Alcohol, health, and the ruthless logic of the Asian flush

I have some patients on disulfiram and it works very well when they take it. The problem is definitely that they can choose not to take it if they want alcohol (or sometimes just forget for normal reasons, then opportunistically drink after they realize they've forgotten). 

The implants are a great idea. As far as I know, the reason they're not used is because someone would have to pay for lots and lots of studies and the economics don't work out. Also because there are vague concerns about safety (if something went catastrophically wrong and the entire implant got released at once and then the patient drank, it would be potentially fatal) and ethics (should a realistically-probably-heavily-pressured patient be allowed to make decisions that bind their future selves)? I think this is dumb and we should just do the implant, but I don't think it's mysterious why we don't, or why (in the absence of the implant) disulfiram doesn't solve everything.

Just kidding. It’s called disulfiram, and it was approved by the FDA in 1951.

Cute turnaround + mention of FDA = instant feeling of reading Scott.

I had the "Europeans evolved to metabolize alcohol" belief that this post aims to destroy. Thanks!

This post gave me the impression that the evolutionary explanation it gives is novel, but I don't think that's the case; here's a paper (https://bmcecolevol.biomedcentral.com/articles/10.1186/1471-2148-10-15#Sec6) that mentions the same hypothesis.

From Wikipedia: "Disulfiram does not reduce alcohol cravings, so a major problem associated with this drug is extremely poor compliance. Methods to improve compliance include subdermal implants, which release the drug continuously over a period of up to 12 weeks, and supervised administration practices, for example, having the drug regularly administered by one's spouse."

My guess is that for a strategy like this to work better, you'd need the pain to come right away, strong enough to build an immediate association between alcohol and suffering. Instead, "about 5 to 10 minutes after alcohol intake, the patient may experience the effects of a severe hangover for a period of 30 minutes up to several hours." By contrast, here's how one Reddit user describes alcohol cravings:

It isn't so much a thirst like for water after a long run, it is more like a thirst for the body buzz and mental clarity that comes with drinking. You cannot enjoy any activity until you have that drink in you, and once you do, ON THE FIRST SIP, your body finally releases you from the tenseness and uncertainty you've been feeling all day. It is an indescribable release.

Note that the effect is immediate and intensely pleasurable. Yet alcohol only reaches the brain 5 minutes after consumption, and only takes effect 10 minutes after consumption. So there's something psychological, not just chemical, going on here. I'm skeptical that a delayed-onset pain that's potentially not even shifting the same motivational mechanism that caused the cravings would be effective.

The fact that people self-harm, despite the fact that the pain must be immediate and intense, should be at least some evidence against the idea that strategies like this would work. My money is on the idea that disulfiram's apparent effectiveness when taken is mainly a third variable problem. People who take it are likely to be highly organized or highly motivated to quit.

Roughly 10% of people in the US are raging alcoholics. Could we offer them the chance to self-exclude from alcohol? Unfortunately, it seems very difficult. We'd have to force some heavyweight process of checking IDs on all bars and liquor stores. Even then, it wouldn't be very effective, since people could still have their friends buy it for them. Do we want to make it illegal to hand out drinks at a party without checking everyone's ID against a database? It would be a nightmare.

I presume you're being ironic here, but part of me worries that you forgot that this already describes the way we handle underage drinking.

Looking at alcohol consumption by country, however, East Asia seems pretty middle of the pack. The main trends seem to be Europe and majority European-settled countries are rather high, and the Middle East and North Africa are very low (religious prohibition). 

https://ourworldindata.org/alcohol-consumption

Since the west is high, the rest is low, or not so-high, with parts of East Asia overlapping parts of the west, it seems like these genetic predispositions aren't as strong in effect as someone might predict given the culture. I have heard Japanese and Korean drinking culture rivals European ones.

Within the US, whites and racial minorities (e.g. African Americans, Asian Americans, Native Americans etc.) do somewhat differ in drinking rates, alcohol problems, but the differences aren't nearly as drastic as super strong "innate" differences would predict (e.g. https://pubs.niaaa.nih.gov/publications/arh40/152-160.htm) 

It also seems like a religious prohibition making entire regions in the Islamic world far lower in alcohol consumption which is (almost?) entirely cultural has a strong effect with no need to resort to genes, unless there have been studies on if other non-East Asian populations are predisposed to be disadvantaged by alcohol consumption.

Such implants are legal in Poland and some other Eastern European countries ( webiste in polsih that offers such product: https://alko-implant.pl/nasza-oferta/wszywka-alkoholowa/disulfiram-i-esperal ). It's really surprising for me that it's not legal in the US: while reading this piece I was thinking "yeah, there's an implant one can get". I have no idea how effective those things are, though.

Thanks, I enjoyed reading this. I'm half Japanese, so this might explain why I don't enjoy drinking so much. But I wonder, could we do the opposite, in order to make drinking more enjoyable? 

Nice piece. My own Asian flush has definitely turned me away from drinking. I wanted to like drinking due to the culture surrounding it, but the side effects I get from alcohol (headache and asthma) make the experience quite miserable.

I don't quite understand why we needed the speculative evolutionary intro here. For me it seems to be a distraction and a bit questionable.

Convincing. Good question re: Disulfiram. Maybe drugs that make it easier to ride out physical dependency (+ alcohol withdrawal poisoning) are of greater practical use/demand - methadone seems popular [for rehabilitating opiate addicts, not alcohol, obv.].

One day at work you discover a protein that crosses the blood-brain barrier and causes crippling migraine headaches if someone's attention drifts while driving.

Seems way too specific. This is going to go off under at least some other condition.

If these genes really are an adaptation, it shows how ruthless evolution can be. If you implanted a device in your kid that mildly poisoned them every time they drank, you'd be a monster. But evolution basically did that.

It doesn't make them get drunk faster?

No one cares about my freedom to rob convenience stores or burn down public buildings.

Unless you live in a tyrannical regime.

so he wanted to remove freedom from himself to overcome that.

He wanted to enjoy the beauty of the song, without the downside of the actions he'd take in response (drowning). It's like someone wanting to try heroine without getting addicted. There's a metaphor involving alcohol here. (And he's lucky that he didn't get addicted to siren song.)

Most real-world scenarios are different:

• We need society to enforce constraints.
• Those constraints affect everyone to some degree, even those who don't want them.

...

What I'd really like is for society to criminalize all mint-chocolate flavored snacks.

Tell us more about your dystopian dictatorship, where people are free from temptation.

I still think there's arguably a fix which doesn't have problem 2 "Those constraints affect everyone to some degree, even those who don't want them." - having opt-in constraints. This might work if you can voluntarily get yourself banned from something (say for the next week), but open tables with snacks don't quite mix with this. 

Less distantly, maybe places could share info about what snacks they will have, in advance.

Say you used to be addicted but now you've quit. If you could snap your fingers and make all drugs disappear, wouldn't you do that?

No. There's a difference between all drugs, and a specific drug. 'Snapping' here, would literally kill people.

Interesting consequentialist question here - do drugs save (and help) more people than they kill (and destroy)?

Obviously, criminalizing cookies (or fentanyl) is bad for both responsible users and people who can't or don't want to quit. I'm just trying to point out that there is a tradeoff. Society has decided that tradeoff in favor of responsible Twinkie users and against responsible fentanyl users.

Are there responsible cookie users? Or do we just resist the urge to buy it, but give in when it's available as a free snack? You want to not have 'mint chocolate' options - you want them banned. You want to stop, but you're having trouble doing so. Are you addicted to mint chocolate sweets? Are we addicted to cookies?

Sometimes we can give people the chance to "Odysseus" themselves without intruding too much on the freedom of others. An example is gambling. Some locations allow people to "self-exclude" from gambling, after which casinos won't let you play for a time period of your choice. This isn't perfect, since now responsible gamblers have their ID checked, and addicts can still cross state lines or play the lotto or whatever.

This is perfect. It's perfect for you, and particular style of irresponsible mint chocolate consumption. 

We can informally picture the different regimes like so:

You're still distinguishing freedom and constraints. From your perspective isn't there just a line, instead of two dimensions?

Roughly 10% of people in the US are raging alcoholics. Could we offer them the chance to self-exclude from alcohol?

Unfortunately, it seems very difficult.

We're back at ignoring the simpler policy that would work for someone like you -  i.e., I want to not buy it, and would opt in to 'not having the option to buy it'.

quantum stem-cell

What?

Some studies show great results for people who are married but not for single people.

Maybe friends aren't the weak link you made them out to be.

This reminded me of an essay on artificial pain, where people whose hands could no longer feel pain in some part of their body would get a computer controlled device attached to another part of their body that would hurt them where they were sensitive if they did something that could damage their insensitive body parts.

One problem was calibrating the mechanism to really detect damaging actions (preferably before damage became at all severe). 

The deeper problem was that the entire mechanism was optional.

Even the patients who were most "adherent" to the treatment and the most intellectually "bought in" to the idea that pain could protect them from damage would sometimes briefly turn the device off to do things that would cause damage to their hands that they just "really wanted to do" in that moment.

It feels like there's a lurking idea here related to agency operating on longer time scales?  Something something months, years, and decades? Something something low pass filter?  Something something Parfit?

I had not heard of casino self exclusion before! Thanks for that pointer :-)

If

[It] is just a "nudge", which is often enough to prevent alcoholism from forming in the first place, but not strong enough to displace alcoholism once it's taken root.

then it would work best early on or in combination with someone helping you, e.g. your spouse

Some studies show great results for people who are married but not for single people.

Or your parent. Could parents give it to their teenagers before they go to a party: "You can go but take this pill first."

The drug is still available today, though not much used for alcoholism except in Denmark, where it's widely prescribed.

This is not quite true. Disulfiram is currently used in Russia (and other former USSR countries) to treat alcohol addiction. (Random clinic website that offers disulfiram implants for ~$200.)
 

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Also in the 90s disulfiram apparently was used to treat alcohol addiction in a quite questionable form:

Coding (kodirovanie) is a catch-all term for various Russian alternative therapeutic methods used to treat addictions, in which the therapist attempts to scare patients into abstinence from a substance they are addicted to by convincing them that they will be harmed or killed if they use it again.

https://en.wikipedia.org/wiki/Coding_(therapy)

This is awesome, I've been curious about Asian flush for ages but never put in the work to research it. Thanks!

Your discussion would suggest that disulfiram might not work at curing alcoholism but could be a useful prophylactic. Lace the drinking water with it and people will avoid alcohol or stop earlier! What could go wrong?

The straightforward conclusion is that human evolution is continuing, in fact accelerating.

There's a drug called Orlistat for treating obesity which works by preventing you from absorbing fats when you eat them. I've heard (somewhat anecdotally) that one of the main effects is forcing you to eat a low fat diet, because otherwise there are quite unpleasant 'gastrointestinal side effects' if you eat a lot of fat. 

But who averages 10 drinks per day, you ask? The answer is an astonishing number of people. 

My question would be "What's a drink?" It doesn't seem to be an intuitive unit.