Does Quantity
of Drinking Matter?
Kirk J. Brower, M.D.
Professor of Psychiatry
Executive Director, Addiction Treatment Services
[email protected]
Benefits of Drinking
• Enhanced sociability,
relaxation, enjoyment,
festivities
• In many countries (including U.S. &
Ukraine), drinking alcohol is normative
• Light to moderate drinking is protective
against cardiovascular disease and
mortality
Adapted from D. Hasin
Yearly Per Capita Total Alcohol
Consumption by Country: WHO (2005)
Country
Total Consumption
(liters of pure alcohol)
Among Drinkers
(liters of pure alcohol)
Russian Federation
15.76
26.70
Ukraine
15.60
27.90
Poland
13.25
17.90
Canada
9.77
12.60
United States
9.44
14.40
Mexico
8.42
27.20
WORLDWIDE
6.13
Ages 15+
Alcohol Use
Full Continuum of Drinking
• Abstaining
• Low-risk drinking
• “Social drinking”
No Use &
Moderate Use
• Risky use
• Hazardous
use
At-Risk Use
High-Risk Use
No problems from use
• Harmful use
• Problem
drinking
Abuse
• Dependent
drinking
• Alcoholism
Dependence
or Addiction
Problems
Alcohol Use
Full Continuum of Drinking
Alcohol Use Disorders
No Use &
Moderate Use
At-Risk Use
High-Risk Use
No problems from use
Abuse
Dependence
or Addiction
Problems
Where in this continuum is quantity important?
Alcohol Use Disorders
• Alcohol Abuse (≈ Harmful Use)
• Alcohol Dependence
DSM-IV Criteria for Alcohol Abuse
at least 1 of the following:
1. Recurrent failure to fulfill obligations at work, school, or
home due to drinking
(e.g., repeated absences or poor work performance)
2. Recurrent use in physically hazardous situations
(e.g., driving while intoxicated)
3. Recurrent legal problems due to drinking
(e.g., arrests for disorderly conduct)
4. Continued use despite social or psychological
consequences caused or exacerbated by drinking
Nothing about quantity here,
but people with this diagnosis are
likely to drink heavily frequently.
DSM-IV Criteria for Alcohol Dependence
3 or more at any time in the same 12-mo period
1.
2.
3.
4.
5.
6.
7.
Tolerance
Withdrawal
Drinking more than intended
Desire yet unable to cut down or control use
Much time spent in drinking-related activities
Social, work, or leisure activities replaced by drinking
Continued drinking despite knowing physical or
psychological problems are caused or worsened by use
DSM-IV Criteria for Alcohol Dependence
3 or more at any time in the same 12-mo period
1.
2.
3.
4.
5.
6.
7.
Tolerance (drinks more than before to get same effect)
Withdrawal
Drinking more than intended
Desire yet unable to cut down or control use
Much time spent in drinking-related activities
Social, work, or leisure activities replaced by drinking
Continued drinking despite knowing physical or
psychological problems are caused or worsened by use
DSM-IV Criteria for Alcohol Dependence
3 or more at any time in the same 12-mo period
1.
2.
3.
4.
5.
6.
7.
Tolerance (drinks more than before to get same effect)
Withdrawal
Drinking more than intended
Desire yet unable to cut down or control use
Much time spent in drinking-related activities
Social, work, or leisure activities replaced by drinking
Continued drinking despite knowing physical or
psychological problems are caused or worsened by use
No set number of drinks that defines alcohol dependence,
DSM-IV Criteria for Alcohol Dependence
3 or more at any time in the same 12-mo period
1.
2.
3.
4.
5.
6.
7.
Tolerance (drinks more than before to get same effect)
Withdrawal
Drinking more than intended
Desire yet unable to cut down or control use
Much time spent in drinking-related activities
Social, work, or leisure activities replaced by drinking
Continued drinking despite knowing physical or
psychological problems are caused or worsened by use
No set number of drinks that defines alcohol dependence,
but people with this diagnosis are heavy drinkers.
Conclusion
While people with diagnoses of alcohol
abuse and alcohol dependence are heavy
drinkers, making a diagnosis does not really
depend on how much they drink.
Diagnosis
More important than quantity for diagnosis is:
• What happens when a person uses?
(loss of control, adverse consequences)
• What happens when that person tries to
stop using? (unable to do so for sustained
periods, withdrawal)
Does Quantity
of Drinking Matter?
Not when making a diagnosis of
alcohol abuse or alcohol dependence
12-month prevalence (8.5%)
Full Continuum of Drinking
• Abstaining
• Low-risk drinking
• “Social drinking”
No Use &
Moderate Use
• Risky use
• Hazardous
use
At-Risk Use
No problems from use
Alcohol Use Disorders
Abuse
Dependence
or Addiction
Problems
8.5% 12-month
prevalence in U.S.
(Hasin et al. 2007)
How much do they drink?
• Project Match (1997 U.S. Study)
AD Inpatients/Day Hospital patients (N=774 ; 80%
men): drinking 80% of days in past 3 month, mean of
15 drinks/drinking day
AD Outpatients (N=952; 72% men): drinking 70-75%
of days in past 3 months, mean of 11-12
drinks/drinking day
• COMBINE Study (2006 U.S. Study)
AD Outpatients (N=1,383; % men) drinking 75% of
days in past month, mean 12-13 drinks/drinking day
Polish Alcohol-Dependent
Inpatients (N=281)
• Mean = 19.8 drinks/drinking day
• Drank on 42% of days in 90 days
prior to admission
When Does Quantity
of Drinking Matter?
Alcohol Use
Full Continuum of Drinking
• Abstaining
• Low-risk drinking
• “Social drinking”
No Use &
Moderate Use
• Risky use
• Hazardous
use
At-Risk Use
High-Risk Use
No problems from use
Defined in terms of Quantity
• Harmful use
• Problem
drinking
Abuse
• Dependent
drinking
• Alcoholism
Dependence
or Addiction
Problems
A Drink Defined
• Standard U.S. drink = 14 g
 12 oz (355 ml) of 5% beer
 5 oz (148 ml) of 12% wine
 1.5 oz (44 ml) of 80 proof (40%) liquor
U.S. Center for Disease Control
NIAAA
Guidelines for Low-Risk Drinking*
REALLY?
0 — 3 — 4 — 7—14 drinks/day
0
Pregnant, medications, medical
illness
3
 3 drinks in 1 day for women
4
 4 drinks in 1 day for men
7
 7 drinks in 1 week for women
14
 14 drinks in 1 week for men
* U.S. Dept. of Health & Human Services, 1995
What?
Where do these numbers
come from?
Binge Drinking
Men
• Weighs 70 kg
Women
• Weighs 55 kg
• 5 drinks in 2 hours
• 70 g pure alcohol
• BAL = .077 g/L
• 4 drinks in 2 hr
• 56 g pure alcohol
• BAL = .078 g/L
Risk of motor vehicle collision is increased 3-4 times.
http://www.intox.com/drinkwheel.aspx
Alcohol, Cardiovascular, &
Other Mortality
“J” curves
 risk
 risk
Klatsky AL (2010).
J Am Coll Cardiol
55(13):1336-8.
Alcohol & Cancer Deaths*
Relative Risk
Men
Women
1.5
1.5
1
1
0.5
0.5
1
2
3+
1
2
*Any cancer
3+
Average Number of Drinks per Drinking Day
Breslow et al. (2011). Am J Epidemiol 174(9):1044-53.
Alcohol Dose & Total
Mortality in Men & Women
“J” curves.
Analysis of 34
studies, total
N = 1,015,835
& 94,533 deaths.
Di Castelnuovo (2006). Arch Intern Med 166(22):2437-45.
Alcohol consumption &
mortality in a Russian city
A:
B:
C:
D:
Abstainers
Non-problem drinkers (< 2 drunken episodes/wk)
>2 drunken episodes per week
Any non-beverage alcohol
N = 2000 men
(25-54 years old)
Prospective study
Non-beverage EtOH
Drunk >2X/wk
Abstainers
Non-problem
All cause mortality by alcohol drinking group (A-D) in
previous 1 year , adjusted for age, smoking, & education.
Tomkins et al.
(2012). PLoS One
7(2):e30274.
Heavy Drinking in Ukraine: 2002
Prevalence
Men
Women
Total
38.7%
8.5%
22.0%
Defined as consuming any one of the following:
• In a typical day
> 80 g
> 60 g (4.3)
• 3-4 days per week
> 60 g
> 45 g (3.2)
• Nearly every day
> 40 g
> 30 g
• In a typical day
5.7 drinks/d
4.3 drinks/d
• 3-4 days per week
15 drinks/wk 11 drinks/wk
• Nearly every day
16 drinks/wk 12 drinks/wk
Webb et al. Alcohol Alcohol 2005;40(4):327-35.
Heavy Drinking in Ukraine: 2002
% Heavy Alcohol Users
60
50
40
Male
Females
30
20
10
0
18-25
26-34
35-54
55+
Webb et al. Alcohol Alcohol 2005;40(4):327-35.
Screening: AUDIT-C
1. How often do you have a drink containing alcohol?
Never, Monthly or less, 2-4X/month, 2-3X/wk, >4X/wk
2. How many drinks containing alcohol do you have on a
typical day when you are drinking?
1 or 2, 3 or 4, 5 or 6, 7 to 9, 10+
3. How often do you have six or more drinks on one
occasion?
Never, < Monthly, Monthly, Weekly, Daily or Almost Daily
HOW TO SCREEN FOR HEAVY DRINKING–Step 1 (continued)
For patients who drink, ask the Screening
Question:
Tip: It may be useful
to show patients the
Standard Drinks
chart on page 13.
‹#›
How many times in the
past year have you had….
5 or more drinks in a day? (men)
4 or more drinks in a day? (women)
Drinking quantity like BP
• Blood pressure
Above a certain number,
risk is significant
Higher the number,
greater the risk
• Risks
Heart attack
Stroke
Drinking quantity like BP
140/90
4+ ♀ / 5+ ♂
# of Drinks
Blood Pressure
Increasing Risk
Drinking quantity like BP
• Generally cannot feel high blood
pressure (sometimes dizziness or
headache), but most people don’t
know they have it.
• Likewise, people with high-risk
drinking don’t know it (sometimes
hangover), but no problems.
Alcohol Use
Full Continuum of Drinking
Heavy Drinkers
Alcohol Use Disorders
No Use &
Moderate Use
No problems
At-Risk Use
High Risk Use
Abuse
Dependence
or Addiction
Problems
Heavy drinkers without problems
Summary
1. Quantity not needed to diagnose
alcohol use disorders
2. Quantity defines & separates lowrisk from high-risk drinking
3. Numeric limits for high-risk drinking
are linked to acute intoxication &
long-term adverse consequences
Summary
4. Screening is simple.
5. However, like high BP, people
without symptoms or problems, will
not know their risk is high to
develop a problem.
Thank you