Evaluating alcohol use in ‘Dry January’
With the pandemic's effects on drinking as a backdrop, public health initiatives like “Dry January” may be enticing to patients who want to pause their drinking and examine their habits.
January marks the start of a new year and, for some patients, a chance to rethink drinking habits after the alcohol-saturated holiday season. This opportunity may be even more timely during the COVID-19 pandemic, which has seen increased alcohol sales and consumption.
One recent survey found that alcohol use in terms of drinks per month increased by 39% from February to November 2020 among U.S. adults of legal drinking age, according to results published in the July/August 2021 Journal of Addiction Medicine. Some of the greatest increases were among women with children under age 5 years in the household (323%), Black and Hispanic women (173% and 148%, respectively), and Black men (173%).
Many people, especially those with children at home, may have turned to alcohol at times of increased stress due to risk factors like loss of work, loss of purpose, increased financial stress, and grief, said addiction medicine subspecialist Ximena A. Levander, MD, FACP, an assistant professor of medicine at the Oregon Health & Science University School of Medicine in Portland.
Although some people who mostly drink in social settings are consuming less alcohol during the pandemic, “Those people who are drinking more are drinking a lot more, which is important because alcohol and its harmful effects are dose dependent,” she said.
Charles Reznikoff, MD, FACP, sees these harmful effects as an addiction medicine subspecialist at Hennepin Healthcare in Minneapolis. “What we observe in the hospital are severe cases of withdrawal,” he said. “It's anecdotal, but it seems that the intensity of drinking, for those who are vulnerable, has increased.”
Research is beginning to reveal such harms linked to increased drinking during the COVID-19 pandemic. Two studies published in October 2021, one by JAMA Network Open and the other by Clinical Gastroenterology and Hepatology, found increases in patients registering for and receiving liver transplants, as well as more hospitalizations for alcohol-related hepatitis during COVID-19.
With the pandemic's effects on drinking as a backdrop, public health initiatives like “Dry January” may be enticing to patients who want to pause their drinking and examine their habits. Started in 2013 in the United Kingdom by the British nonprofit Alcohol Concern (now Alcohol Change UK), the campaign encourages people to abstain from alcohol for the month of January.
Benefits and risks
Dry January is becoming increasingly popular in the U.S. and Europe, with France and Switzerland launching their own campaigns in 2020 and 2021, respectively. This past January, an estimated 6.5 million people participated in the largest Dry January to date, up from nearly 4 million people in 2020, according to Alcohol Change UK.
The initiative taps into the common practice of making New Year's resolutions to improve aspects of one's life, said psychologist Richard de Visser, PhD, who worked with Alcohol Change UK to survey Dry January participants about the campaign's effects.
“There is clear evidence that taking part in Dry January helps people to feel more in control of their drinking, it leads to better sleep and better concentration, and people also save money,” he said. In addition, physiological studies have shown that not drinking for a month results in a range of healthy changes within the cardiovascular system and the liver, said Dr. de Visser.
One of his studies found that Dry January seems to attract people who drink more, have lower self-efficacy for refusing alcohol, and are more concerned about the effects of alcohol on their health than those in the general population. Completion of the dry month was associated with beneficial changes in physical and psychological well-being, control over drinking, and alcohol intake; these benefits were not found among controls, according to results published in May 2020 by Alcohol and Alcoholism.
More than two-thirds of people who participate in Dry January complete it, and even those who only make it partway experience some benefits (albeit at a lower level), noted Dr. de Visser, who teaches psychology at Brighton & Sussex Medical School and the School of Psychology at the University of Sussex in Brighton, U.K. He added that the effects of completing Dry January may last well after the challenge.
“Our follow-up studies have shown that six months after Dry January, those who complete Dry January are drinking alcohol on fewer days per week and that they also drink less on the days when they do drink,” he said.
But for each individual, the effects of Dry January will depend on their mindset as they enter the month, noted Dr. Reznikoff, who is also an associate professor of medicine at the University of Minnesota Medical School in Minneapolis. The right mindset would be to view the exercise as an honest exploration of their relationship with alcohol (or cannabis, or any other substance), he said.
“If someone is thinking, ‘As long as I can get through January, I've got a green light in the rest of the 11 months,’ that's a really dangerous approach,” he said. “On the other hand, if someone is thinking, ‘I'm going to take this month to honestly explore my relationship with alcohol and also my own wellness,’ I think that's a great idea.”
While campaigns like Dry January are positive overall, taking the former approach would be especially concerning, said Ian Hamilton, senior lecturer in addiction and mental health at the University of York in the U.K. and author of a commentary exploring the campaign's potential harms in January 2016 in The BMJ. “Binge abstinence is just as unhealthy as binge drinking, so it would be better to have regular breaks from alcohol than just in one month of the year,” he said.
Dry January may not be appropriate for people who are dependent on alcohol and who may benefit from more focused support, Dr. de Visser cautioned, adding that heavier drinkers are less likely to make it through the full month without drinking.
“If this happens, some experience ‘rebound effects,’ which mean that they drink more than they usually would,” he said. “However, overall rebound effects are only observed in around 10% of participants, whereas 50% go back to drinking at previous levels and 40% drink less than they did before taking part in Dry January.”
For those who drink unhealthy amounts of alcohol regularly, an important risk of quitting alcohol for a month is withdrawal, noted addiction medicine subspecialist Marlene Martin, MD, an associate professor of clinical medicine at the University of California, San Francisco, and a hospitalist at San Francisco General Hospital.
“Depending on how much someone is drinking, it's important to discuss stopping drinking with a clinician because if they're at risk for alcohol withdrawal, we want to be prepared to manage that,” she said. Symptoms of alcohol withdrawal include headaches, irritability, anxiety, nausea, and tremors, and life-threatening complications include seizures and delirium tremens.
Of note, people who have increased their drinking during COVID-19 may be in the high-risk category, suggesting that they should reduce their alcohol with medical supervision to avoid harm from withdrawal symptoms, said Mr. Hamilton.
The most important predictor of alcohol withdrawal is previous withdrawal, said Dr. Reznikoff, adding that a history of seizure, regardless of the cause, would also warrant individualized care. For patients who have not had withdrawal but drink on a daily basis, using the Prediction of Alcohol Withdrawal Severity Scale can help clinicians predict withdrawal risk, he said.
“If that does not show high risk, daily drinkers—especially with poor nutrition and especially people middle-aged and older—could still be at risk,” said Dr. Reznikoff. “So I think it's important to talk to people about their risk, to let them know that the risk occurs throughout the first week after cessation of alcohol (it's not just the first day), and to contact the clinic or other medical help if they believe they're having alcohol withdrawal.”
There are also the broader challenges of opting out of drinking for a limited time. Alcohol is often present in many situations, especially in cultures where consuming alcohol is possible or even expected at celebrations, sporting events, and other social situations, said Dr. Levander.
“It can be really challenging to not drink,” she said. “I think, also, there are very few behaviors where if you choose to not do it, people question why you're not doing it. I think that's especially true if you're a woman: If you're not drinking alcohol, people are like, ‘Oh, are you pregnant?’”
Dr. de Visser agreed, adding that people who don't drink are often expected to justify opting out in the same way vegetarians and vegans are often expected to justify not eating meat. “However, Dry January is now broadly recognized as a ‘valid’ reason for not drinking that is also temporary, and this may make it easier for drinkers to accept,” he said, adding that many participants value the sense of community the campaign offers.
The internist's role
Internists are already accustomed to talking with patients about alcohol use. The U.S. Preventive Services Task Force's 2018 B-grade recommendation is to screen adults for unhealthy alcohol use in primary care settings and to provide brief counseling to those engaged in risky or hazardous drinking.
In addition to screening and brief counseling interventions, internists should be familiar with the DSM-5 criteria for alcohol use disorder, which include 11 consequences, such as a failed attempt to limit alcohol, trouble at work, tolerance, and interpersonal problems, said Dr. Reznikoff. The presence of two to three consequences suggests a mild disorder, whereas four to five and six or more would signal a moderate and a severe disorder, respectively.
“Often our stereotype is that alcohol use disorder is this severe, all-consuming disease that is causing catastrophic life events, and that is true sometimes,” he said. “But … alcohol use disorder is more common than we recognize it.”
For patients diagnosed with an alcohol use disorder, the flagship example of a safe, effective medication is naltrexone, which was approved in 1995 by the FDA as an oral treatment for alcohol dependence and helps patients decrease or stop alcohol use, noted Dr. Reznikoff. “Naltrexone is a good medication for internists to understand the evidence and indication and to start using that for patients who are drinking excessively,” he said.
For patients with an uncertain diagnosis of alcohol use disorder, Dry January can offer an opportunity to gather more information and potentially establish or rule out a diagnosis, said Dr. Reznikoff. It can also help those who do not have an alcohol use disorder but who would benefit from more observation of their drinking patterns.
“What this month provides is insight into the relationship that individual has with alcohol,” he said. “So if someone says, ‘I'm going to go 30 days without drinking,’ and then they drink anyways, technically that is one criteria for alcohol use disorder, and that person should be aware of that.”
Those who participate in Dry January can use the month to assess how removing alcohol affects their diet, mood, energy levels, sleep, and craving for alcohol, Dr. Reznikoff said. In particular, beer or wine drinkers may also lose weight after they stop drinking, although that's not always the case, he said.
“I really like the idea of a dry January … specifically to gather data about the diagnosis of alcohol use disorder,” he said. “But even if someone doesn't have alcohol use disorder, it's very appropriate and healthy to take a month off occasionally.”
It would also be reasonable for internists to encourage patients with chronic health conditions, such as hypertension or elevated liver enzymes, to take a break from drinking and to assess for changes in blood pressure and liver enzyme levels at the end of the month, said Dr. Reznikoff.
“I don't think it's something that has to be offered or suggested to all patients, but there are a lot of opportunities for internists to use this time in patients with chronic health issues to help illustrate the effect that alcohol has on their chronic health issues,” he said.
If patients do not connect their alcohol intake with their health condition, try asking for permission to provide some teaching; patients rarely opt out of education, recommended Dr. Martin. “When you're treating people with respect and not judging them, they're so much more open to these conversations, and it's going to go way further than you talking at them and making assumptions about them,” she said.
A physician should also make sure patients have the ability to change their relationship with alcohol before taking on an abstinence challenge, Mr. Hamilton noted. “If a physician were to recommend Dry January, I think they would need to ensure the individual had a chance of succeeding,” he said. “Otherwise, this may contribute to the person thinking it is impossible for them to change their relationship with alcohol.”
Participation in Dry January should be a patient-centered decision, and internists can elicit patients' reasons and goals for participating via an open-ended conversation, said Dr. Martin. “If it's coming internally like, ‘I want to cut back, these are the reasons why’ … that is so much more powerful than any recommendation I could give,” she said.
Patients who choose to go dry may find it helpful to develop another behavior to continue for the month and beyond, such as an enjoyable exercise or art activity, said Dr. Levander. It can also be helpful to connect with other participants or people who want to cut back on their alcohol intake, she said, adding that journaling can provide insight as well.
“I think people feel like if they're going to stop drinking alcohol, they're going to give something up,” Dr. Levander said. “But instead of having that attitude toward it, it should be more about, ‘What am I gaining? How am I going to feel better? What new thing can I do? What else can I spend my money on?’”
She cautioned against putting on the pressure to make big changes in January, given all the stress around the holidays. “Jan. 1 is a date that people often feel terrible,” Dr. Levander said. “I actually encourage people … to think of January more as a planning month, and to actually try and do behavior change starting in February.”
That means January can be a time to reflect on why one wants to try going dry, think about what behaviors could replace drinking, and make plans that don't involve alcohol, she said. Some countries, such as Canada and the Czech Republic, even campaign for Dry February instead of January.
“Using February as a month to really try and jump into that big behavior change, I think that's where we've seen more longstanding behavior change, where you're setting yourself up for success,” Dr. Levander said.