1

Epidemiology of Alcohol Problems in the United States

NIAAA Social Work Education

Module 1
(revised 3/04)

Objectives
A. Describe demographic characteristics and historical trends of alcohol use, alcohol abuse/dependence and other alcohol-related problems B. Identify the relationship between level of alcohol consumption and health effects C. Recognize the implications of utilizing epidemiological data for early interven-tion and prevention of alcohol problems, and for evaluating intervention impact

Epidemiologic Approach to Alcohol Problems

An

ecological model etiology, natural history

Addresses Identifies

interaction of vulnerability, risk, and resilience factors

Study

of alcohol use, abuse, and dependence in communities, populations

Epidemiologic Rates

Incidence Rate = The rate at which new cases occur in a population during a specific period (e.g., over one year) Prevalence Rate = The proportion of a cases that exist in a population at a point in time

Differing Measures across Studies

New Case can be defined as:

Age or year of first use or first intoxication versus Age of onset of alcohol dependence (age of first experience of any clinical criterion symptoms for diagnosis) versus Age of occurrence of the third dependence symptom or age when symptoms first cluster (2 or more symptoms in a year)

Standard Drink Measure

Defining Alcohol Consumption

Prior

to 1970, per capita consumption =

total alcohol beverage sales total population over age 15 years

Since

1970, per capita consumption =

total alcohol beverage sales total population over age 14 years

The

1997 per capita consumption was 2.18 gallons of ethanol per person

At Risk Drinking by Age and Gender

Population group Per week
Men Women Elders

Per occasion
> 5 drinks > 3-4 drinks > 1 drink
Source: NIAAA, 1995

(65+ )

> 14 drinks > 7 drinks > 7 drinks

Drinking Patterns (Defined according to

9

quantity & frequency of alcohol consumption)

Abstainer:

has never drank or drinks < once/yr

Less

may or may not drink 5 or more drinks at least once/yr

Frequent: drinks 1-3 times/month and

Frequent:
Frequent

drinks at least once a week and may or may not drink 5 or more drinks at one sitting week and has 5 or more drinks at one sitting at least once per week

Heavy Drinker: drinks at least once a

Drinking Episodes Defined

(National Household Survey)
Binge

10

Drinking as 5 or more drinks per occasion alcohol use as 5 or more drinks for 5 or more days per month
2002 Microsoft Corporation.

Heavy

Drinking Episodes Defined

A

11

(NIAAA Advisory Council Task Force)

drinking binge is a pattern of drinking that brings blood alcohol concentrations (BAC) to 0.08 or above. Typical adult males: 5 or more drinks in about 2 hours Typical adult females: 4 or more For some individuals, the number of drinks needed to reach binge level BAC is lower

Drinking Episodes Defined

12

(NIAAA Advisory Council Task Force)

Binge

drinking is distinct from: risky drinking (reaching a peak BAC between .05 gm% and .08 gm%) a bender (2 or more days of sustained heavy drinking)

Drinking Episodes Defined

People

13

(NIAAA Advisory Council Task Force)

with risk factors for the development of alcoholism have increased risk with any 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.
Binge

drinking is clearly dangerous for the drinker and society.

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At Risk or Problem Use

Drinking

above established cut-off limits AND No current problems associated with drinking OR Alcohol use in risky situations

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Definition of Alcohol Abuse

Maladaptive alcohol use causes clinically important distress or impairment, shown in a single 12-month period by one or more of the following:

Failure to carry out major obligations at work, home or school because of repeated alcohol use Repeated use of alcohol even when its physically dangerous to do so.

Repeated experience of legal problems Continued alcohol use despite knowing that it has caused or worsened social or interpersonal problems.

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Definition of Alcohol Dependence

Maladaptive alcohol use causes clinically important distress or impairment, shown in a single 12-month period by three or more of the following:
Tolerance

or withdrawal Amount/duration of use greater than intended. Unsuccessful efforts to control or reduce use Spending much time using alcohol, recovering from its effects, or trying to obtain it.

Reducing

or abandoning important work, social or leisure activities because of alcohol use. Continued alcohol use despite knowing that it has probably caused ongoing physical or psychological problems.

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Historical Trends: 1850-1997

3 2.5 2 1.5 1 0.5 0 Gallons Ethanol

Spirits Wine Beer

Year

Source: Nephew et al., 1999

Prevalence of Lifetime Alcohol Use by Age and Gender

90 80 70 60 50 40 30 20 10 0

18

Percent

Male Female

18-24

25-34

35-44 Age Groups

45-55

55+

19

National Trends
Liters Ethanol Consumed
18 16 14 12 10 8 6 4 2 0

1970 1980 1990

Country

Source: NIAAA, 1997a

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Age Trends: Alcohol Use

90 80 70 60

Percent

50 40 30 20 10 0 1993 1994 1995 8th 10th 12th

1996 1997 Source: Johnston et al., 1998

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Age Trends: Intoxication

70 60 50

Percent

40 30 20 10 0 1991 1992 1993 1994 1995 1996 1997 8th 10th 12th

Source: Johnston et al., 1998

22

Age Trends: Heavy Use in Past 30

Days
35 30 25

Percent

20 15 10 5 0 1991 1992 1993 1994 1995 1996 8th 10th 12th 1997

Source: Johnston et al., 1998

Prevalence of Lifetime Alcohol Dependence (DSM-IV)

25

23

20
Percent 15 10 5 0 18-24 25-34 35-44 45-55 Age Groups 55+ Male Female

Source: SAMHSA, 2000a

Prevalence of Alcohol Use (Men) and Dependence by Age

90 80 70 60 50 40 30 20 10 0

24

Percent

Use Dependent

18-24

25-34

35-44

45-55

55+

Age Groups

Prevalence of Alcohol Use (Women) and Dependence by Age

25

70 60 50

Percent

40 30 20 10 0 18-24 25-34 35-44 45-55 55+ Use Dependent

Age Groups

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Alcohol Use & Aging Populations

National Household Survey on Drug Abuse, 2000 1.6%of elders report heavy drinking in past 30 days Aging primary care patients 15% male, 12% female abuse alcohol

Community sample 2.2 to 9.6%of elders abuse alcohol Hospitalized adults >40: 21%abused alcohol SAMHSA TIP Series, 98 Up to 17%of older adults are affected by alcohol and prescription drug problems

Additional Risks Related to Alcohol Use and Aging

Elderly

27

individuals are more likely to be affected by chronic illness and use of medications. and prescription drug problems are frequently:

Alcohol

Under-identified

Under-diagnosed Under-treated

Under-estimated

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Age and Gender Interactions

70 60 50 40 30 20 10 0

Any Use Binge Heavy

Percent

18 -2

18 -2

26 +

m al

al

m al Fe

al

Fe

26 +

Source: SAMHSA, 1999a

Past Month Alcohol Use by Ethnicity: Ages 18-25

70 60 50 40 30 20 10 0
k n W hi te Bl ac ia n As ia nd isp an ic s

29

Percent

Any Use Binge Heavy

Am .I

Source: SAMHSA,2000a

Past Month Alcohol Use by Ethnicity: Ages 26 or Older

60 50
Percent

30

40 30 20 10 0
k n W hi te Bl ac ia n As ia nd isp an ic s

Any Use Binge Heavy

Am .I

Source: SAMHSA,2000a

Use of Alcohol and Other Drugs:

1999 Ages 1825
90 80 70 60 50 40 30 20 10 0

31

Percent

Lifetime Past Year Past Months

l ho lco A

ob

o cc a a M

iju r

na a

s e n in en tio a g oc no rip i c C c es lu al Pr H

n oi er H

Source: SAMHSA,2000a

Use of Alcohol and Other Drugs:

1999 Ages 26 and Older
100 90 80 70 60 50 40 30 20 10 0
lco A ol h T o cc a ob ar M a an iju oc C e in a H a cin llu s en og r sc e Pr n io t ip H n oi er

32

Percent

Lifetime Past Year Past Months

Source: SAMHSA,2000a

Reported Past Year Substance Dependence by Age, 1999

10 9 8 7 6 5 4 3 2 1 0
o oh c Al l ar M a an iju oc C e in a H a i uc ll s en og n cr es Pr io pt i n H n oi er D c+ Al g ru

33

Percent

age 12-17 age 18-25 26 or older

Source: SAMHSA,2000a

Adolescent Risk Factors

Risk Factors
Negative

34

Increased Odds Ratio

1.6 1.7

mother Negative interaction with father Parental alcohol dependence Parents dislike friends Heavy drinking friends Daily cigarette smoking

interaction with

- 4.6

- 4.0 2.52 3.71 15.5 15.8

Source: Kuperman et al., 2001.

Adolescent Risk Factors (continued)

Risk Factors
Marijuana

35

Increased Odds Ratio

27.1 19.8

abuse Other drug abuse Dropping out of school ADHD Conduct disorder

6.5
5.0 13.5

Source: Califano and Booth, 1998

Problems Reported by Alcohol Users (past year)

10 9 8 7 6 5 4 3 2 1 0 Health Psychological

36

12-<18 18-25 26-34 35+

Percent

Source: SAMHSA,1999a

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Alcohol and Violence

Alcohol

is related to both aspects of violence -- perpetration and victimization were drinking in:
86%

Offenders

of homicides 60% of sexual offences 37% of assaults 27% of females and 57% of males involved in marital violence 13% of child abuse cases Source: Roizen, 1997)

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Alcohol and Violence (continued)

Roizen, 1993 Alcohol is associated with: Miczek et al., 1993 Identified alcohol in: 13%-50% of offenders in rape cases 6%-36% of victims in rape cases

35%-65% of rape cases (6 studies) ~50% of incest cases (2 studies) 20%-83% of family violence cases (3 studies) 10%-83% of homicides (6 studies) 33%-57% of felonies (2 studies)

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Alcohol and Violence (continued)

Risk factors for becoming violent:

History of violence Multiple drug use Co-morbid psychiatric disorder

Rates for alcohol-related violence hard to find:

Rates of alcohol involvement vary across studies making comparison difficult Hard to establish a causal relationship due to other factors (e.g., interaction between personality factors and alcohol)

Alcohol, Drug, and Violent Events Related to Arrest

60 50
40

40

Percent

30 20 10 0

Source: Nunes-Dinis & Weisner, 1997

Alcohol Drug Violence

Alcohol and Drug Use: 12 Months

of Arrests in Northern California
70
60 50

41

Percent

40

30
20 10 0
Alc. Frequent Alc. Infreq. Drug Weekly Drug Monthly

Source: Nunes-Dinis & Weisner, 1997

42

Alcohol-Related Hospitalizations
Hospital

discharges (1997):

Alcohol-related diagnosis was first-listed (primary) diagnosis for 20.2 per 10,000 population aged 15 and older All listed alcohol-related diagnosis was 64.5 per 10,000 population

Alcohol-related

morbidity episodes not appearing as a first-listed (primary) diagnosis = 69%

Alcohol-Related Hospitalizations
(continued)
Disorder
Alcohol

43

Percent
49% 22% 20% 9%

dependence syndrome Alcohol psychosis Cirrhosis of the liver Alcohol abuse, nondependent

Age-Adjusted Liver Cirrhosis Mortality U.S. 1910-1996

25

44

Rates per 100,000

20 15 10 5 0 Male Female

19 10 19 20 19 30 19 40 19 50 19 60 19 70 19 75 19 80 19 85 19 90 19 95 19 96

Source: Saadatmand et al., 1999

Vulnerability to Alcohol-Related Liver Disease

Genetic Factors

45

Dietary Factors Gender Hepatitis C Level of Alcohol Intake

Source: NIAAA, 2001b

Alcohol-Related Cirrhosis by Race and Gender (Age-Adjusted, 1996)

46

14 12 10 8 6 4 2 0
ed ed Re l ifi Un sp ec sp ec ifi at ed

Rates per 100,000

Hisp-M White-M Black-M Hisp-F White-F Black-F

Al c

th er

Source: Saadatmand et al., 1999.

Alcohol Consumption Among U.S. Pregnant & Child-bearing Aged Women

60 50
percent

47

40 30 20 10 0
19 91 19 95 19 99

Pregnant All women

Sources: SAMHSA,1999a; CDC, 1997

Frequent Drinking Among U.S. Pregnant & Child-bearing Aged Women

14 12 10

48

Percent

8 6 4 2 0

Pregnant All women

19 91

19 95

Source: CDC, 1997.

Binge Drinking Among U.S. Pregnant & Child-bearing Aged Women

20 18 16 14 12 10 8 6 4 2 0

49

Percent

Pregnant All women

19 91

19 95

Sources: SAMHSA,1999a; CDC , 1997

19 99

Reported Rates of Fetal Alcohol Syndrome, U.S. 1979-1993

8 7 6 5 4 3 2 1 0

50

Rates per 10,000 Birth

19 79

19 81

19 83

19 85

19 87

19 89

19 91

19 92

Source: CDC, 1995a

19 93

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Prenatal Alcohol Exposure

How

many drinks can a pregnant women consume without harm to the fetus? estimated 550,000 to 750,000 U.S. children are born exposed to drugs/alcohol each year risk of child maltreatment (abuse, neglect) and out of home placement

An

Increased

2002 Microsoft Corporation

52

Risks of Fetal Alcohol Exposure

Low birth weight Prematurity Small for gestational age (SGA) Failure to thrive (FTT) Neurobehavioral symptoms Infectious disease

Sudden Infant Death Syndrome (SIDS) Fetal Alcohol Syndrome (FAS) Other Fetal Exposure Effects Compromised developmental outcomes

Compromised Developmental Outcomes

53

Many unknowns to predict specific outcome Certain physical problems may persist Some problems not immediately apparent Secondary problems may emerge Structured and nurturing environment may compensate and promote development Regular developmental evaluation needed Need early identification of social, language, cognitive, and motor developmental problems

54

Children Prenatally Exposed

Developmental patterns birth to 15 months characterized by:

Unpredictable sleep patterns Feeding difficulties Irritability Atypical social interaction Delayed language development Poor fine motor development

2002 Microsoft Corporation

Children Prenatally Exposed

(continued)

55

Toddlers (16-36 months):

Atypical

social interaction Minimal play strategies

Preschoolers

(3-5 years):

Easy loss of control 2002 Microsoft Corporation Mood swings Hyperactivity/short attention span Difficulty transitioning between activities Difficulty processing auditory/visual info

Children Prenatally Exposed

(continued)
School

56

aged to adolescence:

No conclusive research on long-term biological or constitutional effects of drug/alcohol exposure

Greater risk of maltreatment, learning disabilities, behavior problems
2002 Microsoft Corporation

Alcohol Death Rates by Ethnicity

57

(Age-Adjusted), 1979-1997
30

Rates per 100,000

25 20 15 10 5 0

White-M White-F Other-M Other-F

9 97 1

1 98 1

3 98 1

5 98 1

7 98 1

9 98 1

1 99 1

3 99 1

5 99 1

7 99 1

Source: Hoyert et al., 1999

Rates per 100,000

100 150 200 250 300 50

He art dise a se s er Ca nc bro vas cul ar Pul mo nar y Pne um oni a s Ca rA ccid e nt s O th er A ccid e nt s Alz he i me r's Sui cid e Liv er d ise a se Ho mic ide Dia be t e

Ce re

Male

Age-Adjusted Death Rates for 10 Leading Causes, U.S. (1997)

Female

58

Source: Hoyert et al., 1999

59

Age-Adjusted Death Rates for Causes Other Than Cancer, Heart, or Stroke, U.S. (1997)
45 40 35 30 25 20 15 10 5 0 Male Female
Rates per 100,000

s s s s e e e a ry r' te id nt nt id ni as a e e e c o ic be m ise on id id ui m i a m i d e S o cc cc lm eu D r zh H u n e A A l P P iv A er ar L C th O Source: Hoyert et al., 1999

Age-Adjusted Death Rates by Cause, Ages 25-64 (1997)

Rates per 100,000
300 250 200 150 100 50 0

60

25-44 M 45-64 M 25-44 F 45-64 F

r ea

ise td

s se a

s s e e r r e a IV te la nt id id ni as ce e e c c e u o H n i i s b c d m di ci as Ca Su um Dia o ov H ne er Ac r v P eb Li er C Source: Hoyert et al., 1999

Age-Adjusted Death Rates by Causes Other than Cancer, Heart, or Stroke, Ages 25-64 (1997)
60

61

Rates per 100,000

50 40 30 20 10 0

25-44 M 45-64 M 25-44 F 45-64 F

a ni o m u ne P

Di

t be a

es Ac

s nt e id c

e id c ui S

ive L

e as ise rd

e id ic m o

IV

Source: Hoyert et al., 1999

62

Drug Abuse Deaths 1995-1998

Number of Cases in Thousand

8 7 6 5 4 3 2 1 0 1995 1996 1997 1998 Male Female

Source: SAMHSA, 2000

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Drug-Related Deaths by Age (1996)

7000 6000 6399

Number of Deaths

5000 4000 3000 2090 2000 1000 0 6-17 yrs 18-25 26-34 35+ 825 124

Source: SAMHSA, 1997

Medical Examiner Mention of Drugs, 6-17 Year Old Decedents (n=124)

Category Mentioned:

64

# of % total mentions episodes 52 26 23 22 10 41.9 21.0 18.6 17.7 8.1

Marijuana/hashish Cocaine Alcohol in combination Opiates Diazepam

Source: SAMHSA, 1997

Alcohol Involvement in Emergency Department Episodes

65

35%

of drug episodes (1999) involved a mention of alcohol-in-combination events

per 100,000:
in combination 81 69 36 35
Source: SAMHSA, 1999b
Alcohol
Cocaine Marijuana Opiates

Rate

Traffic Alcohol-Related Fatalities, 1977-1999

100 90 80 70 60 50 40 30 20 10 0 1977 Traffic Crash Fatality Alcohol Fatality

66

In Thousands

1985

1990

1991

1993

1995

1997

1999

Source: Yi et al., 2001

Alcohol Involvement in Accidental Death, Homicide, and Suicide

100 90 80 70 60 50 40 30 20 10 0
r Bu r /Fi n H a g mi nin r e row oth D yp e Fa ll

67

Positive Alcohol Intoxicated

Percent

t e e h ing nsho cid cid Cras n i i m iso Su r Gu Ho Po Ca

Source: Smith et al. , 1999

Alcohol and Trauma by Injury Type

Number of Trauma Patients

68

900 800 700 600 500 400 300 200 100 0

Ca r G un sh ot ll St ab bi ng le yc Fa or c

Not Intoxicated Intoxicated

de str

ot

Pe

Source: NIAAA, 1997

Bl

un t

ia

69

Alcohol and Trauma, by Age

Number of Trauma Patients
900 800 700 600 500 400 300 200 100 0 18-24 25-34 35-44 45-54 55+ Not Intoxicated Intoxicated

Source: NIAAA, 1997

Relative Risk Over 21 Years, Alcohol Consumption & Mortality (Scottish Men)
4 3.5 3 2.5 2 1.5 1 0.5 0
e as ise td St e ok r Al e lr o oh c l e at d l Al e us ca

70

Percent

1-7 drinks/wk 8-14 drinks/wk 15-21 drinks/wk 22-34 drinks/wk 35+ drinks/wk

ar

Source: Hart et al, 1999.

Alcohol and Mortality: 11-Year Follow-up, Adults Age 50+ (16,304 Danish Men & Women)
71

90 80 70 60 50 40 30 20 10 0

Men 50-60 Men 65+ Women 50-60 Women 65+

Percent

<

k /w 1

k /w -6

k /w 3 -1 7

k /w 7 -2 14

k /w 1 -4 28

42

k /w +

Source: Gronbaek et al., 1998

DHHS & USDA Dietary Guidelines for Alcohol Consumption

72

Women- Moderate drinking, no more than 1 drink/day Men- Moderate drinking, no more than 2 drinks/day Children Adolescents Should not drink at all Pregnant women Adults
Unable to control drinking Recovering On certain meds Family history of alcoholism

Should not drink at all

One Day Census of Clients in Substance Treatment by Age

1200 1000
Thousands

73

800 600 400 200 0 1987

65+ 45 - 64 21 - 44 18 - 20 Under 18
Source: SAMHSA, 1997

1989

1990

1991

1992

1993

1995

74

Appendices
Additional Materials Available for Incorporating into Classroom Presentations

Per Capita Consumption, 1935-98

75

Per Capita Consumption, 1977-98

76

Percent Changes in Per Capita Consumption, 1977-1998

77

Total Per Capita Consumption: Ethanol by State, 1997

US total== 2.18 U.S. total 2.18

78

DC

1.99 or below 2.00 to 2.24 1.99 or below 2.252.24 2.49 to 2.00 to 2.25 to 2.502.49 over or 2.50 or over

79

U.S. Drinking Patterns

Abstain 40% Dependent 5%

At Risk or Problem 20%

Low Risk 35%

Source: National Longitudinal Alcohol Epidemiologic Survey, 1992.

Principal diagnosis of discharges with alcohol mentioned (1997)

6.8% 15.3%

80

Alcoholic psychoses Alcohol dependence syndrome Cirrhosis, with mention of alcohol Cirrhosis, without mention of alcohol Nondependent abuse of alcohol Nonalcohol-related first-listed diagnosis

3.7% 2.5% 3.0% 68.7%

Average deaths with explicit mention of alcohol: 1986-1990

81