‘Gray area’ drinking is not a medical diagnosis, but experts say it can still be a problem. What is it and what are the signs?

Angela Teuscher, 50, used to look forward to a few glasses of wine at night.

It was her reward for completing a stressful day as a single mom who worked full-time, said the Portland, Oregon, resident. She deserved it.

Over the years, however, those few glasses at night turned into another glass of wine at 8 o'clock the next morning.

“The scary part about that drinking pattern is that there’s no day or time you can say, ‘This is a problem,’” she said. “It was a slow progression from what was simply acceptable to all of a sudden what was not.”

Teuscher is now nine years sober, but she wished she could have recognized the signs of her unhealthy relationship with alcohol years before it spiraled out of control.

Health experts call this pattern of drinking the “gray area,” and although it’s not a medical diagnosis, they say it’s still problematic and can get worse over time.

As the coronavirus pandemic continues to add stress to everyday life, Teuscher and health experts warn others to take a critical look at their own drinking habits.

What is ‘gray area’ drinking?

“Gray area” drinking is a term used to describe a mild alcohol use disorder, said Dr. Jessica Gregg, chief medical officer for De Paul Treatment Centers in Portland and an adjunct associate professor of medicine at Oregon Health and Science University.

“Someone’s not so far into their drinking that their body is dependent … they’re not in the severe end of the spectrum, but they are drinking in a way that makes their life worse as opposed to better,” she said.

On the Alcohol Use Disorders Identification Test (AUDIT) – a 10-question survey developed by the World Health Organization to assess alcohol consumption – a score of 8 indicates harmful alcohol use. A “gray area” drinker may score a 3.

Gregg said “gray area” drinking is not quantified by how many drinks someone consumes but instead by their relationship with alcohol.

For example, a person who drinks a glass of wine every night may not be a “gray area” drinker, but a person who drinks half as much may still struggle with “gray area” drinking.

“If someone is only drinking three nights a week, but they’re thinking about that night every day … they’re just waiting and it’s occupying their thoughts and distracting them, they’re not drinking as much but their drinking is more disordered,” she said.

Teuscher remembered one of the earliest red flags of her “gray area” drinking was seeing a man standing in line at the grocery store with a six-pack of beer and thinking it was “nowhere near enough” for just one person to drink. She also noticed that she drank more than anyone else in her friend group.

“My friend had half a glass of wine and stopped, and that was a bizarre thought to me, like: ‘Who would leave half a glass of wine? That’s just wasteful,’” she said. “Those little things now in hindsight make sense to me but at the time it just lived in my head, but I didn’t put together that it was really incorrect thinking.”

Although “gray area” drinking has been around for more than a decade, the concept gained renewed interest as alcohol consumption skyrocketed during the coronavirus pandemic.

A YouGov survey in April found 37% of adult Americans reported an increased consumption of alcohol since the start of the pandemic, according to the report commissioned by Field Trip Health, a psychedelic therapies provider.

Another study by the RAND Corporation published in October 2020 found women have increased their heavy-drinking days by 41% compared with before the pandemic.

“This notion of the 'gray area' is challenging,” said Alberto Augusten, head pharmacist and toxicologist at Memorial Regional Hospital in Miami. “The COVID pandemic has made it more difficult.”

Signs of a mild alcohol use disorder or 'gray area' drinking

One sign someone may be struggling with “gray area” drinking is if they know alcohol is harming their life and want to stop drinking, health experts say, but are unable to follow through.

They often silently worry about their habit even though it doesn’t affect their social interactions or daily activities, Augusten said. In fact, friends and family usually don’t notice someone may be struggling with a mild alcohol use disorder.

“Many of these individuals go through that tug and pull of saying ‘I want to stop,’ and many of them can stop for a period of time, and then will be drawn back in to increasing their use,” he said.

Those who may struggle with “gray area” drinking don’t normally hit a “rock bottom” like others who have a severe alcohol use disorder, Gregg said, but they constantly question their drinking habits.

It can be difficult organizing these feelings into possible signs of “gray area” drinking. Physicians typically use a simple questionnaire – called CAGE – to assess problematic drinking, said Dr. K. V. Narayanan Menon, medical director of liver transplantation at the Cleveland Clinic.

CAGE is made up of four questions:

• Have you ever felt you should cut down on your drinking (Cut down)?

• Have people annoyed you by criticizing your drinking (Annoyed)?

• Have you ever felt bad or guilty about drinking (Guilty)?

• Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye-opener)?

Answering yes to at least two questions is considered clinically significant, according to Johns Hopkins Medicine. But not all “gray area” drinking can be captured in simple survey, health experts say.

“If it’s bugging you … that’s enough to say 'Maybe I should explore this more,' whether it’s with your primary care physician or just Googling it,” Gregg said.

How to get help

Even though “gray area” drinking isn’t an official diagnosis, Gregg recommends speaking with a medical professional about alcohol habits.

“Get it out of the shadows and say ‘This is something I want you to be aware of,’” she said. “Having a doctor say ‘I’m a little worried’ is a potent way of intervention.”

The doctor can conduct a formal alcohol and drug use assessment and refer you to a counselor. But if seeking professional helps seems too daunting, Teuscher says, a good first step is to reach out to a trusted friend or family member.

She also suggests taking a critical look at alcohol and replacing it with other activities: What void is alcohol filling, and what can be used instead?

“People shouldn’t lose everything or even have those consequences if it’s not necessary,” Teuscher said. “If you have those thoughts, do some investigation and talk to someone about that before it has the potential to get worse.”

Follow Adrianna Rodriguez on Twitter: @AdriannaUSAT.

Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.

This article originally appeared on USA TODAY: Drinking alcohol: What is the 'gray area' and why can it be a problem?