If I told you I was going to the store to buy “food and bread,” you’d be puzzled. Don’t I think bread is a food? Isn’t bread the quintessential food, consumed around the world in thousands of different ways? Why, bread is so much a food that it represents all food in the expression “our daily bread.”[1] Saying “food and bread” is absurd.
So why do we say “drugs and alcohol”? Alcohol is the quintessential drug, consumed around the world in thousands of different ways. Yet in the US we always talk about drugs and alcohol as related, yet different, things. It would be more logical to say “drugs including alcohol,” “drugs such as alcohol,” or just “drugs.” But we don’t.
Phrasing matters. It can be a kind of polemic. If I told you I was going to the store to buy “food and sugar,” you wouldn’t be puzzled. You’d recognize that I was making a little argument: sugar isn’t food. The great thing about that kind of argument is that no proof is needed. I don’t even have to work out what else sugar could be. With the word “and,” I can just kick sugar out of the “food” category and let you imagine what else it could be. Fake food? Drug? Poison? All three?
“Drugs and alcohol” takes a similar tack. Without citing evidence or using logic, it implies that alcohol is something other than a drug.[2] At the same time, most of us would have a hard time working out what else alcohol could be. It’s not a beverage, though many beverages contain it. It’s not a food, though some alcoholic beverages have nutritional value. The beauty of “and alcohol” is that it doesn’t make a positive claim about what alcohol is, just a negative claim about what alcohol isn’t. It’s not part of the category “drugs,” or, if it is, it’s so hybrid and anomalous that it really deserves its own category, like a platypus or edible wax lips.[3]
It doesn’t. Alcohol fits very neatly into the category “drugs.” It has distinctive traits but none that make it either unique or a non-drug. All of its distinctive features are shared with other drugs, including possible health benefits, hedonic pleasure, and a tradition of use that dates to the Neolithic period.
“Drugs and alcohol” is a distinction without a difference. It obscures the fact that we consume alcohol, like all drugs, because it produces a particular range of effects in the body. Yes, people talk more about other qualities: taste, for example.[4] That’s part of the obscuring. If we were more honest about all the features of alcohol, wine blurbs might look like this:
Earthy and flirtatious with a sweet marionberry flavor and hints of loam, this Merlot will sweep you off your feet — metaphorically or literally, depending on how much you drink.
Moreover, in states where recreational cannabis is legal, connoisseurs now talk about the appearance, aroma, and flavor of pot in the overheated aesthetic language favored by wine lovers. In other words, the cannabis industry recognizes that focus on taste makes pot seem less druggy, just as it has always made wine seem less druggy. It’ll be interesting to see whether the emerging cannabis industry eventually challenges the drugs/alcohol divide or figures out some way to leap over into the “alcohol” camp.
As long as it exists, the divide is a problem, hurting users on both sides. It fosters black-and-white thinking that minimizes the risks of alcohol, exaggerates the risks of illegal drugs, and ignores the risks of mixing them. It distorts and obscures information people need to make sensible choices about their health—and even their survival. Here’s one tiny example from today’s headlines.
By now, everyone knows about the country-wide spike in opioid overdoses. In all the media coverage, however, one crucial fact is missing: many of those overdoses are caused by mixing opioids and alcohol.[5] They are heroin-and-alcohol overdoses or fentanyl-and-alcohol overdoses or oxycontin-and-alcohol overdoses, but the “and-alcohol” part rarely makes the story. This phenomenon is not new. Janis Joplin and Tim Buckley died of heroin plus alcohol, though they’re considered classic heroin overdoses.[6] Why leave alcohol out of the story? Because it makes a cumbersome headline? Sure, that’s a factor. But a much bigger factor is that we don’t treat alcohol like a drug that interacts with other drugs and kills young, healthy people. Overdose is a drug thing, not an alcohol thing.
Except it’s not. People overdose on plain alcohol all the time; we just don’t hear much about it. When we do, the victim is almost always a teenager, and the context is almost always a fraternity gathering. Normally, the conversation turns immediately to hazing, as it did in September 2017 when Maxwell Gruver died with a blood alcohol level of 4.95. Don’t get me wrong: we need to talk about hazing. But, by making hazing our sole focus, we make alcohol overdose seem aberrant, and we transfer the threat from the drug to a very particular social context. Alcohol overdose becomes a freak accident that happens under extreme peer pressure, not an everyday risk.
It is an everyday risk. Every day, on average, six Americans die of an alcohol overdose. Not the cumulative effects of long-term abuse, but drinking more on a single occasion than their bodies can handle. Most of those deaths involve middle-aged white men, though Native Americans OD at seven times the rate of white men. Overall, most who die (about 70 percent) are not considered “alcoholic.”
We don’t see alcohol as having other dangerous qualities either: addictiveness, for example. Look again at the opioid crisis. Even the mainstream press is starting to lay unprecedented blame on the manufacturers, distributors, and sellers of oxycontin. Purdue Pharma, the Sackler family, and other involved in marketing the painkiller are regularly called out as drug dealers, even in the mainstream press. That’s new. There’s also a new “typical addict” in the media: white, downwardly mobile, and, most importantly, hooked on painkillers by those unscrupulous legal dealers. It may not be an accurate picture,[7] but it’s prevalent. This addict has less responsibility for his or her habit than older versions of the “typical addict.”[8] In the public imagination, opioids are so naturally addictive that simply making them widely available has caused an “epidemic.”
Alcohol, on the other hand, is not supposed to be naturally addictive. It’s supposed to be a benign substance that a small fraction of the population can’t handle. In other words, with opioids, the problem lies mostly in the drug, and with alcohol the problem lies mostly in the user.[9] Everyone knows that.
But it’s not true. Among patients prescribed short-term opioids for pain, only a small percentage become addicted.[10] In fact, the percentage is smaller than the percentage of alcohol users who become addicted to their drug.[11] Though it’s hard to make strong comparisons between legal and illegal drugs, alcohol shows every sign of being at least at least as addictive as oxycontin. I’ll stop short of saying twice as addictive, because I’m sure lack of easy access to opioids depresses the first percentage somewhat. I want to be fair, after all.
Not making fair comparisons hurts both alcohol addicts and opioid addicts. It hurts alcohol addicts by assigning all responsibility for our addiction to us and none to our drug or its promoters. Specific blame goes to our genes or our histories or faulty learning or lack of willpower or some unspecified “disease” or all of the above. but alcohol itself gets a pass. We don’t call Anheuser-Busch Inbev or Diageo drug dealers, though, when you think about it, they’re not so different from Purdue and the Sacklers.
To make fair comparisons, we have to view alcohol as a drug, and we have to recognize 60-70 percent of the US population as drug users. Then we have to think about drugs differently. We can’t demonize them and the people who take them. We can’t try to expunge them from the face of the earth, a strategy that never ever works and exacts a horrific toll of death, misery, and injustice while squandering badly needed resources.[12] Instead, we have to figure out how best to balance their benefits and risks, including the risk of addiction, overdose and death.
I doubt we’ll do that any time soon. Powerful interests with a lot of money want drugs and alcohol to remain categorically distinct. A few years back, there was a massive effort to combine the two institutionally, to merge the United States’ National Institute on Alcohol Abuse and Alcoholism (NIAAA) with its National Institute on Drug Abuse (NIDA). Scientists and politicians had long urged the NIH to combine them but been resisted by NIAAA, which sought to insulate its work from the taint of illegal drugs. One researcher describes “genuine repulsion among the alcohol people of mingling or collaborating with the drug people.”[13]
By 2010 the separation of two federal institutes investigating substance abuse seemed unsustainable. The NIH’s Scientific Management Review Board voted 12-3 to create a new institute dedicated to all kinds of addiction, and NIH director Francis Collins publicly concurred. Despite vehement protest by AA-oriented researchers in NIAAA,[14] preparations for the new institute began, and by late 2012 the only question was when Dr. Collins would formally announce it.
He never did. Instead he announced “functional integration,” a partial measure already rejected by the Scientific Management Review Board. To say this move was unexpected would be an understatement; even people who continued to fight the merger were shocked to see it suddenly abandoned.[15] So what happened? It’s hard to know for sure because both NIAAA and NIDA personnel were forbidden to comment.
There are some clues, however. The merger wasn’t blocked by NIDA; they were all for it. It wasn’t blocked by the NIAAA, despite the continued protests of the AA-oriented researchers, nor by any of the other institutes likely to be affected by the change.[16] These and other stakeholders had weighed in—very passionately in some cases—but the merger was going ahead until some new folks joined the fray. I’ll let Director Collins tell you about them.
“We are hearing from some of the lobbying organizations that are involved in the use and sale of alcoholic beverages – the wine, beer and liquor industry. They are not particularly happy about this. . . . They are very well connected from the political side of this. Their view is that alcoholic beverages are an acceptable, social, desirable thing. Consider it to be a food. Noted that it has health benefits. Notion that it will be lumped with drugs of abuse, many of which are illegal, rubs them the wrong way.”[17]
I’ll have much more to say about alcohol lobbyists in another essay; for now, just know one thing: they exercise immense political power. They represent an industry with annual US revenues of $234 billion, so they have masses of money to spread around. They spread it everywhere—local, state, and federal government (both sides of the aisle), as well as public relations. They’re very smart; they saw the mistakes of the tobacco lobby, and they figured out how to avoid them.[18] That’s why, though you know about “Big Tobacco,” “Big Oil,” and “Big Pharma,” you’ve probably never heard of “Big Alcohol, though you live every day with its influence.
Quashing the merger was easy for the industry flacks. With no direct influence over decisions made by the NIH, they instead lobbied politicians, such as Kentucky Representative Hal Rogers, Chairman of the House Appropriations Committee. Because Congress had to appropriate money to create the new addiction institute, blocking the funds blocked the merger. Problem solved.
Did AA-oriented researchers conspire with alcohol industry lobbyists, or did the lobbyists just notice the impending merger and decide independently that it might be bad for business? With those who know pledged to silence, I can only guess. But I don’t need a conspiracy to be alarmed that the alcohol industry has any say about addiction research. Remember, if every American who currently abuses alcohol were to start drinking normally, the industry would lose sixty percent of its bottom line. [19] That’s nearly two-thirds gone, so the alcohol industry’s interest in alcohol addiction is surely in maintaining it. In other words, giving the industry a say in how to run the NIAAA is like giving smallpox a say in how to run the National Institutes of Allergy and Infectious Diseases. Actually, it’s more like giving smallpox, ebola, and rabies a say, but I don’t want to quibble over similes.
Thinking about words lands us back where we started: with the phrase “drugs and alcohol.” The failed merger was just one example of whose interests are served by segregating drugs and alcohol—and how far they will go to preserve an empty distinction.
[1] I know that, in some parts of the world, rice is the quintessential food, so I apologize for not finding a genuinely universal analogy.
[2] Yes, alcohol can also be an antiseptic, a solvent, or a fuel, but the phrase “drugs and alcohol” refers only to ingestible alcohol or ethanol.
[3] For the uninitiated, edible wax lips are giant paraffin lips labeled “candy” and given out at Halloween. They’re almost pure wax, however, so eating them is like eating a candle. In other words, they’re not candy, and they don’t fit into any other category either, except maybe “confection-adjacent gag accessory.” Here’s a cute picture of a child wearing a pair.
[4] Pharmacological values do sometimes appear in the names of beverages with a high alcohol content: Clobberskull (10.5%), Drunkle (10%), Blackout Stout (9%), Faceplant (13.1%), Old Horizontal (11%), Snake Venom (67.5%), Three Sheets Barleywine (10%), and Delirium Nocturnum (8.5%), which has a pink elephant on the label. Traditionally reserved for malt liquors targeted to young African-American men, metaphors of strength—Colt 45 (6.1%), Steel Reserve (8.1%), Hercules (10%)—have expanded to include, not just explicit references to intoxication, but even to negative social consequences—Panty Peeler (8.5%), Substance Abuse (n/a). The trend looks a lot like the kinda-sorta-but-not-really-ironic branding of heroin with names such as Kiss of Death, 911, and, again, Hercules.
[5] Karlyn A. Edwards, Kevin E. Vowles, Katie Witkiewitz, “Co-use of Alcohol and Opiods,” Current Addiction Reports 4(2), 2017, 194-99.
[6] The 2013 death of Glee star Cory Monteith seems to contradict my statement that the media fail to report the role of alcohol in opioid ODs, but Monteith died in Vancouver, which doesn’t have the same blind spots as the US. The BC coroner’s service published the cause of death as “a mixed drug toxicity, involving heroin and alcohol,” and some US papers quoted the statement exactly. Many, however, gave the cause of death as “heroin overdose,” especially in follow-up articles. A Google Advanced search yields more than 25,000 articles that attribute Monteith’s death to heroin without mentioning alcohol.
[7] In recent research, including annual US government surveys of drug use, medical treatment with opioids was found to be a minor cause of addiction, relevant in only 13% of cases. See Maia Szalavitz, “Opioid Addiction Is a Huge Problem, but Pain Prescriptions Are Not the Cause,” Scientific American Mind Guest Blog, May 10, 2016.
[8] In general, the whiter the addict population, the more the willing the press becomes to hold someone other than the addict accountable.
[9] As I mentioned, race complicates this paradigm a lot. What I’m referring to is not actual cases of addiction but pro-drug war rhetoric that assigns a kind of agency to drugs while denying it to alcohol.
[10] Gauging rates of opioid addiction is extremely difficult, and most of the numbers online cannot be traced to legitimate sources. The best we have is a recent study by the CDC comparing the duration of initial opioid prescriptions with the likelihood of continuing to use opioids long-term. The study found, not surprisingly, that longer initial prescriptions increased the likelihood of continued use. For example, among patients given an initial 8-day supply 13.5 percent were still using opioids a year later. Naturally, the media proclaimed those patients “addicted,” neglecting the possibility that patients given strong pain medication, especially for multiple weeks, may continue to need it long-term. For the CDC study, see Shah A, Hayes CJ, Martin BC, “Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use, United States, 2006–2015,” Morbidity and Mortality Weekly Report, 2017 (66) 265–269.
[11] Rates of alcohol addiction are also difficult to calculate. Percentages cited online are particularly variable, independent of hard data, and ideologically bound. To calculate alcohol addicts as a percentage of drinkers, I first used the NIAAA’s claim that, in 2015, 15.1 million adults, or 6.2% of the population, had an Alcohol Use Disorder then subtracted the 35% of the population that abstained. That gave me 9.53 percent. Using Philip Cook’s consumption index, the percentage of drinkers consuming large daily averages (indicative of some kind of alcohol use disorder) gives me 14%.
[12] For the devastation wrought by the war on drugs, check out the information published by the Drug Policy Alliance.
[13] T. Travis, “The NIAAA-NIDA Merger: Comments from the Field I in Points: The Blog of the Alcohol & Drugs History Society, April 20, 2012. Several other sources describe the AA-oriented researchers’ public comments as extremely emotional.
[14] Several assessments of the controversy indicate that NIAAA was divided into factions: one more scientific and interested in polydrug research, the other more recovery-based and interested in alcohol. That “recovery-based” means founded on the principles of Alcoholics Anonymous is clear from the history given in Ron Roizen’s two-part “Reflections on the Scheduled NIAAA/NIDA Merger” in Points: The Blog of the Alcohol & Drugs History, April 12, 2012.
[15] “NIDA-NIAAA merger cancelled in surprise move,” read the December 3 headline in Alcoholism & Drug Abuse Weekly. “This decision was a surprise,” said an observer in Psychiatric News. Some comments go further, to “shocked” and “puzzled” (op cit).
[16] For example, smoking research was expected to migrate to the new addiction institute from the National Cancer Institute. On the question of why the merger was dropped, some AA-oriented researchers take credit for the defeat, but that seems unlikely, given its timing. The last-minute reversal indicates a new influence, and the gag order indicates that it’s not one that will bear public scrutiny.
[17] Dr. Collins answering questions in front of the NIH Scientific Management Review Board, May 29, 2012. Quoted from a science blog by an anonymous NIH-funded researcher posting under the name Drugmonkey.
[18] Some alcohol lobbyists, being former tobacco lobbyists, learned the hard way.
[19] Philip J. Cook, Paying the Tab: The Costs and Benefits of Alcohol Control (Princeton: Princeton UP, 2007).