Question: How can you help a person to stop drinking?

Ralph Hingson: Nearly 3 in 10 U.S. adults engage in at-risk drinking patterns and thus would benefit from advice to cut down or a referral for further evaluation. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), drinking becomes too much when it causes or elevates the risk for alcohol-related problems or the management of other health problems. Men who drink 5 or more standard drinks in a day (or 15 or more per week) and women who drink 4 or more in a day (or 8 or more per week) are at risk for alcohol-related problems, according to epidemiologic research. Approximately 10 percent of the U.S. population exceeds both daily and weekly limits, and approximately half of these individuals can be classified as having an alcohol use disorder, abuse, or dependence. Another 16 percent exceed only the daily limits and 1 in 5 of them can be classified as having an alcohol use disorder.

NIAAA has prepared a document "Helping Patients Who Drink Too Much: A Clinician's Guide, 2005 Edition." This guide provides the information described above and was written to assist mental health clinicians. It identifies a single question as particularly helpful in screening patients to identify those with a risky pattern of drinking, "How many times in the past year have you had 5 or more drinks in a day? (for men) or 4 or more drinks in a day? (for women)." Those who answer 1 or more times to the question can then be asked questions to identify a maladaptive pattern of alcohol use during the past year.

Whether drinking has repeatedly caused or contributed to any of the following indicates the patient has alcohol abuse:

In the past year, experiencing 3 or more of the following indicators means the person has alcohol dependence:

The manual recommends that people who do not exceed the daily recommended alcohol limit be advised to stay within the limits of non-risky drinking and those patients should be re-screened annually.

For those who meet alcohol abuse or dependence criteria, specific counseling steps are recommended.

The conclusion and recommendations of the screening should be provided to the patient and steps taken by the clinician to assess the patient's readiness to change.

The clinician should explore barriers to change, reaffirm his/her willingness to help, and encourage reflection among patients resistant to change.

Among patients willing to change their drinking the clinician should help them set a goal, agree on a plan, and provide educational materials. Alcohol use and abuse drinking goals should be reviewed at each revisit.

Those who meet abuse or dependence criteria should also be advised to consider evaluation by an addiction specialist and participation in a mutual help group. Patients with dependence may need medically managed withdrawal.

Dependent patients who endorse abstinence as a goal are candidates for medications such as Disulfiram, Naltrexone, or Acamprosate. Followup appointments should be scheduled.

Details regarding contra-indications, precautions, common side effects, and serious adverse reactions and prescription instructions are provided in the manual.

Question: Is there evidence that we are succeeding in reducing the negative consequences of college drinking?

Ralph Hingson: No. According to a report in the Annual Review of Public Health (Hingson, et al. 2005) from 1998 to 2001 alcohol-related injury deaths among 18- to 24-year-old college students increased from nearly 1,600 to more than 1,700. More than 1,400 were alcohol- related traffic deaths. Binge drinking rates among college students did not decline. The proportion of 18- to 24-year-old college students who drove under the influence of alcohol increased from 26.5 percent to 31.4 percent, an increase from 2.3 million to 2.8 million.

During both years, more than 500,000 college students were unintentionally injured because of drinking and more than 600,000 were hit or assaulted by another drinking college student. The numbers of college students sexually assaulted by another drinking college student rose from 70,000 to 97,000.

Of note, while a smaller proportion of 18- to 24-year-olds not in college reported binge drinking and driving under the influence, differences between them and 18- to 24-year-old college students are diminishing. Further, the younger college students were when they first started to drink the greater their likelihood in college of experiencing alcohol dependence, driving after drinking, riding with drinking drivers, being injured after drinking, and having unplanned and unprotected sex after drinking.

However, these problems can be reduced. Research indicates that greater enforcement of the legal drinking age of 21 and zero tolerance laws making it illegal for persons under 21 to drive after any drinking, increases in alcohol taxes, wider implementation of screening, and counseling programs and comprehensive college-community interventions can reduce college and college-age drinking and related harms.

Question: What are the detailed effects of long-term alcohol abuse to the body, like the liver and the heart?

Ralph Hingson: Chronic diseases include numerous diseases and conditions related to alcohol consumption. The chronic condition most strongly related to alcohol is liver disease. In 2001, there were 12,201deaths from alcoholic liver disease and 6,719 deaths from unspecified liver cirrhosis that were attributable to alcohol. Together, these 18,920 deaths accounted for more than half of all chronic disease deaths attributable to alcohol as well as over half of the years of life lost attributable to chronic alcohol conditions.

Liver Disease
It has long been established that alcohol consumption is a cause of liver disease. Work which began in the 1920s has continued through several studies demonstrating that heavy drinkers are at increased risk of death by liver cirrhosis (see reviews by Schmidt and de Lint 1972; Pell and D'Alonzo 1973; Thun et al. 1997; and Mann et al. 1993 and 2004). Consistent with this, the relative risk of cirrhosis morbidity rises with increasing levels of alcohol consumption (Tuyns and Pequignot 1984; Coates et al. 1986). In addition, cirrhosis mortality rates are higher in societies where the average per capita consumption of alcoholic beverages is higher (Lederman 1956; Bruun et al. 1975; Skog 1980; Smart and Mann 1991). In the U.S., alcoholic liver disease mortality rates have declined since the 1970s. It has been suggested that the declines may be due to increased participation in alcohol treatment, decreases in alcohol consumption, and changes in consumption of certain types of alcoholic beverage (Mann et al., 2003). However, the specific causes are unknown and there is need of further research. While it is clear that heavy, long-term alcohol consumption can cause alcoholic liver disease in susceptible people, not all heavy drinkers develop cirrhosis or alcoholic hepatitis. This suggests the importance of additional risk factors including heredity, gender, and diet.

The fact that women develop cirrhosis at a lower cumulative dose than men, combined with the fact that dietary intake and metabolic processing of key nutrients, including fatty acids, differs by gender, suggests the need for gender-specific studies of genetic susceptibility, taking nutritional status into account.

Heavy alcohol consumption accelerates the progression of Hepatitis C (HCV) (Poyard et al. 1997, Schiff and Ozden 2004). Heavy alcohol consumption also interferes with the effectiveness of HCV treatment (Poyard et al. 1997).

Among the chronic diseases, liver disease has the most clear-cut association with alcohol. The association is less clear for cardiovascular disease and diabetes where low levels of alcohol appear to be beneficial while higher levels are harmful, and for breast cancer where moderate drinking may increase risk (Gunzerath et al., 2004) .

Aside from diseases of the liver, chronic diseases associated with alcohol consumption include (but are not limited to) heart disease, cancer, and diabetes mellitus (Midakik et al. MMWR 2004).

There have been numerous studies on the association between alcohol and cancer (World Cancer Research Fund, 1997). Convincing evidence demonstrates that alcohol increases the risk of cancers of the liver, mouth and pharynx, larynx, and esophagus. However, the evidence is less clear for lung, breast, and colorectal cancers.

Diabetes
Alcohol has a J- or U-shaped relation with risk of type 2 diabetes similar to that found for cardiovascular disease (Koppes et al., 2005). Moderate drinking appears to reduce risk while heavier drinking appears to result in no increase or a modest increase in risk.

Cardiovascular Disease
Studies of cardiovascular disease and mortality consistently show a J- or U-shaped curve among persons who are middle aged or older. Abstainers and heavier drinkers have higher risks of heart disease than light drinkers.