Alcohol the ambiguous molecule

Alcohol the ambiguous molecule
By Griffith Edwards
Penguin Books,
ISBN 0 -14 - 026666-6, 230pp,
£7.99 (Canada $19.99)

If alcohol is indeed an ambiguous molecule to both the author and the reader, this book is anything but ambiguous. Professor Edwards has written a clear account of the enigma, which alcohol certainly is, in fourteen chapters, followed by a list of references for further reading, and an index. This book is a journey of many kinds: it takes us through history, religious and other societal attitudes, traditions and myths, the psychology of drinking, the scientific basis of what alcohol does to the drinker, the medical treatment of those who develop alcohol-related problems, and what we should expect in the future in relation to alcohol; perhaps at least a future without ambiguity. The book gives the ordinary reader a full account of what s/he needs to know about this ambiguous molecule in the simple, clear and succinct style for which this distinguished author is renowned.

The book starts with an introductory chapter, a voyage around the structurally very simple, but otherwise ambiguous, molecule of ethyl alcohol or ethanol, how its production through fermentation was discovered by chance, how the strength of the alcoholic beverage can be increased by distillation, the importance of blood-alcohol levels in assessing the effects of alcohol, why such levels vary from one individual to another, and how alcohol can be a pleasure to take in small doses, but a poison if taken in excess. The second chapter is a journey around alcohol transformed by religion and popular culture. Thus, we learn the views of the main religions on drinking alcohol, myths and lay rituals about it, that the French consider wine as their emblem, while drinking beer is very much a feature of the British, and the development of that very British institution, the pub.

The third chapter considers the history of drunkenness, the serious views the church held on it, the legislation in 1552 against it as a public offence, and finally the transformation of drunkenness as a public health issue with the introduction by Parliament of the Gin Act of 1736. In this chapter, we learn about the many types of ales (scot-ales, bid-ales, help-ales and bride-ales), we picture a vivid street scene of mass gin drinking, and learn how the founder of the Salvation Army, William Booth, described gin as the "lethe of the miserable". The fourth chapter, entitled "Thomas Nash's Menagerie" tells us about this latter author's earlier typology of drunks, including "ape", "lion", "swine", "sheepe", "mawdlen", "martin", "goate", and "foxe" or "craftie" drunks, and provides explanations of the varied and unpredictable effects of alcohol on individual behaviour.

We learn about disinhibition of behaviour, changes in temperament, cueing, and the role of culture. Professor Edwards concludes that "...Society wants drink and then has to practice the risk management of drunkenness. Sometimes, however, factors will conspire to mould the drunkenness into antisocial manifestations, and then in a moment of lion drunkenness someone may draw a dagger". Aggression indeed!

In the next chapter "Alcohol is a drug of dependence", we study four different cases to learn what alcohol dependence looks like, how the dependence progresses and what its consequences are to the individual and those closest to him or her, and find out why only a minority of people develop dependence, and learn about genetic and non-genetic risk factors.

Society, Professor Edwards says "-from the level of individual citizen to the highest reaches of government should be more aware that alcohol belongs to the class of drugs that can produce dependence".

Chapter 6 takes us on a tour of the "American prohibition experiment", an operation "poorly conceived, administratively flawed, under-funded, outmatched by the forces arrayed against it, and disastrous in its handling of public relations". A turning point came with the realization that alcohol problems are not simply the product of "drunkenness", but one of loss of control and a propensity to get drunk; "the alcoholics became good guys" and the disease concept was thus born (chapter 7). The birth, philosophy, aims, and subsequent development and success of the "Alcoholics Anonymous" movement are described in Chapter 8 and it is heartening to know that "it works for at least 50% of those who make contact with it"; a rate better than many a placebo, not to mention a few therapies in medicine.

The history of alcoholism treatment is described in chapter 9. It has come a long way from prescribing consumption of 231 lemons over exactly 29 days to the more precise and sophisticated drugs used today. An earlier and not very effective treatment involved the drug apomorphine, whose proponent was a Dr Dent. His charismatic personality was more helpful to his patients than apomorphine, leading a commentator to remark that "Dent without apomorphine would be more therapeutically powerful than apomorphine without Dent", thus illustrating the now recognised value of psychological support in therapy.

In the following chapter, we are told of the mysterious essences of treatment with a case history illustrating many fundamental aspects of alcohol dependence and the attitudes of doctors towards its treatment. The main message here is that each patient has his/her own special characteristics, circumstances, and condition and, hence, specific treatment needs, which must be addressed through a flexible, matching and unbiased treatment strategy. The origins and establishment of the idea that "once an alcoholic, always an alcoholic" are discussed in chapter 11, in which research shattering this concept, or "science triumphing over prejudice", and the feasibility of a return to "controlled drinking", at least by moderately-dependent younger patients, are reviewed.

Chapter 12 is devoted to the potential use of the alcohol "molecule as medicine". It seems that alcohol as a medicine had a full and long history, spanning from Asclepiades (131-40 BC) (a treat-all medicine), through St Paul (for stomach sake) to 19th century physicians (all fevers, diabetes, snake and dog bites and wasting diseases).

The size of the drinks bill run by the London and other hospitals became a source of worry (as it would be now!), but, more significantly, "the danger of medically-induced dependence was an anxiety which began to tell against the profession's reliance on alcohol". The medical profession could of course be excused for its reliance on alcohol as a cure-all since the days of Asclepiades, but thankfully no more after the arrival of the more specific sulphonamides and penicillin, not a minute too soon, regrettably only in the 1940's. Recently, however, the use of small amounts of alcohol as a health aid has regained popularity with the demonstration of its cardioprotective properties.

Professor Edwards assembled a hypothetical jury panel to examine the case for and against this new application, and their verdict could be that ".. for men over forty and women past the menopause, alcohol perhaps .. gives a degree of protection against heart disease". But in the light of recent findings, "what until recently looked like a firm scientific consensus that alcohol is good for the heart now goes back to being a hypothesis rather than anything near a certainty".

In the next chapter, the author considers the dilemma facing the social drinker as related to the influence that level of drinking is likely to have on his/her long-term health prospects. We are told of scientific evidence for an increased risk of women developing breast cancer in proportion to the amount of alcohol they drink, from one drink a day upwards, the increased risk of liver cirrhosis in men drinking 5 or more drinks per day and in women drinking less than these amounts, and of a range of other health risks including high blood pressure and stroke.

As well as these long-term medical consequences, we also need to remember the role of drinking in road-traffic accidents, violence, and a range of negative social consequences. In an attempt to advise people on sensible drinking, governments have introduced "sensible" or "safe drinking levels", but Professor Edwards argues that such messages are scientifically dubious and have been shown to have little impact on drinking behaviour, which has in fact increased since their introduction, not surprisingly perhaps, simply because "alcohol impairs sensible decision-making"!

Professor Edwards' remedy is for the government to "put in place a range of external measures to support healthy drinking choices .. and to make alcohol less lavishly available". The final chapter considers the many ambiguities generated throughout history by the simple ethyl alcohol molecule, and asks whether the future will be ambiguous too. Will drinking alcohol go out of fashion, will society discover the ideal recreational drug to replace it, or will the future let alcohol rip?

Professor Edwards ponders the roles of the many players here: free market capitalism, deregulation, free competition, licensing hours, availability of sales outlets, culture and its changing patterns and fashions, the drinks industry's marketing goals, governmental courage to exercise controls, increase taxation and legislate for its citizens. Professor Edwards suggests that "people themselves will increasingly ask their governments for polices on alcohol which better support the public interest", and concludes that the ".. truth staring us in the face unambiguously" is that "around the corner, the only readily available and substantial way to ameliorate alcohol's painful ambiguity is both for the individual and the state to take less of it".

As well as being so informative, comprehensive and well written with great alacrity and humour, perhaps the greatest recommendation for reading this book is that it presents to the ordinary reader a rare opportunity to read a popularised distillation of current scientific and medical knowledge about alcohol by a world expert with a lifetime experience of distinction in this field.

Abdulla A-B Badawy
Consultant Clinical Biochemist
Cardiff & Vale NHS Trust
Biomedical Research Laboratory
Whitchurch Hospital
Cardiff CF14 7XB
Wales,
UK