National Institute on Alcohol Abuse and Alcoholism
FIVE YEAR
STRATEGIC PLAN
FY08-13
ALCOHOL ACROSS THE LIFESPAN
U.S. Department of Health and Human Services
National Institutes of Health
National Institute on Alcohol Abuse and Alcoholism
Table of Contents
Chapter I. |
Chapter II. | Chapter
III. Birth to Age Ten | Chapter
IV. Youth and Adolescence | Chapter
V. Young Adult |
Chapter
VI. Midlife | Chapter
VII. Senior Adult | |||||
Definition of Young Adult | |||||||||||
Epidemiology | Epidemiology | Epidemiology | Epidemiology |
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| Etiology | Etiology | Biology | Biology | |||||||
Prevention | Prevention and Intervention | Prevention | Prevention and Treatment | ||||||||
Treatment | Opportunities | Treatment | Opportunities | ||||||||
Opportunities | Outreach | Opportunities | Outreach | ||||||||
Neurobiology | Outreach | Outreach | |||||||||
Diagnostic Criteria | Collaborations | ||||||||||
Alcohol Health Services Research | |||||||||||
NIAAA STRATEGIC PLAN
ALCOHOL ACROSS THE LIFESPAN
EXECUTIVE SUMMARY
The National Institute on Alcohol Abuse and Alcoholism (NIAAA), a component of the National Institutes of Health, U.S. Department of Health and Human Services, is the lead agency in this country for research on alcohol abuse, alcoholism, and other health effects of alcohol. This document, the NIAAA Strategic Plan for Research, 2008-2013 sets forth a fundamental organizing principle for alcohol research studies and describes research opportunities to deepen and broaden our understanding of alcohol use and alcohol use disorders.
Alcohol use disorders (AUD) is defined as alcohol abuse and alcohol dependence, and arise from drinking too much, too fast and/or too often. Alcohol Abuse is defined as a recurring pattern of high-risk drinking that creates problems for the drinker, for others, or for society. Adverse consequences can also arise from a single instance of hazardous alcohol use. Alcohol dependence, typically considered to be synonymous with alcoholism (alcohol addiction), is a complex disease characterized by persistent and intense alcohol-seeking, which results in a loss of control over drinking, a preoccupation with drinking, compulsion to drink or inability to stop, and the development of tolerance and dependence.
The U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) recently came to similar conclusions about the toll taken by excessive alcohol use. According to the CDC, excessive alcohol consumption is the number-three cause of preventable death in the United States. The WHO also ranks alcohol third among preventable risk factors for premature death in developed nations. In 2003, the worldwide prevalence of alcohol use disorders (AUD) was estimated at 1.7%, accounting for 1.4% of the total world disease burden in developed countries. In the United States, 18 million Americans (8.5% of the population age 18 and older) suffer from alcohol use disorders. Only 7.1% of these individuals received any treatment for their AUD in the past year. Problems related to the excessive consumption of alcohol cost U.S. society an estimated $185 billion annually.
In addition to the adverse health effects that result directly from excessive alcohol consumption, other medical conditions often co-occur among individuals with excessive alcohol consumption. For example, alcohol abuse and dependence commonly occur in people who abuse other drugs, and in people with mood, anxiety, and personality disorders. An estimated 90% of cocaine addicts have alcohol problems and as many as 60% of patients at community mental health centers have alcohol and other drug abuse disorders. The high co-occurrence of alcohol and tobacco dependence poses special problems. An estimated 50% to 90% of alcohol dependent individuals are smokers who, in general, smoke heavily, become more addicted to nicotine and are less successful at quitting smoking than other smokers. This puts them at a much higher risk for certain cancers and cardiovascular diseases that develop more readily in the presence of both alcohol and nicotine.
Lifespan Perspective
Investigators traditionally have pursued solutions to the wide range of alcohol-related issues through studies of alcohol’s effects on biological systems, the genetic factors underlying these biological effects, and the environmental and cultural factors that influence alcohol use. This Plan applies a new organizing principle – the lifespan perspective – to these diverse areas of alcohol research. Scientists now recognize that human biology and behavior continues to change throughout life and changes occurring throughout the lifespan affect individuals' drinking patterns as well as the decisions they may make to change their drinking habits or to seek help for alcohol use problems. A lifespan perspective will allow researchers to identify how the emergence and progression of drinking behavior is influenced by changes in biology, psychology, and in exposure to social and environmental inputs over a person's lifetime, and vice versa. This approach should help researchers discover life stage- appropriate strategies for identifying, treating, and preventing alcohol use disorders.
Contributions to Alcohol Use and Alcohol Problems Across the Lifespan
Numerous factors influence the onset and continuation of alcohol use by an individual. The factors include the individual’s genetic makeup, the environments to which he or she is exposed and complex ways that genes interact with one another and with the environment. These same factors determine an individual's pattern of alcohol consumption and the risks for developing alcohol dependence (alcoholism).
Some of the first evidence of the importance of the lifespan perspective for understanding alcohol use disorders emerged less than ten years ago in an analysis of data derived from NIAAA’s National Longitudinal Alcohol Epidemiologic Study (NLAES). This analysis revealed that people who begin drinking at young ages have a significantly increased risk for developing alcoholism. This finding was confirmed by the recent National Epidemiologic Survey on Alcohol-Related Conditions (NESARC), which showed that young people who began drinking before age 15 are four times more likely to develop alcohol dependence during their lifetime than those who began drinking at age 21. This is true for individuals from families where a parent had a history of alcoholism and for individuals with no parental history of alcoholism. Therefore, while parental history clearly contributes to the risk for developing alcoholism, likely a reflection of genetic risk factors, early initiation of drinking is also an important predictor of risk for alcoholism. Researchers hypothesize that early exposure to alcohol may alter brain development in ways that increase an individual’s vulnerability to alcohol dependence. Some other biological factor, perhaps affecting personality, may also be responsible for both the early onset of drinking and the heightened risk for alcoholism.
Alcohol Policy and Public Health
A wide range of alcohol policies may affect alcohol consumption and other behaviors relating to alcohol, and can have important influences on public health outcomes. In the United States, laws, regulations, and jurisprudence address various aspects of alcohol use ranging from alcohol taxation to behaviors affected by alcohol, such as drinking and driving. Scientific research has identified a number of alcohol-related policies that have significant effects on public health outcomes. Examples of these include a reduction in the number of traffic fatalities (raising the minimum drinking age to 21, enforcing stricter drinking and driving penalties), a reduction in child abuse and sexually transmitted diseases (raising taxes on alcohol beverages), and enhancement of access to alcohol treatment programs (State-mandated provision in health care financing). In general, alcohol policies are designed to serve individuals at all levels of the lifespan through harm reduction and prevention of alcohol-related illness or injury.
Lifespan Perspective--Practical Implications Understanding the interactions of alcohol with stages of life will enable us to address the prevention and treatment of alcohol problems in a life stage-appropriate manner. In particular, such an approach should lead to a better understanding of:
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RESEARCH OPPORTUNTIES AND OUTREACH
The following is a brief outline of Research Opportunities and Outreach activities identified by NIAAA that will help guide the Institute’s research program and activities over the next 5 years.
Opportunities that Transcend the Lifespan Perspective
Several scientific issues have impact on all stages of life. While the manner by which they affect an individual may differ depending upon the person's stage of life, these issues are best considered from an overarching perspective and include: alcohol metabolism; genetic and environmental influences including epigenetics; neurobiological effects of alcohol; and improvements in the diagnostic recognition of alcohol use disorder.
Metabolism -- Individuals differ in how fast they metabolize alcohol and in the extent to which they are affected by a given dose of alcohol. These differences affect drinking behavior, the potential for the development of alcohol dependence, and the risk for developing alcohol-induced organ damage.
Alcohol and Gene/Environmental Interactions -- Neither genes nor environment alone can explain why any particular individual develops alcohol dependence. Rather, as a complex disorder, risk for alcohol dependence is a consequence of the interplay of multiple genes, multiple environmental factors, and the interaction of these genes and environmental factors. The alcohol field has benefited from the ability to model various aspects of alcohol consumption in animal models, but advances in our understanding of neurobehavioral aspects of drinking and its consequences requires the development of new models. The identification of a number of genes contributing to the vulnerability to alcohol dependence in human studies, coupled with technological advances including the ability to conduct genome-wide association studies, offer great promise to further define genetic risk factors and their interactions with environmental factors.
Epigenetics -- Metabolic and environmental factors can influence the manner in which genes are expressed through a process known as epigenetics. Epigenetics refers to stable alterations in the genome, sometimes heritable through cell division, that do not involve the DNA sequence itself. Epigenetic processes act as an additional source of biologic variation beyond that attributable to the genetic code. These processes involve the chemical modification of the constituents of the chromosome, the DNA molecules and the gene-regulating proteins known as histones, and may occur as a consequence of exposures to specific environmental substances and stimuli.
Neurobiology -- The brain, which is the primary target for alcohol-induced neurotoxic effects including alcohol dependence, continues to develop and mature from conception through birth into early adulthood. Alcohol consumption may affect the normal physiology of the central nervous system at any point throughout the lifespan, and those effects may differ depending on lifespan stage.
Diagnosis of Alcohol Use Disorders -- While the diagnostic criteria for alcohol dependence and alcohol abuse provided in current diagnostic schemes, including the DSM-IV and ICD-10, have contributed to improved case recognition and served researchers well over the past decade, research has begun to focus on developing quantitative representations of these criteria using statistical methods that provide differential severity weighting for individual AUD symptoms and allow for the inclusion of alcohol consumption variables. The development of quantitative criteria will lead to better understanding of the pathological stage of the disease for any given individual, provide the researcher an improved understanding of the etiology of alcohol dependence, and augment translational research to develop improved treatment approaches for the differing severity levels of alcohol dependence.
Alcohol Health Services Research--Alcohol health services research is a multidisciplinary field of applied research that seeks to improve the effectiveness, efficiency and equity of services designed to reduce the public health burden of alcohol use disorders across the lifespan. It does this by examining how social factors, financing systems, service environments, organizational structures and processes, health technologies, and personal beliefs and behaviors affect access to and utilization of healthcare, the quality and cost of healthcare, and in the end our health and well-being. Ultimately the goal of alcohol health services research is to identify ways to organize, manage, finance, and deliver high-quality care conistent with developmental needs of patients and their families.
Opportunities: Embryo and Fetus
The earliest stages of life are periods of great vulnerability to the adverse effects of alcohol. Embryonic and fetal development are characterized by rapid, but well-synchronized patterns of gene expression, including epigenetic imprinting, which makes the embryo/fetus particularly vulnerable to harm from alcohol, a known teratogen (an agent capable of causing physical birth defects). Alcohol's teratogenic effects were recognized over three decades ago, and it is now the leading known environmental teratogen. Alcohol may also damage neurological and behavioral development even in the absence of obvious physical birth defects. Alcohol-induced birth defects are known as fetal alcohol spectrum disorders (FASD). The severity of defects depends on the dose, pattern, and timing of in utero exposure to alcohol. Research in animal models has demonstrated that the potential for adverse effects increases with the maternal blood alcohol concentration (BAC). Research has also suggested that alcohol's causative role in FASD can be influenced by maternal hormones, nutrition, age, parity, years of drinking, and genetic factors. The most serious adverse consequence of prenatal alcohol exposure is fetal alcohol syndrome (FAS), a devastating developmental disorder characterized by craniofacial abnormalities, growth retardation, and nervous system impairments that may include mental retardation. Children and adults with FAS have irreversible neurobiological deficits that affect multiple systems, ranging from motor control to executive function.
Outreach: Embryo and Fetus
Opportunities: Birth to Age Ten
A number of significant research opportunities and directions exist for the birth to age ten years group. The first two are very high priority since there is little to no information in these areas. The third is also a very high priority as there is a need to better understand why drinking is a normative behavior among American adolescents and how drinking becomes so widespread among youth. The remaining opportunities represent areas where increased knowledge about known developmental pathways into alcohol use and AUDs will enhance prevention efforts with specific groups of youth at high risk.
In some cases, familial, neighborhood, and peer structures act in concert to encourage the development of early involvement with alcohol. Determine the degree to which these concurrent risk factors are synergistic for the development of risk.
Outreach: Birth to Age 10
Located in the section on Youth/Adolescence
Opportunities: Youth/Adolescence
The beginning of adolescence is demarcated biologically with the onset of puberty, and is understood to end when an individual assumes adult roles and responsibilities. Puberty consists of many biological processes that do not occur at the same chronological age and do not necessarily progress at the same pace or have the same pattern of unfolding in every individual. Importantly, brain development, marked by continuous generation of neurons and connections between neurons, and the refinement of communication among those neurons, continues during puberty and into the young adult ages. Drinking alcohol during this dynamic period of brain development may result in brain effects leading to an earlier onset of alcohol-induced specific diseases or to an earlier transition towards the development of alcohol use disorders. Very important to understanding alcohol use by youth from a developmental perspective is the fact that, over the past 100 years, the endocrine changes associated with puberty have been occurring at younger ages, while the attainment of adult roles such as starting a career, finding a partner, owning a home and becoming a parent are occurring much later. The result is the dramatic expansion of the period referred to as adolescence which prolongs the potential duration of one of the heaviest drinking periods of the lifespan and therefore may exacerbate the harmful effects on alcohol on development. In sum, adolescence is a period of dramatic biological change -- occurring in the context of equally dynamic socio-environmental change with regard to the adolescent's school, peer group, family, and social milieu. The majority (80%) of youth begin to drink by the end of high school, and some experience significant alcohol-related problems including the development of alcohol use disorders.
Outreach: Youth/Adolescence
Opportunities: Young Adult
Entry into young adulthood is defined by a variety of self-directed transitions that signal an individual's burgeoning independence from parental care. The pursuit of post-secondary education, enlisting in the military, and entering the workforce are a few such milestones, which traditionally have occurred when an individual is in his or her late teens or early twenties. Other events that traditionally mark this period include assuming large financial obligations, courtship, and marriage. In the U.S, most states have adopted age 18 as the legal age of majority – the point at which individuals assume responsibility for their own actions. However, from a developmental rather than a legal perspective, emerging or young adulthood now comprises an extended period of unsettled behavior for many individuals, as age of marriage and age of career initiation in the U.S., for example, have increased relative to historic norms. Compared to all other age groups, the prevalence of periodic heavy or high-risk drinking is greatest among young adults aged 18 to 24. Alcohol use disorders including alcohol dependence (alcoholism), also peak during this period. While most young adults transition out of harmful drinking behaviors, a minority will continue to drink heavily into the later stages of adulthood. These phenomena raise important research questions. For example, what factors allow some young adults to discontinue harmful drinking patterns, most often in the absence of formal alcoholism treatment? Why do others experience protracted alcohol problems well into their adulthood?
Outreach: Young Adult
Opportunities: Midlife
A broad spectrum of alcohol-related problems and issues becomes manifested during the adult period of life often referred to as midlife. At midlife, many of the pathological consequences of heavy alcohol use become most evident, and individuals with alcohol dependence are most likely to seek treatment of their alcoholism at this time.
Metabolism and Organ Injury
Alcohol and HIV/AIDS
Treatment and Behavioral Change
Medications Development
Outreach: Midlife
Opportunities: Senior Adult
Aging is associated with a variety of changes that place senior adults at special risk for alcohol-related health problems. Senior adults are known to differ in their physiological and behavioral responses to alcohol in a variety of social contexts, and their ability to develop tolerance to alcohol is greatly altered during the senior years. Drinking can aggravate a variety of pathological conditions in the senior adult including stroke, hypertension, neurodegeneration, memory loss, mood disorders, and cognitive or emotional dysfunction. As the percentage of persons in the senior age category is rapidly growing in the United States, improving knowledge about the effects of alcohol at this life stage is becoming increasingly important.
Outreach: Senior Adult
The National Institute on Alcohol Abuse and Alcoholism (NIAAA), a component of the National Institutes of Health, U.S. Department of Health and Human Services, is the lead agency for U.S. research on alcohol abuse, alcoholism, and other health effects of alcohol. Its role is enunciated in the Institute Mission Statement:
A. Mission and Vision of NIAAA
The NIAAA Mission is to provide leadership in the national effort to reduce alcohol-related problems by:
The Institute's efforts to fulfill its mission are guided by the NIAAA Vision to support and promote, through research and education, the best science on alcohol and health for the benefit of all by:
This document, the NIAAA Strategic Plan for Research, 2008-2013, sets forth research opportunities to increase our understanding of why, how, and when people drink, as well as why and how some people develop alcohol use disorders (AUD). Throughout the years, investigators have pursued answers to these very questions through studies of alcohol’s effects on biological systems, the genetic factors underlying biology, and through the study of environmental and cultural factors. This Plan, however, proposes a significantly different direction for alcohol studies by applying the lifespan perspective -- the consideration of how the emergence and progression of drinking behavior is influenced by multiple changes (in biology, psychology, and in exposure to social and environmental inputs) over a person’s lifetime. These changes occurring throughout the lifespan affect the pattern of drinking (quantity and frequency) and the actions individuals may take to modify their drinking behavior or to seek help for an alcohol use disorder. Viewing alcohol use and alcohol problems through a lifespan perspective will provide knowledge that will, through early identification and intervention, significantly contribute to the ability to decrease the prevalence of alcoholism and other alcohol-related disorders, and to the treatment of these disorders.
This overview describes the origins of the lifespan perspective, highlights the complexity of alcohol issues in health, and provides a view to why solutions to these problems cannot be approached from any single discipline but must be approached in a multidisciplinary and transdisciplinary manner. Further, the findings at any investigative level (molecular, cellular, animal model, human laboratory, human clinical to community) must be translated to other levels and eventually to clinical practice in the world environment. Transdisciplinary and translational research over the course of the next decade will be aided by the intellectual and technical developments arising from the NIH Roadmap and the NIH Neuroscience Blueprint, and their potential application to address health issues related to alcohol use has been integrated into this Plan.
B. Drinking Patterns and their Definitions
An understanding of the drinking patterns that exist in the population, as well as the alcohol-use disorders that arise from drinking too much, too fast and/or too often, is important for identifying targets for future research pursuits.
Alcohol Abuse and Alcohol Dependence are two clinical disorders characterized by either a persistent pattern of inappropriate alcohol use or of adverse consequences. Alcohol dependence is typically considered to be synonymous with alcoholism. Alcohol abuse and alcohol dependence may be defined as shown in Tables I-1 and I-2. A proposal has recently been made to use the term addiction to specify the behavioral, CNS neuroadaptive responses to chronic alcohol exposure vis a vis loss of control, preoccupation with drinking and compulsion to drink, as distinct from the physiological dependence symptoms of tolerance and withdrawal.
Table I-1. Harmful or Hazardous Alcohol Use (Alcohol Abuse)
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Table I-2. Alcohol Dependence (Alcoholism)
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While recurrent or persistent harmful or hazardous alcohol use results in adverse consequences in the long-term situation, adverse consequences can occur in individuals who may have used alcohol in a harmful or hazardous manner on only one occasion. These adverse consequences include alcohol-related traffic crashes, drownings, and alcohol poisonings, among many others.
Drinking in a manner that will cause intoxication clearly poses risks to the drinker. A term frequently used to describe this pattern is binge drinking. Different definitions often have been used for this pattern of drinking. To provide clarification, the National Advisory Council on Alcohol Abuse and Alcoholism (NAC) in 2004 developed a standard definition for binge drinking as a pattern of drinking alcohol that brings the blood alcohol concentration to 0.08 gram percent (the legal limit for drinking and driving in all states) or above. The NAC further noted that for a typical adult male, this BAC level may be obtained after the consumption of 5 drinks in a 2 hour period, and for females, 4 drinks in the same period. The Council definition of binge drinking and recommendations are provided in Table I-3.
Table I-3. Definition of Binge Drinking
A "binge" is a pattern of drinking alcohol that brings blood alcohol concentration(BAC) to 0.08 gram percent or above. For the typical adult, this pattern corresponds to consuming 5 or more drinks (male), or 4 or more drinks (female), in about 2 hours. Binge drinking is clearly dangerous for the drinker and for society.
* In the above definition, a "drink" refers to one serving of 12 g of absolute alcohol (e.g., one 12-oz. Beer, one 5-oz. glass of Wine, or one 1.5-oz. Shot of distilled spirits).* Binge drinking is distinct from "risky" drinking (reaching a peak BAC between .05 gram percent and .08 gram percent) and a "bender" (2 or more days of sustained heavy drinking).* For some individuals (e.g., seniors or people taking other drugs or certain medications), the number of drinks needed to reach a binge level BAC is different than for the "typical adult".* People with risk factors for the development of alcoholism have increased risk with any level of alcohol consumption, even that below a "risky" level.* For pregnant women, any drinking presents risk to the fetus.* Drinking by persons under the age of 21 is illegal.
Source: NIAAA, National Advisory Council, February, 2004
Binge drinking is common across most life stages. Fifty percent of college students who drink engage in binge drinking, and twenty percent do so twice or more every three weeks. More than two-thirds of binge drinking episodes in the U.S. occur among adults age 26 and older, and half of all binge drinking episodes occur among people who otherwise drink moderately.
The NIAAA also provided a definition of moderate drinking as this term has been used in many different ways. Moderate drinking is defined by the NIAAA as consuming up to two drinks per day for men and one drink per day for either women or senior adults. While moderate drinking is considered to offer some benefits to some individuals, drinking at this level poses real risks for others. For example, women who are pregnant or considering pregnancy, persons driving or operating heavy machinery, and those taking one or more of the more than 150 medications that interact with alcohol should not drink even moderately. Persons with a high vulnerability to develop alcohol dependence may be encouraged to refrain from alcohol use.
The National Epidemiological Survey on Alcohol and Related Conditions (NESARC) study completed its first wave of data collection, which involved recording the responses to questions posed to over 43,000 individuals about alcohol and other drug use, abuse and dependence, and their associated disabilities. These data were used to develop extremely valuable information relating quantity and frequency of alcohol use to the risk of developing alcohol abuse and alcoholism. These data have been used to establish the following cut points for risk drinking, which mirrors the definition for moderate drinking: Exceeding 2 drinks per day for men, 1 drink for women, and 14 drinks per week for men and 7 drinks per week for women. The NESARC data revealed that, compared with individuals who adhere to the weekly and daily limits, those who exceed only the weekly limits have an 8-fold increase in risk for developing alcohol abuse and a 12-fold increase in risk for becoming alcohol dependent at some point in their lives (Table I-4). Exceeding daily limits once a week or more increases risk for alcohol abuse by 30-fold, and for dependence by 80-fold. Exceeding both weekly and daily limits increases the risk of alcohol dependence by more than 200-fold.
Table I-4. U.S. Adult Drinking Patterns and Risks 2001-2002: Odds RatiosSource: NIAAA 2001-2002 NESARC data
C. Prevalence of Alcohol Problems and Their Consequences
How extensive are the health problems arising from inappropriate alcohol use and what are those problems? Excessive, long-term alcohol consumption can cause a variety of adverse health effects, including alcoholic liver disease, alcoholic pancreatitis, brain damage, and cardiomyopathy and compromised immune and endocrine functions. Excessive drinking is also associated with an increased risk for cancers of the esophagus, liver, and larynx, irregular heartbeats, and can exacerbate the health consequences of infection with hepatitis C, HIV and other infectious agents. Alcohol consumption can also alter neuronal function, resulting in cognitive deficits, and in neuroadaptations that contribute to the behavioral changes observed with alcoholism (tolerance, sensitization, loss of control, dependence, withdrawal, and relapse).
Epidemiologic data inform us of the problems associated with alcohol consumption and, when collected over time, allow us to track our progress in addressing these problems. The U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) recently came to similar conclusions about the toll taken by alcohol misuse. According to the CDC, excessive alcohol consumption is the number-three cause of preventable death in the United States. The WHO also ranks alcohol third among preventable risk factors for premature death in developed nations. The extent of the alcohol use disorders problem in the U.S. and worldwide is summarized in Table I-5.
Table I-5. Extent of the Alcohol Use Disorder Problem
Globally:* In 2003, the prevalence of alcohol use disorders was estimated at 1.7%, accounting for 1.4% of the total world disease burden in developed countries
United States:* 18 million Americans (8.5% of the population age 18 and older) suffer from alcohol abuse or dependence. Only 7.1% of these individuals received any treatment for their alcohol problems in the past year.* Alcohol problems cost U.S. society an estimated $185 billion annually* Alcohol was the third leading cause of death in the US in 2003 (an estimated 85,000 deaths)
Source: World Health Organization, 2003
Alcohol also contributes significantly to mortality from a wide-range of acute and chronic injuries and diseases (see Table I-6). In the U.S. in 2001, 75,766 deaths were attributable to alcohol, 40,933 deaths were attributable to acute conditions primarily unintentional injuries such as motor vehicle injuries, and fall injuries, and intentional injuries such as homicide and suicide, and 34,883 deaths were attributable to chronic conditions especially alcoholic liver disease and liver cirrhosis. Because alcohol attributable deaths resulting from acute conditions occur earlier in the life span than chronic alcohol attributable deaths, they account for nearly twice as many years of productive life lost (e.g., 1,491,317) compared with chronic alcohol attributable deaths (e.g., 788,005). Recently, the NIAAA Extramural Advisory Board (EAB; a working sub-group of the NIAAA National Advisory Council) recommended that researchers could improve the estimation of alcohol-attributable factors (AAF) for morbidity and mortality by better characterizing the relationship between patterns of drinking (e.g., binge-drinking) and a variety of outcomes, and by incorporating relevant indicators of drinking (e.g., medical examiner data).
Injuries are the leading cause of death in the U.S. from ages 1-44, and alcohol is the leading contributor to those injury deaths. It should be noted that many people who die from alcohol attributable injury deaths are persons other than the drinker. For example, 40% of people who die in crashes involving drinking drivers are persons other than the drinking driver e.g. passengers in the same vehicle, passengers in vehicles struck by the drinking driver, bicyclists and pedestrians. Further, many homicide victims are fatally injured by persons who had been drinking. This underscores the need to identify, through rigorous research programs, policies that protect individuals from their own excessive drinking, as well as from the potential harms excessive drinking may cause society. One manner in which to get some indication of how policies affect excessive alcohol consumption leading to harm would be to undertake systematic studies of key alcohol and other relevant public policies and their outcomes (Recommendation of the NIAAA EAB, August 2006).
Table I-6. Number of deaths and years of potential life lost (YPLLs) attributable to the harmful effects of excessive alcohol use for selected conditions, by cause and sex United States, 2001
Deaths |
YPLLs |
Cause | Male | Female | Total | Male | Female | Total |
Chronic conditions | ||||||
Acute pancreatitis | 370 | 364 | 734 | 7,138 | 6,054 | 13,192 |
Acute cardiomyopathy | 443 | 56 | 499 | 10,195 | 1,552 | 11,747 |
Alcohol-induced chronic Pancreatitis | 224 | 71 |
295 | 6,209 | 2,135 | 8,344 |
Alcoholic liver disease | 8,927 | 3,274 | 12,201 | 221,369 | 94,952 |
316,321 |
Chronic pancreatitis | 126 |
106 |
232 |
2,606 |
1,952 |
4,560 |
Esophageal cancer | 394 |
53 |
447 |
6,213 |
788 |
7,000 |
Liver cancer | 518 |
172 |
690 |
8,640 |
2,633 |
11,273 |
Liver cirrhosis, unspecified | 3,917 | 2,802 | 6,719 | 80,616 | 54,528 | 135,144 |
Oropharyngeal cancer | 303 |
57 |
360 |
5,280 |
889 |
6,169 |
Total | 24,448 | 10,285 | 34,883 | 549,396 | 239,619 | 788,005 |
Acute conditions | ||||||
Alcohol poisoning | 253 |
78 |
331 |
8,798 |
2,952 |
11,750 |
Homicide | 5,963 |
1,692 | 7,655 | 262,379 | 71,543 | 333,922 |
Motor vehicle | 10,674 |
3,000 | 13,674 | 442,943 | 136,558 | 579,501 |
Suicide |
5,617 |
1,352 | 6,969 | 186,568 | 49,297 | 235,865 |
Falls | 2,500 |
2,206 | 4,766 | 41,627 | 24, 288 | 65,
914 |
Total Acute Conditions | 30,309 | 10,534 | 40,933 | 1,131,028 | 350,289 | 1,491,397 |
Total | 54,947 | 20,918 | 75,766 | 1,679,414 | 599,908 | 2,279,322 |
Source: Adapted from the table in Alcohol-Attributable Deaths and Years of Potential Life Lost --- United States, 2001 MMWR September 24, 2004, 53;866-870.
Co-Morbid Conditions
In addition to the many adverse health effects that result directly from alcohol misuse, co-morbid conditions often present further complications for individuals with alcohol abuse problems. Alcohol abuse and dependence commonly occur in individuals who suffer from mood, anxiety, and personality disorders as well as the effects of other drugs of abuse, (see Table I-7). For example, an estimated 90% of cocaine addicts have alcohol problems. It also has been estimated that as many as 60% of patients presenting at community mental health centers have co-morbid alcohol and other drug abuse disorders. Patients suffering from both disorders often have poorer treatment outcomes and are more likely to drop out of treatment. Unfortunately, effective pharmacological and behavioral treatments have yet to be established for the various conditions of co-morbid AUD and other drug abuse disorders.
The high co-morbidity between alcohol and tobacco dependence poses special problems. Fifty to ninety percent of alcoholics smoke, a rate that is three times higher than among the population as a whole. Alcoholics smoke heavily, are more addicted to nicotine and are less successful at quitting smoking, which puts them at a greatly increased risk for the synergistic effects of alcohol and nicotine on the development of certain cancers and cardiovascular diseases. According to one study, more individuals with alcoholism die from smoking-related diseases than alcohol-related diseases. Furthermore, there is experimental evidence that smoking may lead to a reduction in blood alcohol concentration for a given amount of alcohol consumed, thus leading to an increased use of alcohol to achieve the same pleasurable feelings from alcohol ingestion. Thus, smoking increases the amount of alcohol consumed and subsequently the risks for short-term and long-term adverse effects from the increased consumption of alcohol, including the perpetual cycle of use leading to dependence on both substances. Finally, there is evidence to suggest that the brain pathways that underlie the pleasurable feelings derived from alcohol consumption and smoking are thought to be the same, thus accounting for the increase in use of both substances, which suggests that treatment programs to reduce or cease alcohol consumption should also address cessation of smoking. There are some data indicating that treating one use disorder without treating the other concurrently leads to a higher relapse rate for either substance.
Table I-7. Odds of Current (past 12-month) DSM-IV Alcohol Dependence Co-Occurring with Selected Psychiatric Conditions and Other Drug Dependencies