July 21, 2005 - Alcoholism is only a small part of America's alcohol problem.
Risky drinking affects far more people than alcoholism -- or alcohol dependency, as it's more accurately described. And making things worse is our current way of dealing with alcohol abuse.
That's the consensus of an expert panel convened by the American Medical Association. It was not an exercise in hand wringing. The panel recommends an aggressive plan to enlist doctors and health care plans in identifying and helping people whose drinking puts them and others at risk.
"I believe we are on the cusp of a major shift in how we conceptualize and treat alcohol dependency disorders in the U.S.," said panelist Mark L. Willenbring, MD, director of the division of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism.
- Make people and their doctors aware that most risky drinkers are not alcoholics.
- Identify risky drinkers and educate them about their risks.
- Help people at all levels of alcohol risk get appropriate treatment.
- Vastly improve access to treatment.
- Explore new treatments for risky drinking, alcohol abuse, and alcohol dependence.
Thirty percent of Americans are at least risky drinkers, notes Richard Saitz, MD, MPH, professor of medicine and epidemiology at Boston University Schools of Medicine and Public Health and president-elect of the Association for Medical Education and Research on Substance Abuse.
"The spectrum of use ranges from abstinence, to low-risk alcohol use, to risky or problem drinking, to alcohol abuse, to alcohol dependence," Saitz says. "Risky use and problem drinking are actually much more common than more severe alcohol problems. Four in 100 people have alcohol dependence. Three in 10 are drinking at risky levels."
What Is Risky Drinking?
Saitz puts the definitions in a nutshell:
- Risky drinking means drinking at levels that put a person at risk of medical or social problems.
- Problem drinking means drinking too much and having a medical or social consequence.
- Alcohol abuse means drinking too much too fast.
- Alcohol dependence is drinking too much too often.
"Risky drinking is not defined by consequences already suffered," Saitz says. "Risky drinking is simply defined by consumption … at levels that put people at risk of future consequence."
For men this means more than 14 drinks per week, or more than four drinks on any occasion. For women this means more than seven drinks per week or more than three drinks on any occasion.
What is a "drink?" It is one 12-ounce beer, or one 5-ounce glass of wine, or 1-1/2 ounces of 80-proof spirits.
Who's counting? Everyone who drinks should, says panelist Marc Schuckit, MD, professor of psychiatry at the University of California, San Diego, and director of the alcohol and drug treatment program and the alcohol research center at the Veterans Affairs San Diego Healthcare System.
Safe drinking means not exceeding the recommended number of drinks. It isn't safe drinking if you drink to reach a certain effect, Schuckit says.
"A variety of things contribute to risky drinking," he notes. "One is the hollow leg -- the relative resistance to alcohol. People who are resistant to the effects of alcohol will drink more and hang out with people who drink more. So setting limits would control alcoholism."
At first, drinking makes a person feel good. After too much risky drinking, a person doesn't feel good until he or she has a drink.
"People say it doesn't feel good anymore, but I can't stop," Willenbring says. "At this point, people are not drinking to get high anymore. They are drinking to reduce stress. Once these changes occur, they may be permanent."
Current Treatment Inadequate
The health care system is failing people with drinking problems, Willenbring says.
"Only 24% of those who have ever had alcohol dependency seek treatment," he notes. "Only 12% of those who seek it ever receive any form of treatment. It is disconnected from mainstream health care. And reimbursement is almost impossible to obtain."
Even when people get treatment -- and can pay for it -- it's usually not good enough.
"Minimum standards for treatment of alcohol disorders are met only 11% of the time," he says. "That's the worst of all major causes of death in the U.S."
In fact, it's the worst treated of all major medical conditions, reports panelist Eric Goplerud, PhD, professor of health policy at George Washington University School of Public Health in Washington, D.C.
The findings come from a new study, released today, based on data from 64 health plans in 24 states covering 10 million Americans.
"The quality of care for alcohol disorders was 25th out of 25 conditions," Goplerud says. "Not only was alcohol treatment 25th nationally, it was 25th in every one of 12 communities looked at individually."
Goplerud notes that 8% of working people have an alcohol abuse disorder. But health plans report that only 1% of their members get diagnosed and receive alcohol-related services.
The findings, he says, aren't meant to put health care providers and payers in a bad light. They're meant to point the way to better care.
"The first couple of years we looked at diabetes care, health plans did a lousy job," Goplerud says. "It was the same thing with asthma and with heart disease. But they improved over time. We think the same thing will help with alcohol as people realize the quality of treatment for alcohol dependence has to get better."
How can treatment get better?
"Right now, treatment of alcoholism in this country is seen as something done via mutual support and self-help, not through health care," Goplerud says. "And there is substantial stigma. But we are only just now developing medical treatments that are as helpful as mutual support and self-help."
The first step, the AMA panel agrees, is for doctors to routinely screen patients for alcohol risk.
"The best screening test to date is by asking validated questions," Saitz says. "This is the shortest: When was the last time you had four or more drinks, if a woman, or five or more drinks, if a man? A positive result is any time in the last year. The test does not mean alcoholism. It is an indicator of risky alcohol use."
Whom should doctors ask? Everyone who steps into their office. That's because alcohol use is linked to a number of medical conditions. It does not cause all of them, but it does increase risk.
"Once we identify unhealthy alcohol use, we can do something about it," Saitz says. "And I'm talking about the early stages. Ten or 15 minutes talking with a doctor can significantly decrease alcohol consumption a year and even four years later."
Here's what doctors are supposed to do, according to the NIAAA's 2005 guidelines:
- Ask about alcohol use.
- Assess for alcohol-use disorders.
- Advise and assist the patient. Set and discuss goals for the patient.
- Follow up with continued support. Patients with alcohol-use disorders may need referral to a specialist.
"Risky alcohol use is more common than alcohol dependence and is responsible for more than half of the health consequences due to alcohol," Saitz says. "It can be identified quickly. And brief counseling can have an impact. People with alcohol dependence can start with brief counseling and then go on to what they need."