One of Dr No’s retired medical friends, not teetotal, but almost, inherited an adequate wine cellar, mostly reds, from a relative. Given a science backed consensus that small amounts of red wine would be good for him, he decided not to dispose of the cellar on favourable terms to Dr No – Dr No is always happy to help an old friend out – but to indulge in a spot of self prescribing: ℞ vinum rubeum, 1-2 glasses nocte.
Elsewhere, an old biddy friend of Dr No’s mother, bereaved last year, has taken to keeping a bottle of sweet sherry in with the tea cosies, and of an evening she warms her soul as she dozes in front of the television with a tipple or two. Not so long ago, a grandad patient of Dr No’s asked: ‘No harm in an evening sharpener? Just scotch and water, you understand.’ Dr No knew it would be a large tumbler, and a generous slop, but still he answered ‘not at all’ – and didn’t even caution against excess. This chap had survived the not only the horror of Burma in the Second World War, but the long years of following memories as well, and the last thing he needed was a ticking off from Dr No.
Yet, if a recent report by the Royal College of Psychiatrists is to be believed, all three have their cards marked as invisible addicts, part of a hidden but growing army of ancient dopers, druggies and sherry pilots hiding behind the net curtains, hell bent of getting blasted. Indeed, so vast is this army of secret silver soaks that GPs are urged to screen all patients over sixty five years of age for covert gin-swilling. Any more than one and a half units day is reckless in the extreme, a dalliance with an eternal hell of mental and physical decline. Biddies who down three units (four and a half for Gilberts) at a sitting, meanwhile, are the new zimmer-bingers, a crash of crumpled aluminium tubing waiting to happen as they mindlessly stagger towards the glass fronted doors of the drinks cabinet.
The press is predictably and properly awash with outrage at this latest incursion of the nannies. And were this just a bunch of nannies out to nanny, we could leave it at that. But the report is published not by the Royal College of Nannies, but by the Royal College of Psychiatrists, and so lays claim to medical – and thereby scientific – authority. But sadly some Colleges – and notably Pants when he was CMO – have form on rhetoric-heavy evidence-lite reports. So Dr No thought he would read the report, to see what evidence lay behind the psychiatrists’ claims. He was not surprised to find once again that the evidence did not match the rhetoric. In fact, it was even worse – not only does the report not have a research leg to stand on, it is actually misleading.
The report’s headline recommendations:
‘[younger adult] ‘safe limits’ are too high for older people; recent evidence suggests that the upper ‘safe limit’ for older people is 1.5 units per day’
‘In older people, binge drinking should be defined as >4.5 units in a single session for men and >3 units for women’
require, if they are to stand up, evidence of harm above these limits.
So Dr No checked the report and followed the reference trails. The first thing he looked for was evidence of harm in the report itself. Stumbling on the relevant section almost by accident – only two brief pages (pages 23 and 24) in a 60 page report – he came across an eye-watering disclaimer right at the start:
‘A detailed review of the physical and psychiatric complications of substance misuse by older people is beyond the scope of this report. A comprehensive account of such complications can be found elsewhere (e.g. Crome & Day, 2002; Crome & Bloor, 2005b).’
‘Beyond the scope of this report’? Ho hum…but what about those two references. Well, for starters, the first author for each is – double ho hum – the current report’s lead author. Naturally there are no rules against quoting one’s own work, but it is, shall we say, prudent to quote wider authorities in support of one’s assertions…
Never mind: what about those references? The first is ‘Crome, I. B. & Day, E. (2002) Substance misuse. In Mental Health in Primary Care (eds. A. Elder & J. Holmes): pp. 221–240. Oxford University Press.’: awkward to access, and hardly promising ground for a detailed review. The second ‘Crome, I. B. & Bloor, R. (2005) Older substance misusers still deserve better diagnosis – An update (Part 2). Reviews in Clinical Gerontology, 15, 255–262’ is even less promising. The abstract is available here, and seems more in the way of a polemic than a ‘detailed review of the physical and psychiatric complications of substance misuse by older people’. Double ho double hum…
So what about the evidence for the lower ‘safe limits’ (note the authors’ use of inverted commas, implying there is no such thing as a ‘safe limit’) and binge limits for the over 65s? The relevant passage reads:
‘More recent evidence from the USA, based on alcohol-related harm/alcohol misuse, has defined ‘at-risk’ drinking in older people as being more than 1.5 units of alcohol on any one day or more than 11 units per week for both men and women (National Institutes of Health, 2005). The most recent evidence suggests that more than 3 units per day and 11 units per week for older men and women are associated with alcohol-related problems. Whereas in younger people, acute heavy (‘binge’) drinking is defined as 8 or more units in a single session for men and 6 units for women, the corresponding limits for older men and women are 4.5 and 3 units respectively (Moos et al, 2009).’
OK – two clear references given to support the limits. Or do they? The NIH report, available here (2005 report, updated in 2007) is in fact a ‘Clinician’s Guide’, a how-to for all age groups (albeit elderly included), with lots of helpful flow-charts and pro-formas, but no evidence whatsoever to underpin lower limits in the elderly. Moos et al’s paper, available here, actually found that alcohol consumption among the elderly declined over the 20 year study period – hardly evidence of a rising tide of silver soaks – with somewhat limited detail, so to speak, on the limits themselves. One possibly relevant passage reads:
‘Several guidelines have been proposed to identify high-risk drinking patterns in mixed-age populations. General nutritional guidelines recommend limits of no more than 1 drink per day for women and 2 drinks per day for men . The National Institute on Alcohol Abuse and Alcoholism  has advised limits of no more than 3 drinks per day or 7 drinks per week for women and no more than 4 drinks per day or 14 drinks per week for men. The American Geriatrics Society  has defined high-risk drinking as more than 3 drinks on heavier drinking occasions or more than 7 drinks per week for adults 65 and older.’
The three references – ,  and  – aren’t much help either.  is long on waffle and notably short on evidence, while  has gone – 404’d – and so we are left with , our old friend the NIH report, which, as noted, contains no evidence whatsoever. All roads, it seems, lead to NIH report 07-3769 – but not to any substantial evidence…
What about all the other evidence out there, evidence not included in the vague, circular references considered so far? Well – there is plenty of it, and the consensus, as Dr No’s retired medical friend knows only to well, is that low to moderate amounts of alcohol are generally not harmful; in fact, if anything, they are good for you. Study after study has replicated the so-called J or U-shaped curve – the relationship between mortality and alcohol consumption shows mortality at its lowest (the bottom of the J/U) for low to moderate consumption. Of all the many papers Dr No could mention, he will quote but one, because it is the one that persuaded his friend to self prescribe red wine:
‘Although some of the apparently protective effect of alcohol against disease is artefactual, some of it is real’
The paper, with Doll and Peto listed as authors, is in fact a continuation of the British male doctors study which first established the link between smoking and lung cancer. While we must always be cautious about extrapolating findings from one group to wider populations, it remains a sound study which looks clearly at the relationship between alcohol and mortality. As Table 5 and Figure 1 in the paper show, even 21 units of alcohol a week – twice the psychiatrists’ recommended safe limit – are protective, in this elderly male population.
Naturally, Dr No’s medical friend prefers to rely on sound research presented by reputable researchers, rather than the proselytising zeal of a psychiatrists’ report that doesn’t have a research leg to stand on. So he changed the habit of a life-time. And, do you know what? – he told Dr No only the other week he has actually started to enjoy his new prescription!