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EW NEWS & OPINION 22 May 2015 by J.C. Noreika, MD, MBA Insights Hancock was a purveyor of spirits and Patrick Henry was a bartender. The essence of the nascent United States of America was distilled in an alcohol-permeated environment; Thomas Jefferson, apparently in the pursuit of happiness, penned the first draft of the Declaration of Ind - pendence at a tavern in what is now Philadelphia's Old City. A year later, the mindful General Washington at Valley Forge, his troops frostbitten for Jefferson's impertinent idealism, ordered the Continental Army's foot soldiers be awarded rum prior to his officers. Alcohol has been touted for its medicinal properties through- out history. The Old and New Testaments mention its beneficial advantages—191 times. At the turn of the 20th century, a medical report suggested that responsible imbib- ing reduced the risk of heart attack. Since then there have been thou- sands of articles in the most presti- gious journals purporting to show the benefits of moderate alcohol use. One meta-analysis of 34 studies examined alcohol consumption and total mortality; it included more than 1 million subjects. Temperate imbibing was found to favorably impact not only total mortality and cardiovascular disease, but posi- tively affected diabetes (an article in the Archives of Internal Medicine studies adult-onset diabetes, alcohol consumption, and male physicians), rheumatoid arthritis, benign pros- tatic hyperplasia, dementia, age-re- lated macular degeneration and the occurrence of epidemic oyster-borne hepatitis A. "Moderation" is the key. The famous U-shaped curve of alcohol's advantage is well known. Too little ethanol is thought detrimental to an individual's overall mortality; too much sows the seeds of addictive tragedy for users, innocents, and society as a whole. What constitutes the moderate use of alcohol is un- settled. Researchers discuss alcohol in terms of grams consumed on a daily basis or at peak intervals. A 12-ounce beer, 5 ounces of wine and 1½ ounces of whiskey contain be- tween 12–14 grams of alcohol. The salubrious bottom of the U-shaped curve seems to be about 26 grams per day for men, fewer for women. Knott et al raise important issues. Addiction in 2010 published an article purporting that high alcohol consumption has been correlated with more than 200 acute and chronic medical conditions. Although his selection of cohorts evokes calculation of angels dancing on points of needles, Knott warns of the rise of alcohol abuse among the elderly, especially those isolated, unsupervised, and taking multiple medications, especially psychotropic drugs. Ashley Alberta, a substance abuse treatment expert, cautions "people don't wake up one day and suddenly become alcoholics. It can be a long progression from first use to addiction. The warning signs are often ignored and significantly more people get into trouble with alcohol than most people perceive because they don't seek treatment for their abuse." She stresses that Substance Use Disorder (SUD) is a chronic disease. "Like diabetes and hyperten- sion, it can be managed but is prone to non-compliance (with ongoing care) and frequent relapse. Addic- tion is not a 'choice' that is 'cured' after treatment." Despite advances in genetic research and functional imaging techniques, it is impossible to predict whose hypothalamus is likely to express addictive tenden- cies. Gerald and Sara Murphy, who welcomed the most illustrious Lost Generation artists to their summer home in Cape Antibes, famously said, "living well is the best revenge." For me, that might include a good book, a well-tended fireplace, and 14 grams of a sophisticated red from the Sinskey, Mazzocco, or Jessup vineyards. A stone carving at the Temple of Apollo at Delphi bears the warning Medèn ágan—"nothing in excess." Advice for the ages ... and the aging. EW References 1. Desenclos JA, Klontz KC, Wilder MH, et al. The protective effect of alcohol on the occurrence of epidemic oyster-borne hepatitis A. Epidemiology. 1992;3(4):371–4. 2. Knott CS, Coombs N, Stamatakis E, et al. All cause mortality and the case for age spe- cific alcohol consumption guidelines pooled analyses of up to 10 population based cohorts. BMJ. 2015 Feb 10;350:h384. 3. Obisesan TO, Hirsch R, Koroko O, et al. Moderate wine consumption is associated with decreasing odds of developing age- related macular degeneration in NHANES-1. J Am Geriatr Soc. 1998; 46(1):1–7. 4. Ajani UA, Hennekens CH, Spelsberg A, et al. Alcohol consumption and risk of type 2 diabetes mellitus among U.S. male physicians. Arch Intern Med. 2000; 160(7): 1025–30. Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com The conundrum of C 2 H 5 OH "A hangover is the wrath of grapes" –Dorothy Parker A s if things in medicine ar- en't complicated enough, a recent study in the Brit- ish Medical Journal chal- lenges whether imbibing moderate amounts of alcohol prove salutatory as hundreds of studies published in medical journals have purported. The products of fermentation have been around a long time. The science of zymology studies its im- port. Progression from the Paleolith- ic to the Neolithic period of Homo sapiens' evolution saw the introduc- tion of wild cereals as food substanc- es. This led to farming and inevita- bly the production of foodstuffs that contained, by design or serendipity, ethanol. A second milestone was the creation of pottery. In 2012, archae- ologists wrote of receptacles used to brew beer found at a cultic celebra- tory site in Turkey. The site dates to 11,000 BCE or thereabouts. Evolu- tionary psychologists and sociolo- gists might contend that alcohol's universality through diverse eras, regions, and societies suggests its advantage in propagating the gene pool. An informal survey of spring break in Panama City could have saved them time. In ancient Egypt, beer was an important food even before bread. Osiris, that civilization's great god of the underworld, was ascribed its inventor. Whether the architects of the pyramids gathered at sundown for a beer-drenched debriefing is lost to history. Among the ancient Greeks, Macedonians earned a reputation as hearty partiers, not the least of whom was Alexander the Great. A reputation for inebri- ety didn't prevent his amassing the most impressive, far-flung empire the ancient world had seen. History may judge the Puritans too harshly; the Mayflower was laden with more beer than water. At the nation's founding, John J.C. Noreika, MD, MBA