Clinical Protocols to Reduce High-Risk Drinking in College Students
The College Drinking Prevention Curriculum for Health Care Providers
Developed for the NIAAA Task Force on College Drinking
October, 2002
Michael Fleming, MD, MPH, Professor
Department of Family Medicine, University of Wisconsin - Madison
(mfleming@fammed.wisc.edu)
Workshop Outline
Module 1
Epidemiology and Prevention (30 minutes)
Module 2
Screening and Assessment (30 minutes)
Module 3
Treatment (Brief Intervention) (45 minutes)
Module 4
Motivational Interviewing (45 minutes)
Module 1
What’s a Clinician to do About Alcohol And Drug Use Disorders in a College Age Population?
Why Bother?
Reduce life-threatening risks (e.g., motor vehicle accidents, falls, overdoses)
Reduce alcohol-related medical problems (e.g., STDs, HIV, depression, suicide)
Difficult to treat headaches, epigastric pain, depression, anxiety and STDs in presence of heavy alcohol use
Students who are trying to quit smoking relapse at much higher rates if they continue to drink
Prevalence of Alcohol Use in College Students (O’Malley & Johnston, 2002)
Binge drinking - 5 or more drinks per occasion for males, and 4 or more for females
Males – 20-60%
Females – 10-40%
(Depends on age, race and college setting)
Figure 1: Prevalence of Annual, 30-day, and Heavy alcohol use Among College Students
Bar chart with 13 items.
Item 1, Source: MTF in 1999. Prevalence of annual alcohol use among college students is 82.
Item 2, Source: MTF in 1999. Prevalence of thirty-day alcohol use among college students is 68.
Item 3, Source: MTF in 1999. Prevalence of binge alcohol use among college students is 38.
Item 4, Source: CAS in 1999, Prevalence of annual alcohol use among college students is 78.
Item 5, Source: CAS in 1999, Prevalence of thirty-day alcohol use among college students is 65.
Item 6, Source: CAS in 1999, Prevalence of binge alcohol use among college students is 43.
Item 7, Source: NCHRBS in 1995, Prevalence of thirty-day alcohol use among college students is 66.
Item 8, Source: NCHRBS in 1995, Prevalence of binge alcohol use among college students is 34.
Item 9, Source: CORE from 1992 to 1994, Prevalence of annual alcohol use among college students is
82.
Item 10, Source: CORE from 1992 to 1994, Prevalence of thirty-day alcohol use among college
students is 68.
Item 11, Source: CORE from 1992 to 1994, Prevalence of binge alcohol use among college students is
37.
Item 12, Source: NHSDA from 1991 to 1993, Prevalence of thirty-day alcohol use among college
students is 62.
Item 13, Source: NHSDA from 1991 to 1993, Prevalence of binge alcohol use among college students
is 12.
Figure 2: Trends in Annual, 30-day, Heavy, and Daily Alcohol use Among College Students, 1980-1999
Source: MTF
Line chart with 20 items, each from A to D.
Item 1a, In 1980, the prevalence in annual alcohol use among college students is 91.
Item 1b, In 1980, the prevalence in thirty-day alcohol use among college students is 82.
Item 1c, In 1980, the prevalence in binge alcohol use among college students is 44.
Item 1d, In 1980, the prevalence in daily alcohol use among college students is 7.
Item 2a, In 1980, the prevalence in annual alcohol use among college students is 93.
Item 2b, In 1980, the prevalence in thirty-day alcohol use among college students is 82.
Item 2c, In 1980, the prevalence in binge alcohol use among college students is 44.
Item 2d, In 1980, the prevalence in daily alcohol use among college students is 6.
Item 3a, In 1980, the prevalence in annual alcohol use among college students is 93.
Item 3b, In 1980, the prevalence in thirty-day alcohol use among college students is 83.
Item 3c, In 1980, the prevalence in binge alcohol use among college students is 44.
Item 3d, In 1980, the prevalence in daily alcohol use among college students is 6.
Item 4a, In 1980, the prevalence in annual alcohol use among college students is 92.
Item 4b, In 1980, the prevalence in thirty-day alcohol use among college students is 80.
Item 4c, In 1980, the prevalence in binge alcohol use among college students is 43.
Item 4d, In 1980, the prevalence in daily alcohol use among college students is 6.
Item 5a, In 1980, the prevalence in annual alcohol use among college students is 90.
Item 5b, In 1980, the prevalence in thirty-day alcohol use among college students is 79.
Item 5c, In 1980, the prevalence in binge alcohol use among college students is 45.
Item 5d, In 1980, the prevalence in daily alcohol use among college students is 7.
Item 6a, In 1980, the prevalence in annual alcohol use among college students is 93.
Item 6b, In 1980, the prevalence in thirty-day alcohol use among college students is 80.
Item 6c, In 1980, the prevalence in binge alcohol use among college students is 44.
Item 6d, In 1980, the prevalence in daily alcohol use among college students is 5.
Item 7a, In 1980, the prevalence in annual alcohol use among college students is 92.
Item 7b, In 1980, the prevalence in thirty-day alcohol use among college students is 79.
Item 7c, In 1980, the prevalence in binge alcohol use among college students is 44.
Item 7d, In 1980, the prevalence in daily alcohol use among college students is 5.
Item 8a, In 1980, the prevalence in annual alcohol use among college students is 92.
Item 8b, In 1980, the prevalence in thirty-day alcohol use among college students is 78.
Item 8c, In 1980, the prevalence in binge alcohol use among college students is 43.
Item 8d, In 1980, the prevalence in daily alcohol use among college students is 6.
Item 9a, In 1980, the prevalence in annual alcohol use among college students is 89.
Item 9b, In 1980, the prevalence in thirty-day alcohol use among college students is 76.
Item 9c, In 1980, the prevalence in binge alcohol use among college students is 43.
Item 9d, In 1980, the prevalence in daily alcohol use among college students is 5.
Item 10a, In 1980, the prevalence in annual alcohol use among college students is 89.
Item 10b, In 1980, the prevalence in thirty-day alcohol use among college students is 76.
Item 10c, In 1980, the prevalence in binge alcohol use among college students is 42.
Item 10d, In 1980, the prevalence in daily alcohol use among college students is 4.
Item 11a, In 1980, the prevalence in annual alcohol use among college students is 88.
Item 11b, In 1980, the prevalence in thirty-day alcohol use among college students is 74.
Item 11c, In 1980, the prevalence in binge alcohol use among college students is 41.
Item 11d, In 1980, the prevalence in daily alcohol use among college students is 4.
Item 12a, In 1980, the prevalence in annual alcohol use among college students is 88.
Item 12b, In 1980, the prevalence in thirty-day alcohol use among college students is 74.
Item 12c, In 1980, the prevalence in binge alcohol use among college students is 43.
Item 12d, In 1980, the prevalence in daily alcohol use among college students is 4.
Item 13a, In 1980, the prevalence in annual alcohol use among college students is 87.
Item 13b, In 1980, the prevalence in thirty-day alcohol use among college students is 72.
Item 13c, In 1980, the prevalence in binge alcohol use among college students is 42.
Item 13d, In 1980, the prevalence in daily alcohol use among college students is 4.
Item 14a, In 1980, the prevalence in annual alcohol use among college students is 85.
Item 14b, In 1980, the prevalence in thirty-day alcohol use among college students is 70.
Item 14c, In 1980, the prevalence in binge alcohol use among college students is 40.
Item 14d, In 1980, the prevalence in daily alcohol use among college students is 4.
Item 15a, In 1980, the prevalence in annual alcohol use among college students is 83.
Item 15b, In 1980, the prevalence in thirty-day alcohol use among college students is 68.
Item 15c, In 1980, the prevalence in binge alcohol use among college students is 40.
Item 15d, In 1980, the prevalence in daily alcohol use among college students is 4.
Item 16a, In 1980, the prevalence in annual alcohol use among college students is 83.
Item 16b, In 1980, the prevalence in thirty-day alcohol use among college students is 68.
Item 16c, In 1980, the prevalence in binge alcohol use among college students is 38.
Item 16d, In 1980, the prevalence in daily alcohol use among college students is 3.
Item 17a, In 1980, the prevalence in annual alcohol use among college students is 83.
Item 17b, In 1980, the prevalence in thirty-day alcohol use among college students is 67.
Item 17c, In 1980, the prevalence in binge alcohol use among college students is 38.
Item 17d, In 1980, the prevalence in daily alcohol use among college students is 3.
Item 18a, In 1980, the prevalence in annual alcohol use among college students is 83.
Item 18b, In 1980, the prevalence in thirty-day alcohol use among college students is 66.
Item 18c, In 1980, the prevalence in binge alcohol use among college students is 41.
Item 18d, In 1980, the prevalence in daily alcohol use among college students is 4.
Item 19a, In 1980, the prevalence in annual alcohol use among college students is 85.
Item 19b, In 1980, the prevalence in thirty-day alcohol use among college students is 68.
Item 19c, In 1980, the prevalence in binge alcohol use among college students is 39.
Item 19d, In 1980, the prevalence in daily alcohol use among college students is 3.
Item 20a, In 1980, the prevalence in annual alcohol use among college students is 84.
Item 20b, In 1980, the prevalence in thirty-day alcohol use among college students is 69.
Item 20c, In 1980, the prevalence in binge alcohol use among college students is 40.
Item 20d, In 1980, the prevalence in daily alcohol use among college students is 4.
Figure 3: Prevalence of Annual, 30-day, Heavy and Daily Alcohol use Among College Students and Non-College Peers
Source: MTF: 99, NHSDA: 91-93
Bar chart with 12 items.
Item 1, Source: MTF in 1999. Prevalence of annual alcohol use among college students is 83.
Item 2, Source: MTF in 1999. Prevalence of annual alcohol use among noncollege students is 81.
Item 3, Source: MTF in 1999. Prevalence of thirty-day alcohol use among college students is 78.
Item 4, Source: MTF in 1999. Prevalence of thirty-day alcohol use among noncollege students is
60.
Item 5, Source: MTF in 1999. Prevalence of binge alcohol use among college students is 39.
Item 6, Source: MTF in 1999. Prevalence of binge alcohol use among noncollege students is 34.
Item 7, Source: MTF in 1999. Prevalence of daily alcohol use among college students is 4.
Item 8, Source: MTF in 1999. Prevalence of daily alcohol use among noncollege students is 5.
Item 9, Source: NHSDA from 1991 to 1993. Prevalence of thirty-day alcohol use among college
students is 62.
Item 10, Source: NHSDA from 1991 to 1993. Prevalence of thirty-day alcohol use among noncollege
students is 55.
Item 11, Source: NHSDA from 1991 to 1993. Prevalence of heavy alcohol use among college students
is 12.
Item 12, Source: NHSDA from 1991 to 1993. Prevalence of heavy alcohol use among noncollege
students is 11.
Figure 4: Prevalence of Heavy Drinking Among College Students by Gender
Source: MTF, CAS, NCHRBS, CORE
Bar chart with 8 items.
Item 1, Source: MTF in 1999. Prevalence of binge drinking by male is 48.
Item 2, Source: MTF in 1999. Prevalence of binge drinking by female is 32.
Item 3, Source: CAS in 1999. Prevalence of binge drinking by male is 49.
Item 4, Source: CAS in 1999. Prevalence of binge drinking by female is 38.
Item 5, Source: NCHRBS in 1995. Prevalence of binge drinking by male is 47.
Item 6, Source: NCHRBS in 1995. Prevalence of binge drinking by female is 33.
Item 7, Source: CORE in 1994. Prevalence of binge drinking by male is 47.
Item 8, Source: CORE in 1994. Prevalence of binge drinking by female is 29.
Figure 5: Prevalence of Heavy Drinking Among College Students by Race/Ethnicity
Source: MTF, CAS, NCHRBS, CORE
Bar chart with 12 items.
Item 1, Source: MTF from 1997 to 1999. Prevalence of binge drinking among African American college
students is 13 percent.
Item 2, Source: MTF from 1997 to 1999. Prevalence of binge drinking among White American college
students is 43 percent.
Item 3, Source: MTF from 1997 to 1999. Prevalence of binge drinking among Hispanic college
students is 30 percent.
Item 4, Source: CAS in 1999. Prevalence of binge drinking among African American college students
is 15 percent.
Item 5, Source: CAS in 1999. Prevalence of binge drinking among White American college students is
48 percent.
Item 6, Source: CAS in 1999. Prevalence of binge drinking among Hispanic college students is 38
percent.
Item 7, Source: NCHRBS in 1995. Prevalence of binge drinking among African American college
students is 11 percent.
Item 8, Source: NCHRBS in 1995. Prevalence of binge drinking among White American college students
is 38 percent.
Item 9, Source: NCHRBS in 1995. Prevalence of binge drinking among Hispanic college students is 29
percent.
Item 10, Source: CORE from 1992 to 1994. Prevalence of binge among African American college
students is 21 percent.
Item 11, Source: CORE from 1992 to 1994. Prevalence of binge drinking among White American college
students is 41 percent.
Item 12, Source: CORE from 1992 to 1994. Prevalence of binge drinking among Hispanic college
students is 34 percent.
Figure 6: Prevalence of Heavy Drinking Among College Students By Gender and Race/Ethnicity
NCHRBS: 95, CAS: 99
Bar chart with 12 items.
Item 1, Prevalence of binge drinking among male African American college students is 22.
Item 2, Prevalence of binge drinking among female African American college students is 5.
Item 3, Prevalence of binge drinking among male White American college students is 47.
Item 4, Prevalence of binge drinking among female White American college students is 30.
Item 5, Prevalence of binge drinking among male Hispanic college students is 38.
Item 6, Prevalence of binge drinking among female Hispanic college students is 21.
Item 7, Prevalence of binge drinking among male African American college students is 21.
Item 8, Prevalence of binge drinking among female African American college students is 11.
Item 9, Prevalence of binge drinking among male White American college students is 53.
Item 10, Prevalence of binge drinking among female White American college students is 43.
Item 11, Prevalence of binge drinking among male Hispanic college students is 46.
Item 12, Prevalence of binge drinking among female Hispanic college students is 33.
Figure 7: Prevalence of Current (past 30 days) use of Marijuana, Cocaine, Cigarettes, and Alcohol Among College Students
Source: MTF, CAS, NCHRBS, CORE, NHSDA
Bar chart with 25 items.
Item 1, Source: MTF in 1999. Prevalence of marijuana use among college students is 20.
Item 2, Source: CAS in 1999. Prevalence of cocaine use among college students is 15.
Item 3, Source: NCHRBS in 1995. Prevalence of cigarettes use among college students is 14.
Item 4, Source: CORE from 1992 to 1994. Prevalence of alcohol use among college students is 16.
Item 5, Source: NHSDA from 1991 to 1993. Prevalence of binge drinking among college students is
12.
Item 6, Source: MTF in 1999. Prevalence of marijuana use among college students is 2.
Item 7, Source: CAS in 1999. Prevalence of cocaine use among college students is 3.
Item 8, Source: NCHRBS in 1995. Prevalence of cigarettes use among college students is 1.
Item 9, Source: CORE from 1992 to 1994. Prevalence of alcohol use among college students is 3.
Item 10, Source: NHSDA from 1991 to 1993. Prevalence of binge drinking among college students is
2.
Item 11, Source: MTF in 1999. Prevalence of marijuana use among college students is 30.
Item 12, Source: CAS in 1999. Prevalence of cocaine use among college students is 28.
Item 13, Source: NCHRBS in 1995. Prevalence of cigarettes use among college students is 28.
Item 14, Source: CORE from 1992 to 1994. Prevalence of alcohol use among college students is 31.
Item 15, Source: NHSDA from 1991 to 1993. Prevalence of binge drinking among college students is
21.
Item 16, Source: MTF in 1999. Prevalence of marijuana use among college students is 68.
Item 17, Source: CAS in 1999. Prevalence of cocaine use among college students is 66.
Item 18, Source: NCHRBS in 1995. Prevalence of cigarettes use among college students is 67.
Item 19, Source: CORE from 1992 to 1994. Prevalence of alcohol use among college students is 67.
Item 20, Source: NHSDA from 1991 to 1993. Prevalence of binge drinking among college students is
63.
Item 21, Source: MTF in 1999. Prevalence of marijuana use among college students is 39.
Item 22, Source: CAS in 1999. Prevalence of cocaine use among college students is 44.
Item 23, Source: NCHRBS in 1995. Prevalence of cigarettes use among college students is 34.
Item 24, Source: CORE from 1992 to 1994. Prevalence of alcohol use among college students is 37.
Item 25, Source: NHSDA from 1991 to 1993. Prevalence of binge drinking among college students is
12.
Figure 8: Change in Heavy Drinking from High School Senior Year to Post-High School by College Students and Non-College Peers (MTF, 1997-1999 combined)
(MTF, 1997-99 combined)
Line chart with 2 items.
Item 1, The binge drinking prevalence increased from 24 for high school senior year, to 39 for
post high school year by college students.
Item 2, The binge drinking prevalence increased from 29 for high school senior year, to 34 for
post high school year by college students.
Estimated Frequency of Alcohol Related-Events (Hingson, 2001)
Mortality - 1,400 student deaths/year
Morbidity - 500,000 students injured/year
Sexual assault - 70,000 cases/year
Driving under the influence - 25% of all college students in previous year
How Much Alcohol is Too Much?
Association Between Alcohol Consumption & Mortality
Source: Andreasson S, et al. British Medical Journal. 1988;296:1021-25.
Bar chart showing the violent and other deaths per thousand deaths as weekly alcohol consumption increases.
Item 1 There are approximately 6 violent deaths per thousand for 0 grams of alcohol consumption per week
Item 2 There are approximately 4 other deaths per thousand for 0 grams of alcohol consumption per week
Item 3 There are approximately 10 violent deaths per thousand for 1 to 100 grams of alcohol consumption per week
Item 4 There are approximately 3 other deaths per thousand for 1 to 100 grams of alcohol consumption per week
Item 5 There are approximately 17 violent deaths per thousand for 101 to 250 grams of alcohol consumption per week
Item 6 There are approximately 5 other deaths per thousand for 101 to 250 grams of alcohol consumption per week
Item 7 There are approximately 27 violent deaths per thousand for 251 to 400 grams of alcohol consumption per week
Item 8 There are approximately 2 other deaths per thousand for 251 to 400 grams of alcohol consumption per week
Item 9 There are approximately 43 violent deaths per thousand for over 400 grams of alcohol consumption per week
Item 10 There are approximately 18 other deaths per thousand for over 400 grams of alcohol consumption per week
Estimated Pooled Risk Function Curves: Alcohol & Cancer Risk
Line chart showing the relative cancer risk as grams of daily alcohol consumption increases.
Item 1 The relative cancer risk to the Larynx increases from 0 to appoximately 2.7 as alcohol consumption increases from 0 to 100 grams per day
Item 1 The relative cancer risk to the Pharynx increases from 0 to appoximately 2.3 as alcohol consumption increases from 0 to 100 grams per day
Item 1 The relative cancer risk to the Oral increases from 0 to appoximately 2 as alcohol consumption increases from 0 to 100 grams per day
Item 1 The relative cancer risk to the Liver increases from 0 to appoximately 1.7 as alcohol consumption increases from 0 to 100 grams per day
Item 1 The relative cancer risk to the Breast increases from 0 to appoximately 1.5 as alcohol consumption increases from 0 to 100 grams per day
Item 1 The relative cancer risk to the Esophagus increases from 0 to appoximately 1.4 as alcohol consumption increases from 0 to 100 grams per day
Item 1 The relative cancer risk to the Stomach increases from 0 to appoximately 1.3 as alcohol consumption increases from 0 to 100 grams per day
Item 1 The relative cancer risk to the Colorectal increases from 0 to appoximately 1.2 as alcohol consumption increases from 0 to 100 grams per day
Deaths in Europe and the United States from Cirrhosis per 1,000 Living
Edwards et al. Alcohol Policy and the Public Good. Oxford University Press, 1994.
Tabular Data
For Hungary the percentage of Cirrhosis deaths per 1,000 living were total 54.8, breakdown, males 79.7 , females 32.6
For Romania the percentage of Cirrhosis deaths per 1,000 living were total 8.1, breakdown, males 47.5 , females 28.8
For Germany, Dem Rep the percentage of Cirrhosis deaths per 1,000 living were total 33.7, breakdown, males 47.9 , females 19.4
For Austria the percentage of Cirrhosis deaths per 1,000 living were total 28.2, breakdown, males 41.2 , females 16.4
For Portugal the percentage of Cirrhosis deaths per 1,000 living were total 26.9, breakdown, males 39.3 , females 15.1
For Italy the percentage of Cirrhosis deaths per 1,000 living were total 26.8, breakdown, males 31.7 , females 18.0
For Czechoslovakia the percentage of Cirrhosis deaths per 1,000 living were total 25.1, breakdown, males 38.1, females 13.4
For Germany, Fed Rep the percentage of Cirrhosis deaths per 1,000 living were total 22.2, breakdown, males 30.4, females 14.6
For Spain the percentage of Cirrhosis deaths per 1,000 living were total 21.0, breakdown, males 30.0, females 12.9
For Luxembourg the percentage of Cirrhosis deaths per 1,000 living were total 18.7, breakdown, males 21.9, females 15.4
For Former Yugoslavia the percentage of Cirrhosis deaths per 1,000 living were total 18.4, breakdown, males 27.7, females 10.2
For France the percentage of Cirrhosis deaths per 1,000 living were total 17.0, breakdown, males 23.3, females 10.6
For Bulgaria the percentage of Cirrhosis deaths per 1,000 living were total 15.0, breakdown, males 22.0, females 07.8
For Poland the percentage of Cirrhosis deaths per 1,000 living were total 13.9, breakdown, males 19.1, females 09.2
For Belgium the percentage of Cirrhosis deaths per 1,000 living were total 11.9, breakdown, males 14.4, females 09.5
For Finland the percentage of Cirrhosis deaths per 1,000 living were total 10.7, breakdown, males 15.3, females 04.2
For Switzerland the percentage of Cirrhosis deaths per 1,000 living were total 09.5, breakdown, males 12.9, females 06.1
For Malta the percentage of Cirrhosis deaths per 1,000 living were total 09.0, breakdown, males 14.0, females 03.9
For Greece the percentage of Cirrhosis deaths per 1,000 living were total 08.9, breakdown, males 12.1, females 05.8
For Israel the percentage of Cirrhosis deaths per 1,000 living were total 08.7, breakdown, males 10.3, females 07.0
For United States the percentage of Cirrhosis deaths per 1,000 living were total 07.2, breakdown, males 12.0, females 05.1
For Sweden the percentage of Cirrhosis deaths per 1,000 living were total 06.8, breakdown, males 08.8, females 04.7
For United Kingdom the percentage of Cirrhosis deaths per 1,000 living were total 06.1, breakdown, males 06.9, females 05.3
For Netherlands the percentage of Cirrhosis deaths per 1,000 living were total 05.1, breakdown, males 06.3, females 03.9
No use in risky situations (e.g. driving, pregnant)
A “Standard Drink”
A mug of ordinary beer, ale, or malt liquor 12 oz.
A single shot of spirits -- whisky, gin, vodka, etc. 1.5 oz.
A glass of wine 5 oz.
A wine cooler 12 oz.
A small glass of sherry, liqueur, or aperitif 4 oz.
High-Risk Use
Men who drink 14 or more drinks per week
Women who drink 7 or more drinks per week
Men who drink more than 4 drinks per occasion, women who drink more than 3 drinks per occasion
Men and women who drink in high-risk situations
Problem Use
Students with one or more alcohol-related problems
Academic performance
Interactions with campus police
Relationships
Mental health
Accidents/falls
Medical
Interpersonal violence
Alcohol-Dependent
Inability to control
Making rules
Preoccupation with use
Alcohol-related problems
Tolerance or morning withdrawal
Women
Women become intoxicated on less alcohol than men.
Possible Mechanisms:
Women have lower total body water content which results in higher concentrations of alcohol in the blood
Women have decreased levels of alcohol dehydrogenase in their gastric mucosa which causes 30% more alcohol to be absorbed into the blood
Gonadal hormone levels during the menstrual cycle may affect the rate of alcohol metabolism, increasing vulnerability to physiological consequences of drinking
Prevention of Alcohol and Drug Problems Among College Students
Interventions that seem to work
Changing university norms
Clinician-delivered screening and brief intervention
Reducing the number of liquor licenses in campus area
Increasing penalties for alcohol use in various situations
Having the active support of parents and alumni
Administrative leadership
Interventions that may work (insufficient evidence)
