholism. 


[05:30] Dr. Nzinga Harrison: Yes, the stigma around alcoholism is actually quite high. As you may have guessed, as you may have experienced, certainly as our listeners have guessed and experienced, and I think this stigma is really associated with this idea of “the alcoholic.” And so even as I say and, you know, I put that in quotes because that’s not the way that I talk about people. But even as we say, “the alcoholic,” that is automatically conjuring up an image in the brains of all of our listeners. And so to the work that we do on this show, hopefully every week, I don’t want you to judge yourself for whatever image that just conjured up for you. But I do want you to take an awareness of the image that that conjured up, because the typical image that that conjures up is maybe a homeless person who doesn’t have a job, who’s walking down the street in dirty clothes with a bottle and a brown paper bag outside the liquor store.


[06:35] Dr. Nzinga Harrison: And that is not what the definition of alcoholism is. There’s for certain a set of people whose alcohol use disorder gets so severe that it leads to that image. But overwhelmingly — and so this is interesting. I want to say I was in residency training when this statistic came, like across whatever, somebody told me about it. And this is old language because, my friends, this was a long time ago. It said less than 10 percent of people with alcoholism are on ”Skid Row.” And so that image that I just described, which is the common image when you hear the word alcoholic, is that, quote, “Skid Row” image. Less than 10 percent. The other 90 percent are going to work everyday. It’s what you would conjure up if I “functional alcoholic.” And so the distinction that is being made there by people is like, oh, functional alcoholism is somehow better than not functional alcoholism. But the truth of the matter is that dysfunction is part of the definition of the diagnosis of alcohol use disorder. And so what I’ve spent a long time telling folks is, again, breaking down that barrier between us and them. It’s like, there is no “functional” alcoholic, because dysfunction is inherent in the definition of that. And the way we’re using that is to say, well, at least I’m not that person. At least I go to work every day. At least I pay my bills. And it’s kind of decreasing the scariness of accepting that alcohol may be a problem for me. And so as we talk about alcohol throughout this episode, what I want to remove from the stigma is the same thing I say every week about everything that we talk about is just like, let’s recognize if a person, whether that’s yourself, whether that’s somebody you care about, whether that’s a coworker, you see that person drinking alcohol and having negative consequences from it, that we cannot put any judgment on that and just say, like, this is a mild, moderate, severe illness and these are the interventions that we have that we know work. 


[09:07] Claire Jones: That actually makes me think of one of the first questions that we got, which comes from Jackie, who as many of you may know, is a producer from Last Day. And she left us a voice memo asking a question that came up a lot while she was producing Last Day. So let’s play that really fast.


[09:27] Jackie: This is Jackie. I’m calling because I’ve had a question for a little while now that came up a lot when we were producing season one of Last Day, which is is alcoholism less serious than other addictions? Because when we were dealing with the opioid crisis, a lot of things come up, whether it’s AA teachings or just different stories coming from self-identified alcoholics. And it never was quite clear how much these two things had in common. And if a conversation about alcoholism really even belongs in a conversation about the opioid crisis. So that’s the overall question: is alcoholism less serious than other addictions? And is alcoholism itself fatal? Is the withdrawal from it deadly? I’m definitely interested in anything Nzinga has to say about this. So thank you very much. Looking forward to hearing your answer. Bye. 


[10:20] Dr. Nzinga Harrison: So Jackie snuck in about 10 questions in that voicemail, which was amazing. I encourage all of you guys listening, like literally call us and sneak in all 10 of your questions, because that’s the whole point of the show. So at a high level, Jackie’s question was, is alcohol use disorder more dangerous than opioid use disorder? And I’m going to answer this from a couple of different angles. The first angle is that like all illnesses, these illnesses come in mild, moderate, severe. So I could be, like, very nuanced about it and say, yes, there’s an opioid use disorder mild that is not as deadly as an alcohol use disorder severe. Or I flip that and say there’s an alcohol use disorder mild that’s not as deadly as an opioid use disorder severe. So I want to make sure that although I’m about to answer this question in black and white, the answer to that question is not black and white. The way I’m going to answer this question is based on the number of people in the United States who die each year from alcohol-related illnesses or opioid-related illnesses. And so I will say the number one substance that kills people each year in the United States is actually cigarettes and tobacco. 480,000 people died in 2017 alone from cigarette and tobacco related illnesses. So just short of half a million people. 


[11:58] Dr. Nzinga Harrison: When we look at alcohol, alcohol is coming in number two. And that’s a big surprise to a lot of people that alcohol is number two for substances that are killing people. So alcohol-related illnesses accounted for about 88,000, dramatically less than cigarettes and tobacco, although interestingly, we don’t heap the same stigma on cigarette smoking that we do on alcohol use disorder or opioid use disorder. And then finally, opioids are coming in at number three at about 70,000. So if you use that metric, you would say cigarettes and tobacco are the deadliest substance we have in this country, followed by alcohol being number two, followed by opioids being number three. That’s the black and white answer. The second grayscale that I’m going to give you, Jackie and everyone else who’s listening to this answer, is that you also have to look at the number of people that have a cigarette tobacco disorder and alcohol use disorder or an opioid use disorder. And so when we look at the number of people, and look at it relatively, opioids are relatively more deadly than alcohol use disorders just because a lot of people are using alcohol and 88,000 are dying. And a way smaller, about one-tenth of that are using opioids. And it’s still getting close with 70,000 compared to 88,000. So I think this is kind of like when you get into trauma wars like this, trauma was worse than that trauma. I don’t think we have to think about it that way. All of these substances can be deadly if a person develops a use disorder. And so what I want us to do is — because this is part of alcohol being legal, this is part of alcohol being an intimate part of our culture here in the United States — is that people realize that opioids can be very dangerous and they will kill you tonight. And people don’t necessarily realize how dangerous alcohol can be. And so I’m hoping that’s kind of like — I felt like that was the intent of your question, Jackie. And so if I got that intent right, I would like to magnify that intent. Alcohol can be very deadly. As a matter of fact, it is number two deadly in the United States behind cigarettes and tobacco. 


[16:45] Claire Jones: So, going off of what you just said about how a lot of people don’t necessarily know how dangerous it is, we had somebody write into the In Recovery email. They want to remain anonymous, but they say, “For 29 days I watched my then-fiance fight with everything she had through detox following an initial hospitalization for liver failure. For the first 10 days in the ICU, I left the hospital each evening, uncertain if she would make it through the night. I met dozens of nurses and specialists, including a transplant doctor that gave her exceptional care. Long story short, she fought so hard to the point that she was discharged in mid-February. Five days later, after some things surfaced during an impromptu intervention, I had to ask her to leave. Many have told me that addicts and alcoholics are all the same: liars, cheats and thieves. The web of lies spiraled out of control. She’s been my best friend for almost a decade and we were to be married this July. And yet, as angry and hurt as I was in the immediate weeks after her departure, this is a person worthy of a second chance at life and love as well. Two weeks after she left, she notified me that she was checking herself into a women’s health facility in Nevada that requires a one year commitment. Despite her flaws and her struggle with alcohol, she’s the love of my life. the person I chose. And while we needed this time apart to work on ourselves, she would not have to hit her rock bottom had she stayed. Here are the two questions: what might I expect out of her completion of a program which is heavily faith-based? And if she and I are able to rekindle our intimate relationship, how can I, as a partner, assist her in her recovery process? What should a partner’s role be to set her up for success and to start the relationship up for success?”


[18:23] Dr. Nzinga Harrison: Thank you so much for sending this question in. So first, I want to talk, before I start talking about your fiance directly to you. And just say I can hear your pain and I can hear your struggle and I can hear you trying to be hopeful through that pain and that struggle. And so the first thing I would say is, I need you to get some support for yourself. Just like when you have a fiance with cancer or who has a stroke or in older age develops Alzheimer’s, and we see the illness stealing that person from us, that is excruciating and awful and painful. But it is easier when the symptoms are physical to be able to see that that is the illness and not the person that has the illness. And so as angry as we get, and as hurt as we are, and as much as it’s tearing us apart, we can direct all of those feelings at the illness rather than the person. With alcohol use disorder or alcoholism, that’s a lot harder because, like you said, the symptoms, which, lying can be a symptom of alcohol use disorder, returning to alcohol use after a period of sobriety is a relapse of the illness. Like not the person that relapsed. Feeling like you can’t trust your fiance. All of those are symptoms of the illness. But because they’re emotional and because of their interpersonal and because they’re thinking and because it’s in the relationship space between you, it can be really hard to tease apart what are the symptoms of the alcohol use disorder versus who your fiance is? And so I was encouraged to hear when you said she never felt worthy of being loved. She is, and I do. That was so beautiful to me because even through your pain, you see she’s a beautiful person. You love her. She is worthy. She has value. 

But she has an illness that is severe and that almost killed her just now. And that will, without ongoing longitudinal care, will almost, if not kill her again in the future.


[20:45] Dr. Nzinga Harrison: So, number one. Number one. Number one, I want you to get some individual support in place for yourself. I’m talking about you go get a therapist for yourself. I want to drop you two resources right now as a place where you can start. Number one is Eleanor Health actually offers free online support groups, no commitment, no costs, no nothing for family members and support systems to help with this work. So you can go to EleanorHealth.com and join one of our free family support groups. WeTheVillage.co is an entire online community that is dedicated to supporting loved ones of people with addiction, because we know this path is so difficult, and we know that you need your own support and recovery, even separate from hers. And then the third is YouTurn.net, which has a lot of video content that helps loved ones understand the illness of addiction and alcoholism. So put that support in place for yourself, because the work that I want you to start doing is being able to direct this hurt and the struggle and this pain that comes from having a loved one with addiction. I want you to be able to direct that at the illness, not at your fiance. Number two, in terms of what you might be able to expect out of her upon completion of her program, which is heavily faith-based, I know you’ll be able to expect that she is not cured. OK? Alcohol use disorder is a lifelong disorder, just like diabetes, just like high blood pressure. Once you have it, you have it.


[22:38] Dr. Nzinga Harrison: And even when your symptoms are under control, that does not mean you don’t have the illness. And that does mean that any number of factors — biological factors, illness, stress, life, any of these things can lead to your symptoms coming back. And so when she finishes this one-year commitment at this women’s health facility, you want to make sure she has ongoing care, because, one, she’s still going to be early in remission of that substance use disorder. What we know is that her risk of relapsing to alcohol — and I’m sorry. Let me say that again. And I need to correct my own language because it’s not your fiance who is going to relapse. It is your fiance’s illness that is going to relapse. So if her alcohol use disorder relapses, we know the risk of that does not fall to the risk of the general public for five years after that alcohol use disorder is in remission. So if you had this idea that she would finish this year and we would be done with it, I want to throw that idea out the window. She has severe alcohol use disorder. This is going to be life long, because even once she gets to the five years of remission — I’m gonna go ahead and name that and claim that for y’all, OK? Once she gets to the five years remission, there is no point at which the risk of relapse falls to zero. And so from that point then it’s maintenance and it’s relapse prevention forever, just like a person with diabetes. I can control your blood sugar for five straight years, but if I stop your insulin and feed you red velvet cake and sweet tea, your blood sugar is going to go up. We know that red velvet and sweet tea are triggers for blood sugar. And so what we’ll need to find for your fiance is what are those triggers that can drive her to drinking? 


[24:39] Dr. Nzinga Harrison: The other thing I want to make sure — because when you say she never felt worthy, this to me is a person that I absolutely want to evaluate for depression, anxiety, childhood trauma, other issues that drive an alcohol use disorder relapse. So even if they’re not giving that to her in the context of the program that she’s in, one, they should be, OK? So any alcohol treatment that does not include an evaluation and treatment for depression, anxiety and trauma is not an effective treatment. So she needs to get evaluated for depression, anxiety, trauma, childhood experiences, other psychiatric needs. Those need to be treated at the same time. Because it’s the same way high cholesterol increases your risk of having a heart attack. If you don’t treat the cholesterol, the risk you will have a heart attack is going up. If you have untreated depression, anxiety, trauma, childhood experiences, the risk that that alcohol use disorder is going to relapse is going up. So longitudinally, I want her evaluated for that. I want her treated for that. And then often — again, I don’t know the program that she’s in, but often programs that are heavily faith-based are sometimes much lighter on the biological intervention. So I’m talking about medication for alcohol use disorders. And so I would absolutely want her evaluated. Her illness is severe such that I would be trying to pull out every single weapon from my tool box against this alcohol use disorder. So I would want to see her on a medication for alcohol use disorder specifically. I would want to see her on a medication for any depression, anxiety or other mental health need that is going there. I would want to see her in individual therapy ongoing for the alcohol use disorder, relapse prevention, the depression, the anxiety, dealing with anything else that might be driving that illness. I will want to make sure from a biological perspective, that she’s seen a gynecologist, that she has a primary care doctor because if she has thyroid issues, guess what? That can drive risk for relapse about alcohol use disorder. 


[27:01] Dr. Nzinga Harrison: If she has abnormal menses and unusual menstrual cycles, the hormonal load on emotions that come with that can drive a risk for relapse for alcohol use disorder. And so we have to take a 360 degree view of her. And then socially, I’m bringing it back to you, awesome fiance, who cares so much about this woman that you left us this message on email. Socially, we have to figure out how your relationship can start to mend, if that’s what both of you want. And part of that, again, is your own individual work. But part of that, you guys have to be in couples therapy, family therapy, because you have to get to the point where both of you can be angry at alcoholism without that making you angry at each other. And that is easier said than done. So that was a long answer, but I hope that it was helpful.


[28:00] Claire Jones: OK. So I heard you mentioned medications. I didn’t really know that those existed. What are some examples of medications that work for alcoholism? 


[28:09] Dr. Nzinga Harrison: Whenever I talk to people about MAT, they usually think I’m talking about MAT for opioids. And I always say we have FDA-approved medications for opioids, alcohol and cigarette/tobacco. And so to talk about the FDA approved medications we have for alcohol use disorder/ For anybody like the fiancee that I was just talking to that has their own severe alcohol use disorder or knows someone with it, medication should be part of the consideration. And each person can make their own decision. but it’s the same way — like you always hear me say — any person with severe diabetes, medication is always part of the discussion. So the same should be true for alcohol use disorder. And so we have a few medications. I’ll start with the most commonly used medications. There are — I’ll call it three. So the number one is a medication — I’m not saying this is the number one most commonly used, just the first one that we’re going to talk about is a medication called Naltrexone. So you may have heard of Naltrexone because we also use Naltrexone for opioid use disorder. But what the research studies show us is that alcohol use disorder is also responsive to Naltrexone. So people that take naltrexone have decreased cravings, decreased heavy use of alcohol, decreased risk for relapse to an alcohol use disorder once in remission. Naltrexone is a tablet. You can take it everyday. So I use a lot of Naltrexone. I’ve had a lot of success with my folks that I helped to get prescribed Naltrexone. Naltrexone also comes in an injection which is called Vivitrol. 


[29:56] Dr. Nzinga Harrison: Also FDA-approved for opioid use disorder, FDA-approved for alcohol use disorder. So, Vivitrol, you take once a month and it’s the same medication that’s in the oral naltrexone. And same thing: decreased cravings, decreased risk of relapse to alcohol use disorder, decreased heavy drinking days for people who are still drinking. This is important because remember, complete and total abstinence is not every person’s goal, but not being sick from alcohol use disorder, not dying from alcohol use disorder, not having alcoholic liver damage from alcohol use disorder typically is within people’s goals. So even if we’re not benchmarking to complete abstinence, starting Naltrexone or Vivitrol gets us closer to that goal.


[30:57] Dr. Nzinga Harrison: A second medication — so I group those even though it was two different ones, I group them into one because they are both naltrexone — a second medication is called Campral. The generic name for Campral is Acamprosate. It’s a little bit harder to take than Naltrexone just because it’s dosed three times a day, and the recommended dose is two capsules, three times a day. So that’s like a high pill burden. But for my people that get good results with Acamprosate, they swear by it. They’re like, I started my Campral, I was craving all day, every day. This has taken my cravings way down to the point that I cannot resist a craving and not take a drink when it comes, like, have time to think about what triggered it. Put my safety plan in place. Call my accountability buddy, Campral basically creates the space for that work. So Campral is another option. The third one is gabapentin. Gabapentin is a seizure medication. And then we found that, oh, man, this is great for, like, nerve pain. Then we were like, oh, snap. This also works for anxiety. And then because it works on this chemical in the brain, which is gaba, which is the same receptor where alcohol works in your brain. It was like, could this have a use in alcohol use disorder? And the answer turned out to be yes. 


[32:17] Dr. Nzinga Harrison: So we use gabapentin to help with alcohol withdrawal, with alcohol detox, with ongoing treatment, to reduce cravings, to reduce anxiety that could be driving relapse. So gabapentin is definitely a medication that should be considered. And then Antabuse. I know you listeners are like, well, I know this girl didn’t just say Antabuse. Yes. Antabuse is the oldest medication that we have for alcohol use disorder. And it has a bad rap because if you take Antabuse and then you drink while you’re taking Antabuse, you literally get so sick and you can die, OK? So if I prescribe Antabuse for a person, which I definitely have, I’ve been practicing addiction medicine for 20 years. I have not prescribed Antabuse in, I want to say maybe like eight or nine, but it is a perfectly good option. But I definitely have to like, give the disclaimer upfront to people. Like your consent is that you understand if you drink alcohol while you’re taking Antabuse, you could get so sick your heart could collapse, you could die. Like cardiovascular collapse. But the idea of Antabuses is that because, you know, you will get sick, that is supposed to be a deterrent to taking the drink. I have had patients that I’ve taken care of over the last 20 years that are like, yes, I hear you on all of those other medications. The medication that works for me is Antabuse. And for that person, I am going to prescribe Antabuse. It is not my go-to, it is not my number one choice, but if a person that tells me this is what has kept me from dying from my disease of alcoholism, then trust and believe Dr. Nzinga Harrison believes in that person’s experience. 


[36:16] Claire Jones: OK, so our next question is from a woman named Jessica, who sent us an email that says, “Dear Dr. Harrison, I’m really struggling to have a proactive conversation with my husband about alcohol. I grew up with multiple self-identified alcoholics in my immediate family, so that definitely impacts my perspective. Here’s the situation: my husband has at least three to five drinks a night when there’s alcohol in the house. A large bottle of liquor never lasts more than a couple of days. Since quarantine, I’ve had times where I would like to have a couple of drinks, but I know that we rarely share equally. He’ll keep drinking after I go to bed. The problem is that he doesn’t see this as a problem. He doesn’t get intoxicated. He doesn’t have hangovers. So he’s not experiencing the negative consequences typically associated with addiction. The only negative is me. I’ve brought it up several times and tried to convey that this is triggering because of my childhood experience with people who drink. So do I have to stop drinking because he’s becoming a problem drinker? Do I have to go back to Alanon on our marriage counseling? Or am I actually creating a problem that is not really there?”


[37:18] Dr. Nzinga Harrison: Thank you so much for asking this question, because you are not alone in this. And I always like to start out with that because, you know, we put a lot of stigma on alcohol and substance use disorders, and we force ourselves into thinking that we’re on an island, when really so many people are going through this. I want to start out with your question. Are you creating a problem that’s not actually there? And I think this goes back to what we talked about at the top of this episode, which is this concept of what a “alcoholic” is. And so I’m going to answer this from a couple of different ways, academically, and then I want to roll more in to kind of just like supporting you after I can lay that on this educational foundation. So, one, the World Health Organization, the WHO, you’ve heard of them because of all this coronavirus business that we’re dealing with and they’re on the forefront of educating us on that, along with the CDC, tells us that heavy drinking, which is associated with psychological and physical consequences over time, for men is defined as more than 14 drinks per week or more than four drinks at once. So, no, you’re not creating a problem where there is not one, because if your husband is drinking four to five drinks per night, let’s just say he’s doing that five nights per week, not even all seven, then he’s as high as 25 drinks per week, which is almost double the threshold that we use to define heavy drinking, because that level of drinking has been associated with physical and mental health problems. So, no, you are not creating a problem where there is not a problem. So let me give that information because everybody’s person is not male. So for females — and sorry that this information is gender binary, this is how we have it in the medical literature right now — it’s greater than 14 drinks per week or four at once for males. For females, that goes down to greater than seven drinks per week, or more than three drinks in one setting. So more than three drinks in a setting for a woman is considered binge-drinking, and more than four drinks in a setting for a man is considered binge-drinking. So language differently, your husband is actually binge drinking several nights per week. And so your wifely-spidey senses are spot-on. And even more than your wifely-spidey senses, I heard you say this comes from my experiences as a child and growing up. 


[40:19] Dr. Nzinga Harrison: And so you have what is probably a fuller concept of what it means for alcohol to be causing problems than a lot of folks here in the United States. So, no, you’re not pulling this out of the air. The other place that I want to — I’m gonna take you to more educational resources, and then I’m going to try to help you figure out how to have this conversation with the hubs. The other is the criteria that we use for alcohol use disorder. So you’ve heard me refer to the DSM-5, our Diagnostic and Statistical Manual that behavioral health clinicians use to make our diagnoses. And you can look up the DSM-5 criteria for alcohol use disorder. This is where I want to drive home the concept that we have of a person with alcoholism. Alcohol use disorder, like the rest of our illnesses, comes in mild, moderate, severe. And the way we define that is by the number of criteria that a person meets. So we have 11 diagnostic criteria in the DSM-5. And one of the criteria is continued alcohol use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of alcohol. So you have to meet two criteria to get to a diagnosis of mild. Just one criterion doesn’t do it. But the fact that that is criteria number seven, persistent interpersonal problems, just by virtue of the fact that you and your husband are having arguments, marital distress, emotional pain over alcohol means that alcohol is a problem, even if he doesn’t get to a number two criterion on this list. At Eleanor Health, this is what we will call rising risk for an alcohol use disorder.


[42:23] Dr. Nzinga Harrison: Even if he doesn’t meet another criteria, the fact that he meets one means it is time to do something, because even if he only meets one right now, that is at risk that he will meet two, three, four, five later. And so you are taking the right approach to try to address this early before it turns into the scary experiences that you had when you were younger with people that had alcohol use disorder. So to quickly go through the rest of them. Number one: alcohol is often taken in larger amounts or over a longer period of time than was intended. So this is oh, I’m going to go to the bar after work with my boys. I’m going to drink a couple of drinks, but then ends up drinking five or six drinks, is too drunk to drive home. Number two: there’s persistent desire or unsuccessful efforts to cut down or control alcohol use. And so I think I heard you give me this criteria when you said he has stopped drinking before to resolve your stress about it, but that he has gone back to drinking. That would qualify for number two. If that’s the case, then your husband has met two out of the eleven criteria. So I know that I’m dealing at least with a mild alcohol use disorder. Number three is that a great deal of time is spent in activities necessary to get the alcohol, use the alcohol or recover from its effects. I don’t think I heard this from you because you said he’s not getting drunk. He’s not hungover. So it sounds like probably number three is not a criterion that he meets. Number four is craving or a strong desire or urge to use alcohol. I don’t have this information directly from you, but I think we probably will meet this criteria because he’s drinking four to five drinks every day. And so my anticipation is that he’s probably thinking about those drinks, waiting for the day to get late enough where he can have those drinks. And that would qualify for a number four. Number five, recurrent alcohol use resulting in a failure to fulfill major role obligations. 


[44:30] Dr. Nzinga Harrison: Our major role obligations are spouse, parent, employee, friend, sibling. So that sentence goes on to say at work, school or home. And so one of his major role obligations is to create an environment where you feel safe as his wife. I would count number five as positive for your husband, because as a result of the amount of alcohol that he’s drinking, he’s creating what feels like an emotionally unsafe environment for you. And that satisfies criteria number five. So we’re up to three for your husband. Number six, continued alcohol use despite having persistent recurrent social interpersonal. We already did that one. So you already know when I’m thinking on that, I think we meet it. So we’re up to four criteria. Number seven, important social, occupational or recreational activities are given up or reduced because of alcohol use. I don’t have this information from you, but you know the answer to that question. And for everybody else who is listening and who is ticking down, the reason I’m going through each of these and giving examples is because I want you ticking down this list for yourself. And I want you taking down this list for somebody that you’re concerned about. Because I think we don’t necessarily always know the point at which it becomes an alcohol use disorder, which is why this listener asked this question in the way that she did, which was, am I making this up? 


[46:04] Dr. Nzinga Harrison: Criterion number eight: recurrent alcohol use in situations in which it is physically hazardous. And so the most common one we think about there is drinking and driving, but also depending, this is different, right? If you’re a surgeon, then I’m gonna reach number eight before I reach number eight for a person who’s maybe a marketing professional that is on video conferences all day. So that person can drink on the job, and that’s not necessarily physically hazardous the way it is if a surgeon is drinking on the job, right? Number nine: alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely caused by or worsened by alcohol. Number 10: tolerance. So tolerance is you need to drink more and more and more and more to get the same effect. or the opposite side of that same coin, if you drink your regular amount, you don’t feel it the way you used to. And so I think your husband probably has tolerance because it’s unusual that a person comes out of the gate being able to drink five drinks and not get drunk. And so I think he’s meeting the drinking five drinks is no longer giving him a feeling of intoxication that will qualify for tolerance. So we’re up to five criteria for your husband. Number 11: withdrawal manifests when you get sick when you stop drinking or you drink so that you won’t get sick. Doesn’t sound like your husband is experiencing that. 


[47:33] Dr. Nzinga Harrison: So it sounds like we have at least four to five diagnostic criteria, and the way we determine mild, moderate, severe is that you have to have two criteria to even get a diagnosis. So if you have one criteria, then we are what we’re calling rising risk. We still need to do something about it because we want to prevent you, just like a heart attack. We want to change your nutrition and your diet before we get to the heart attack. So same thing here. We want to change things before you get to a diagnosis. If you meet two to three criteria, and that’s considered mild. If you meet four to five, that’s considered moderate. If you meet six or more, that’s considered severe.


[48:15] Dr. Nzinga Harrison: Now, that’s a lot of work going through all 11 of those criteria. That’s why you come to me, an expert. But there is a shorter inventory. It’s called the CAGE. All of us learn it in medical school. We have put the CAGE on Eleanor Health’s website. And so, Claire, I’m going to point you to that because you actually can answer these four questions about yourself or about somebody you’re concerned about. And if the answer to only one of those questions is yes, there is a significant risk that you or that person either is at rising risk for alcohol use disorder or has alcohol use disorder, mild, moderate or severe. And we’ll give you some guidance for how to get help after that. 


[49:04] Dr. Nzinga Harrison: So I did want to give you just a little support on how to approach this conversation. It’s similar to what I talked about in the previous episode when the mom asked us the question about how to talk to her kid because she was worried about his marijuana use. I want you to try to take the same approach here, which is that I’m worried about you. I’m not trying to nag you. I listened to this podcast, and she said more than 14 drinks a week for a man is associated with long-term physical health problems. And I’m trying to prevent us from getting there. I feel alcohol creating space between us, and I don’t want that space between us. And so I want to be supportive to you. I don’t want to create something where there’s nothing. But I want you to know there’s something because I’m worried. I’m worried about you. I’m worried about us. And I want us to be on the same team for how we approach this. And then send him to Eleanor Health’s website and have him take the CAGE. And then see how the conversation goes from there. Because often when there’s an external resource that gives an objective piece of information, like over and over and over the 20 years I’ve been taking care of people, family members have been saying, “I’m worried about you, I’m worried about you, I’m worried about you.”


[50:19] Dr. Nzinga Harrison: And then they come to me for something else, or they go to their primary care doctor and the primary care doctor draws a set of labs and the liver enzymes are just a little elevated. And the primary care doctor says these liver enzymes are elevated because of your drinking. And when you’re drinking more than 14 drinks per week, that’s what leads to your liver screaming out for help. And that one objective piece of information can often make that change for people. So that he has tried to stop in the past in response to you sharing, you know, the pain that it’s causing you is a very, very, very positive sign. And the other part of it is if your husband has alcohol use disorder, and from our walk through the diagnostic criteria, it’s possible that he does. I have not evaluated him. I cannot say what your husband has or does not have. But the risk we know is definitely there. If he has it, the same thing I said earlier in this show: this is an illness. This is not your husband. And part of the illness, it is in the brain. It is the brain where this illness starts, but it’s also the brain that tells us when we have an illness. So part of the reason people with alcohol use disorders and other addictions don’t see that they have the illness as quickly as we see it from the outside, is because it’s the brain that has the illness and it’s the brain that you’re asking to recognize that it has an illness. 


[51:49] Dr. Nzinga Harrison: And so I just want you to try to keep that information to help you create some space and some compassion for understanding what your husband might be experiencing on the other side when he hears you saying, “I have a concern.” We don’t know how that information is landing on him, because if there is an illness here, it’s his brain that has that illness. So get some support for yourself. Try to get an objective piece of information, I’ve shared a lot of them with you that you can share with him. But above all, approach it with him like this is space between us that I don’t want to be space between us. So how do we tackle this?


[52:30] Claire Jones: I think that’s a wrap.


[52:34] Dr. Nzinga Harrison: All right. So what am I going to say in closing? Claire always asks me to be wise right before we close the show. So let me see. How can I be wise? What I have known from a little kid, but which I figured out after I became a psychiatrist, and so I’ve been telling kind of like my physician origin story. And the physician origin story is I didn’t have doctors in my family, but I was in love with the human body and physiology from a very young age. And so at six years old, I decided to be a doctor. And part of that was because I didn’t feel like my pediatrician was a good doctor. Now, I clearly had no medical expertise at the age of six, and I have no idea what I was basing that on. But then I got this surgeon for my scoliosis — you’re like, oh snap, she’s sharing all her protected health information. Yes, you can have it all. I had scoliosis when I was 12 and I got this surgeon and he was amazing. 


[53:38] Dr. Nzinga Harrison: And what I realized was amazing about him was that he talked to me. He cared about my experiences. He’d spent time to invest in a relationship with me, even though we only spent every three months together for an appointment. And every time I came in, it felt like he knew me as a human being separate from the scoliosis, which was the illness that I had. It was at that point, I was like, this is what was different about that pediatrician, because my pediatrician never talked to me. He only talked to my mom. And I felt invisible in the room, even though they were talking about me. And so my words of wisdom are whatever it is, whether it’s alcohol or other drugs, some other addiction, something that has nothing to do with health, like whatever it is, just try to make sure you’re seeing the person that you’re talking to, and that they know you see them, and that you’re investing in the relationship no matter what else is going on, that they know they’re important enough to you to invest in the relationship even when it’s painful. Those are my words of wisdom. 


[54:55] Claire Jones: Oh, those are great words of wisdom. I knew that you would come through with that. 


[55:07] Dr. Nzinga Harrison: In Recovery is a Lemonada Media original. The show is produced by Claire Jones and edited by Ivan Kuraev. Music is by Dan Molad. Jessica Cordova Kramer and Stephanie Wittels Wachs are our executive producers. Rate and review us and say nice things. And follow us @LemonadaMedia across all social platforms, or find me on Twitter @naharrisonmd. If you’ve learned from us, share the show with your others. Let’s help destigmatize addiction together. 


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