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Ask Maia: How Many Drinks Is Too Many?

Developing a physical dependence on alcohol is a little different for everyone, but the most common red flag is found in numbers—and they are big ones.

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By Maia Szalavitz

12/13/12

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Alcohol is the most commonly used intoxicant in America: about two-thirds of us had at least one drink in the past month, a proportion that has been reasonably steady for decades. But even though I’ve been writing about alcoholism and other addictions for years, I recently stumped myself with a question about drinking that I couldn’t answer—so as the peak of the holiday drinking season approach, I figured that I'd write a "Maia asks Maia."

My question: how much do you have to drink for how long in order to become physically dependent on alcohol?

As a former heroin addict, I knew that simply using opioids daily—even initially in doses that later come to seem laughably small, like a street “bag” or two a day—can result in physical dependence, generally within two to four weeks. For me, this occurred in less than a month: if I did heroin daily for this amount of time, I’d suffer shaking, nausea, vomiting, anxiety, insomnia and other nasty effects if I suddenly tried to (or had to) go without.

Is it the same when quitting drinking booze?

Thankfully, the answer is no, according to Reid Hester, director of research for Behavior Therapy Associates and creator of the Drinker’s Checkup, a self-test you can now take anonymously online that has been shown by research to reduce drinking problems. “There are large individual differences when it comes to developing physical dependence,” he says. “In my clinical experience, though, it's usually a matter of years of heavy drinking that leads to physical dependence.” 

He adds, “A daily pattern of moderate consumption is less risky than a weekend pattern of heavier drinking, assuming the same level of consumption. Heavier episodic drinking tends to produce more tolerance and withdrawal symptoms than steady, moderate drinking.”

In fact, multiple studies now find that for middle-aged or older people, having one drink on a daily basis for women or up to two a day for men is actually healthier than abstaining. (This is not true, of course, for people with alcoholism or other addictions whose recovery program involves complete abstinence.) Research shows pretty consistently that daily drinking at low levels—but not less frequent consumption—is associated with lower cardiovascular disease mortality. If you're bingeing that allotment—having all seven drinks on one day, say—this pattern is harmful, not healthy. And while some argue that the association between daily light drinking and health itself is a spurious one—caused by other factors found in moderate drinkers rather than the alcohol itself—there are biological reasons to suspect that the alcohol matters.

Dr. Mark Willenbring, former director of the treatment and recovery research division at the National Institute on Alcoholism and Alcohol Abuse, provides more specific details. “Generally, mild withdrawal may occur at six to eight drinks a day,” he says. “But clinically significant withdrawal is not seen until someone is consuming more. This seems to be greater than an average of 12 drinks daily and more typically 17 to 24 or more. A liter a day of vodka (about 24 drinks) is somehow a very typical pattern for severely dependent drinkers.”

"A liter a day of vodka (about 24 drinks) is somehow a very typical pattern for severely dependent drinkers."

Consequently, while severe physical withdrawal is more common in those with a long history of alcoholism, it can still affect some young people: singer Amy Winehouse, for example, had clearly reached this level of consumption when she died of an alcohol overdose at 27. Three empty vodka bottles were found near her body.

Moreover, lack of physical dependence with low doses doesn’t mean that daily drinking is safe if it doesn’t produce withdrawal: as people in AA know, alcoholism is about continued use despite negative consequences, like having your drinking interfere with important responsibilities at home and work.

You can certainly be addicted to alcohol but never suffer physical dependence, and the same is true of cocaine and marijuana. Indeed, physical dependence is not the key problem in addiction that it was once thought to be: this mistaken assumption led scientists in the early '80s to claim that crack is not addictive because you don’t become physically ill when you stop taking it. That was not a good way of defining addiction.

Nonetheless, with alcoholism, most people can be safely detoxed without hospitalization because they haven’t developed physical dependence so severe that withdrawal will cause the potentially deadly seizures associated with the DTs, or delirium tremens. Only about 60% of alcoholics have the two or more symptoms of withdrawal (restlessness, sweating and/or elevated heart rate, nausea, insomnia, anxiety, shaking, hallucinations, seizures) that qualify them for a diagnosis of alcohol withdrawal according to the DSM. Just 10% have hallucinations, and a mere 3%, seizures.

So, if you’re worried that you or a friend or family member is becoming physically dependent on alcohol as a result of having a glass of wine or two every night with dinner, relax. But if that habit starts inching up to three or four—or if frequent hangovers, sleeping problems or difficulty meeting work or social obligations are the result—why not check out the Drinker’s Checkup site and consider whether you are drinking toward health or toward an alcohol problem.

Maia Szalavitz writes the biweekly "On the Contrary" column at The Fix in addition to her new advice column, "Ask Maia." She is also a health reporter at Time magazine online, and co-author, with Joe Volpicelli, MD, PhD, of the first evidence-based guide to addiction treatment, Recovery Options: The Complete Guide: How You and Your Loved Ones Can Understand and Treat Alcohol and Other Drug Problems (Wiley, 2000). She has published four other books on issues related to drugs and addiction.

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