When Does Alcohol Use Become a Problem?
By: the Medical College of Wisconsin
It’s not easy to establish the defining lines between social drinking and drinking that veers out of control. A moderate drinker might be pulled over for a traffic violation, register slightly above the legal limit of alcohol consumption and receive a stiff penalty for Driving Under the Influence. Another drinker might consume huge amounts of alcohol but never leave the house or harm another person. Whose problem is more “serious”?
By necessity, medical professionals are becoming more aware of the consequences of alcohol use disorders and alcoholism; as a result they have established a variety of criteria to detect the signs and symptoms of these conditions. Various measurements rely on factors including amount of alcohol consumed, health consequences, family history, drinking behaviors and effects on social or work functions.
Three-quarters of Americans use alcohol, but many of them drink lightly or moderately. In general this doesn’t present a problem, and light-to-moderate alcohol consumption may even provide some health benefits. About 18% of men and 6% to 8% of women are thought to have drinking disorders, and because of the potentially disastrous effects on families and communities, a considerable number of Americans are directly or indirectly harmed by alcohol overuse.
Initial Signs Might Indicate a Problem
According to Richard Lofgren, MD, MPH, early indicators of alcohol-related problems typically appear sometime between an individual’s mid-twenties and early 40s. He describes early signs and symptoms as “social disruption, failure to meet obligations, poor work performance, conflict in work and personal relationships, and minor medical problems such as gastritis, hypertension and repeated traumas.” Basically, he says, “any physical problems that seem out of order with the person’s lifestyle or behavior should be tracked. Does a teenager start showing up with a series of injuries and accidents? Does an individual constantly have trouble carrying out responsibilities or showing up at work? In the best interest of our patients, we need to pursue these problems.”
Overall in the US, the consequences of alcohol misuse are staggering. Dr. Lofgren notes that “Not just individuals, but families and communities suffer from the effects of alcohol overuse and alcoholism. The consequences can be devastating in terms of personal grief, societal penalties and even the economy.” Alcohol disorders cross all socioeconomic classes and ethnic boundaries. Current data suggest that 15 million Americans are alcoholic – and that number only includes those aged 18 and older. It’s estimated that the US loses up to $200 billion every year as a result of alcohol use disorders. This includes the cost of complications of alcohol disorders, lost productivity and the cost of treatment.
People with alcohol-related problems experience a death rate that’s four times higher than that of the general population, and alcoholism is the third leading cause of preventable death in the United States. That’s about 100,000 deaths every year.
Hazardous Drinking
Confirming that an alcohol use disorder is present can be tricky. Few of the guidelines are absolute, and the criteria change with the individual. A 13-year-old boy consuming 2 drinks per day is at greater risk for serious consequences than is a 31-year-old man drinking the same amount, even if factors such as weight and other physical characteristics are similar. The physical, emotional, social and psychological costs to a child who drinks alcohol are potentially far more significant than the outcome for an adult who may be able to better control his actions and emotional and social responses.
The National Institute on Alcohol Abuse and Alcoholism has established thresholds between drinking habits that are generally considered safe and habits that could be hazardous.
- Threshold for men: More than 14 standard drinks per week or more than 4 drinks per occasion.
- Threshold for women and people over age 65: More than 7 standard drinks per week or more than 3 drinks per occasion.
(One standard drink equals one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits.)
People who stay at or below these limits are not usually at great risk for adverse consequences, says Dr. Lofgren. The problems start when levels of alcohol use exceed these thresholds, especially if heavy drinking occurs on a regular basis. When the quantity or pattern of alcohol use puts the drinker at risk for adverse consequences, it’s defined as hazardous.
Alcoholism
Functionally, “hazardous drinking” means that consumption of large quantities of alcohol are putting the drinker at an increased risk of medical, emotional and social complications. These individuals show no clear evidence of dependence and most find it possible to reduce their consumption to social levels (see the thresholds listed above). Some, however, may have the much more serious disease of alcoholism – and it is a disease.
Although it might be easy to dismiss people with alcoholism as simply lacking in willpower or discipline, Dr. Lofgren emphasizes that “as with many other chronic diseases, there’s a strong genetic component at work in alcoholism.” And as with other chronic diseases with genetic factors, family members of people with alcoholism need to be aware that they too may be at risk – and act accordingly. Dr. Lofgren clarifies the point with an example: “Just as people with diabetic family members need to watch their weight and blood sugar,” he says, “people with alcoholic family members have to be aware of their own potential for problems with alcohol.”
Compared to hazardous drinking, the standards for determining alcoholism are far more straightforward and the outcomes often more deadly. Diagnosis is based on both functional and physical symptoms. The World Health Organization defines alcoholism as “a chronic, progressive and potentially fatal disease characterized by tolerance, physical dependence, pathologic organ changes or disruption of social functioning” as direct or indirect consequences of alcohol misuse.
Evidence of alcoholism includes a preoccupation with getting or using alcohol, persistent or unsuccessful efforts to quit drinking, and continued alcohol use in spite of adverse consequences. In addition, alcoholics typically deny that a problem exists. Dr. Lofgren notes that people in denial may make up own criteria for alcoholism – none of which apply to them – despite overwhelming evidence to the contrary. As an example he cites a patient who might deny being alcoholic because he only drinks top-shelf liquor.
People with alcoholism typically demonstrate a loss of control when it comes to alcohol use. It’s often easier to have no alcohol than it is to stop after a predetermined limit. Once alcoholics start drinking they can’t stop, even if they’ve decided beforehand only to have a limited number of drinks. According to Dr. Lofgren, one simple method for doctors to test patients’ alcohol dependence is to ask them to go home and have one or two drinks, then stop. If they can’t do this, he says, they likely have a problem.
For alcoholics, complete abstinence – no alcohol, ever – is the only goal.
Assessment, Support, Treatment
The best hope for resolving alcohol problems – either one’s own or those of a friend or family member – is to ask a medical professional for help. Most doctors have experience detecting the disorders and will facilitate their patients’ treatment. Primary care doctors regularly treat people with hazardous drinking habits through brief intervention consisting of counseling sessions in the office. Patients with clear evidence of alcoholism, however, are usually referred to specialist for care and might need to enter a treatment program.
Increasingly, Dr. Lofgren reports, medical professionals are being trained to recognize alcohol disorders and to intervene when patients show symptoms of misuse or alcoholism. “Primary care doctors usually serve as patients’ first contact for medical resources in the community. If a patient has a history of fractures, dislocations and sprains, the doctor should be able to recognize that there could be a problem with alcohol. Even individuals with an assortment of minor problems – like headaches, gastritis, reflux, anxiety or depression – might be showing signs of alcohol-related illness. In this case it’s up to the doctor to ask the right questions and come up with some guidance for the patient.”
Eileen Early, RN, BSN
HealthLink Editor
Richard P. Lofgren, MD, MPH is Senior Associate Dean of Clinical Affairs at the Medical College of Wisconsin. He also serves as Chief Medical Officer of Medical College Physicians, Director of the Primary Care Initiative and Professor of Medicine.