Humanity sure does have a weird relationship with alcohol.

It’s pretty well documented that alcohol use is declining in the U.S. and in other relatively wealthy nations. The Economist has a fascinating article about this, for those who have access to it.

I’m probably going to irritate a lot of people with these comments, but here I go anyway.

When I was in graduate school in clinical psychology, one of my professors—whose course on substance abuse and addiction I took—was a recovering alcoholic. He made a comment I found unforgettable. In fact, I remember it.

He said that if he were forced to choose—in a gun-to-the-head scenario—between drinking again and using heroin, he would choose heroin.

His choice, though, came with conditions: the heroin would be supplied to him, it would be clean and dose-regulated, and he would have immunity from prosecution if he were caught with it.

Fair enough, since it’s an imaginary scenario.

Still, I was shocked by his answer, so he elaborated. The terrible wreckage associated with heroin dependence is often driven by (1) illegality, which forces people into high-risk behavior to obtain it; (2) overdose risk tied to unknown potency; and (3) disease and medical complications related to injection practices—needle sharing, poor hygiene, and unsafe supply.

But strictly as a drug, he argued, clean, dose-controlled heroin does not damage the body in the same broad, multi-system way that alcohol can.

Alcohol contributes to fatty liver disease, alcoholic hepatitis, fibrosis, cirrhosis, and liver cancer. Heroin doesn’t do that. Alcohol raises the risk of cancers of the mouth, throat, and larynx; it also increases risk of esophageal cancer, colon and rectal cancer, and breast cancer. Heroin doesn’t. The same “alcohol does, heroin doesn’t” comparison applies—certainly or plausibly—to several other long-term medical harms: cardiomyopathy and other cardiovascular problems, cognitive impairment, peripheral neuropathy, gastrointestinal disorders (including GI bleeding), pancreatitis, and immune dysfunction.

None of this means heroin use is a good idea. We’re dealing with a hypothetical that doesn’t exist in real life: cheap, clean, dose-regulated, legal heroin.

This is really a comment on just how medically destructive alcohol can be, especially when used to excess.

And I haven’t even gotten to the psychosocial wreckage: lost productivity, domestic violence, child abuse, crime, motor vehicle crashes, and more.

My professor also posed another hypothetical. Suppose alcohol had never existed. Of course it has—it turns out when carbohydrates ferment they throw off ethyl alcohol—but pretend alcohol hasn’t existed. Now suppose ethanol is suddenly synthesized in a lab somewhere and introduced on the street. We quickly notice that it’s incredibly fast-acting, reliably disinhibiting (causing people to do truly dumb things), dramatically increases accident rates, and is addictive for a substantial portion of the population. My professor said—and I believe him—that there is no way it would remain legal.

The social and economic costs of alcohol use and abuse are so broad and deep that they’re hard to estimate. That hasn’t stopped people from trying. Here’s one plausible ballpark: if you add up healthcare costs, workplace productivity losses, motor vehicle collisions, and criminal justice-related costs, we’re probably looking at something like $350 billion per year—and that’s just the U.S.

I’m not calling for prohibition, and it would hardly matter if I did. What I do wish is that our culture would come to terms with the price we pay—in suffering and in economic impact—for our strange relationship with alcohol.

And to those whose response is that I’m ignoring the benefits of alcohol: I’ll leave that up to you to argue. What are they, exactly? Feeling kind of good? Having fun being disinhibited?

Thanks. I know some of you hate me now.

Dale