ALCOHOL USE AND ABUSE

Ethyl alcohol, or ethanol, is the most commonly used drug in the world. Pharmacologically, alcohol is classified as a central nervous system depressant. Like other depressants, in small doses alcohol slows heart rate and respiration, decreases muscular coordination and energy, dulls the senses, and lowers inhibitions—resulting in feelings of relaxation and greater sociability. Large amounts of alcohol can result in depression of the various body systems, resulting in coma or death. The immediate physical effects of alcohol depend on the amount and frequency of drinking, while the mental and emotional effects are influenced by the mood of the drinker and the setting in which drinking takes place.

Two physical effects resulting from prolonged, heavy alcohol use include tolerance and withdrawal. Alcohol tolerance refers to the need for increased amounts of alcohol to achieve the same level of intoxication. For example, five or six drinks may be needed to achieve the same effects produced by one or two drinks when the individual first began drinking. Alcohol withdrawal, on the other hand, refers to a number of physical and psychological reactions an individual experiences when significantly reducing or stopping prolonged heavy drinking. Symptoms of withdrawal include nausea, vomiting, anxiety, and hand tremors.

An interaction of biological, psychological, and environmental factors come into play in the development of drinking behaviors and problems. For example, some individuals may be genetically predisposed to alcohol problems, but whether or not they actually experience negative alcohol consequences will also depend upon their immediate social and physical surroundings, such as family drinking patterns and alcohol availability, as well as their drinking habits.

ALCOHOL USE AND MISUSE

Most people who drink alcohol do so without negative consequences. Others may actually obtain a health benefit from its use. Some, however, drink in ways that place themselves or others at risk for experiencing alcohol-related problems. While no pattern of alcohol use is without risk, certain drinking patterns may help reduce risk significantly.

The Dietary Guidelines for Americans, issued jointly by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services, define moderate drinking as no more than two standard drinks per day for men, and no more than one per day for women and people sixty-five years of age and older. A standard drink is 0.5 ounces of alcohol, equivalent to 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits. These guidelines suggest that moderate or low alcohol use is linked to a reduced risk for the occurrence of negative alcohol consequences. For others, however, abstaining from all alcohol consumption is the safest thing to do. Groups who should avoid all alcohol use include pregnant women, children and adolescents, those planning to drive or participate in other activities requiring alertness, people who cannot maintain moderate alcohol use, and those who are using over-the-counter or prescription medicines that interact with alcohol.

Another way to understand drinking problems is to examine definitions of alcohol misuse. The World Health Organization (WHO) defines alcohol misuse as alcohol use that places people at risk for problems, including "at-risk use," "clinical alcohol abuse," and "dependence." At-risk alcohol use is the consumption of alcohol in a way that is not consistent with legal or medical guidelines, and it is likely to present risks of acute or chronic health or social problems for the user or others. Examples include underage drinking; drinking by individuals with a family history of alcoholism or problem drinking; or drinking if one has a medical condition that could be worsened by drinking, such as a stomach ulcer or liver disease. Clinical alcohol abuse is a more serious type of misuse that results in one or more recurrent, adverse consequences, such as failure to fulfill important obligations or the repeated use of alcohol in physically dangerous situations. Alcohol dependence is the most severe type of alcohol misuse and involves a chronic disorder characterized by three or more symptoms within a twelve-month period. These symptoms include alcohol tolerance, withdrawal, loss of control, and continued use despite knowledge of having a physical or psychological problem.

Negative consequences resulting from alcohol use are estimated to affect more than 10 percent of the U.S. population, with many of these individuals going undetected. A number of brief screening tools are available to help detect possible alcohol problems. One of the most widely used among these is the four-item CAGE questionnaire, which derives its name from the following four self-administrated questions:

1. Have you ever felt you should C ut down on your drinking?
2. Have people A nnoyed you by criticizing your drinking?
3. Have you ever felt bad or G uilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (E ye-opener)?

Answering "yes" to as few as one or two items on the CAGE questionnaire may indicate a drinking problem.

PREVALENCE

In the United States, 44 percent of adults eighteen years of age and older are current drinkers, consuming at least twelve drinks in the last year. Meanwhile, 7.4 percent, or approximately 14 million Americans, experience alcohol abuse or alcohol dependence. Heavy episodic or binge drinking has remained at the same approximate level of 16 percent for all adults since 1988, with the highest rate, 32 percent, among young adults ages eighteen to twenty-five. Over one-half of adults report having a close family member who has experienced alcoholism.

As few as 5 percent of the heaviest drinkers consume as much as 42 percent of the alcohol drunk in the United States, and 20 percent of drinkers account for nearly 90 percent of the alcohol consumed. The bulk of the alcohol drunk in the United States, therefore, is consumed by a relatively small population of very heavy drinkers.

Alcohol is also the drug most frequently used by children and adolescents. In 1999, over half (52%) of eighth graders (14-year-olds) and 80 percent of twelfth graders (18-year-olds) reported having used alcohol at least once. More problematic drinking occurs in 15 percent of eighth graders and 31 percent of twelfth graders, who reported binge drinking (consuming five or more drinks in a row) in the previous two weeks. Of American high school adolescents, over half (51%) currently drink alcohol. In 1999, one in three high school students reported heavy episodic drinking of five or more drinks on at least one occasion during the previous thirty days. The prevalence of heavy drinking commonly increases through adolescence into early adulthood.

HEALTH OUTCOMES

Alcohol use has health and social consequences for those who drink, for those around them, and for the nation as a whole. Approximately 100,000 deaths each year are attributed to alcohol use, making it the third leading cause of preventable mortality in the United States. Worldwide, 750,000 deaths are attributed to alcohol use each year. Alcohol-related deaths occur from cancer, cirrhosis of the liver, pancreatitis, motor-vehicle crashes, falls, drowning, suicide, and homicide. Alcohol affects nearly every system in the body, and contributes to a range of medical problems, including altered immune system functioning, bone disease, hypertension, stroke, cardiovascular disease, reduced cognitive functioning, fetal abnormalities, traumatic injury, depression, gastrointestinal disorders, and cancers of the neck, head, stomach, pancreas, colon, breast, and prostate. Alcohol also produces significant social problems, including domestic violence, child abuse, marital and family disruption, violent crime, motor-vehicle crashes, worksite productivity losses, absenteeism, and lowered school achievement. The estimated cost of alcohol misuse in the United States in 1998 was nearly $185 billion.

Young people are particularly vulnerable to acute alcohol effects due to their lower tolerance to alcohol, their lack of experience with drinking, and drinking patterns that often include heavy episodic drinking in high-risk situations, such as during driving and sexual encounters. Leading causes of mortality and morbidity among youths include alcohol-related motor-vehicle injuries, homicide, and suicide. Alcohol use among young people is associated with reduced scholastic achievement, increased delinquency, and the development of psychiatric problems later in life. Alcohol has also been found to precede other illicit drug use, thereby serving as a "gateway" to other drug consumption, including marijuana and cocaine use.

Women and the elderly are also at greater risk for experiencing alcohol harm because of their lower levels of body water, meaning that smaller amounts of alcohol result in higher levels of intoxication than in younger men. Drinking during pregnancy has been linked to higher rates of miscarriage, stillbirth, and premature births, and fetal alcohol syndrome—a set of birth defects caused by maternal consumption of alcohol during pregnancy. For the elderly, drinking even modest amounts of alcohol may cause considerable problems due to chronic illness, interactions with medications, and grief and loneliness from the death of loved ones.

At the same time, moderate to low levels of alcohol consumption have been linked to a lower risk for heart disease and stroke. These positive effects appear to be confined primarily, however, to middle-aged and older individuals in industrialized countries with high rates of cardiovascular diseases. Individuals and populations must weigh the risks and benefits of drinking to themselves and others, including such factors as the situations under which drinking is to take place and the amount likely to be consumed, to determine the net results of drinking.

SOLUTIONS

The burden of alcohol misuse is measured in a number of ways, including the prevalence and incidence of deaths, injuries, and illnesses attributed to alcohol; hospitalization rates; potential years of life lost to alcohol misuse; and quality of life indicators. Vast resources are expended each year in the United States to address the health and social problems resulting from alcohol misuse. Because no single solution can reduce all alcohol-related harm to individuals and populations, a comprehensive approach using a range of strategies that address the multiple causes and dimensions of alcohol problems is needed. These strategies should include educational approaches—such as public health education and awareness programs, including school, family, and community-based prevention programs; environmental approaches—such as controls on the price and availability of alcohol, minimum age for purchase of alcohol, legislative measures to curb driving under the influence of alcohol, and restrictions on the promotion, marketing, and advertising of alcohol; and health care efforts—such as primary health care screening, advice by health care providers, preventive services, and effective treatment using psychological and pharmacological approaches.

For more information about alcohol use among individuals and populations, its relation to health and social problems, or how to reduce alcohol risk, contact the following:

• National Institute on Alcohol Abuse and Alcoholism (NIAAA), Scientific Communications Branch, (301) 443–3860, or online at http://www.niaaa.nih.gov.
• Substance Abuse and Mental Health Services Administration, National Clearing-house for Alcohol and Drug Information,(800) 729–6686, or online at http://www.health.org.
• National Council on Alcoholism and Drug Dependence, (800) NCA-CALL, or online at http://www.ncadd.org.
• Healthy People 2010, Objectives on Substance Abuse, (800) 336–4797, or online at http://www.health.gov/healthypeople.
• World Health Organization, Health Communication and Public Relations, 41 22/791/2543, or online at http://www.who.ch/.

Chudley E. Werch

(see also: Addiction and Habituation; Center for Substance Abuse Prevention; Drug Abuse Resistance Education [DARE]; Substance Abuse, Definition of )

Bibliography

Centers for Disease Control and Prevention (1999). Fact Sheet: Youth Risk Behavior Trends. Atlanta, GA: Author.

Dawson, D., and Grant, B. (1998). "Family History of Alcoholism and Gender: Their Combined Effects on DSM-IV Alcohol Dependence and Major Depression." Journal of Studies on Alcohol 59(1):97–106.

Dawson, D.; Grant, B.; Chou, S.; and Pickering, R. (1995). "Subgroup Variation in U.S. Drinking Patterns: Results of the 1992 National Longitudinal Alcohol Epidemiologic Study." Journal of Substance Abuse 7(3):331–344.

Ewing, J. (1984). "Detecting Alcoholism: The CAGE Questionnaire." Journal of the American Medical Association 252:1905–1907.

Grant, B.; Harford, T.; Dawson, D.; Chou, P.; DuFour, M.; and Pickering, R. (1994). "Prevalence of DSM-IV Alcohol Abuse and Dependence: United States, 1992." Epidemiologic Bulletin No. 35. Alcohol Health & Research World 18(3):243–248.

Greenfield, T., and Rogers, J. (1999). "Who Drinks Most of the Alcohol in the U.S.? The Policy Implications." Journal of Studies on Alcohol January 1999:78–89.

Inaba, D., and Cohen, W. (2000). Uppers, Downers, All Arounders, 4th edition. Ashland, OR: CNS Publications.

Johnston, L. D.; O'Malley, P. M.; and Bachman, J. G. (1999). "Drug Trends in 1999 Among American Teens Are Mixed." University of Michigan News and Information Services, national press release, December 17, 1999:1–33.

Kandel, D., and Yamaguchi, K. (1993). "From Beer to Crack: Developmental Patterns of Drug Involvement." American Journal of Public Health 83:851–855.

Substance Abuse and Mental Health Services Administration (2000). Summary of Findings from the 1998 National Household Survey on Drug Abuse. Rockville, MD: Author.

U.S. Department of Agriculture and U.S. Department of Health and Human Services (1995). Nutrition and Your Health: Dietary Guidelines for Americans, 4th edition. Washington, DC: Author.

U.S. Department of Health and Human Services (2000). Tenth Special Report to the U.S. Congress on Alcohol and Health from the Secretary of Health and Human Services. NIH Publication No. 00–1583. Washington, DC: Author.

—— (2000). Healthy People 2010. Washington, DC: Author.

World Health Organization (1994). Lexicon of Alcohol and Drug Terms. Geneva: Author.