Guest bio : https://us.macmillan.com/author/drcharlesknowles
Why do we sometimes drink too much, even when we know the risks? In this episode, surgeon, author, and recovering alcoholic Dr. Charles Knowles joins us to explore the neuroscience of alcohol use and addiction. Drawing from his book Why We Drink Too Much and his own lived experience, Dr. Knowles describes how alcohol alters the brain’s reward pathways, and how drinking problems exist on a spectrum. Through neuroscience and deeply personal insight, he speaks to alcohol’s impact on mental and physical health and gives inspiration to others through sharing his own journey to recovery.
Phil Stieg
Alcohol is one of the most ubiquitous and celebrated substances on the planet. It is woven throughout our social lives and culture, often without acknowledgement of its impact on the brain or the impact of addiction. Our guest, Dr. Charles Knowles, is a surgeon and Chief Academic Officer at Cleveland Clinic, London. His new book, “Why We Drink Too Much: The Impact of alcohol on Our Bodies and Culture”, is his first popular science work, driven by a deeply personal reason, his own battle with alcohol.
Today, we’ll discuss what alcohol actually does to the brain, why its use becomes addictive, and how those who suffer from addiction can begin to find hope for recovery.
Charles, thanks for being with us today.
Charles Knowles
Philip, it’s a pleasure. Thank you for having me on.
Phil Stieg
Your book is about, I don’t know, 240 pages long, and it’s woven with your personal story and then the science and the emotion and all that that goes with it. Is there a unique way that you can summarize the key periods that led you to having an alcohol addiction, and then the experiences that you had that led to the fact that you knew you need to get treatment?
Charles Knowles
Well, in summary, I think I started drinking regularly when I was about 17. It was probably 10 years 10 years of fun, 10 years of fun and consequences, and then 10 years of not much fun and consequences. And then since then, I’ve been sober for 10 years. So that’s it in a nutshell.
In my early days of drinking, it was a great enabler in my life, from about the age of 17.
Alcohol was a revelation for me. I mean, it seemingly removed all the problems in my life overnight. I mean, it changed me as a person. I was a rather nerdy, unpopular, socially awkward teenager at a boarding school where we had girls. And alcohol transformed me from that to being the life of the party in a far more popular and outgoing individual, playing in a school band, having relationships with girls, et cetera, was transformational.
I mean, I now know, looking back on this, that there were many, at the time, undiagnosed problems. So I was diagnosed later in life with ADHD, and I have the brain that has an elephantine capacity for negative thinking. And looking back at school this, the experience of negative feelings and memories are a feature of neuroticism and neurotic personality trait. That and the ADHD were greatly helped by alcohol. And they were then for many years afterwards until, of course, the alcohol was no longer a solution. And then I’ve had to deal with them.
The transformation of the real self to an ideal self by the consumption of alcohol or another drug, I think is a really important and understated aspect of this.
And then, of course, life changes, and I got married and had children. And the behavior that served me well, or at least served me well some of the time when I was younger, no longer serve me as well in my 30s.
I knew in myself, I was an alcoholic by the time I was 33, at the time I got married. I wasn’t diagnosed as an alcoholic until the age of 40. And I then spent seven years, the most painful seven years of my life, trying to give it up. And though I was mostly alcohol free during that time, I would not be what I describe as sober. I was defined by the person I wasn’t anymore. I was a non-drinking persona, but still with all the downsides that had come from that.
Phil Stieg
I was struck by your wife, Annie – Her interactions with you, her dealing with it. I’d like you to highlight a little bit about what it was like for her and for somebody who may be listening who’s an alcoholic or is married to an alcoholic. Give some insight about what are ways that you can work with that individual.
Charles Knowles
Yes, I think our relationship was perhaps a little atypical of a relationship where one person is alcohol dependent, particularly the man. At home, there were none of the problems that people commonly associate with alcohol, either violence, abuse, overt drunkenness, and the irresponsibility. I hadn’t crashed cars, or hit the house down, or done anything else. Really, we were living in the same house, but my best companion was alcohol, not my wife.
This sort of runs contrary to what many people may think, because the classic paradigm here is of the man who drinks a lot and causes all sorts of problems in the family relationship, and the wife petitions him to stop drinking, and then he stops drinking and they live happily ever after.
And the reality is with alcohol removed and all of its effects on my ability to be affectionate and to interact socially in general, with that crutch removed from my social abilities, things became very, very difficult. Actually, we moved further apart when I stopped drinking.
I mean, another aspect here was that my wife felt that replacing my time in the pub with my friends, with AA meetings, was replacing one set of drinking buddies with another set of new buddies, both of which removed me from my commitments as a father and a husband.
These resentments are very real, and it’s a thing that people need to watch out for this. I’ve heard, I sometimes raise this in AA meetings, and it chimes with many people who have not heard someone share that before.
Phil Stieg
You couch it in the book as you were a workaholic, and then you also then became an alcoholic, and somehow she had to tolerate that. Did she understand that you were an alcoholic?
Charles Knowles
Not until the psychiatrist rang her. I mean, she knew I was a heavy drinker, and there have been some tensions around drinking, but she had no idea of the gravitas of the situation of my own mental health at that time. I mean, one of the things that I think is important for the audience is that actually the worst time in our marriage was when I stopped drinking that first time, because all the things that had enabled our relationship were often tied in with alcohol. We’d met drinking. My ability to interact with her and to demonstrate affection required alcohol. When that was removed, actually, the nearest we came to divorce was after I’d stopped drinking the first time.
Phil Stieg
What was the moment that helped you have the resolve to say, I’m addicted and I’ve got to stop this stuff?
Charles Knowles
So for most people, in my experience, rock bottom is the end of being sick and tired of being sick and tired. I mean, being addicted to something is very, very tough, particularly if you’re trying to stop it. And eventually, I think you just go round and round this cycle until you just don’t have it in you to do it one more time. And the night before that morning was no worse than another night. It’s just I had the realization that morning that I just couldn’t do it anymore.
People imagine that this is like leaving Las Vegas with Nicolas Cage. For most people, it isn’t. It’s just the sick and tired of being sick and tired. The cognitive dissonance required on the one hand, for having half of your brain telling you desperately need a drink, and the other half of your brain, knowing what the consequences of that are, eventually, after years and years, just becomes very difficult to carry on.
Most people would agree that if you believe you have a dependence on alcohol, the only solution to that is to stop drinking completely. I’d been a bit on and off with that idea until things reached a crisis at the age of 40. I was diagnosed with depression and alcoholism, put on treatment for depression, and posted off to AA.
Phil Stieg
You just spontaneously went to a psychiatrist?
Charles Knowles
I had a mental health crisis and was taken to a psychiatrist.
Phil Stieg
I see. Okay.
Charles Knowles
That was the first of- The psychiatrist said,
Phil Stieg
You know you’re an alcoholic.
Charles Knowles
Yeah. Actually, my psychiatrist was very direct with me. He told me that if you carry on drinking, you will have further episodes like this, and you will end up in a mental health institution, lose your job, lose your marriage, and will eventually die.
Interstitial theme music
Narrator –
For centuries, popular culture has been remarkably tolerant of heavy drinking. In 1863, the New York Times reported that President Lincoln, when informed that General Grant drank too much whiskey, replied, “Tell me what brand it is, and I’ll send a barrel to each of the other generals.”
Vaudeville comedian and movie star WC Fields famously reveled in his reputation as a heavy drinker –
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Man: You’re Drunk!
Fields: And you’re crazy. But tomorrow I’ll be sober and you’ll be crazy for the rest of your life.
Narrator
Crime solving film duo Nick and Nora Charles drank their way through the 1930s and ’40s in the movie series The Thin Man, fueling their spirited repartee with plenty of spirits.
Film clip –
Nora Charles: How many drinks have you had?
Nick Charles: This will make six martinis.
Nora Charles: [to the waiter] All right. Will you bring me five more martinis, Leo? Line them right up here.
Narrator
And in the movie Animal House, John Belushi’s character offered these words of wisdom to a befuddled freshman:
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My advice to you is to start drinking heavily.
Narrator
Society’s tendency to celebrate artists who are heavy drinkers is often rooted in the idea that drunkenness fuels their creativity. Hard-drinking author Ernest Hemmingway was often mis-quoted as giving this advice to aspiring writers: Write drunk and edit sober.
But the idea that alcohol increases creativity is as misleading as it is persistent. Research suggests that while mild intoxication can enhance divergent thinking and creative problem-solving, it simultaneously diminishes executive function and focus. For many artists and writers, alcohol became a double-edged sword, offering fleeting inspiration while ultimately hindering their ability to act on it in any meaningful way.
As actor Dudley Moore’s character said in the movie “Arthur,” “Everyone who drinks is not a poet. Some of us drink because we’re NOT poets.”
In reality, successful artists who drink to excess manage to be creative despite their drinking. One can only imagine what the artistic output of Hemingway, Vincent van Gogh, Dorothy Parker or other well-known imbibers might have been … if only they’d given sobriety a try.
Phil Stieg
Given the 12-step mantra of alcoholics anonymous, do you think that it’s important for you, the person who is an alcoholic, to just readily admit it and then learn how to not be shamed by that? It’s part of your biology, just like if I had cancer. Sorry, I can’t do that. I have cancer. That’d be a showstopper in a conversation also.
Charles Knowles
It would.
Phil Stieg
Will people see it that way?
Charles Knowles
I wish they did. I think the problem, if there is one with the term alcoholic, is the public perception of what the stereotype, if you like, of what an alcoholic is. And we’re fed that stereotype. Everyone in their mind’s eye has this idea of someone on a park bench with a beard and a brown paper bag shouting at passers by or begging. And in fact, when I first went to AA meetings, I didn’t see any of those people. I did find some of my consultant colleagues, surgeons and other people from all walks of life in it. So that stereotype is clearly untrue.
But look, I would never force anyone to wear a label that they were unhappy with. And so I’m not set on the idea of someone having to stand up and say, “I’m an alcoholic”. If someone finds that helpful, that’s good. If they don’t, they don’t. I do think that underpinning your question is the idea that recognizing you have a problem is a pathway to at least dealing with that problem, whatever we call it.
Phil Stieg
One marvels as I think about as a kid growing up in America how we are actually kind of taught that drinking too much is socially acceptable and actually celebrated. TV, media, advertising, really, as we’ve said, have normalized excessive alcohol consumption, playing in my mind, as I read your book on the positive reinforcement. I was also shocked to see that 75% of the profits alcohol are actually generated from only 20% of the drinkers.
Charles Knowles
I think it’s an interesting area because I don’t think the alcohol industry is really advertising the drink itself. It’s advertising the outcome. And I think this brings us back in particular to this idea of changing a person from their real self to an ideal version.
So if you look at the thematics of advertising around alcohol, really, the whole thing is about the person being displayed in an exuberant or wealthy environment, being successful, being attractive to women, being successful at sports, chivalrous, brave. James Bond, of course, is the classic example of this. Wearing a tuxedo and ordering his Martini, he displays all of those things. You can imagine that people who watch that are not so worried about what brand of Martini it is, so much as that if I drank vodka martinis, I might be more like James Bond.
Phil Stieg
Can you briefly summarize what the alcohol is doing to our brains and bodies that reinforces our utilization of alcohol.
Charles Knowles
Yeah, absolutely. So akin to any behavior, we learn to drink. And we learn to drink based on, as you’ve mentioned, reinforcement. Alcohol’s popularity, ultimately, is because for many people, drinking alcohol is fun. Or the outcome of drinking alcohol results in having a great time. And if something’s good, we’re more likely to repeat it.
That fun comes from alcohol’s basic properties. The fact that alcohol gets to our brain very quickly, crosses the blood-brain barrier without any difficulty because of its unique chemical properties. So it can get into cells in our brain where it affects levels of neurotransmitters, notably neurotransmitters that act through the reward pathway and other pathways and result in this hedonistic outcome, the feeling that’s called the psycho-stimulatory effects and relaxant effects of alcohol.
Phil Stieg
You really emphasize throughout the book the role that memory plays in the addictive nature of alcohol. Can you explain that?
Charles Knowles
Yes. Well, this is not an easy concept, but there is a groundswell of neuroscientists who believe that addiction is mainly a problem of memory. For instance, when we learn anything, learning to ride a bike, for example, you cannot de-memorize otherwise learning to ride a bike. If you go back to a bike many years later, you’ll still know how to ride a bike. And this problem is implicit with addiction.
Obviously, there is no deliberate way that you can forget the learning and experience that we’ve had from an addictive substance like alcohol. And so this then places memory at the heart of the problem, and in particular, the reactivation of memory, which for rewarding stimuli like alcohol is induced by reward cues.
Phil Stieg
Throughout the book, you treated alcohol addiction as a spectrum, like many other diseases.
Charles Knowles
One of the things that I think I do for the first time in the book, is to introduce the idea that between the black and white, there is genuinely shades of gray in this
Phil Stieg
So just so I understand, would you consider the functional… I’ll use the term. I know you want to use a different term, but the functional alcoholic, is that a gray area or is that a person who’s an alcoholic and just geting away?
Charles Knowles
No, that’s an alcoholic. Alcohol is in the black.
Phil Stieg
So the gray area is what?
Charles Knowles
The problem here is that we tend to look at alcohol in terms of consumption, and then this black and white view of someone who’s a significantly problematic drinker who sees a doctor versus someone who hasn’t got a problem. And the reality is that that is not the way to look at it. Consumption is only one aspect and probably not a terribly important one unless you’re talking about liver disease and obesity. But actually more important are the consequences and the loss of control. So these are the three Cs, consumption, consequences, control. And when we look at that, there are grades of consequences and control.
So taking consequences, the WHO, for instance, define something called hazardous alcohol use. So this is where someone’s using alcohol in a way that puts us at risk of harm, but those harms have not actually yet materialized. It’s what many people call the “yet.” I haven’t lost my job yet. I haven’t lost my wife yet. I haven’t crashed the car yet. I haven’t ended up in the police cell yet. But these are things that might happen if that behavior continues.
Whereas overt harms, called harmful drinking, is where those things have happened or significant health or mental health consequences have developed. So there’s already a gray and a black in terms of the consequences.
But now, if we look at control, there’s similarly a white, a gray, and a black. So someone in the white is someone who’s completely neutral around alcohol. It doesn’t matter how much they consume. We all know people like that, people who can drink very heavily. But if they were told tomorrow, Sorry, mate, you got to stop drinking, they’d just be able to say, Oh, well, okay, I can stop drinking.
Then at the other end of the spectrum are people like me who in trying to stop drinking, realized they were significantly addicted to alcohol. And that was very difficult. That would fall in what the World Health Organization called alcohol dependence, or in old man’s terms, was known as an “alcoholic”. Then we got the gray in the middle. The gray, I introduced the term alcohol reliance in the book to provide something that isn’t in the literature at the moment that lies between dependence and neutrality.
Phil Stieg
However, in your book, you also suggest that even moderate drinking does have physiologic health consequences. Could we go into that a little bit about what’s moderate versus severe, and then the effects that it has on your heart, your liver, your kidneys, your brain, cancer?
Charles Knowles
Again, if only it were so easy as to place a single parameter around this. Different countries around the world have different safe limits of alcohol consumption and based on different ideas. And indeed, in most countries, the unit of alcohol by which that’s even measured varies. So for instance, in the UK, a unit of alcohol is eight grams. A standard drink in the United States is 14 grams. Most of the world It has 10 grams as a unit. And so it’s difficult to make a single conclusion. But if we take common diseases, the majority of them are what in common parlance, we would say moderate or heavy drinking is required to induce the problem. But there are some exceptions to this.
So for example, in women, an increased risk of breast cancer is associated with almost any level of alcohol consumption, even below government recommended limits in nearly all countries. Similarly, the increased risk of stroke does not require much more than a very modest level of regular consumption.
Clearly, problems like obesity and metabolic syndrome depend not only on alcohol consumption, but also on food. Any level of alcohol consumption, if you’ve already got risk factors for obesity, adds to the problem because we don’t tend to offset calories with alcohol. So they’re additive. And of course, alcohol contains a great deal of calories, particularly drinks like beer. So very often they’re linked. And yes, you’re quite right. In terms of prevention, smoking alcohol and obesity are the biggest modifiable risk factors for disease worldwide. Yeah.
Phil Stieg
For the listener that’s, sober curious, they’re not dependent on alcohol, what’s your message to them?
Charles Knowles
I think people who call themselves sober curious do not tend to fall in the alcohol dependent group. They are people who might be in the gray area drinking group or might be people who are just interested in improving their health and really have very little in the way of a strong relationship with alcohol.
In my own part, someone who was addicted to alcohol, I knew the writing was on the wall. It’s just that when you try to stop, the alcohol-dependent cycle is one where it makes it very, very difficult. So for the first part of that, you’ve obviously got to deal with the immediate consequences of withdrawal, which is a horrible experience, let me tell anyone listening. I still can feel what that felt like even now, a decade later. And going back to that last time I had a drink, I was kneeling on the floor of my friend’s bedroom in a house in Florida, praying to any God that would listen, sweating, shaking, at et cetera. That’s where this brings you.
And having got out of that immediate withdrawal, of course, the problem is not over there. If the problem were over there, we would not have the need for all of the treatments and interventions like AA that are required to prevent much later relapse. And here we’re back to the idea that relapse can occur years and years later. And really what needs to happen then is a change in the thinking around alcohol and addressing the underlying drivers, psychological or otherwise, that pushed a person like me to drink in the first place.
Phil Stieg
This is a huge problem worldwide. Obviously, it was a devastating problem for you in a fairly long period of your life. What is your take home message to the listeners? What do you want to really convey today?
Charles Knowles
I think if I can only say one thing, I’d like to ask people to be a bit more tolerant and to change there the way they view people suffering with alcohol addiction. Maybe in a way where alcoholic doesn’t have to be a derogatory term, and people don’t need to be anonymous.
I think, secondly, I’d like the book and the information, information we’ve been discussing to be out there, to be out there in a way that it isn’t at the moment, so that people can make a reasoned, educated decision about their relationship with alcohol. That doesn’t necessarily need to be stopping it, but to have more information than they currently have.
Who was it who said, I drink to make other people interesting? Hemingway.
Phil Stieg
Okay. Dr. Charles Knowles. Thank you so much for being with us today. I want to refer everybody to his recent book, “Why We Drink Too Much”. It’s a personal story, but he also talks about, we as society, how we need to change our acceptance of individuals that are struggling with this disease process.
Charles, thank you so much for being with us today.
Charles Knowles
It’s been a pleasure, Philip. Thank you for having me on.
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