On coffee

The DSM-IV defines substance dependence as a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12 month period:

(1) tolerance, as defined by a need for markedly increased amounts of the substance to achieve intoxication or desired effect and markedly diminished effect with continued use of the same amount of the substance
(2) withdrawal
(3) the substance is often taken in larger amounts or over a longer period than was intended
(4) there is a persistent desire or unsuccessful efforts to cut down or control substance use
(5) a great deal of time is spent in activities necessary to obtain the substance (e.g. visiting multiple doctors or driving long distances), use the substance, or recover from its effects
(6) important social, occupational, or recreational activities are given up or reduced because of substance use
(7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

The diagnosis of substance dependence can be applied to virtually every category of substance but interestingly, caffeine is excluded from the DSM-IV. My best friend in medical school, however, met every one of the DSM criteria and was clearly dependent on coffee. By the end of medical school, he was drinking 22 cups a day despite the fact that his frequent trips to the bathroom were cutting into his "important social, occupational and recreational activities". He's now a plastic surgery resident... go figure.

I wonder if part of the reluctance to include caffeine in the DSM is related to the fact that coffee is at the heart of some of medicine's most timeless rituals. Indoctrination in the coffee camp starts early in medical education, with senior med students being introduced to coffee binges as the treatment of choice for on-call sleep deprivation. There's the nurses' coffee break, and I'm reminded of a charge nurse who seemed principally concerned with scheduling the other nurses' coffee breaks and ensuring that they did indeed take their sacred 15 minutes. In radiology, everyday at 10 on the dot, the head of the department would round up the other radiologists and everyone would trot over to the coffee shop to refill their mugs. And then there's my favourite ritual of all, the hallowed ritual of the staff person buying coffee for the residents, or the resident buying coffee for the medical students. Prepare yourself for suspicious, sidelong looks if you decline or decide you want a bottle of water instead. In fact, I'll admit to social coffee drinking myself, just to fit in with my colleagues.

But there's a darker side to coffee, that of the exploitation of coffee farmers in developing countries, which is very elegantly detailed in the documentary Black Gold. How much money from that tall double americano goes to the impoverished farmers who do the hard labour of growing and harvesting the coffee beans? Click on the CoffeeCalculator to find out.

So what to do about this issue? Some people say that buying fair trade coffee is one possible course of action. I'm not an expert on trade and economics by any means, and fair trade does have its proponents and opponents, so it's worth checking out a few resources on fair trade and making your own decision, but for starters, you could try to make a point of buying fair trade coffee (Starbucks will brew a pot of fair trade coffee if you ask). If you feel more strongly about the issue, you could ask your campus/hospital/local coffee shop to carry fair trade coffees. Starbucks has supposedly committed to offering only fair trade coffees on campuses where they do business... if the students ask for it. There's ethics involved in just about every other area of medicine, so why not our coffee breaks?