The science of hangovers with Dr Sally Adams

In this episode we talk to Dr Sally Adams, a hangover researcher at the University of Bath's Addiction and Mental Health Group about the science around hangovers! Questions include what hangovers really are, how individuals vary in their hangover symptoms, what really 'works' to treat them and other common hangover myths.

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Transcript

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James Morris: 0:01

Thanks so much, Sally for joining me on this episode, I'll just start off by asking you what kind of got you into hangover research. And you know, what's the basic sort of scientific idea or definition of a hangover.

Dr Sally Adams: 0:13

I actually wrote a blog for Susie gauge when she was writing for The Guardian. And it was time for Christmas. And so I wrote this blog, and I realised that was so little research in this area, but also the quality was quite dubious. But also, I guess one of the main things is, why do we continue to do something to ourselves when we know that the consequences are so negative and so aversive? Why isn't this a real deterrent to us in engaging this behaviour, and you know, that whole I'm never drinking again, but somehow you find yourself doing that. And I find that, you know, as a psychologist, a behaviour that makes you feel sick, or actually makes you physically sick, should be so aversive that you don't repeat it. So to me, that's fascinating. And in terms of what we know, scientifically, it's taken a really long time to arrive at a definition that researchers are comfortable with. But essentially, it's a combination of physical and psychological symptoms. They're experienced after a single episode of drinking, really, when you're the concentration of alcohol in your blood is approaching zero. So it's the time when really, we would all think I'm safe to drive a car, I'm safe to go to work. This is actually when hangover starts. And I think it's important that we've included psychological symptoms, as I think these can be some of the most harrowing symptoms of a hangover. Oh, absolutely. There's huge, huge questions in there about, you know, why do we do what we do and Hang Hang over seems like a really interesting area to explore that. I suppose one of the big challenges surely in researching this is, you know, the individual variability, as you say, you know, the psychological aspects of it. I know, for me, headaches, terrify me of even relatively small amounts of red wine or something, but rarely feel the sort of physical side effects that I think, yeah, I think it's huge. One of the biggest problems is individual variation. So quite often, when we do research, we have to compare an individual's hunger over to their state for whatever is normal to that. And then that's seems the best way of being able to control for that. But there are differences even between males and females and report of hangover and severity. But there also seems to be some genetic differences. we inherit some of our ability to metabolise alcohol, but also genetic factors do account for some experience of hangover frequency and how susceptible we are as fascinating.

James Morris: 2:40

And can you maybe unpick that a bit? So is it to do with the amount of enzymes you have in your liver and how well they break down alcohol? Is that the kind of mechanism that genetics might influence in terms of how much we might experience hangovers?

Dr Sally Adams: 2:54

Yeah, when we're metabolising, alcohol, we convert it into something called acetyl. aldehyde, which is actually toxic to humans, is actually responsible, we think, for a lot of the negative effects we see the next day. So the sweating, the palpitations, nausea and vomiting. But the way that we some of the genes that are involved in the metabolism of alcohol to acetaldehyde, we have genetic variations that can increase that metabolism or slow it down. So different variants of the gene, we're saying, I'm not a geneticist, if anyone's listening and thinking this isn't quite, but the idea is that sometimes we see people with a certain variant of these genes, they experienced negative effects of alcohol, quite immediately, they get flushing, they feel very sick after a very small amount of alcohol, it's sort of like they're getting the hangover before they've even finished drinking.

James Morris: 3:51

And in certain populations, I think East Asian is where the that's kind of more common?

Dr Sally Adams: 3:56

Yes, and, and that was a real protective factor against developing an alcohol use disorder or an alcohol problem, because it's so aversive. But other people can be categorised as something called low responders, and therefore, you know, even a large amount of alcohol doesn't necessarily affect them in the same way as someone else. So they need to use more of the alcohol to experience not only the rewarding effects, you know, but also the metabolism is different.

James Morris: 4:24

So those are the people that are low responders in sort of scientific terms, who might be regarded as having a kind of hangover immunity?

Dr Sally Adams: 4:32

It's really complicated and no one really understands this hangover immunity. It's a very new concept, and so little research has been done on it. So I think there was a study in about 2008 said about 25% of drinkers are hungover immune. But actually, if you look back at the actual data, it showed that most of the people in that study they were administered alcohol in a laboratory wasn't in a normal setting. And their blood alcohol concentration didn't really achieve a level that we might expect people to have a hangover. And this is sort of backed up by another study that was conducted in Holland with around 5000 participants. And they found when they asked people to sort of self report what was their heaviest drinking episodes in the last month, and whether they'd had a hangover, it found that the higher the estimated amount of alcohol, it was less likely that they could claim hangover immunity.

James Morris: 5:31

So we just don't have the evidence to support this. But from a sort of personal anecdotal point of view, I am convinced that I have some friends who consistently show inability to drink far more than I could ever get away with, or want to get away with and wake up the next day and carry on almost as normal. I mean, obviously, I might be, for instance, because they drink more regularly, and they've developed more tolerance. But just even from a headache point of view, even when I was drinking very heavily, I would still get always this piercing headache that I've don't see in a lot of other people.

Dr Sally Adams: 6:05

Yeah, I think you're right. I think tolerance is definitely one factor that I would consider in that if you're someone who drinks quite infrequently, you know, and then you go to an office Christmas party, and there's not any, there's not very much research on this. But I think the idea that you have some sort of tolerance to the effects, the next day effects must be a thing. But also, I think it's about what you expect to happen as well, I think and also how you cope with it as well, because I think sometimes, because there's not good evidence for this immunity at all. And it seems to suggest that people who are claiming immunity just haven't really drank enough. It may be the way that they cope with the symptoms, maybe they're able to tolerate it and put it to the back of their mind, or they've expected that that's what's going to happen. And that influences the way that they feel the next day.

James Morris: 6:54

So mind over matter, maybe. I mean, what about what kind of happens though, when you get a headache I heard once on a podcast, I was sort of the brain almost dehydrated, and that was somehow kind of stretching the neurons or something, you know, said I'm sure but yeah, is there any evidence at all that says, Why does alcohol induce headaches?

Dr Sally Adams: 7:16

The problem with hangovers? And I think the reason why we don't have any good evidence is you obviously the main thing we often talk about is that hangover causes dehydration, which then leads to headaches. And that's a really tiny part of the puzzle. And the more that I've read, the reason why we're kind of no closer to understanding or finding a cure is because we really still don't understand what the mechanisms are that underlie the way that alcohol makes us feel the next day. So you're right, one of the main things is dehydration. And alcohol is a diuretic. And obviously, we also lose fluids to being sick or sweating when we're in a hangover, but also, it's an inflammatory response. So we see that there's inflammation in the stomach and the small intestine. Also, your body's working really hard to metabolise this acetaldehyde, it also affects your blood sugar. So it's having an effect on your glucose production, it also affects the way that you sleep. So it's so multifaceted that we just don't understand really the way that these different effects interplay in order to cause this. I mean, before we had that fully established combination of psychological and physical definition, I think, one of the actual scientific definitions because it's a general state of misery.

James Morris: 8:40

Well, yeah, that certainly makes it a bit more easier to start make sense of in a way, doesn't it? Because, you know, I'm sort of thinking, it's unbelievable that we don't have more understanding about what causes hangovers, and what the mechanisms are. But yeah, when you put it in that way, it really does sort of reinforce, you know, what we know about our colours, what's often called a really messy or dirty drug, the way it just sort of affects so many different parts of the body in so many different interacting ways. And when you put it like that, I do sort of forgive the scientific community a bit more for not having understood this quite yet. And so we've talked a bit about the sort of some of the biological factors, some of the question marks around some of the other mechanisms. I mean, obviously, there's the practical stuff as well like how quickly you drink my for some people affect it more but the types of drinks that's just a myth, isn't it? Is our call or are there things like convenors? Or is it again, we don't have good evidence, it's always so disappointing to often say that we don't know in the hangover research. And we're trying so hard to progress these studies but it is difficult to encourage people to come to a lab when they're hungover and also quite difficult to have research in this area funded Have you tried leaving them with bacon sandwiches and fry ups that kind stuff ?

Dr Sally Adams: 10:00

That's actually so funny I have written breakfasted into grants before saying we can't expect these p ople to come and do hours of c gnitive testing and not feed t em! But yeah, you're right, I think amount of alcohol is obv ously a fairly obvious one where we talk about, the more alc hol you consume, the more likely you are to have a hangover. And I think that's undeniable. But h talked about conveners, w ich are essentially they're j st like another biologicall active compounds that peopl add to make drinks taste in a certain way smell or look in a certain way. And they're added ormally when people have fe menting alcohol. And so bevera es that have got a higher pure thanol, so that's the sort o active part of alcohol drinks such as gin and vodka, they have less of these conveners. And the things like brandy, red wine darker drinks have more f these conveners. And there i a very small but an also an old and unsupported area of esearch that suggests that hav ng more of these congener So n these dark drinks leads to hig er self report of hangover sympt ms, but that's been found that it affects the way tha people report how they feel. ut when it comes to sort of more objective tests of ho people are performing on veryday tasks, the amount of c nveners didn't impact that kind of objective performance, but did influence their self re orts so that there might be this kind of expectation, you know, t e myths that we have, you kn w, that gene makes you feel ad, and that certain things ake you aggressive. I think lot of this is expe

James Morris: 11:39

That's really interesting, because you know, myself as a researcher, you know, I'm very aware of the expectancies and beliefs as influencing, you know, people and I'm always trying to convince people that know, certain drinks don't make you behave in this way. But I still find it personally hard not to convince myself that I might not be more sensitive to dark drinks, and that I'm going to have less chance of a headache if I have a couple of gin and tonics versus a few whiskies.

Dr Sally Adams: 12:07

Yeah. And it's not that that doesn't exist, it just might be that there's not enough good quality evidence. And there was a more recent study in the last couple of years that looked at that whole wine before, for wine makes you feel fine. Yeah, yeah, the order of drinks. And that sound there was there was absolutely no difference in whether participants had drank wine before beer or beer before wine, it was just about the amount of alcohol really that influenced hangover the next day. But I think it's still something worth exploring and get some really nice robust data on this would be really, really helpful.

James Morris: 12:46

We've obviously got to talk about hangover cures. I mean, these are all myths, right? Other than sort of staying hydrated as much as possible. Maybe before, during, and after these kind of adverts that I've seen on social media, these are fraudulent online.

Dr Sally Adams: 13:01

It's such an interesting area. And the more I go to conferences, the more I see, particularly alcohol conferences, that there are people who are very keen to monopolise on this area. And who wouldn't, because imagine if you can find an effective hangover cure, it's a billion dollar industry, I would say, as a researcher that I haven't really seen any convincing evidence that the is a in inverted commas hangover cure, there was a really nice review in 2005, which was backed up by a review in 2010. That said, you know, in a review of the evidence of both sort of alternative products, but also pharmaceutical medicines, and that there was no convincing evidence that any of these prevented or treated hungover, but then again, I find this unsurprising given that we don't understand all of the mechanisms that underlie hangover. So as I mentioned, just now, we know that there's dehydration, we know that people are sick, we know there's poor sleep inflammation, you know, imagining that you can develop something that's going to target all of those different underlying mechanisms is a very difficult job. So at the moment, I would say the only thing that we can do is treat these different elements, because people often ask me, What do I do when I get a hangover? Because I should know, I guess, what do you say? that's what that's what I do say that I said, I think it's unreasonable to expect that you'll find anything that will you know, completely rid you have your hangover, but you can do sensible things to treat the symptoms so we can drink more water to fight your dehydration. electrolyte imbalance is a big part. So sometimes those sachets that you take after you've had diarrhoea, people swear by those something to reduce inflammation, so an anti inflammatory drug, just thinking of all the different aspects that you could individually treat, but on the whole, I think it's difficult but I think you hit on a really interesting point about how ethical is to kind of promote these kind of cures? if they if they don't really work?

James Morris: 15:06

Oh, yeah, I mean, I think you've arnstadt really well. And as you said, you know, if we it's the scientific consensus can't really identify or is very early stages of understanding the mechanisms, then how can you cover kind of scientifically, you know, legitimate here as sort of in in inverted commas? Unless, of course, there's been some sort of private investment in, you know, intensive hangover research. That seems hugely unlikely. But yeah, I think goes back to that point about the power of these kind of psychological beliefs and expectancies that if you're buying or even are taking a, you know, an ibuprofen or whatever, it's very hard, isn't it to separate the belief that this is going to help you from any actual kind of mechanism that might be taking place?

Dr Sally Adams: 15:51

Absolutely. I mean, it's an age old problem in, in pharmaceutical research that, you know, you have to show that what you're giving people is better than placebo, or nothing, the expectation that this is going to be a one to cure can be very powerful. I think one thing that I wanted to mention was that the approach that Germanys recently took, so there was a court ruling in the last couple of years that they've declared that hangover is an illness. And therefore, because of this, any products that kind of claim that they can alleviate symptoms, they have been ruled as illegal. You can't You can't say that something works, if it doesn't. And even the FDA in the US, they've got a similar ruling that these claims can not make products that they will cure a hangover. If they don't.

James Morris: 16:42

Well, that seems rather sensible. But I suppose it just comes down to politics, to what extent you believe these sort of markets should be regulated, or people can kind of choose to buy so called cures and supplements for anything and everything. But yeah, that perhaps, no, absolutely, you're right. It's bigger, a part of a much bigger idea about whether things that people can buy over the counter do, do you actually work? Or whether they just make people feel like they're doing something or Yeah, not this expectation that they'll work? Yeah. Because then I guess placebo effect is, you know, again, it's a big, big whole other debate about To what extent is it useful to be able to tap into it just we kind of touched on it earlier. But I think, you know, the, the evidence just really isn't clear then. But in terms of the development of alcohol problems, it makes sense that if you are more susceptible to hangovers, which again, we don't really know about, then it would potentially act as a bit of a break on how much you might drink or how regularly you might drink. But of course, in combination with a whole load of other factors, but there has been a little bit of research has been there about relationship between sort of self reported hangover and alcohol problems or dependency.

Dr Sally Adams: 17:57

Yeah. So on one hand, you have that genetic research that suggests that these genes that are genetic variants that control the metabolism of alcohol, and might act to disincentivize, drinking, so as I mentioned, if you experience these negative effects very quickly, then you might be put off from drinking excessively, and then therefore not having a hangover. But there's a lot of evidence to suggest the opposite as well, that actually having frequent or you know, severe hangovers actually aren't a very good deterrent at all. And I think, you know, anecdotally, before we even move on to the evidence, it's, like I said, we've all said, I'm never doing this, again, you have the worst hangover, you could be on your knees hooking the toilet and saying, I did this to myself, I'm never going to do this, again. The likelihood that you won't is very low.

James Morris: 18:50

I mean, I yeah, I relate to that, you know, I late teens and early 20s I was drinking very heavily and experiencing you know, what felt like devastating hangovers, one I think lasted three days, you know, if I, if I kind of was writing my appraisal, but you know, that time, my drinking motives and all the other stuff going on in terms of I suppose my mental well being and those kind of things were so different from where I am now that now just even a sort of slight hangover is quite a powerful motivator for me because it would interfere with playing golf or, you know, work out comics or whatever. Whereas back then, you know, just didn't think about any of those things. And I had all this kind of other stuff that was a really powerful driver for you know, getting wasted as it as it was. So yeah, I guess it varies over the life course as well.

Dr Sally Adams: 19:39

Absolutely. We put we published a qualitative paper that looked at hangovers in young people, really, university students and for them hangover wasn't really a deterrent at all, because it was seen as part of the drinking experience sharing funny stories. The next day, all suffering together was actually the title of the paper came from one of our quotesIn our interviews, but yeah, it does change significantly throughout the life course. But I guess going back to this idea of link with problem drinking, it seems to be the opposite that you would expect in that having more frequent and severe hangovers can be, you know, it looks like it might be a marker for the development of alcohol use disorders, but also bi directionally, that people with a family history of alcohol dependence, so perhaps a mother or a father that was had a drinking problem, this seems to predict for frequency and severity in the offspring, which I find really fascinating. Yeah, how can we make sense of our Don't you know what, this doesn't seem obvious to me in terms of the way in which that works. I mean, other than the genetics, the one way that it might work is I don't know if you've heard of the opponent process theory. And so if these people, they have family risk already for alcohol use disorders, and they're experiencing more frequent, and they're more severe hangovers, which suggests that they are drinking more, it might suggest that people are using alcohol to maybe escape these negative states of hangover to where you get locked into this sort of vicious cycle. So you might be drinking for, especially when you're younger, you might be drinking for lots of reasons that are social, you know, contextual, and you drink heavily, you experience these very frequent and severe hangovers. And then the time to next drinking might be very quick, because you're trying to avoid these chase away negative symptoms. So it really is a vicious cycle. So the kind of more complex interpretation of how the dog if you like, I'm fascinated by that there's so little research, but I'm really interested in what sort of switches from, you know, I've got a terrible hangover, and I just want to get over it. And maybe I want to have a break before I drink again, you know, I don't want to be in this situation, too. You know, the best way to get over this would be to just drink again, or that the hangover is so severe or so punishing, that the old, the kind of only quick fix ways to get to drink get in as soon as possible.

James Morris: 22:14

Sounds like those, that research is amongst people with much higher severity alcohol problems, rather than perhaps a bigger population of people who may be, you know, my expect to have a hangover, once or twice on the weekend. And, you know, just kind of wait until the next weekend before have to deal with it again, you're less likely to maybe use hair the dog, difficult to say,

Dr Sally Adams: 22:37

yeah, I think I think you know, I still think we talked about young people. But I'm also interested in sort of that meet group, I guess, within my age group is what you know, I'm sort of in my late 30s, you know, that idea of, you know, going out on a Friday night, but then maybe doing a brunch The next day, it doesn't look like hair of the dog, but it doesn't mean that it's not. And I think this life course approach is really important, because I think the way we feel about alcohol in general, but also hangover, I think is so important at the moment with the lockdown in the pandemic, because most of us don't have the responsibility of having to drive to work or going to work. And I am interested to know whether we may see it as a bit more acceptable to have a hangover, and get away with it when we're not having to deal with people or engage in our everyday responsibilities absolutely is gonna be you know, we're going to be trying to answer these questions for years to come. What's the impact in terms of drinking behaviours? And, you know, as we know, the sort of emerging data is starting to tell us that perhaps a lot of kind of lower risk, more infrequent drinkers are drinking the same or less, but the heavier drinkers, the people, we're likely to see more extreme hangovers and all those complicating factors. You know, many of them are drinking more. Yeah. Because you don't have that barrier in place where most people I imagine. I imagine I do this myself, like I have a rule where I don't really drink in the week because the thought of having to give a lecture hungover or do my job hungover is just totally not worth it. But just know the idea that actually I probably can have a drink in the week. I haven't got to get up. I haven't got to see anybody.

James Morris: 24:17

That's really interesting. Because I was I was gonna ask you just to kind of conclude, you know, how does this insight and understanding to the ways in which hangovers kind of a thought to work at least how's that affect your own appraisal of drinking? Because, you know, it's one part of it, but certainly, you know, for me, I tend not to drink in the week because I'm worried about the risk of psychological dependency at least probably more so than I'm worried about feeling a little bit hungover the next day because I will generally drink quite enough personally to feel alive. It's only not in the week, but yeah, how does it How does it sort of factor into how you think about alcohol use very in tuned to my own alcohol use? I would say

Dr Sally Adams: 24:58

I'm very in tune to my drinking. You know, perhaps drinking too much and definitely was guilty of that a little bit in lockdown of sort of the the drink was coming a little bit earlier. So maybe on a Thursday or a Wednesday rather than the weekend, I am conscious of how it impacts, you know, things that I have to do my job, but I'm also very, not wanting to ever it to be something that I get out of control with. I think the importance of having alcohol free days is something I've always, you know, done. But I think you know, just telling people to, you know, oh, you won't have a hangover, if you drink, drink in moderation. I know it's not that easy. Particularly when stressful things are happening. Or in our culture, we drink for everything we drink to reward ourselves, we drink, to condole ourselves, we drink, because it's Thursday or Friday, and it can be really difficult to kind of keep tabs on it, really. And the whole of this year, I have used an app to kind of look at my drinking. So I've recorded my drinking every day this year. And it's been really interesting. And I think it does help you think about what your relationship is, and which of the drinks that you enjoy the most, or which are the ones you think maybe I could go without that one. So I you know, I'm as a researcher, I'm very attuned to my own drinking, and probably everyone else's probably makes me really boring at parties.

James Morris: 26:23

I suppose, as long as it's not judgmental, or you don't just talk about it you'll hang on to your friends. But yeah, absolutely, I think you might be what's called mindful drinking, you know, this, this movement about not necessarily just being alcohol free or whatever. But being more mindful about how much you drink and counting units, or at least keeping a rough track of it can be a really helpful or important strategy for kind of doing so. But I didn't think payload was so interesting, because it is the one really very obvious marker of the negative effects of alcohol use, whereas so much more of the risks. And the public health messages, which could argue don't really work in most cases are based on these longer term or less tangible kind of outcomes. And certainly, again, when I was drinking really heavily, all I factor in as well, I'm going to feel really rough, but that's it, but no in no way would I ever consider even the behavioural consequences. But again, a lot of that was again, as you said about social context and the camaraderie and all that kind of stuff that went along with it. I do think hangovers Are you know, it's fascinating from that psychological point of view of how people factor into their decision and assessment of their own drinking as either kind of on a spectrum of being, you know, problematic in some way, if it's causing hangovers.

Dr Sally Adams: 27:40

Yeah, I think it's, um, I think it's a really missed trick that we aren't looking at it more as something to base intervention on or just to increase awareness. This is the one thing that I really fascinates me, and is definitely very personal to me is the anxiety, anxiety. Yes, um, you know, I've done a couple of research studies on this, kee to explore further. So ne of the things that really uts me off is the experience o anxiety The next day, it's ju t so this fear of what I've sa d, or what I've done, but al o just the general underlying a xiety. And I think the idea of hese kinds of psychologica consequences. So a lot of my ot er research has looked at a rain doesn't seem to work very well, the way it doesn't when we're drunk. So things like, you know, reaction times, makin decisions, reacting to hings, our attention, t ese all still to be seemed to be really impaired the next day. An this is even when you would pa s a breathalyser if you were in car, but these are obvious proc sses that you use when driving a car or going to work. And al o this idea of anxiety and he way that it makes you fe l and the way that you interact with other people. That's what hat's the bit that I'm most kee to, you know, when people say t me, what do you want to achi ve from your research, it would be that there's grea er consideration of just how muc of the effects of alcohol carr over into hangover and how we m ght not know that, but that the might lead us to make choices about when we drink next. I thin that's really important. S, especially with the anxiety hing, I always think, you k ow, I feel very anxious to t e next day. And then someone might say, you know, do you want to come out for Sunday b unch or Sunday lunch, and y

James Morris: 29:22

Hangxiety? u know, that probably hav ng a glass of wine would probab y would make you feel nauseou, but in the long run, you get into this vicious cycle. So I ind that fascinating. So that really makes what you're saying earlier a lot more sense. It's not just about hair of the dog. It's about you know, even on a maybe subconscious level, you know, you might feel a bit sort of anxious and a drink kind of calms you down. Because as I've said before, I enjoy a drink because I noticed that it certainly feels like having a drink alleviate still a kind of mild level of anxiety. I mean, that's part of the pharmacological he effect of the drug alcohol can alleviate anxiety. But of course, the homeostatic response is then it's all thrown out of balance teaser is out an accurate kind of response in terms of when the hangover kicks in. Yeah, like a rebound effect. And yeah, the one thing that I mean, I've done a lot of kind of public engagement work and given talks in pubs. And one of the best things that I always get from those is a perspective that even though I am a drinker, sometimes I can step away from that when I'm in my research shoes. And people often say to me, no, it's really interesting. You're talking about the harms, and all of these things, but you're forgetting why I drink in the first places, because it really relieves my stress. And I feel relaxed, and it makes me feel nice, and it's pleasurable. And I think I always try to not forget that in my research, and we have to think about why people use alcohol in the first place or any drug. Really, it's because it does have this euphoric or pleasurable effect. And that's a really important part of understanding why people use alcohol. And it's important in the hangover to have certainly, and you know, people don't like being told what to do, if it's kind of a finger wagging approach, or I don't like being told what they already know, which is I like drinking and it makes me feel rough if I do a bit too much. So yeah, we have to be a bit more nuanced in in the ways in which we kind of have these discussions, I think, and it's been brilliant to have you on and you've explained so well how complex this kind of area is, and again, how kind of complicated alcohol is both in terms of its pharmacological and psychological and all the other kind of aspects and ways it affects us. So thanks so much, Sally.

Dr Sally Adams: 31:37

Thanks for having me.