alcohol and health alcohol combinations€¦ · wine, beer, cider and spirits are part of everyday...

A L C O H O L A N D H E A LT H

ALCOHOL COMBINATIONS

TABLE OF CONTENTSForeword 1

Alcohol combinations 2

Green light: A happy combination 3

Orange light: Pay attention 4

Red light: Look out! 8

Purple light: Severe danger 12

978-2-923548-27-2Dépôt légal - Bibliothèque nationale du Québec, 2008Dépôt légal - Bibliothèque et archives Canada, 2008

A L C O H O L A N D H E A LT HALCOHOL COMBINATIONS

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Wine, beer, cider and spirits are part of everyday livingin Québec, commonly enjoyed by most people. Morethan eight in ten Quebecers aged 15 or older drinkalcohol occasionally or regularly. The vast majority ofthem do so with balance and moderation.

People drink now and then, under particular circum-stances. For example, they’ll have a drink at the endof the day with friends on a sidewalk terrace.

At other times, alcohol is enjoyed in a pleasantcombination with food, either during a meal or withsnacks at the cocktail hour. Such combinations arebeneficial for various reasons that are explained inthis publication.

Occasionally, however, people drink while consumingsubstances or engaging in activities which, in combinationwith alcohol, can have harmful effects on their health.Such is the case with caffeine, tobacco, gambling,soft and hard drugs, and the energy drinks that haverecently appeared on the market.

This report is designed to be both comprehensiveand readable. It covers substances and activitiesthat, when combined with alcohol in moderation,present a minimal or negligible health risk. It alsolooks at the harmful effects of certain combinationsof alcohol and tobacco or alcohol and drugs; and itexamines the significantly more dangerous effects ofalcohol and sedatives.

Ultimately, the report serves as a reminder that, evenwith low-risk combinations, moderation is always ingood taste.

The Éduc’alcool Board of Directors

FOREWORD

A L C O O L E T S A N T ÉL’ALCOOL ET LES MÉLANGES

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In Western culture, a drink after work is a pleasant way tomark the start of a well-deserved period of rest.1 Drinkingalcohol often indicates a break with routine and structuredactivity.2 It is a symbolic pause3 that means it’s time to relax!

In Québec, surveys show that most people drink socially –at get-togethers with family and friends, during holidaysand at celebratory events. Drinking is thus associated withsocializing and fun.

Aside from alcohol, other substances – and behaviours –are also symbolic of relaxation and time out. Many peopletake breaks by eating a good meal, having a coffee or sippingan energy drink. Still others gamble, smoke tobacco, ortake soft or hard drugs to mark a break in routine.

Alcohol is often consumed in combination with these otherproducts or activities.

Unfortunately, it is not always a happy marriage. In associationwith certain substances, the specific properties of alcoholcan produce an explosive mix!

Except in the case of food, there is always a risk involvedwhen combining alcohol with other substances. Understandingthe biological processes and other issues at stake can helppeople modify their behaviour appropriately.

ALCOHOL COMBINATIONS

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The only substance that has a beneficial effect on humanhealth when combined with alcohol is food.

The presence of food in the gastrointestinal system has apositive effect on the absorption of alcohol by the blood.The type of food also makes a big difference. The fattierthe food, the longer it takes for the alcohol to pass fromthe stomach to the intestine4 and the slower the absorptionprocess, thus reducing the person’s blood alcohol content.5

It is important to keep in mind that an elevated blood alcoholcontent (BAC) can have a harmful effect on health: a highBAC is often the cause of falls, fights and road accidents.On the other hand, the benefits of taking an extendedbreak involving alcohol are not merely physiological!Pleasure is another important biological phenomenon producedwhen wine, cider or beer are sipped moderately in combinationwith good food, enjoyed in good company.

• ALCOHOL AND FOOD Studies show that people who drink alcohol after eating ameal high in fat, protein and carbohydrate absorb the alcoholabout three times more slowly than those who drink on anempty stomach. Clearly, however, this does not mean weshould all be eating high-calorie meals full of fat, proteinand carbohydrate.

Matching foods with wines heightens the enjoyment ofboth, to a degree that would be difficult to achieve if onewere to eat the food and drink the wine separately.Combining the right food with the right wine also meanstaking into account the balance of flavours, the time of day,the season and the type of meal.

At cocktail time, beer, cider, whisky and other aperitifsshould always be accompanied by snacks, such as nuts orcheese.

In studying alcohol and health, researchers should considerthe context in which drinking occurs, since drinking with ameal can have certain health benefits.6 Many studies do, infact, take this into consideration.

• ALCOHOL IN MIXED COCKTAILSFor the same reasons explained above regarding food, it isbetter to mix alcoholic cocktails with 100% natural purefruit or vegetable juice, rather than carbonated or flavouredbeverages with minimal nutritional value.

If you absolutely must use a carbonated or flavoured mixer,it’s better not to use “diet” versions, since sugar helpsmetabolize the alcohol. According to a recent Australianstudy7 of young men, when cocktails are made with artificiallysweetened beverages, as opposed to naturally sweetenedones, alcohol passes more quickly from the stomach to theblood and blood alcohol levels are higher.


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Green light Orange light Red light Purple light

A happy combination Pay attention Look out! Severe danger

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GREEN LIGHT:A HAPPY COMBINATION

• ALCOHOL AND COFFEEWhen consumed in moderate amounts, there is no dangerin mixing alcohol and coffee. Drinking alcohol and coffeetogether, either separately or combined in one drink is notharmful in itself. In fact, in many cultures, it is a long-standingpractice. After a meal, many people enjoy the way thecombination brings out the flavours and aromas of bothingredients.

However, people often drink coffee with alcohol for otherreasons, in particular when they have drunk too much alcoholand are hoping to mask the symptoms of intoxication.

What they’re trying to do is use coffee to counter the negativeeffects of the alcohol, which has a sedative effect on thecentral nervous system and slows down the brain functionsthat affect judgement, emotion and behaviour. Coffee containscaffeine, a known stimulant, as well as chemical agentsthat stimulate the production of the hormones cortisoneand adrenaline, which are also stimulants.8

Studies have demonstrated the antagonistic effects of caffeineand alcohol. Caffeine will slightly attenuate the effects ofinebriation and allow a person to perform certain psychomotortasks.9 That being said, drinking coffee after drinking alcoholin no way restores all the faculties necessary to drive amotor vehicle.

In fact, the amount of coffee consumed has absolutely noeffect on blood alcohol content.

People who drink coffee and alcohol, either together orsequentially, should remember that they are almost certainlyunderestimating their blood alcohol content. While thestimulating effects of the coffee may lessen some of thesedative effects of the alcohol, it is physiologically impossiblefor coffee to reduce blood alcohol content and renderanyone “straight!”

Vigilance is therefore called for when drinking alcohol withcoffee since the combination may have unpleasant conse-quences, particularly with regard to driving or other activitiesrequiring full control of all faculties.

• ALCOHOL AND ENERGY DRINKSIn recent years, soft drinks have been losing market shareto energy drinks, which people are drinking for the samereason they drink coffee, i.e. their stimulant effect.

While rumours that these drinks owe their kick to bullsperm or urine are merely urban legends, they do indeedcontain taurine,10 glucuronolactone11 and about as muchcaffeine as there is in a cup of coffee, i.e. 80 mg.

But it’s the way people drink them that makes energydrinks very different from coffee. Energy drinks are drunkcold and packaged for drinking quickly, which means theeffects of the caffeine are felt much sooner than with coffee,which is generally served hot and sipped more slowly.12

ORANGE LIGHT:BE ATTENTIVE

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Consumer characteristics and behavioural context

Young people are the biggest consumers of energy drinks.They have them primarily at parties and raves, in bars andat clubs. More than one-third of 18 to 24 year-olds saythey drink energy drinks regularly.

A recent study13 shows that mixing energy drinks with alcoholis very popular among students. In fact, it is common practiceamong almost half of them (48.5%).

Users say that energy drinks help them “keep going.” Asthe director of communications of one brand notes, thedrinks provide a boost of energy for people who like to godancing and clubbing – all night long.14

These are precisely the type of circumstances in whichyoung people tend to drink excessively.15 When young peoplemix alcohol with energy drinks, they are likely drinking aconsiderable amount. And that’s what makes the combinationdangerous.

False perceptions and increased risk-taking

Young people are more likely than adults to take risks andbehave dangerously. They are more likely to be involved inroad accidents, engage in unprotected, unplanned and orunwanted sex, behave violently or suffer from the violenceof others, and attempt suicide. The sense of power andinvulnerability that generally accompanies such behaviourscan be further exaggerated when alcohol is combined withenergy drinks.

One study16 compared people drinking alcohol only withthose drinking alcohol mixed with energy drinks, and foundthat the mix drinkers were far less likely to complain ofheadache, weakness and dry mouth, and decreased motorcoordination.

And yet there was no significant difference between thetwo groups with regard to blood alcohol content or motorcoordination and visual reaction speed, as objectivelyobserved.

In other words, people who combine alcohol and energydrinks are definitely drunk and their faculties are impaired,but they don’t feel the effects of intoxication. A recentstudy17 of cognitive performance and the perception ofintoxication among social drinkers resulted in the sameconclusions.

Because these drinkers do not feel the effects of alcoholintoxication, the normal self-regulating mechanisms associatedwith drinking are no longer operational. A clear warning istherefore in order for young people who mix alcohol andenergy drinks, since this particular combination furtherincreases risky behaviour.

A study18 of 4,271 students at ten American universitiesshowed that, compared to people who drank alcohol only,those who mixed alcohol with energy drinks were twice aslikely to:

• hurt themselves or be injured;• require medical attention;• get into a vehicle with a drunk driver;• assault someone sexually;• be sexually abused.


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Impact on drinking

Given that people who mix alcohol with energy drinks oftendo so to mask the unpleasant taste of the alcohol, we canexpect that such people will drink a greater amount morequickly and drink more on each occasion.19

It has also been reported20 that people who mix alcoholwith energy drinks tend to drink more than those who don’tmix the two: about 5.8 drinks compared to 4.5. Similarly,the mixers report drinking an average maximum of 8.3drinks per occasion, compared to 6.1 for the non-mixers.Mixers are also twice as likely to get drunk every week: 1.4occasions, compared to 0.73 for the non-mixers.

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Dehydration

Another warning needs to be issued about the risk ofdehydration when mixing alcohol and energy drinks.Caffeine and alcohol are diuretics, meaning they keepwater from being reabsorbed by the kidneys and causemore water to be eliminated. This creates a chain reaction:the more alcohol you drink, the thirstier you feel. The realdanger lies in continuing to drink alcohol – instead of water– which increases thirst and dehydration.

At parties and where people are dancing it also tends toget particularly warm, and the combination of alcohol andenergy drinks further increases dehydration.

“Morning after” symptoms – headache, general discomfort,major fatigue – are all related to dehydration. During theparty, energy drinks mask the symptoms of intoxication andtemporarily quench thirst, but the next day, mixers shouldexpect to feel worse than non-mixers.

WARNING! People should be extremely careful when purchasingenergy drinks, because some are already premixed with alcohol.As a result, those who have no intention of mixing alcoholwith their energy drink may end up doing so inadvertently.Also, some companies that produce this new kind of alcoholicbeverage are packaging them to look like the non-alcoholicversions. This can lead to confusion and mislead young people,their parents, and even employees working in stores whereboth types of energy drinks are sold.


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• ALCOHOL AND GAMBLINGThere is a causal relationship between alcohol abuse andpathological gambling. There are more pathological gamblersamong those who drink abusively than among the generalpopulation. Similarly, pathological gamblers are more likelyto drink abusively than the general population.21

Over the last decade or so, a number of studies haverevealed more about the link between abusive drinking andpathological gambling. Thus far, the reasons for the connectionhave not been clearly identified, but both behavioursappear to have the same causes.

Abusive drinking and pathological gambling are bothaddictive behaviours that indicate a loss of control andinvolve obsessive thoughts about alcohol and gambling.Even when they are aware of the harmful consequences oftheir habits, addicts continue their abusive behaviour.

Among both alcohol abusers and pathological gamblers,changes can be observed in the brain centres responsiblefor pleasure and emotions.22 Both behaviours are associatedwith a disturbance in the neurobiological mechanismsrelated to impulse control and reward.

Clinical studies have underscored the limits of geneticexplanations and stressed the need to examine contextualfactors as well. The comorbidity of alcohol abuse andpathological gambling are explained by the fact that abusivedrinking disinhibits pathological gambling. People commonlygamble while drinking alcohol.23

It is generally accepted that, when consumed beyondmoderation, alcohol has a negative impact on cognitivefunction. Alcohol impairs judgement and increases thetendency to take risks.24 People with an elevated blood alcoholcontent are distracted from immediate and importantconcerns.25

It is possible that, where gambling is concerned, even asmall amount of alcohol can be harmful. In one experiment,26

participants – all social drinkers – received a placebo or amoderate dose of alcohol and then had to make gamblingdecisions. Compared to those who received the placebo,the group that received alcohol demonstrated an impairedability to factor in the magnitude of gains and the likelihoodof winning when the losses were large.

People with a high blood alcohol level are thus less able toevaluate the real chance of winning and are less likely toremember past losses. These contextual explanationscomplement the observations of brain activity.

A definite causal connection between alcohol andpathological gambling cannot be made. Abusive drinkingdoes not necessarily lead to pathological gambling; otherstudies have actually shown that pathological gamblingcauses abusive drinking. There is no ignoring the fact that,in some people, gambling has led to increased drinking,while in others the opposite is true.

Éduc’alcool feels compelled to issue a warning: peoplewho enjoy gambling should avoid drinking alcohol at thesame time. The combination of alcohol and gamblingincreases the risks of gambling inappropriately, i.e.pathologically.

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Data on the general population reveal that smokers drinkmore than non-smokers; that drinkers smoke more thannon-drinkers; that alcohol abuse is associated with heavytobacco use; and that the vast a majority of alcoholicssmoke.27 Alcohol and tobacco seem to make the “perfect”couple.

Three explanations have been offered regarding the correlationbetween drinking and smoking:28

• Both have similar contextual risk factors, i.e. they are bothassociated with “time out.” Until just recently, they werethe two main products found in locations where peoplerelax and enjoy themselves, particularly where alcohol isavailable. Anyone who went for a drink was virtuallyguaranteed to be surrounded by smokers and the promotionof smoking.

• Drinking and smoking share the same genetic and psychiatricrisk factors. Thus far, experiments on the subject29 havebeen conducted primarily on laboratory rats, but there

seems to be a consensus on the effect on humans of thecommon pathophysiological risk factors30 associated withthe development of alcohol and nicotine dependence.This vulnerability – which is not genetic but results fromearly use – would explain why about 85% of alcoholicssmoke, a rate three times higher than among the generalpopulation.

• The astonishing aspect of the alcohol-tobacco connectionis the association between episodic drinking and occasionalsmoking. Many social or weekend smokers experience asudden and acute craving for a cigarette when they aredrinking excessively. Similarly, people who quit smokingoften find themselves starting up again during a night ofheavy drinking. Such phenomena are caused by thepharmacological interaction between alcohol and tobacco,and are characterized by an intense physical need tosmoke.

RED LIGHT:LOOK OUT!

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• ALCOHOL AND TOBACCO

In one study,31 39 occasional smokers were administeredthree different doses of alcohol – a placebo, the equivalentof 2-3 drinks, and the equivalent of 4-5 drinks – at threedifferent times, and a connection was observed betweenthe amount of alcohol and the desire to smoke.Researchers noted that the higher their blood alcohol content,the more people craved a cigarette, and the more intenselythey felt the craving. The study’s authors concluded that, ifoccasional smokers experience the need to smoke whendrinking heavily as opposed to moderately, it’s not to combatthe sedative effects of alcohol but because of the neu-ropsychological stimulation of the nicotine.

In another laboratory experiment,32 researchers gave alcoholto heavy drinkers who smoke daily and then offered thema choice between a cigarette and monetary compensation.Compared to participants who received a placebo, thosewho drank alcohol were significantly less likely to refusethe cigarette and, after smoking the first one, they smokedmore cigarettes than the participants who were sober.

One study33 demonstrated that drinking increases theintensity and value of the craving for a cigarette. Not onlydoes alcohol increase the desire to smoke, but the veryfact that people are drinking also increases the craving. Inthis experiment, even participants who had received theplacebo exhibited a greater desire to smoke, although itwas less pronounced than the craving felt by those who hadactually received alcohol. In the presence of a lit cigarette,those who had drunk alcohol displayed more facial expressionsassociated with positive affect than the other participants.

In an experiment involving American university students,34

74% of smoking episodes occurred while participants weredrinking alcohol. The opposite was also true. Anyone who,at any time, consumes both tobacco and alcohol shouldknow that smoking can lead to drinking more.

And in yet another study,35 researchers hypothesized thatnicotine slows gastric emptying, which would allow morealcohol to be metabolized in the stomach, leaving less to beabsorbed by the small intestine. People who smoke tobaccoand seek the intoxicating effects of alcohol would thereforehave to consume a greater quantity of alcohol. This leadsto increased production of acetaldehyde and more notabletoxicity.


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• ALCOHOL AND DRUGSThe combination of alcohol and drugs or illegally obtainedmedication is observed most commonly among drugaddicts. In the general population, thrill-seekers and youngpeople – who have a pronounced taste for new experiences– are most at risk for this dangerous mix.

Alcohol and drugs are generally combined to enhance thepleasurable effects of one or the other, or to diminish suchunpleasant effects as anxiety or drowsiness.36 Whateverthe reason, the combination of alcohol and drugs creates apharmacological interaction that can be extremely dangerousand even deadly.

One of the great dangers in combining alcohol and drugsis that the effects are impossible to predict.37 So many factorscan influence the results that it is not possible to considerboth substances together with any accuracy. Among otherthings, the effects of the mix will depend on the mix itself,the dose, how it is administered, the order in which thesubstances are taken and the sociocultural circumstances,as well as the person’s age, sex, weight, nutritional condition,physical health and psychological state.

• ALCOOL ET MÉDICAMENTS

• ALCOHOL AND MEDICATIONSome medications, in particular over-the-counter productslike painkillers, may hinder the elimination of alcohol,increase or mask their effects, or cause unpredictablereactions. Conversely, alcohol can make medications lesseffective or interfere with their elimination. Anyone takingmedication should be properly informed about contraindi-cations before drinking alcohol at the same time. It isimportant to remember that, like alcohol, medications areeliminated by the liver, and as a general rule, it is better notto drink while taking medication.

• ALCOHOL AND CANNABISCannabis use in Québec is not uncommon. Currently,15.8% of Quebecers aged 15 and older use cannabis -marijuana and hashish - while 46.4% of Quebecers saythey have tried cannabis at least once.38 It is impossible toknow how many of these people combine it with alcohol,but a warning is in order for those who do.

When taken together, a synergy is produced, increasingthe sedative effects of both the alcohol and the cannabis.Judgement, reaction time and coordination are obviouslyaffected and driving is out of the question.

Because cannabis inhibits the part of the brainstemresponsible for vomiting, combining it with alcohol can beparticularly dangerous, and even deadly.39 When peopledrink too much and are in danger of alcohol poisoning, thebody’s natural response is to vomit. By inhibiting the vomitinstinct, cannabis thus increases the danger of alcoholpoisoning.

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Only 2.5% of the general Québec population use cocaine,speed, ecstasy and hallucinogenic drugs.40 A strong warningmust be issued against combining such narcotics, stimulantsand hallucinogens with alcohol.

These combinations can produce an antagonism in whichthe properties of one substance suppress or attenuate theeffects of the other. This can be extremely serious, as peoplemay be unable to detect the impact of the substances theyare taking. In other words, they may not feel as pronounceda “high” even though the physical effects of the drugs andalcohol on various organs and functions will be the same.41

The combination of alcohol and stimulants can create anadditive synergy that increases the risks of overdosing oneither substance. For example, drinking alcohol with a stimulantlike cocaine increases the speed with which alcoholspreads throughout the body, which means it reaches thebrain more quickly. The result is a significant increase inblood alcohol content, as if the person had drunk veryquickly.

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• ALCOHOL AND OTHER ILLICIT DRUGS

All the various aggravating and attenuating factors notwith-standing, the most dangerous alcohol-drug combinationsare those in which alcohol – which is a sedative – is mixedwith another sedative, such as a barbiturate, a benzodiazepineor an antihistamine. The sedatives sold by drug dealersinclude PCP (Mescaline, Mess, Horse, Angel Dust, TH) andketamine (Special K, Vitamin K, Ket, Ketty).42

When alcohol is combined with these psychotropic drugs, amutually reinforcing synergy is created in which the combinedsedative effect is greater than if the two substances weretaken separately. Such combinations can severely depressthe central nervous system, with consequences rangingfrom confusion to unconsciousness to death.43

PURPLE LIGHT:SEVERE DANGER

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CONCLUSIONCombining alcohol with other substances is a common andfairly frequent practice. In the case of tobacco and drugs –neither of which can ever be condoned – alcohol is clearlycontraindicated. No one should ever drink alcohol while takingother sedatives. And whenever medication is prescribed,people should always check with their pharmacist to findout whether alcohol is permitted or contraindicated.

When it comes to drinking alcohol with coffee, energydrinks or gambling, vigilance is called for. Such combinationsare not necessarily harmful, but serious problems may ariseif they are taken to excess.

Drinking alcohol in combination with food is recommendedand may even have a positive effect.

In short, our examination of the effects of combining alcoholwith other substances and activities reminds us once againthat when it comes to drinking, moderation is always ingood taste!

IN THE SAME COLLECTION:The reports in Éduc’alcool’s Alcohol and Health series are well-researched and easy to read. Each one gets straight to thepoint and is a valuable health, education and information resource. All of them may be downloaded from the Éduc’alcoolwebsite educalcool.qc.ca or ordered by calling 1-888-ALCOOL1.

THE EFFECTS OF MODERATE AND REGULARALCOHOL CONSUMPTIONA review of the research on how moderate,regular alcohol consumption affects humanhealth.

ALCOHOL AND THE HUMAN BODYAn explanation of what happens to alcohol asit passes through the body and the effects itproduces.

ALCOHOL AND SENIORSA description of the effects of alcohol onpeople 65 and older. Includes valuable advicefor seniors, their families, friends andcaregivers.

THE EFFECTS OF ABUSIVE DRINKINGA review of the physiological and psychologicaleffects of abusing drinking. The consequencesof both chronic and occasional excessivedrinking are highlighted.

LOW-RISK DRINKING: 2 3 4 0A basic guide to the rules of low-risk drinkingfor men and women.

THE EFFECTS OF EARLY ALCOHOL USEExamines the harmful effects of early alcoholuse and explains the basic reasons why youngpeople should not have unrestricted accessto alcohol.

PREGNANCY AND DRINKING: YOURQUESTIONS ANSWEREDStraightforward answers to frequently askedquestions about drinking during pregnancyand breast-feeding, for pregnant woman andthose who might become pregnant.

ALCOHOL HANGOVERAbusive drinking has long-lasting effects evenwhen blood alcohol content is back to zero.

ALCOHOL AND MENTAL HEALTHExplains the connections and interactionsbetween mental health disorders and problemdrinking and provides useful information andadvice.

ALCOHOL AND SLEEPAlcohol is a fickle friend of sleep. That's oneof the most important conclusions of thisreport on the impact of drinking on sleep.There are many more.

ABOUT ÉDUC’ALCOOLÉduc’alcool is an independent, not-for-profit organization whose solemission is to improve the relationship between Quebecers and alcohol.

To that end, it implements prevention, education and informationprograms designed to help young people and adults makeresponsible, enlightened decisions about drinking. Éduc’alcool’scommitment is accurately reflected in its slogan: La modérationa bien meilleur goût / Moderation is always in good taste.

Éduc'alcool would like to thank Catherine Paradis, M. Sc., doctoral candidate andresearcher with GRASP at Université de Montréal, for her rigorous work and datasimplification.

ALCOHOL AND WOMENA report on women and drinking that explainswhy women are more vulnerable than men– both physiologically and socially – to theeffects of alcohol.

If you have a comment about this publication or want to order more copies, contact Éduc’alcool.

Téléphone: 1-888-ALCOOL1 (1-888-252-6651) Courriel : [email protected]

educalcool.qc.ca

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